Is Farming a Risk Occupation for Cardio-cerebrovascular Diseases? A Scoping Review on Cardio-cerebrovascular Disease Risk in Farmers

Article information

J Prev Med Public Health. 2024;57(6):521-529

Publication date (electronic) : 2024 August 23

doi : https://doi.org/10.3961/jpmph.24.302

Hyeonjun Kim ¹

, Wongeon Jung ²

, Sunjin Jung ¹

, Seunghyeon Cho ³

, Inho Jung ¹

, Hansoo Song ⁴

, Ki-Soo Park ⁵

, Seong-Yong Yoon ⁶

, Joo Hyun Sung ⁷

, Seok-Ju Yoo ⁸

, Won-Ju Park^,

¹Department of Occupational and Environmental Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, Hwasun, Korea

²National Institute of Agricultural Sciences, Rural Development Administration, Jeonju, Korea

³Department of Occupational and Environmental Medicine, Chonnam National University Hospital, Gwangju, Korea

⁴Department of Occupational and Environmental Medicine, Chosun University Hospital, Gwangju, Korea

⁵Department of Preventive Medicine, Gyeongsang National University College of Medicine, Jinju, Korea

⁶Department of Occupational and Environmental Medicine, Soonchunhyang University Gumi Hospital, Gumi, Korea

⁷Department of Occupational and Environmental Medicine, Institute of Medical Science, Gyeongsangnamdo Environmental Health Center, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Jinju, Korea

⁸Department of Preventive Medicine, Dongguk University College of Medicine, Gyeongju, Korea

Corresponding author: Won-Ju Park, Department of Occupational and Environmental Medicine, Chonnam National University Medical School and Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun 58128, Korea E-mail: wonjupark@jnu.ac.kr

Received 2024 June 16; Revised 2024 July 21; Accepted 2024 August 1.

Abstract

Objectives:

In Korea, cardio-cerebrovascular disease (CCVD) is recognized as an occupational disease when sufficient evidence of a work-related burden exists. In 2021, approximately 26.8% of the payments from occupational disease insurance under the Industrial Accident Compensation Insurance Act were allocated to CCVDs. However, due to the specific nature of insurance policies for farmers, CCVD is not acknowledged as an occupational disease in their case.

Methods:

We reviewed studies on the differences in the incidence, prevalence, and mortality rates of CCVDs between farmers and the general population or other occupations and described the exposure of farmers to risk factors for CCVDs.

Results:

Several studies showed that farming is a high-risk occupation for CCVDs, with the following risk factors: long working hours, night work, lack of holidays, and strenuous physical labor; physical factors (noise, cold, heat, humidity, and vibration); exposure to hazardous gases (diesel exhaust, carbon monoxide, hydrogen sulfide, carbon disulfide, nitrogen oxides, and polycyclic aromatic hydrocarbons), pesticides, and dust (particulate matter, silica, and organic dust); exposure to a hypoxic environment; and job-related stress. Social isolation and lack of accessible medical facilities also function as additional risk factors by preventing farmers from receiving early interventions.

Conclusions:

Farmers are exposed to various risk factors for CCVDs and are an occupation at risk for CCVDs. More studies are needed in the future to elucidate this relationship. This study lays the groundwork for future research to develop guidelines for approving CCVDs as occupational diseases among farmers.

Keywords: Agriculture; Cardiovascular diseases; Cerebrovascular disorders; Heart disease risk factors; Occupational diseases

GRAPHICAL ABSTRACT

INTRODUCTION

Industrialization has rapidly progressed in Korea, leading to long working hours, night shift work, and various work-related burdens. Thus, cardio-cerebrovascular disease (CCVD) is recognized as an occupational disease in Korea when a sufficient work-related burden is confirmed [1]. In Korea, most workers (excluding those in occupations protected by other insurance, such as civil servants, military personnel, and teachers) are covered for various diseases, including CCVDs, under the Industrial Accident Compensation Insurance Act (IACIA). The compensation paid to workers for occupational CCVDs has been increasing annually; in 2021, it reached 581.15 billion Korean won [2]. However, agriculture, forestry, and fishing are exempt from this law under certain conditions. These sectors are not protected if the activity involves fewer than 5 people or is classified as a family employment activity. Therefore, the agricultural sector is in a blind spot, outside the scope of protection of the social security system known as industrial accident insurance. Traditionally, small-scale farmers and their families have been considered business owners or self-employed rather than workers. As a result, farmers who are both business owners and workers have faced high insurance premiums to obtain IACIA coverage. It is estimated that only about 2-3% of the farm population is covered by the IACIA [3]. Farmers with optional rather than mandatory insurance face several challenges in voluntarily joining the IACIA due to poor economic conditions. Farmer Safety Insurance (FSI) was implemented in 1996 to address these issues through government support. However, FSI is optional and not mandatory, resulting in a relatively low subscription rate (64.8% in 2019), and it primarily covers accidents rather than diseases such as CCVDs. Additionally, there are challenges such as a narrow scope of coverage and the fact that FSI is managed by private financial institutions rather than the government. Despite the establishment of the FSI system, many farmers hesitate to join due to poor economic conditions [4,5]. This scoping review aimed to describe and summarize the scientific literature on the risk factors for CCVDs in farmers. Additionally, we reviewed studies that describe the differences in the incidence, prevalence, and mortality rates of CCVDs among farmers compared to the general population or other occupations. Through this review, we intend to provide evidence to support the expansion of insurance coverage for CCVDs in farmers.

