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Secondary Injury Potential of Assistive TechnologiesUsed by Farmers With Disabilities: Findings FromCase StudiesSamuel N. Mathew PhD a , William E. Field EdD b & Brian F. French PhD ca National Institute of Speech and Hearing , Trivandrum , Kerala State , Indiab Department of Agricultural and Biological Engineering , Purdue University , WestLafayette , Indiana , USAc Department of Educational Leadership and Counseling Psychology , Washington StateUniversity , Pullman , Washington , USAPublished online: 05 Jul 2011.

To cite this article: Samuel N. Mathew PhD , William E. Field EdD & Brian F. French PhD (2011) Secondary Injury Potentialof Assistive Technologies Used by Farmers With Disabilities: Findings From Case Studies, Journal of Agromedicine, 16:3,210-225, DOI: 10.1080/1059924X.2011.581542

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Journal of Agromedicine, 16:210–225, 2011Copyright © Taylor & Francis Group, LLCISSN: 1059-924X print/1545-0813 onlineDOI: 10.1080/1059924X.2011.581542

CASE REPORTS

Secondary Injury Potential of Assistive TechnologiesUsed by Farmers With Disabilities: Findings From

Case Studies

Samuel N. Mathew, PhDWilliam E. Field, EdDBrian F. French, PhD

ABSTRACT. In order to complete essential tasks, farmers with disabilities often make and useassistive technology (AT), which itself may cause further injuries known as secondary injuries. A set of19 case studies was used to investigate the potential for injury on home-fabricated assistive technolo-gies (ATs) used by farmers with disabilities. The case studies consisted of close-ended and open-endedinterviews that were designed to help understand the farmers’ perception of potential for injuries andsafety measures implemented or not implemented. The qualitative study used grounded theory prin-ciples and the collected data were analyzed to arrive at a list of features on ATs that have substantialpotential to cause injury to the user. Based on the case study results, AT user characteristics and environ-mental factors were also considered as factors that contribute to potential injuries. Findings were usedto develop an instrument for use by rehabilitation professionals to evaluate ATs for potential injurycausing hazards.

KEYWORDS. Agricultural safety, agriculture, assistive technology, case studies, disabilities,farmers, interviews, rehabilitation, secondary injury

Samuel N. Mathew is Executive Director, National Institute of Speech and Hearing, Trivandrum, KeralaState, India.

William E. Field is Professor, Department of Agricultural and Biological Engineering, Purdue University,West Lafayette, Indiana, USA.

Brian F. French is Associate Professor, Department of Educational Leadership and CounselingPsychology, Washington State University, Pullman, Washington, USA.

Partial funding for this research study was provided by the National AgrAbility Project, funded by the USDepartment of Agriculture through grant no. CSREES/USDA-2008-41590-04796.

Address correspondence to: William E. Field, ABE Building, 225 South University Drive, West Lafayette,IN 47907-2093, USA (E-mail: field@purdue.edu).

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INTRODUCTION

Farming ranks as one of the most haz-ardous occupations, along with mining and con-struction. Reasons for the high injury and fatal-ity rates include exposure to powered equip-ment, the wide age range of workers, highfrequency of working alone, and the need forconsiderable physical effort in an unpredictableand harsh environment.1 It is also among thefew occupations in which family members of theworker are also at risk for injury because theworksite often is an integral part of the livingarea.2–4 Although technology has reduced thephysical rigor of farming in the United States,agricultural workers are still twice as likely asother workers to experience a disabling injuryand six times more likely to suffer a fatal injury.3

Additionally, it has been reported that farm-ers with prior injuries have four times the riskfor additional injuries compared to the generalfarm population.4 Injuries can lead to disabilitywhere the functional limitations may prevent thefarmer from completing tasks previously withinhis or her capability.

Despite the occupation’s hazardous nature,farmers commonly exhibit a love and passionfor the work they have engaged in for so long,sometimes handed down through several gener-ations. Even after experiencing injuries or subse-quent permanent disabilities, it is not unusual forfarmers to return to farming, making the neces-sary adjustments and accommodations that willenable them to continue working.5–10 In somecases, previous injuries or related experiencesmay deter the returning farmers from continuingto use certain equipment or production practicesthey used prior to the disability, even foregoingpossible economic advantages. However, stud-ies of farmers with disabilities have found thata majority of them make modifications to farmequipment and tools or use specially designeddevices to help overcome their disability-relatedrestrictions.6–15 Such modifications, devices,or practices are termed assistive technologies(ATs).7 These ATs may be termed as home-fabricated ATs, since no commercial regulationsor production practices are involved in theirfabrication and are customized to a person’sneeds. Prior research has shown that those ATs

fabricated by farmers to help complete varioustasks sometimes directly or indirectly increasethe risk of secondary conditions or injuries.15,8

The conditions that contribute to secondaryinjuries are sometimes enhanced due to the lackof information on what are appropriate designcharacteristics, safety measures, and/or avail-able alternatives for certain ATs.7,11 Hence itcan be concluded that many of the injuries andnegative outcomes might have been avoided ifoperators with disabilities knew what to expectwhen they used the equipment or recognizedthe potential risks before an injury occurred.9

In other words, the assistive technology (AT)devices would be safer if the risks involved wereidentified, assessed, or made known to the usersin advance. The focus of this study was to iden-tify features on AT that may pose a potentialfor injury to farmers with disabilities when usedto complete everyday tasks on the farm. Thisarticle presents the results from 19 case studiesof farmers with disabilities who have fabricatedor used ATs; the results were further used todevelop an assessment tool to evaluate hazardsof ATs in the agricultural workplace.

