Sowing seeds of hope: providing agricultural communities with crisis services specific to their needs.

by Rosmann, Michael R.

Behavioral Healthcare • April, 2008 • CULTURAL COMPETENCY

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Farming and ranching are among the most stressful and dangerous careers, with some of the highest occupation-related rates of injuries and fatalities. They share this dubious distinction with commercial fishing and lumber harvesting, which also are agricultural occupations because they involve the production of food and fiber. These industries are dangerous to not only physical health but to behavioral health as well. Serious psychological distress and suicide are nearly twice as common among persons engaged in agriculture than among the general population.

AgriWellness, Inc., is a nonprofit corporation devoted to improving the behavioral well-being of the agricultural population. Located in Harlan, Iowa (in the rural western part of the state), AgriWellness works with partners in seven upper Midwestern states to improve the behavioral health supports available for agricultural people. The partners comprise the Sowing the Seeds of Hope Network. Each state (Iowa, Kansas, Minnesota, Nebraska, North Dakota, South Dakota, and Wisconsin) operates a free confidential telephone helpline/Web site available 24/7 to agricultural people (see sidebar).

Between 2003 and 2006, 35,000 calls were made to the crisis helplines. Two percent of callers reported suicidal ideation; 12 persons had attempted suicide, and another 10 had a suicide plan. Stress due to financial difficulties and daily living is the main reason farm and ranch people contact the helplines (28%), but callers have many other reasons, such as personal mental health issues or a depressed family member (14%), marital and family problems (14%), and gambling and substance misuse (3%). Many callers need help with a particular problem, such as a livestock disease outbreak or a fence dispute. Fifty-three percent of callers are male, and some helplines offer services in Spanish as well as English.

Helpline responders have farm backgrounds and training in a behavioral health profession (e.g., psychology, nursing, human services). Responders must understand agriculture and farm people's language in order to provide culturally appropriate assistance, as farm people are especially savvy at detecting responders who don't understand their situation. After all, what good does it do a farmer concerned about farrowing difficulties or a margin call if the responder doesn't understand these agricultural terms?

Besides providing a good shoulder and helpful advice, the helplines connect callers with legal advice, financial management expertise, and disaster assistance (e.g., locating electricity generators after a power outage or emergency livestock feed during droughts or winter storms). Each state has a network of professional counselors, psychologists, social workers, substance abuse counselors, and other behavioral healthcare providers who have at least some training in issues important to people in agricultural communities. Callers are referred to these professionals to obtain outpatient behavioral health assistance at no cost when they lack health insurance or the means to pay for private care.

Lack of healthcare insurance coverage and access to behavioral healthcare are problems for the agricultural population. Nine percent of farm operators nationally lack health insurance, as do 60% of farm workers and nearly all migrant laborers. The recently completed 2007 Health Insurance Survey of Farm and Ranch Operators (www.accessproject.org) in seven rural states indicated that farm families with health insurance struggle with the high cost of individually owned policies, which now average $12,000 per family annually. About 70% of families seek off-farm employment of one or both spouses to obtain health insurance coverage through outside employers, although many policies have high deductibles or caps on behavioral healthcare. About 20% of all farm operators have medical debts, and about 14% of farm residents put off seeking care because they can't afford the out-of-pocket expenses. In addition, a lack of behavioral healthcare providers contributes to access problems in rural areas because the number of psychiatrists, psychologists, social workers, and other behavioral healthcare professionals per 100,000 residents is half that of urban areas.

The vision of Sowing the Seeds of Hope is a sustainable, fully funded, regional strategic partnership that provides culturally competent, accessible, affordable behavioral health services to the agricultural community. AgriWellness and its partners offer (in addition to the helplines/Web sites) community outreach through newsletters, farm radio broadcasts, and magazine articles; behavioral health screening at farm fairs and trade shows; educational programs for farm families; and visits by trained outreach workers to farm and ranch homes. Partners collaborate with specialized healthcare providers such as the AgriSafe Clinic Network and Rural Health Clinics. Each state has a coalition of agencies (e.g., human services, public health, extension services), farm organizations (e.g., Farmers Union, Farm Bureau), faith-based groups (e.g., Catholic Family Services, Lutheran Social Services), educational institutions, and advocates (e.g., Mental Health America). The state partners, with assistance from their state coalitions, take responsibility for maintaining the helplines/Web sites, and AgriWellness and its partners take responsibility for sustaining the behavioral health services, social marketing, advocacy at regional and national levels, and provider training.

AgriWellness is developing the first textbook and curriculum in the newly emerging discipline of agricultural behavioral health. We are conducting a comprehensive research evaluation to determine if services reach the agricultural population as intended and if they deter suicide. The Sowing the Seeds of Hope services have been identified as a best-practice model in Rural Healthy People 2010: A Companion Document to Healthy People 2010, but this research is needed to determine if the services are evidence-based best practices.

The farm bill being debated in Washington has a provision that would make behavioral health services like ours available in all agricultural areas of the country. The Farm and Ranch Stress Assistance Network would be administered through the U.S. Department of Agriculture. This first-of-its-kind network would invest in and protect the welfare of the most important resource in agriculture--the people who produce our food and fiber.

I close with the words of someone who commented on the need for this nationwide network:

It took me two years of drought and too much rain to lose a business

I spent twenty years preparing for and seven years building. I am not

a farmer, but I was a produce packer and shipper contracting acres

with dozens of farmers, which experienced the same wrath of weather my

business did during that period of time, as well as economical

hardships. Some of those farmers survived. Some did not. In our case,

we did have each other to lean on to some extent, but we never spoke

of things in depth. There is no doubt in my mind, your program serves

as a valuable outlet for those unspoken words. To this day, I have

still never really financially recovered from the damage caused by the

weather in those two years. And on almost a daily basis, I certainly