METHODS

Steps for Conducting a Scoping Review

A scoping review is a type of review that rapidly identifies the main concepts, resources, and evidence within a specific field of study. This study was conducted using the scoping review methodology [6,7].

Identifying the Research Question and Purposes

In Korea, the standards for occupational compensation for CCVDs among farmers are inadequate. Currently, most occupational CCVDs in this group are not covered by insurance. As an initial step toward establishing compensation standards for CCVDs in farmers, we plan to conduct a scoping review addressing the following questions: (1) What is the status of approval of CCVDs as occupational diseases among farmers in Korea? (Figures 1 and 2, Table 1). (2) Is the incidence of CCVD among farmers higher than that in the general population? (Table 2). (3) What are the occupational risk factors for CCVD? (Table 3). (4) Which of these risk factors can farmers be exposed to? (Supplemental Material 1).

Figure. 1.

Number of diseases and deaths of occupational cardio-cerebrovascular diseases under the Industrial Accident Compensation Insurance in Korea.

Figure. 2.

Total amount paid of occupational cardio-cerebrovascular diseases under the Industrial Accident Compensation Insurance in Korea (unit: 100 million Korean won).

Table 1.

Approval status of cardio-cerebrovascular diseases (CCVDs) as occupational diseases among farmers according to the Industrial Accident Compensation Insurance Act in Korea

Table 2.

Published studies on the incidence, prevalence, and/or mortality rate of CCVDs in farmers

Table 3.

Occupational risk factors and exposure status for CCVDs in farmers

Identifying a Team of Experts and Consulting

A scoping review was conducted by a team comprising 5 researchers and 6 experts, totaling eleven members. The team employed a specific search methodology, wherein the 5 researchers examined a broad spectrum of literature and organized overlapping content to draft this review paper. The findings were discussed over 4 research meetings and were further presented at a professional conference (23rd Asian Congress on Occupational Health). Feedback received from experts at these forums was incorporated to strengthen the results.

Searching and Selecting Relevant Studies

Three researchers conducted a review of the risk factors, incidence, prevalence, and mortality associated with CCVDs in farmers using the PubMed and Google Scholar databases. The primary search methods were standardized, with additional searches performed at the discretion of individual researchers if initial results were insufficient. The search terms for cardiovascular diseases included: (“cardiovascular diseases” OR “CVD” OR “myocardial infarction” OR “AMI” OR “angina” OR “ischemic heart disease” OR “IHD” OR “aortic dissection” OR “aortic aneurysm” OR “atrial fibrillation” OR “cardiac arrhythmia” OR “heart failure” OR “tachycardia”) AND (“agriculture” OR “farmer”). The search terms used for cerebrovascular disorders were as follows: (“subarachnoid hemorrhage” OR “SAH” OR “cerebral hemorrhage” OR “ICH” OR “cerebral infarction” OR “intracranial hemorrhage” OR “intracranial arteriosclerosis” OR “intracranial aneurysm”) AND (“agriculture” OR “farmer”). Two researchers investigated the risk factors, incidence, prevalence, and mortality of CCVDs in farmers based on published textbooks and reports. We also received and analyzed related research reports from researchers affiliated with the National Institute of Agricultural Sciences [8].

Charting, Collating, Summarizing, and Reporting the Results

We presented 4 tables corresponding to the questions of this study, as well as 2 figures showing that although the number and amount of compensation for occupational CCVDs is increasing in Korea, farmers are being excluded. Through this review, we intend to provide evidence for expanding the scope of insurance coverage for CCVDs in farmers.