REVIEW OF LITERATURE

A review of literature conducted on stud-ies related to disabilities within the farm andranch population estimated the prevalence ofdisability, and the effect of disease and injury.9

The findings of this study showed that amongthe agricultural labor sector, the estimates ofdisability range from 1.04 million to 2.23 mil-lion individuals depending upon which surveysand censuses are used. The inability to pro-vide a more precise number is explained as aresult of nonuniformity of survey methodolo-gies. Although the “imprecision” impedes calcu-lation of more reliable exposure levels to injuryand disability, the fact remains that the popu-lation with disability is significant and requiresattention.

Having a disability is the precursor for devel-oping common secondary conditions such aspain, weight problems, fatigue, difficulty tosocialize in the community, falls and injuries,sleep problems, muscle spasms, and bowel and

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bladder problems.17 Severity of the primary dis-ability may determine the after effects of thesesecondary conditions and how they may lead tofurther injury or disability. Because of the workenvironment on a farm, farmers with disabili-ties might have additional conditions or chal-lenges. When they try to complete tasks suchas operating machinery, the potential of sec-ondary injury is greatly increased due to therestrictions in strength, stamina, agility, vision,or hearing.11,12,10,11

A Purdue University survey of farmers whowere severely disabled (N = 552) found that(a) over 25% had experienced at least onefarm-related injury caused by their disability;(b) more than 60% felt they were at greater riskfor injury because of their disability; (c) over11% had more than one farm-related injurywithin the preceding year; and (d) nearly 73% ofthose injured within the previous year believedtheir disability was a contributing factor.11

A University of Iowa study of farmers(N = 150) reported that hearing impairmentincreased the risk of secondary injury becauseof several reasons: (a) auditory warning sig-nals were masked due to the hearing loss andhence not heeded thus increasing the risk ofinjury; (b) higher sound levels that were requireddue to hearing loss triggered increased stressand fatigue that heightened the risk of injury;and (c) extra noise induced additional hearingloss in those already hearing impaired, furtherincreasing injury risk.12 Similar increased riskof secondary injury or disabling conditions dueto an existing disability is likely in the case ofother disabilities, such as vision impairmentsand mobility restrictions.

In a University of Pittsburgh investigation,21 case studies of farm tractor operators withspinal cord injuries were assessed for risk offurther injuries. It was found that (a) bumping,scraping, and catching of one’s lower limb ontractor components when entering or exiting theoperator’s station were the most significant fac-tors contributing to secondary injury; and (b) themost serious injuries were due to falls trying toaccess or exit the person-lift.13

The research suggests that (a) existing dis-ability conditions of farmers can contribute tofurther injury, and (b) the use of adaptive devices

and practices that are meant to help overcomethe disabling conditions may themselves besources of secondary injury. In order to mini-mize or even eliminate these risks of injury, itis necessary to first identify the most signifi-cant potential hazards to those with disabilities.A suitable method selected to accomplish thisgoal was to conduct case studies on-site whereAT have been fabricated and used by farmers fortheir own use. The reason for this choice wasthat interaction during the case studies with theindividuals would give insights into the possi-ble hazardous situations as well as the strate-gies they employed to prevent further injuries.In addition, on-site interviews would allow fordocumentation of ATs being used for futureeducational purposes.

METHODS

A qualitative design based on grounded the-ory principle was utilized for the multiple casestudies that were completed as a part of thedata collection and analysis process. Case studyresearch can be defined as studying a phe-nomenon in its real-life context that reflects theetic (outside) perspectives of the researchers andthe emic (inside) perspectives of the partici-pants involved. The unit of analysis for eachcase study in the current research was “the ATsused by the participant farmer with a disabil-ity,” whereas the focus was the “safety aspectof the AT.”14 The decision to conduct multiplecase studies was based on the assumption thata variety of the customized, “home-fabricated”AT devices are likely to have different safetyfeatures depending on the design detail, theexperience of the users, the functions of the ATs,and the environments in which they are used.The choice of the specific number of case stud-ies to be conducted was based on expert advice,resource constraints, and the methodology fol-lowed in grounded theory.15

Grounded theory is used in areas where littleprevious research has been conducted becauseit follows constant comparison of data obtainedduring the research process. This allows fordata categorization and theme identification asthe study progresses, and variables that impactthe phenomenon under study are explored

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and identified.16 Grounded theory is based on“grounded” field data collected utilizing spe-cific criteria. This means that the researcher isnear the “real world” of the phenomenon underconsideration so that data and the results aregrounded in the observed event of interest.17

Additionally, continuous comparison of the dataallows one to arrive at a “stop point” fordata collection—that point being when no newthemes emerge. This is important in qualita-tive studies where a definite number of samplesis not determined at the beginning because theemergent themes are discovered in the processof data collection.24

Research Instruments Utilized

The instruments for the case studies includedclose- and open-ended questions, reports ofexamination of the ATs on-site, and documen-tation of the ATs through photographs takenon-site. The interview questions were drafted toobtain answers to the following two researchproblems: (a) What are the contributing factorsto the increased risk of secondary injury whileusing home-fabricated ATs? and (b) Whatare the common safety features and strategiesneeded to prevent further injury when usinghome-fabricated ATs?

The close-ended questions focused on theAT’s design, fabrication, intended use, and otherassociated details; they also inquired into anymodifications carried out to prevent secondaryinjury after the participant started to use theATs, especially if the participant reported expe-riencing any secondary injuries or “close-calls”during regular use. The three open-ended ques-tions were intended to gather information onthe participant’s perception of hazards and anysafety strategies he/she employed. After ini-tial formulation, the questions were reviewedand refined by staff members of the BreakingNew Ground (BNG) Resource Center at PurdueUniversity in order to maximize effectiveness ofdata collection.

The interview questions used are shownin Table 1. Tabular templates were designedto collect structurally organized data dur-ing interviews and the interviewer also tookfield notes. Interviews were recorded using an

TABLE 1. Close-Ended and Open-EndedQuestions for the Case Study Interviews

Close-ended questions for the case study interviews1 How long have you used the AT (number of years)?2 How did you choose the AT (personal choice or

recommended by another person)?3 How was the AT fabricated and installed (self or with

help from another person)?4 What tasks are performed using the AT?5 Do you need assistance to access or operate the AT

(if so, how often)?6 Frequency of use (daily/seasonal)?7 What safety features were considered before

building the AT?8 Did anybody else evaluate the AT for safety before

you started using it (if so, who)?9 What safety features were added after you started

using the AT (even before any injury)?10 Did you have injuries using the AT?11 How many injuries did you have using the AT?12 If you had injuries, did you incorporate any extra

features to prevent further injury?13 Does anybody else use this AT (specify if they have

the same or any other disability)?14 Did any of the other individuals using the AT have

any injuries?15 Do you perform any maintenance on the AT (if so,

how frequent)?16 Do you have a maintenance/operation manual for

the AT?17 Do you keep an updated maintenance schedule?18 Have you posted warning labels on AT (if so, how

many and where)?19 Is any training required to use this AT?20 Did you undergo any formal training before you used

this AT?21 Do others use the AT without training?22 What other tasks are completed with this AT besides

what it is primarily intended for?23 What are the hazardous conditions that prevent you

from using this AT safely?

Open-ended questions for the case study interviews1 What are your ongoing strategies to prevent injuries

to yourself while you use this AT?2 In event of an injury while using the AT, do you have

a plan of action to get help?3 In event of an injury while using the AT, how will you

prevent that situation from recurring?

audiorecorder and a digital still camera wasused to take pictures of the ATs as consideredappropriate.

Participant Recruitment

Potential participants for the study were iden-tified from a national database maintained by

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214 SECONDARY INJURY POTENTIAL AT CASE STUDIES

the BNG Resource Center that contains infor-mation on farmers with disabilities who havebeen assisted in the past. In consultation withtwo rehabilitation specialists associated with theResource Center, a list of potential participantsfrom Illinois, Indiana, Kentucky, and Michiganwho met specific criteria was compiled. The cri-teria were as follows: the participant (a) haddesigned, fabricated, or used one or more ATson the farm to accomplish work-related tasksthat were otherwise not within their capability;(b) had used the ATs for at least three sea-sons of farming; (c) agreed to participate in theresearch study; (d) agreed to be audio recorded,video recorded, and photographed, along withtheir ATs; and (e) agreed to the use of the pho-tographs of the ATs in reports without personalidentification of the participant.

The prospective participants were contactedafter obtaining necessary approvals, for human-subject involvement, from the InstitutionalReview Board (IRB) at Purdue University. A setof 11 participants were contacted for the firstphase, out of which 10 agreed to participate inthe study, whereas for the second group, a totalof 17 were contacted, out of which 9 agreedto participate in the study. The methodologyfollowed was the same in both groups of casestudies and hence the group was considered asone for analysis and discussion purposes.

Initial contact with the prospective partici-pants was via telephone, during which (a) thepurpose of the study was explained, (b) their par-ticipation was sought if they indicated interest,(c) further information was provided regardingthe details of the case study, and (d) a date andtime was set for the on-site visit to conduct theinterviews and observe the ATs.

Researcher’s Role

Defining the role of the researcher is animportant part of qualitative methodology, asthe researcher is actively involved in the datacollection process right from the beginning toend.26 Researcher bias is inevitable and the bestway to deal with this aspect is to identify thebiases early on and articulate them.18 The roleof the researcher was to interview the partici-pants, observe the ATs on site, and document

the ATs as required. The participant was encour-aged to take the lead to choose the locationand duration of the interview. In some cases,the participant allowed the researcher to oper-ate the ATs independently, whereas in othercases it was perceived that operating the ATswas not appropriate and possibly unsafe. Theinterviews were one-on-one with the interviewerasking the questions based on the close-endedand open-ended questions.

An initial period of time was set apart at thebeginning of each on-site interview to estab-lish rapport with the participant and his familymembers as the situation required. It was per-ceived that spending time to build rapport andgenerate a trusting, relaxed setting with the par-ticipants was an important step in obtainingcandid feedback.

The interviewer had significant backgroundand experience in special education includinginteraction in special education classrooms. On-site interviews with farmers having disabilitiesand interview questions for the study may havebeen influenced because of the special educa-tion experience of the interviewer. Also, theresearcher’s experience as a vocational reha-bilitation counselor would have influenced thequestions and interview sessions. These expe-riences, however, gave the ability to the inter-viewer to understand the problems faced by thestudy participants more realistically. The inter-viewer had no significant previous exposure tofarming and hence there was no specific biasabout farming or safety that could have nega-tively influenced the study.