Ethics Statement

This study was a scoping review of published literature and did not involve direct human subjects research. As such, it did not require approval from an institutional review board. All data analyzed were from previously published studies that had already undergone ethical review and approval as part of their original publication process. No additional ethical considerations were required for the conduct of this secondary analysis of publicly available data.

RESULTS

Table 1 displays the number of farmers affiliated with IACIA, which includes agricultural corporations or businesses with 5 or more employees, alongside the number of CCVDs recognized as work-related diseases. In 2021, 78 999 farmers from 20 302 agricultural businesses enrolled in IACIA. Of these, 6 farmers were officially recognized as having occupational CCVDs, and 2 of them died [9]. The IACIA subscription rate of farmers remains unchanged (Table 1); however, FSI, a type of private insurance, does not classify CCVDs as an occupational disease within its terms and conditions. Consequently, the cases of insurance coverage for farmers’ CCVDs represent only a minor fraction of the total compensations at IACIA, and finding such compensation cases at FSI was challenging.

Although inconsistent, several studies analyzing the incidence, prevalence, and mortality rate of CCVDs among farmers have indicated high rates in this demographic. Specifically, among females, the age-standardized prevalence rate of circulatory system diseases (International Classification of Diseases-10th revision: I00-I99) was higher in farmers (24 498.8 per 100 000) compared to non-farmers (23 957.1 per 100 000) across all years, according to data from Korea’s National Health Insurance (KNHI). The KNHI also offers insurance premium reductions for farmers and fishermen, which helps distinguish between farmers and non-farmers [10]. In another study using the KNHI database, the age-adjusted incidence per 1000 person-years was significantly higher in farmers for both myocardial infarction (0.766 vs. 0.585) and stroke (0.559 vs. 0.321) [11]. In a population census study in Spain, the excess mortality rate of cardiovascular disease among farmers was 22.3% higher [12]. The research results from several countries are also included in Table 2 [10-17].

Various chemicals, heavy metals, dust, radiation, abnormal temperatures, vibration, noise, physical labor, mental stress, long working hours, and night shift work are recognized as occupational risk factors for CCVDs (Supplemental Material 1). A literature review was conducted on the exposure levels of farmers to these occupational risk factors for CCVDs, summarizing the high exposure level values. The findings from previous studies indicate that farming is a high-risk occupation for CCVDs. The associated risk factors include stress from long working hours, night shifts, limited holidays, and intense physical labor; physical factors such as noise, cold, high temperatures, humidity, and vibration; exposure to hazardous gases including diesel exhaust, carbon monoxide, hydrogen sulfide, carbon disulfide, nitrogen oxides, and polycyclic aromatic hydrocarbons; pesticides; and dusts like particulate matter, silica, and organic dust. Additionally, farmers face exposure to hypoxic environments and job-related stress (Table 3) [18-32]. Focusing on temperature-related risk factors, an increase of 1°C in temperature correlates with a 2.1% increase in cardiovascular diseases-related mortality. During high-intensity heatwaves, this mortality risk can surge by 18.9%. The pooled relative risks for extreme cold (first percentile of temperature) and cold (10th percentile of temperature) over lags of 0-14 days are 1.39 and 1.11, respectively, compared to the 25th percentile. Similarly, the relative risks of stroke mortality are 1.06 for extremely hot temperatures and 1.14 for hot temperatures, compared to the 75th percentile of temperature [31,32]. This review confirms that farmers are potentially exposed to a high level of various CCVD risk factors.

DISCUSSION

In this study, we reviewed research on the differences in incidence, prevalence, and mortality rates of CCVDs among farmers compared to the general population and other occupations. We also explored the exposure of farmers to various CCVD risk factors. The findings from multiple studies indicate that farming is a high-risk occupation for CCVDs. The associated risk factors include stress due to long working hours, night shifts, limited holidays, and intense physical labor; physical factors such as noise, extreme temperatures, humidity, and vibration; exposure to hazardous gases including diesel exhaust, carbon monoxide, hydrogen sulfide, carbon disulfide, nitrogen oxides, and polycyclic aromatic hydrocarbons; and contact with pesticides and dusts like particulate matter, silica, and organic dust. Additionally, exposure to hypoxic environments and job-related stress are significant concerns. Social isolation and the lack of accessible medical facilities hinder early intervention for farmers, further elevating their risk.

Agriculture, construction, and mining rank among the top 3 most hazardous occupations. According to the International Labor Organization, approximately 170 000 agricultural workers globally lose their lives each year due to workplace accidents. The rate of fatal accidents in agriculture is twice that of other industries, with an additional 40 000 agricultural workers dying annually from pesticide exposure. Sustainable agriculture practices are essential not only for food security but also for human health and environmental well-being [33,34]. To support societal development and ensure its survival, it is imperative to establish a safe working environment for farmers.