Data Collection and Analysis

The informal “orientation time” (lastingabout 30 minutes) was followed by the for-mal part of the visit, which consisted of thethree sequential sessions—(a) initial interviewof the participant, during which the close-endedquestions were asked; (b) observation, exami-nation, and photographing of the ATs; and (c)follow-up interview based on the results of ses-sions a and b plus the open-ended questions. Inmost cases the ATs had been in use for morethan 3 years and the participant needed timeto recall various details of its construction and

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early development. Also, since the participanthad significant personal investment in the ATs interms of money, effort, and resources, he neededto be at ease and be confident as well as be will-ing to share information with someone he hadjust met.

The qualitative data collected during eachcase study consisted of (a) the participant’sanswers to the close- and open-ended questions,(b) the audio recording of the interviews, (c) thefield notes taken during the interview, (d) theobservation notes about the ATs, and (e) the pic-tures taken of the ATs. The collected data werethen consolidated into a summary report thatdescribed the users, details of the disabilities,photographs of the ATs, and relevant informa-tion about the farms. The report also containedtwo lists identifying and describing the fol-lowing: (a) the features on the ATs that couldcause secondary injury, and (b) safety measuresemployed by the users to prevent further injury.The summary reports provided a systematicallyorganized set of data ready for the next stepin the study employing the structural analysismethod used in qualitative research.23 The struc-tural analysis involved examining the data toidentify structures or patterns in the events orphenomena under study. Since grounded theorywas the basis of the qualitative data collectionand analysis, the data from each case study wereanalyzed before conducting the next case study.

The three-step procedure of assembling rawcase data, constructing the case record, and writ-ing the final case study narrative was followed ineach instance so as to obtain meaningful infor-mation from the case study interaction.26 Thecase studies (and participants) were code-namedto avoid personal identification. The uniquelyidentified items in each case study were pulledtogether to form a comprehensive list that con-stituted the record of secondary injury potentialand safety measures.

Triangulation

Triangulation is a reasonable and practi-cal strategy used in qualitative methodologyto check the reliability and validity of datathrough different methods, perspectives, andmeasures. Triangulation may be in the formof data triangulation, where several sources of

data are used, and methodological triangulation,where the use of multiple methods of study areemployed for a problem.26 The summary reportsent to each of the participants for verification ofits contents (called a “member-check”) providedthe first method to triangulate the data. Theresponses confirmed the accuracy of the reportswith only minor corrections. Additional trian-gulation was achieved through examination ofavailable literature, including relevant AmericanNational Standards Institute/American Societyof Agricultural Engineers (ANSI/ASAE) andSociety of Automotive Engineers (SAE) safetystandards for agricultural machinery and equip-ment. The standards provided specifications toensure safety for equipment used in agricul-tural workplace. The significance of the hazardsexamined during the case studies was comparedto the relevant specifications in the standards.As a third method to triangulate the generalaccuracy of the data, the reports were reviewedby a second professional with over 30 years ofexperience in farm safety and AT-related ser-vices for farmers. Interviews and observationsby the researcher during the on-site case studiesbecame a fourth method of verifying the validityof the data.26

RESULTS

The Participant Farmers—Disabilities andAT-Related Experience

The disabilities of the participants were wide-ranging, including spinal cord injury (SCI), trau-matic brain injury (TBI), Parkinson’s disease,cerebral palsy, degenerative bone disease, arthri-tis, chronic back pain, and upper limb ampu-tation. Five of the participants had degenerat-ing health conditions but were still ambulatory,whereas the remaining were nonambulatory andused wheelchairs for mobility.

The ATs observed in the study includedthe following: added steps on tractors, plat-forms on chemical sprayers, a modified util-ity vehicle, person-lifts, a harvesting cart thatgoes over rows of plants, a cultivating cartto help move by the side of the vegetablerows, a modified chemical sprayer, and a plat-form to access a skid loader. The variety ofperson-lifts observed included one modified

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from a self-propelled cherry picker, an assistant-operated hydraulic lift fabricated from a cherrypicker, and equipment-attached overhead elec-tric cable winch and platform that served as aperson-lift. These ATs were utilized in a varietyof farm enterprises, including cash crops, beefcattle, dairy cattle, vegetables, flowers, gardenplants, and fruits.

From the collected and analyzed data, it wasevident that the case study participants had awide variety of relevant experience in addition tousing the ATs for completing agricultural tasks.These included design and fabrication of ATsfor their own independent living needs and ATsfor other farmers who had similar needs. Someparticipants were also part of peer-support net-works that provided assistance and advice toother farmers with disabilities. A summary ofthe participants’ farming backgrounds, disabil-ities, ATs, and secondary injuries is presented inTable 2. All of the participants had severe barri-ers to completing everyday farm-related tasks.However, it is significant to note that 17 outof 19 had designed and fabricated their ownAT (89%). Earlier studies among farmers hadreported that more than 72% of the farmerswith disabilities had fabricated their own AT.11

Although 9 out of the 19 participants had expe-rienced secondary injuries, only 6 participants(32%) reported making modifications to preventfurther injuries. Although 88% of the partici-pants acknowledged the need for safer practicesand technology, only 26% considered it worththe effort to implement them.19

More than three quarters of the participants(15 out of 19) had made multiple ATs for theirworkplace to complete tasks that were otherwisebeyond their abilities. Most of the participants(84%) were able to access the ATs and usethem independently to complete tasks. All of theusers having paraplegia had either independentor attached lifts to access operator stations offarm equipment.

Secondary-Injury Causative Factors andSafety Features on the AT

Based on the completed case studies, aninclusive list of features was generated and cate-gorized into three major groups: (a) the absenceof a specific feature on the AT (e.g., seat belt,

guard, substitute controls) that could contributeto an injury; (b) the presence of a specific fea-ture on the AT (e.g., wrap point, hot surfaces)that could cause injury while using the AT; and(c) an inappropriate/inadequate feature on theAT that could cause injury (e.g., inappropriatelocation of controls, weight of the AT). Table 3is the compiled list of items that were found tohave potential for injury based on above factors.

Similarly, another list of items was com-plied (see Table 4) that itemizes the safetymeasures adopted by the participants to pre-vent further injuries. Several of the participantsexpressed their apprehension that not takingthese safety measures would have increasedrisk of injury while using the AT (Interviewrecords, December 11, 2008, and February 6,2009).

With regard to using the AT devices, the focusof the participants was on overcoming the task-barriers as well as keeping the cost of fabricationlow. The participants fabricated the AT based ontheir own ideas or those of others. With regardto the cost of fabricating an AT, all of the par-ticipants agreed that their home fabricated ATscost much less than a comparable commercialAT. As an example, one participant fabricateda lift on his tractor based on an idea from aBNG Resource Center publication. He drew thedesign of the lift on paper, and built it with hisfather’s help. He stated that:

“My dad and I went to the scrap yardand picked up a sturdy beam, went tothe store and bought a sturdy winch andan American-made sturdy cable to useon the winch. We spent about $300 forthe material. We welded and fitted every-thing ourselves and spent about a week’stime building it, and that saved us somemoney on labor too.” (Interview records,December 11, 2008)

The estimated cost of a commercially manu-factured lift that functionally performs the sametask would have been substantially higher, butwould have included additional safeguards suchas a lifting mechanism that did not use a cable orwinch not certified for human transport (S. Swain,personal communication, March 27, 2009).

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TABLE 2. Disability-Related Information Summary of Case Study Participants

Categories Participant characteristics Total %

Farming background Participants had a farming background 19 100Cause of injury Disability from farm-related injury 7 37

Disability through automobile injury 4 21Disability by other injury/disease 8 42

Type of disability Disability—paraplegic 12 63Disability—lower limb amputation 3 16Other disabilities 4 21

Commercial/self-fabricated AT Designed own AT 17 89Used commercial AT 9 47Fabricated multiple AT 15 79

Type of AT and use Needed no help to use AT 16 84Wheelchair user 13 68Person-lift user 12 63Hand control user 13 68Added steps user 8 42Modified tools user 14 74

Modifications to AT Reported secondary injury 9 47Modification to AT after secondary injury 6 32

TABLE 3. Factors Observed as Potential Primary Causes of Secondary Injuries on ATsUsed in Agricultural Production Worksites

Absence of features Presence of features Inappropriate/inadequate

Alternate means of exit Abrasive contacts Activation of controlsBack-up controls Adverse environment Cable tensionBack-up/alternative power source Clutter on or around AT Medicative restrictionsBraking mechanism Crush points Extended useEmergency stop devices Damaged cables Location of controlsFire extinguisher Damaged hydraulics/components Manual force requiredFunction labels for controls Excessive vibrations Modifications on the ATGuards, rails, or hand-holds Excessively loud noise Nature of the user’s disabilityInter-locking mechanism Exposed electrical cables Overall weight of the ATMaintenance/operator manual Hot surfaces Poor constructionRegular maintenance requirement Physical damage Projections on moving partsRoll-over protective structures Pinch points Release of springsPersonal protective equipment Sharp edges Shape and size of controlsSeat belts/restraints Shear points Unsafe terrainSpeed regulation Slippery surfaces Training for the userStabilizing supports Toxic material Weak joints and connectionsSubstitute controls Un-insulated electrical components Weight capacityTraining for assistant Unsafe cable winches Work habits/user traitsTwo-way communication Unsecured cables Wrongly fused circuitsSafety messages Wrap points

From the data collected, AT specific featureswere identified that were critical and not so crit-ical. For example, the absence of an emergencystop for a powered AT might be critical whereas it may not be critical for a manually operatedslow-moving cart. The presence of a sharp edge

or a pinch point is critical in all circumstances,except for purposes of function. The farmersfocused on features they perceived as criticaland fabricated the AT accordingly. When oneof the participants was asked about his safetyfeatures, he replied,

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TABLE 4. Safety Measures Adopted for ATDevices by the Study Participants

1 Access to two-way communication device to call forhelp in an emergency

2 Adequate training for the user to ensure correctoperation

3 Precautions to avoid bumping and sudden jerking ofbody during movement

4 Use of AT for only intended purposes to avoidunexpected risks

5 Battery back-up for electrically operated devices incase of power failure

6 Guarding to prevent crushing points7 Guarding to prevent pinching points8 Guarding to prevent potential wrap points9 Easily usable levers, appropriate push or pull based

on user ability10 Easily operable on/off switch to ensure smooth

intentional activation only11 Master control switch in easy access location for

quick activation12 Provision for manual operation for electrically

powered AT13 Rearrangement of controls for easier accessibility14 Regulation of user’s body temperature by

environmentally controlled workstations15 Roll-over protection structures to provide zone of

protection in the event of an upset16 Use of seatbelts or body restraints to prevent

instability and falls17 Use of smooth surfaces to transfer the user from one

seat to another18 Use of quality material and rugged construction to

fabricate the AT19 Weight carrying capacity posted to minimize the

chance of breakage or fall20 Working habits (e.g., organization, alertness, clean

working environment)