In the 1970s, the Korea was predominantly an agricultural nation, with 14.422 million people, or 44.7% of the total population, engaged in agriculture. By 2021, this number had decreased to 2.215 million, representing just 4.3% of the population [35]. The country’s economic development plan promoted industrialization, leading to a migration from rural areas to urban centers. This shift not only delayed agricultural development due to technical and financial limitations but also broadened the scope of compensation for injuries and diseases among general workers through the Occupational Safety and Health Act and the IACIA (Figures 1 and 2). However, the development of protective systems for farmers has lagged behind. For instance, while general workers can receive approval for CCVDs as an occupational disease, farmers face significant challenges in obtaining similar recognition.

Korea is experiencing a demographic shift, with a rapidly increasing proportion of its population aged 65 years and older, presenting challenges for the agricultural sector. In 2000, over 7% of the population in Korea was elderly, a figure that rose to over 14% by 2017. As of July 2023, this proportion has reached 18.5% and is expected to exceed 20% by 2025, marking the transition to a post-aged society [36]. Rural areas are aging more rapidly than urban ones [37], and the farming population is not only shrinking but also aging, significantly heightening the risk of CCVDs. In Korea, the majority of farmers operate small family units comprising fewer than 5 people, serving both as laborers and business owners [3]. Thus, the incidence of CCVDs among these farm members directly results in a decline in agricultural productivity, effectively leading to the loss of an agricultural business. This situation contributes to long-term income disparities between farmers and non-farmers. The aging farmer community thus represents a major socioeconomic burden on farms and will play a crucial role in determining the future of agriculture in Korea. To address this, comprehensive primary, secondary, and tertiary preventive measures for CCVDs among farmers are essential.

Advances in agricultural technology can help address these challenges by enhancing productivity and efficiency through modern technologies and automation, such as artificial intelligence and robots. The adoption of precision agriculture, smart farm technologies, and sustainable farming practices represents key strategies for modernizing agriculture. Each year, more than 15 000 farmers and their families return to farming in Korea, with the number reaching 16 906 in 2022 and peaking at 20 559 in 2016 [38]. Given the global economic challenges and the weaponization of food, the agricultural output of each country has become crucial to societal well-being. Implementing smart farm technologies can lead to more efficient resource use and increased productivity, thus boosting agricultural competitiveness. Furthermore, the development of innovative agricultural technologies is vital for tackling the issues posed by climate change and population growth. In this era of agricultural innovation, a national-level social safety net is necessary to keep the population engaged in agriculture, necessitating more effective insurance for farmers.

This study has several limitations. Primarily, it is a scoping review rather than a systematic review, serving to organize and catalog related research without offering conclusive evidence on whether farmers have a higher or lower risk of CCVDs than the general population. As a result, this study only suggests potential associations and carries a risk of publication bias by potentially excluding studies that report low-risk or non-significant findings. In Korea, criteria for determining the work-relatedness of workers’ CCVDs have been established and are continuously refined by the IACIA [1]. However, these standards are not directly applicable to self-employed farmers. Therefore, it is crucial to carefully consider their applicability when evaluating the work-relatedness of CCVDs in farmers.

This study is significant as it explores the association between CCVDs and farming, a topic that has previously received limited attention. Through our research, we have identified multiple studies indicating that farmers are exposed to various risk factors for CCVD, categorizing them as an occupation at risk. Future studies should aim to further elucidate this relationship through systematic reviews of specific diseases and risk factors, the development of objective methods for evaluating farmers’ exposure to these risk factors, or the analysis of big data from health insurance records. Looking ahead, based on the findings of this study and the broader social consensus, several issues warrant consideration: (1) Should it become mandatory for farmers to join IACIA? (2) Should CCVDs be added to the list of diseases covered by FSI? (3) What should the approval process look like if CCVDs are included in the FSI disease list? Although the process of professional investigation and committee rulings such as IACIA is highly valid, it can be time-consuming and socioeconomically expensive. Automatic approval under certain conditions would enable a quicker process and reduce the socioeconomic costs associated with investigations and decisions. However, it may not account for the unique aspects of each case, and if the standards are set too high or too low, accurate judgments may be compromised.

CONCLUSION

Workers’ rights and social safety nets have rapidly developed in Korea. However, the development of systems to protect farmers has lagged, positioning them within the vulnerable occupation group. The modernization of agriculture is essential for national development, necessitating the establishment of systems to safeguard farmers. This study lays the groundwork for future research on guidelines for occupational disease approval for CCVDs among farmers.

Supplemental Materials

Supplemental material is available at https://doi.org/10.3961/jpmph.24.302.

Supplementary Material 1.

Occupational risk factors for cardio-cerebrovascular diseases

jpmph-24-302-Supplementary-Material-1.docx

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

This study was supported by a grant from the National Institute of Agricultural Sciences, Rural Development Administration, Republic of Korea (No. RS-2022-RD010387).

Author Contributions

Conceptualization: Song H, Park WJ, Park KS. Data curation: Kim H, Cho S, Jung S, Jung I. Formal analysis: Song H, Jung W. Funding acquisition: Jung W, Park KS. Methodology: Yoon SY. Project administration: Park KS, Song H, Yoo SJ. Writing – original draft: Kim H, Jung S, Jung I, Yoon SY. Writing – review & editing: Park WJ, Jung W, Cho S, Song H, Park KS, Sung JH, Yoo SJ.

Acknowledgements

We would like to thank all the researchers who participated in the project for developing Korean farmers’ guidelines for work-related diseases and customized health management systems. We are also grateful to members of the National Institute of Agricultural Sciences, Rural Development Administration for their assistance in the research.

References

1. Kim UJ, Choi WJ, Kang SK, Lee W, Ham S, Lee J, et al. Standards for recognition and approval rate of occupational cerebrocardiovascular diseases in Korea. Ann Occup Environ Med 2022;34e30. https://doi.org/10.35371/aoem.2022.34.e30.

2. Korean Statistical Information System (KOSIS). Insurance benefit payment status by disease; 2022 [cited 2024 May 15]. Available from: https://kosis.kr/statHtml/statHtml.do?orgId=118&tblId=TX_11811_A099&vw_cd=MT_OTITLE&list_id=118_11811&scrId=&seqNo=&lang_mode=ko&obj_var_id=&itm_id=&conn_path=MT_OTITLE&path=%252FstatisticsList%252FstatisticsListIndex.do (Korean).

3. Song HS. High-risk occupation; farmers. In: Kang SG, editor. Occupational and environmental medicine, revised edition. Seoul: Gyechuk; 2022, p. 667-670 (Korean).

4. Ministry of Agriculture, Food and Rural Affairs (MAFAR). Farmer Safety Insurance project implementation; 2022 [cited 2024 May 15]. https://www.mafra.go.kr/home/5248/subview.do (Korean).

5. Korea Rural Economic Institute. Agricultural outlook 2021. Agricultural sector risks: how to manage them?; 2021 [cited 2024 May 15]. Available from: https://www.krei.re.kr/krei//researchReportView.do?key=67&pageType=010101&biblioId=527072&pageUnit=10&searchCnd=all&searchKrwd=&pageIndex=363 (Korean).

6. Mak S, Thomas A. Steps for conducting a scoping review. J Grad Med Educ 2022;14(5):565–567. https://doi.org/10.4300/JGME-D-22-00621.1.

7. Seo HJ, Kim SY. What is scoping review? J Health Technol Assess 2018;6(1):16–21. (Korean). https://doi.org/10.34161/johta.2018.6.1.003.

8. National Institute of Agricultural Sciences. Major research achievements; 2022 [cited 2024 May 15]. Available from: https://www.naas.go.kr/02_research/Research_List.do?menu_code=2&tg=0&mmode=11 (Korean).

9. Ministry of Employment and Labor. Analysis of work-related injuries and illnesses in 2022; 2023 [cited 2024 May 15]. Available from: https://www.moel.go.kr/policy/policydata/view.do?bbs_seq=20231201612 (Korean).

10. Kang DY. A comparative study on disease prevalence between farmers and non-farmers using National Health Insurance Service data. Wonju: Yonsei University; 2022 (Korean).

11. Lee S, Lee H, Kim HS, Koh SB. Incidence, risk factors, and prediction of myocardial infarction and stroke in farmers: a Korean nationwide population-based study. J Prev Med Public Health 2020;53(5):313–322. https://doi.org/10.3961/jpmph.20.156.

12. Zhao G, Regidor E, Astasio P, Ortega P, Barrio G, Ronda E. Cardiovascular disease, digestive diseases, traffic accidents, and suicides: leading causes of death responsible for excess mortality in farmers in Spain. J Occup Environ Med 2019;61(5):e212–e216. https://doi.org/10.1097/JOM.0000000000001571.