“When I originally made [the AT], I waschecking for pinch points and sharp edgesand things like that and tried to smoothenthe sharp edges or grind them. I didn’treally think about the pulley snappingand then falling. Once that happened, Iput in a fall-arrestor.” (Interview records,February 6, 2009)

Commercially manufactured machines andequipment generally have “hazard” alert mes-sages posted at appropriate locations. None ofthe home-fabricated AT devices or the modi-fied equipment observed in these case studieshad posted warning labels, operator instructions,or maintenance schedules; neither were there

written maintenance and operation manuals. Theperceived need for these aids was not high fromthose who fabricated these ATs for their ownuse. However, most of the participants did pro-vide some level of maintenance on their ATs, butnot on a routine, scheduled basis. Those who hadelectric- or hydraulic-powered AT devices saidthat they made visual inspections for any evi-dence of problems such as broken cable strands,loose fasteners, shaky connections, and dirt onmoving parts before every use. For example, oneparticipant, a paraplegic who farms 650 acreswith his brother and has a home-fabricated lifton his combine plus a commercially made oneon his tractor, stated:

“I look at the chains to see if there is anymud or grease stuck, and if so I will clear it.I operate the lift initially while I am on thewheelchair itself to observe its smoothnessof operation. If there is anything unusuallike an odd sound or sluggish movement, Iwill make sure that I get to the bottom ofit before I transfer myself to the lift seat. Ialso visually inspect the cable on the winchmechanism on my home-made lift for anyfrayed cable strands, so that I can replacethe cable before using the lift. I lubricatethe moving parts at the beginning of everyseason when I change oil on my tractor.”(Interview records, February 6, 2009)

The AT users who had only hand controlsand added steps fitted on their farm equipmentgenerally did not perceive a need for sched-uled maintenance or inspection, since these ATdevices were not powered and remained sta-tionary. Most, however, did acknowledge theimportance of checking periodically for loos-ened fasteners and broken welds.

Even when participants identified secondaryinjury potential on their AT devices, nonereported making any additional modificationsin advance so as to prevent possible injury.However, of the nine who had experienced a sec-ondary injury, six made modifications after theirinjury occurred, whereas the other three decidedjust to be “more cautious” during operationrather than make any modifications.

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One of the participants installed a fall arresterafter he fell from the person-lift due to a bro-ken cable, whereas another moved a batteryelsewhere on his combine after it caught fireand burned the battery wire, which preventedhim from using the lift to exit the equipment.Another participant made modifications to hislawn tractor after experiencing injuries duringoperation, whereas yet another installed addi-tional hand-holds on the side of his truck afterslipping off the running board lift and breakinghis ankle.

One participant, a paraplegic with no sensa-tion below the waist, had sustained severe burnson his ankle while resting his leg near hot enginecomponents. After this occurrence, he did notinstall any insulation to prevent another suchincident. His explanation was as follows:

“After that incident, I place my hand andfeel the temperature of any place initiallybefore I keep my leg at that place. I do thisevery time. I understand that I have no wayof knowing if my leg is burning if the placegets hot after I keep my leg there. But I amjust cautious this way.” (Interview records,December 10, 2009)

Another participant, a 70-year-old havingparaplegia who farms 3000 acres with his son,uses a manual cherry picker engine hoist as aportable lift to access his tractors and combine(see Figure 1). He pulls the lift with his poweredwheelchair to the machinery, transfers himselffrom the chair to the lift seat, then from the liftseat to the operator’s station. However, he has noalternative way to exit if an emergency occurswhile he is away from the lift. Twice in the past,his combine caught fire while he was in the field;fortunately, his son was nearby and was able totransfer him to safety using a tractor. Since thesecond incident, he has formulated the following“strategy” in the event of another emergency:

“I will drive the combine to a ditch orsomeplace similar where the level of theground by the side is not as steep as theregular ground below, and I will throwmyself on the ground hoping there won’tbe much injury and then try to dragmyself away from the fire. Of course, Ido keep two fire extinguishers for emer-gency use, one near me and the other belowthe combine for the anticipated rescuer.”(Interview records, February 5, 2009)

FIGURE 1. Portable lift fabricated from cherry-picker engine hoist (color figure available online).

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Although he likely has the financial meansto have an emergency exit lift installed, he haschosen not to do so. He is willing instead totake the risk of finding an alternate escape route,despite two potentially hazardous situations inthe past that could have caused injury—or pos-sibly resulted in death.

Although all the participants had fabricated ormodified ATs to complete tasks, several statedthat they were reluctant to implement addi-tional safety features that would involve exten-sive alterations if doing so required considerableinvestment of time and money. Rather, theyrelied on their own judgment and prudence tooffset potential safety hazards and were will-ing to take risks, even after recognizing thepossibility of injury (or having experienced aprior one).

Adoption of Safety Measures

All participants identified the “availabilityof a communication device” as their primary“safety measure” to summon help in case ofan emergency or breakdown—cell phones ortwo-way radios. However, at least two acknowl-edged that they sometimes forget to carry thesedevices. One participant, a paraplegic who uti-lizes a modified tractor with an attached lift onhis 40-acre truck farm, stated:

“My mom hands me the cell phone everytime I start from home to get on the tractor,and she reminds me to carry it with me; butsometimes I will leave it on the wheelchairwhen I am in a hurry to get on the tractor.”(Interview records, December 11, 2009)

By his own admission, he does not pay muchattention to his limitations. Although he has notyet had an emergency situation while withoutthe cell phone, he did acknowledge that it wouldbe critically important in case of an emergency(Interview records, December 11, 2009).

One participant with paraplegia, who has askid steer fitted with a home-fabricated lift,admitted to twice being stranded in the machineaway from home, having forgotten to takehis cell phone. One of those times he was

in the rain for several hours before his wifefound him.

Many participants stated that they consideredtheir ability to physically move or operate theirAT as important safety features. One participantaffected by childhood polio and currently a veg-etable grower made a lightweight cart on whichhe kneels to complete planting, cultivating, andharvesting tasks (see Figure 2). The farmer puta tow-bar at one end so it can be pulled by handwithin a field or transported by tractor from onefield to another.

The case studies completed in this researchprovided insights into some of the safety mea-sures employed, or not employed, by the partici-pants. Considering the variety of AT devices, thewide range of disabilities, and the diversity offarm environments covered through these casestudies, the potential list was lengthy. Most ofthe needed preventative measures are compara-ble to those needed to reduce the frequency andseverity of work related injuries on any farmoperation.

Impact of User Characteristics on ATsInjury Potential

Although the initial emphasis of this researchfocused on the features of AT devices thathave the potential to cause injury, it becameapparent that there are factors other than theAT features themselves that may contribute tothe injury risk while using the AT. The con-versations with the participants and the infor-mation gathered during interviews revealed thatthe AT users’ temperament, behavior, attitudes,work habits, strengths, disability-related limita-tions, and effects of medications are additionalfactors that may increase the potential for fur-ther injury.

Two of the participants presented an exampleof the contrast in user characteristics. Both wereparaplegic and used wheelchairs for mobility,and both designed their own AT—a person-lift.One uses his lift to access his tractor withoutanyone’s help, whereas the other needs assis-tance to get into his attached lift sling but canthen operate the lift and transfer onto the oper-ator seat of the farm equipment unassisted. Intheir interviews, one mentioned that he was very

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FIGURE 2. Portable vegetable cart (color figure available online).

diligent to carry his cell phone at all times,whereas the other said that he had forgotten sev-eral times to take his phone with him to the field.He admitted that his risk-taking behavior greatlyincreased the injury potential and he was morediligent to take the phone with him after beingstranded twice.

Another participant, who also uses awheelchair for mobility and has limited useof his fingers due to advanced arthritis andParkinson’s disease, had fabricated a numberof ATs for completing farm tasks as well asfor daily living activities. He has made all ofhis essential farm equipment accessible for hisuse. Ideas for modifications are his own andinvolve considerable trial and error. However,from observing his workmanship, it was evidentthat he gives more attention to the functionalityof his ATs than to their safety and reliability,stating, “If it works, I can use it.” But his wifehad a different opinion. During the case-studyvisit, as he was preparing to demonstrate the lifton a large harvesting machine, she questionedhim, “You are not going to get on that, areyou?” She was obviously concerned about thefact that it raises him 15 feet off the groundthen swings him 90 degrees so he can accessthe operator’s seat. The lack of safety restraints,

fall protection, and backup means of operationmade this homemade device very hazardous.

One of his ATs—a raising mechanism forthe operator-seat of a tractor using an electri-cal actuator that enables him to position himselfin the narrow space between the steering wheeland operator seat—caught fire when the motoroverheated. Fortunately, his wife and an aidewere nearby to help him exit unharmed. Whenfabricated there was no safety fuse in the elec-trical system to prevent overheating. There werealso no fall-arrestors on any of the person-liftsused at several locations on his farmstead. Afriend had bought one portable lift for him,but he had not yet installed it at the time ofthe case study visit. One of the stand-alonelifts used to access the tractor was made fromcomponents salvaged from a trailer. Observingthe lift in use and by his own admission (“ifit works, I can use it”), the conclusion wasdrawn that there was little consideration givento personal safety.

The most frequently used AT of this partic-ipant was a platform lift he designed and builtto access his house from ground level whileon his powered wheelchair—with a total weightexceeding 400 pounds (see Figure 3). The lifthad no safety interlocks to prevent unintended

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FIGURE 3. Home-fabricated wheelchair lift (color figure available online).

starts, no guards to prevent falling off the plat-form, no fall-arrestor in case the chain or cablebreaks, and uses an electric winch labeled as notcertified to lift humans.

The data gathered during the case studiesreveal a general pattern of user characteristicsthat increase the risk of injury when functionwas considered substantially more importantthan user safety. This philosophy was reflectednot only in the design and fabrication aspects ofthe ATs but also the practices observed in usingthe ATs.