13. Lee HE, Kim HR, Chung YK, Kang SK, Kim EA. Mortality rates by occupation in Korea: a nationwide, 13-year follow-up study. Occup Environ Med 2016;73(5):329–335. https://doi.org/10.1136/oemed-2015-103192.

14. Wada K, Eguchi H, Prieto-Merino D. Differences in stroke and ischemic heart disease mortality by occupation and industry among Japanese working-aged men. SSM Popul Health 2016;2:745–749. https://doi.org/10.1016/j.ssmph.2016.10.004.

15. Robinson CF, Walker JT, Sweeney MH, Shen R, Calvert GM, Schumacher PK, et al. Overview of the National Occupational Mortality Surveillance (NOMS) system: leukemia and acute myocardial infarction risk by industry and occupation in 30 US states 1985-1999, 2003-2004, and 2007. Am J Ind Med 2015;58(2):123–137. https://doi.org/10.1002/ajim.22408.

16. Lee WJ, Cha ES, Moon EK. Disease prevalence and mortality among agricultural workers in Korea. J Korean Med Sci 2010;25(Suppl):S112–S118. https://doi.org/10.3346/jkms.2010.25.S.S112.

17. Sjögren B, Weiner J, Larsson K. Ischaemic heart disease among livestock and agricultural workers. Occup Environ Med 2003;60(8)e1. https://doi.org/10.1136/oem.60.8.e1.

18. Sun D, Liu C, Ding Y, Yu C, Guo Y, Sun D, et al. Long-term exposure to ambient PM2·5, active commuting, and farming activity and cardiovascular disease risk in adults in China: a prospective cohort study. Lancet Planet Health 2023;7(4):e304–e312. https://doi.org/10.1016/S2542-5196(23)00047-5.

19. Weichenthal S, Villeneuve PJ, Burnett RT, van Donkelaar A, Martin RV, Jones RR, et al. Long-term exposure to fine particulate matter: association with nonaccidental and cardiovascular mortality in the agricultural health study cohort. Environ Health Perspect 2014;122:609–615. https://doi.org/10.1289/ehp.1307277.

20. Rural Development Administration. Measures to improve agricultural hazards. Jeonju: Rural Development Administration; 2013 (Korean).

21. Shin HS, Roh YM, Seo JW. The relationship between accessibility to local cardio-cerebrovascular disease centers and mortality ratio. Health Soc Welf Rev 2023;43(1):85–100. (Korean). https://doi.org/10.15709/hswr.2023.43.1.85.

22. Kim M, An D, Lim J. Urban-rural gap of healthcare and cultural service accessibility in South Korea. In: Batabyal AA, Higano Y, Nijkamp P, editors. Rural–urban dichotomies and spatial development in Asia 2021. Singapore: Springer; 2021, p. 91-126.

23. National Institute of Agricultural Sciences. Measurement and abatement of noise level of major agricultural machinery. Jeonju: Rural Development Administration; 2019 (Korean).

24. Kwon SC, Lee SJ, Jeong M. Work-related hazards among farmers. J Korean Med Assoc 2012;55(11):1046–1053. (Koran). https://doi.org/10.5124/jkma.2012.55.11.1046.

25. Kumar D, Sinha SN, Rajendra S, Sharma K. Assessing farmer’s exposure to pesticides and the risk for non-communicable diseases: a biomonitoring study. Sci Total Environ 2023;891:164429. https://doi.org/10.1016/j.scitotenv.2023.164429.

26. Dayton SB, Sandler DP, Blair A, Alavanja M, Beane Freeman LE, Hoppin JA. Pesticide use and myocardial infarction incidence among farm women in the agricultural health study. J Occup Environ Med 2010;52(7):693–697. https://doi.org/10.1097/JOM.0b013e3181e66d25.

27. Berg ZK, Rodriguez B, Davis J, Katz AR, Cooney RV, Masaki K. Association between occupational exposure to pesticides and cardiovascular disease incidence: the Kuakini Honolulu Heart Program. J Am Heart Assoc 2019;8(19)e012569. https://doi.org/10.1161/JAHA.119.012569.

28. National Institute of Agricultural Sciences. Occupational diseases of farmers. Jeonju: Rural Development Administration; 2021 (Korean).

29. Roh S. Work-related diseases of agricultural workers in South Korea. J Korean Med Assoc 2012;55(11):1063–1069. (Korean). https://doi.org/10.5124/jkma.2012.55.11.1063.