Another important insight into the relevanceof user characteristics was provided in thecase study of another participant who becameparaplegic from childhood disease and uses awheelchair for mobility. He has fabricated ATsfor his own use but also currently builds ATs forothers. He stated during the interview:

“When I go to a person’s house to installthe lift or another piece of equipment, I

first look around to see how the houselooks. If he has clothes lying around andthe kitchen sink is full of dirty dishes andhis backyard is cluttered, I have a differ-ent approach to training him to use theequipment than another customer who haswell-kept surroundings. I know that if theguy cannot take care of his surroundings,probably he is going to be more dangerousto himself when he uses the equipment.”(Interview records, January 19, 2009)

Impact of Environmental Factors on ATsSecondary Injury Potential

During the case study data collection andanalysis, it became evident that environmentalfactors also increased potential for secondaryinjury when a farmer with disabilities uses anAT. For example, one of the participants lackstemperature regulation in his body, which isa fairly common side effect of spinal cord

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injuries that result in paraplegia or quadriplegia.Although he tolerates a warmer environmentbetter than a colder one, he knows that unlesshe is careful, the warmer environment can bedetrimental to his health and have severe con-sequences. He stated,

“I carry water with me to douse myselfintermittently when I work in summer hotweather out on the farm. I do this reli-giously as I know that, although I like itwarm, I need to cool myself often. Mybody doesn’t do that for me. When it iswinter, I just don’t like the cold weatherbecause I cannot tolerate it; and so I juststay home whenever possible.” (Interviewrecords, December 10, 2008)

In many cases, those interviewed wereunaware of or oblivious to the environment-related conditions around them and carried ontheir work as if they posed no threat. This hightolerance level was observed frequently, even incases where the risk levels were high for boththe user of the ATs and others, including thoseproviding assistance.

DISCUSSION

The number of case studies conducted waslimited, but also that number was consideredadequate based on the grounded theory prin-ciple, where a “stop point” is reached whennew themes cease to emerge as data collec-tion progresses.24 The case studies completed inthis research provided insights into the poten-tial for secondary injury specific to ATs and thesafety measures employed by the participants.Considering the variety of ATs, the wide rangeof disabilities, and the diversity of farm envi-ronments covered through these case studies,the list of potential sources of secondary injurycan be considered fairly inclusive of the com-mon ATs found in the agricultural workplace.The data obtained through this research effortprovided the foundation for a larger project todevelop an assessment tool for evaluating thesecondary injury potential of home-fabricated

ATs. Input from the case study participants whowere farmers and additional input from a setof rehabilitation professionals were integrated to“build” the assessment tool. The tool was val-idated using a panel consisting of six expertsexperienced in the areas of rehabilitation and ATassessment.

The study was initiated with the aim toexplore the possible features that AT in the agri-cultural workplace may have for potential sec-ondary injuries when used by those with existingdisabilities. The data gathered through the casestudies provided valuable insights into the exis-tence of potential hazards and helped identifya variety of features that may have potentialfor injury.

The participant farmers in this study con-firmed the earlier reports regarding perceptionsof risk for injury.28 Despite the awareness andknowledge about possible injury, and even sus-tained injury in the past, the farmers had notmade the necessary modifications on ATs toenhance user safety. Several stated that theywere more cautious while using ATs. Whitmanand Field28 reported the inconsistency in knowl-edge and practical implementation is driven bytime and economic constraints. This aspect maybe investigated further in future studies amongfarmers and other populations that have higherrisk of occupational risks.

The conclusion drawn from the completedcases is that user characteristics and environ-mental factors are also important factors indetermining potential risk for secondary injurywhile using an AT. The user traits identifiedas potentially hazardous should lead to appro-priate preventive measures that may reduce thepotential for injury. The following factors con-sidered specific to individual users were identi-fied as causative factors to injury: work habits,user’s disability, medications, extended use, anduse of communication devices. Similar to usercharacteristics, environmental factors were alsoidentified as hazardous and can heighten thepotential for injury when AT is being used.Corrective action such as avoiding hazardousenvironments may help to reduce injury. Thefollowing additional factors were consideredas hazardous environmental factors: adverse

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weather conditions, clutter on or around ATs,and uneven terrain that reduces stability.

CONCLUSIONS/STUDY LIMITATIONS

In conclusion, it is recognized that the assis-tive technology devices and techniques adoptedby farmers with a variety of disabilities areunique to their particular needs. It is like-wise recognized that features and characteristicscommon to those ATs can be the cause of addi-tional injuries to the users. Analysis of the datacollected from the case studies conducted dur-ing this research was successful in identifyingmany potential factors relative to the ATs, theusers, and the environments that heighten thesecondary-injury risk potential.

There were several limitations to this study.They are as follows:

• It is acknowledged that, although home-fabricated ATs evaluated in this studywere widely used in the agricultural work-place, other unique devices can be—andlikely have been—fabricated by farmers toovercome their disabilities that were notaddressed by the study.

• Of the 19 case-study participants, only 1was a woman; therefore, the data collectedmay lack additional unique insights fromfemale farmers who have disabilities.

• Although this research found that sec-ondary injury was due to not only AT fea-tures, but also certain user and environmentrelated factors, time and resource limita-tions did not allow the researchers to focuson these other two factors with as muchintensity as the first (i.e., AT features).Thus, further investigation into the impactof user characteristics, such as medica-tion use, and environmental factors, suchas cold weather, is called for if the list ofinjury-causing items for an AT assessmenttool is to be truly inclusive.

• The focus was mainly on physicalimpairments and hence potential injuriesassociated with cognitive and behavioralimpairments were not addressed. It isacknowledged that these factors may also

have their impact on the risk of injurywhile using AT.

FUTURE RESEARCH

The study has brought out several poten-tial factors for secondary injury to agriculturalworkers while using ATs. Further research isrequired to understand yet other factors thatmay increase the risk and the study should beexpanded further and categorized in terms of agegroup, ethnicity, the ATs used, and geographicallocations. The reported study results as well asfuture research in this direction can encouragefurther steps to be taken to prevent injuries tothe AT users on farms.

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