30. Daghagh Yazd S, Wheeler SA, Zuo A. Key risk factors affecting farmers’ mental health: a systematic review. Int J Environ Res Public Health 2019;16(23):4849. https://doi.org/10.3390/ijerph16234849.

31. Chen R, Wang C, Meng X, Chen H, Thach TQ, Wong CM, et al. Both low and high temperature may increase the risk of stroke mortality. Neurology 2013;81(12):1064–1070. https://doi.org/10.1212/WNL.0b013e3182a4a43c.

32. Liu J, Varghese BM, Hansen A, Zhang Y, Driscoll T, Morgan G, et al. Heat exposure and cardiovascular health outcomes: a systematic review and meta-analysis. Lancet Planet Health 2022;6(6):e484–e495. https://doi.org/10.1016/S2542-5196(22)00117-6.

33. Food Information Statistics System. Key statistics for Agriculture, Food and Rural Affairs; 2023 [cited 2024 May 15]. Available from: https://www.atfis.or.kr/home/board/FB0028.do?act=read&subSkinYn=N&bpoId=4603&bcaId=0&pageIndex=1 (Korean).

34. International Labour Organization (ILO). Agriculture: a hazardous work; 2015 [cited 2024 May 15]. Available from: https://www.ilo.org/resource/agriculture-hazardous-work-0.

35. International Labour Organization (ILO). Facts on agriculture; 2003 [cited 2024 May 15]. Available from: https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/documents/publication/wcms_067555.pdf.

36. Korean Statistical Information System (KOSIS). Resident registration population; 2023 [cited 2024 May 15]. Available from: https://kosis.kr/statisticsList/statisticsListIndex.do?vwcd=MT_ZTITLE&menuId=M_01_01 (Korean).

37. Kim KW, Kim OS. Super aging in South Korea unstoppable but mitigatable: a sub-national scale population projection for best policy planning. Spat Demogr 2020;8(2):155–173. https://doi.org/10.1007/s40980-020-00061-8.

38. Korean Statistical Information System (KOSIS). Number of people who moved to rural areas; 2022 [cited 2024 May 15]. Available from: https://kosis.kr/statHtml/statHtml.do?orgId=101&tblId=DT_1A02001&vw_cd=MT_ZTITLE&list_id=K1_6&scrId=&seqNo=&lang_mode=ko&obj_var_id=&itm_id=&conn_path=MT_ZTITLE&path=%252FstatisticsList%252FstatisticsListIndex.do (Korean).

Article information Continued

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Year	No. of places of agricultural business¹	No. of farm workers¹	No. of people in whom occupational disease was approved (death)	No. of CCVDs approved for occupational diseases (death)	Incidence rate of occupational CCVDs (%)
2021	20 302	78 999	38 (2)	6 (2)	0.008
2020	19 382	78 940	46 (3)	5 (3)	0.006
2019	18 785	79 482	43 (3)	9 (2)	0.011
2018	17 449	83 540	45 (4)	4 (3)	0.005
2017	15 452	76 033	26 (1)	0 (0)	0.000
2016	14 954	80 990	28 (1)	2 (1)	0.002
2015	12 350	68 697	28 (2)	3 (2)	0.004
2014	10 871	61 681	26 (2)	2 (1)	0.003

Study	Country	Epidemiological indicator	Database	Summary
Kang et al., 2022 [10]	Korea	SPR	National Health Insurance Sharing Service	Among females, the SPR of diseases of the circulatory system was higher in farmers (24 498.8 per 100 000) than in non-farmers (23 957.1 per 100 000)
Lee et al., 2020 [11]	Korea	SIR	National Health Insurance Service	Age-adjusted incidence per 1000 person-years; Farmers: 0.766 for MI and and 0.559 for stroke; Controls: 0.585 for MI and 0.321 for stroke; Farmers had a higher age-adjusted incidence of MI and stroke
Zhao et al., 2019 [12]	Spain	Excessive mortality rate	Population census	There was an excess mortality of 22.3% from cardiovascular diseases in farmers
Lee et al., 2016 [13]	Korea	SMR	National Employment Insurance	The highest SMR was for agricultural, forestry, and ﬁshery workers; The SMRs per 100 000 were high for IHD (25.8), cerebrovascular disease (42.9), and diseases of the circulatory system in males and IHD in females (7.1)
Wada et al., 2016 [14]	Japan	SMR	Ministry of Health, Labour, and Welfare of Japan	The relative risks for stroke and IHD mortality were 2.75 (95% CI, 1.96 to 3.87) and 2.55 (95% CI, 1.90 to 3.42) in the agriculture industry; The reference group was sales
Robinson et al., 2015 [15]	US	SMR	NIOSH National Occupational Mortality Surveillance	After adjusting for smoking, the SMR of acute MI was higher in farmers, agricultural worker occupations, and in the wholesale farm supplies, agricultural chemicals, and agricultural crop industries
Lee et al., 2010 [16]	Korea	SPR	Korean National Health and Nutrition Examination Survey	No significant differences in CCVDs prevalence were identified among agricultural workers
Sjögren et al., 2003 [17]	Sweden	SMR	Swedish National Censuses	Livestock workers had a slightly higher SMR for IHD than all gainfully employed; The SMR for male workers was 1.06 (95% CI, 0.95 to 1.18); The SMR for female workers was 1.10 (95% CI, 0.98 to 1.23); Agricultural workers had lower SMRs

Table 3.

Occupational risk factors and exposure status for CCVDs in farmers

Risk factors	Hazards	Detailed description¹	Reference
Air pollution	PM	Increased the cerebrovascular disease risk (HR, 1.18; 95% CI, 1.09 to 1.28) among farmers with exposure to annual average PM_2.5 concentrations of 54 μg/m³ or greater; Increased risk of cardiovascular mortality (HR, 1.87; 95% CI, 1.04 to 3.36) among male farmers	[18,19]
Chemicals	Volatile organic compounds	Using a powered sprayer inside a greenhouse: EL 6.0-19.4 mg/m³	[20]
Dust	PM	Rice straw input work: EL 26.34 mg/m³	[20]
Gas	Carbon monoxide	Using a powered sprayer inside a greenhouse: EL 4.6-352.0 ppm	[20]
Medical vulnerability	Difficulty in accessing medical institutions	Accessibility to local CCVD centers: the average adjusted mortality rate in vulnerable areas significantly higher at 1.51±0.48 for CVD and 1.54±0.21 for cerebrovascular disease (p<0.05).	[21,22]
Noise	Time-weighted average, 8 hr	Tractor without cabin: EL 95.0±3.3 dB(A); Harvesters, grain dryers, brush mowers, or chainsaws: EL≥100 dB(A)	[23,24]
Pesticides	Farmers with experience using pesticides	Acute pesticide poisoning experience rate: 7.0-86.7%; Pesticide concentrations ranged from 0.20 to 12.12 ng/mL in the blood; Pesticides (chlorpyrifos, coumaphos, carbofuran, metalaxyl, pendimethalin, and trifluralin) pesticides evaluated were significantly associated with MI, which all had odds ratios >1.7 among female farmers; In a cohort of 7557 Japanese-Americans, a positive association was observed between CVD incidence and high levels of pesticide exposure (HR, 1.46; p = 0.009)	[25-27]
Physical load	Musculoskeletal burden factors	Prevalence of occupational musculoskeletal disorders: total 4.4%; male 3.7%; female: 5.2%; Rate of complaints of musculoskeletal symptoms: 81.9%; Farmers vs. non-farmers: 72.4 vs 49.8%; Prevalence of physician-diagnosed musculoskeletal disorders: farmers (72.4%) and non-farmers (49.8%)	[28,29]
Stress, mental	Financial difficulties, pesticide exposure, climate variabilities/ drought, and poor physical health/past injuries	A systematic review of 167 articles on farmers’ mental health: psychological health disturbances were more common in farmers and farm workers; Outcomes included loss of self-esteem, withdrawal from social/community activity, relationship breakdown, hopelessness, nervousness, inability to function in occupational roles, feelings of suffocation, fatigue, insomnia, violence involving loss of control, and substance abuse	[30]
Temperature	Cold and hot	Both low and high temperature increase the risk of stroke mortality; Heatwaves and global warming are significant risk factors for CVD; Working inside a greenhouse: EL temperature 50°C, humidity exceeds 90%, and the temperature difference between inside and outside is 23°C	[24,31,32]
Vibration	Frequency weighted acceleration, 8 hr	Agricultural machinery causes whole-body and local vibrations; Rice harvesting using a combine: EL 4.07 m/s2	[20,24]
Working hours, overwork	Long working hours	The daily working hours of Korean farmers are 10 hr 35 min and 11 hr 11 min for males and females respectively, which is one of the highest in the world	[29]

CCVD, cardio-cerebrovascular disease; PM, particulate matter; PM_2.5, particulate matter with a diameter of less than 2.5 μg/m³; HR, hazard ratio; CI, confidence interval; CVD, cardiovascular disease; EL, exposure levels; MI, myocardial infarction.

Among various tasks, tasks with a high level of exposure are selected and described.