TABLE OF CONTENT

Table of Content ................................................................................................................................................. 1

Preface ................................................................................................................................................................ 3

Pesticides and occupational health ................................................................................................................. 3

Pesticides ........................................................................................................................................................ 4

Pesticide hazard list ........................................................................................................................................ 4

Uganda and pesticides .................................................................................................................................... 5

Search strategy ............................................................................................................................................... 6

The framework of the project ......................................................................................................................... 6

Article ................................................................................................................................................................. 8

Pesticide use and how it affects the health of small scale farmers in Uganda: a cross-sectional study ......... 9

Abstract .......................................................................................................................................................... 9

Background .................................................................................................................................................. 10

Method ......................................................................................................................................................... 12

Study design ............................................................................................................................................. 12

Setting ....................................................................................................................................................... 12

Participants ............................................................................................................................................... 12

Standardized interviews ........................................................................................................................... 13

Exposure variables ................................................................................................................................... 14

Outcome variables .................................................................................................................................... 14

Potential confounders ............................................................................................................................... 15

Statistical method ..................................................................................................................................... 15

Missing data ............................................................................................................................................. 15

Ethical considerations ............................................................................................................................... 16

Results .......................................................................................................................................................... 17

Participants ............................................................................................................................................... 17

Crops ........................................................................................................................................................ 17

Pesticides .................................................................................................................................................. 17

Symptoms ................................................................................................................................................. 18

Knowledge ............................................................................................................................................... 18

Practice and attitude ................................................................................................................................. 18

Association between symptoms and pesticide usage ............................................................................... 18

Supplementary analyses ........................................................................................................................... 20

Discussion .................................................................................................................................................... 21

Conclusion .................................................................................................................................................... 24

Tables for Pesticide use by Ugandan small scale farmers: a cross sectional study. ..................................... 25

Table 1 ...................................................................................................................................................... 25

2

Table 2 ...................................................................................................................................................... 26

Figure 1 .................................................................................................................................................... 27

Table 3 ...................................................................................................................................................... 28

Figure 2 .................................................................................................................................................... 29

Figure 3 .................................................................................................................................................... 30

Table 4 ...................................................................................................................................................... 31

Table 5 ...................................................................................................................................................... 32

Table 6 ...................................................................................................................................................... 34

Table 7 ...................................................................................................................................................... 35

Table 8 ...................................................................................................................................................... 36

Reference List .................................................................................................................................................. 37

Appendix .......................................................................................................................................................... 40

Appendix 1 ............................................................................................................................................... 41

Appendix 2 ............................................................................................................................................... 47

Appendix 3 ............................................................................................................................................... 56

3

PREFACE

PESTICIDES AND OCCUPATIONAL HEALTH

The World Health Organization has estimated a worldwide incidence of 3.000.000 cases of acute and

severe poisoning. 300.000 of these cases are fatal. Nearly all of these deaths occurred in developing

countries. The effortless availability of highly toxic pesticides in farmers’ homes has made pesticides the

most common remedy for suicide [1-3].

Approximately one third of the deaths are due to occupational hazards, as the extensive use of pesticides

exposes farmers to both long term and acute occupational health problems [4, 5]. In addition to this comes

an even greater number of unreported cases of mild-to-moderate intoxication [4, 6, 7].

Medical treatment in the rural areas is difficult since few medical resources are available. Case fatality

rates for pesticide poisoning are often high in developing countries due to lack of the necessary

equipment, medicine and sufficient educated medical staff [5]. The necessity of ensuring agricultural

production and food security in low-income countries while also protecting the population against health

impacts following exposure to pesticides has emerged as a major global public health problem [5].

4

PESTICIDES

Pesticides are poisonous chemicals intended for preventing, destroying or controlling pests during the

production, processing, transporting and marketing of food. This includes vectors of human and animal

disease, unwanted species of plants or animals causing harm during the production, processing, storage,

transport or marketing of food, wood or animal feedstuffs [8]. They are mainly used in agriculture, but

can also be used in health campaigns; e.g. to eradicate vector diseases such as yellow fever and malaria.

Approximately 1.500 active ingredients have been registered as pesticides, and 50.000 commercial

pesticides are registered for use. Because of the enormous number of commercial formulations, pesticides

are available in almost any community [9].

The health effects of pesticides can be divided into acute poisoning and chronic effects. Acute pesticide

poisoning is any illness or health affects appearing shortly after a single or multiple doses of pesticide.

This includes a wide range of reactions in different target organs like neurological, dermal or respiratory.

Chronic poisoning occurs gradually after prolonged exposure to pesticides. Increasing development of

cancer and reproductive abnormalities have been seen in people who have gone through a long-term

exposure to pesticides. This study will focus on the short-term effects of pesticide poisoning [6, 7, 10,

11].

PESTICIDE HAZARD LIST

In an effort to accommodate the improper use of pesticides, the World Health Organisation (WHO) has

made an Essential Drug List (EDL), classifying the pesticides into five groups according to their health

hazards; Ia = Extremely hazardous; Ib = Highly hazardous; II = Moderately hazardous; III = slightly

hazardous; U = Unlikely to present acute hazard in normal use. The hazards described are the acute risks

to one’s health (i.e. the risk that emerges from a single exposure or multiple exposures over a relatively

short period of time). The EDL is primarily based on oral and dermal danger [12]. WHO accentuates the

importance of products classified with a high degree of hazard, especially Ia and Ib, being labelled

correctly. These labels should indicate the high degree of hazard by skull and crossbones pictures and,

furthermore, having colour coding and phrases saying ―toxic‖ or ―poison‖. WHO also accentuates the

importance of labels being formulated in the respective local language. The presentation of the symbol

and phrase should thus provide the user with sufficient knowledge when choosing a pesticide [12]. Some

of the most dangerous classes of pesticides are chlorinated hydrocarbons, organophosphates and

dithiocarbamate pesticides, due to a high index of toxicity [4]. Numerous studies have explored the health

effects of organophosphate in developing countries, and have found an increased risk of pesticide

poisoning [13-15].

The Food and Agriculture Organisation of the United Nations (FAO) indicates that developing countries,

rather than the least developed nations, consumed the majority of reported organophosphates and

5

dithiocarbamates. This finding is not surprising since pesticides are expensive, and older and cheaper

pesticides becomes preferred alternatives to the newer and often safer ones [7].

The pesticide industry is an important player in this problem. The use and selling of pesticides has

become a billion dollar business for many national and international agents. The industry states that they

are fully supporting police restricted use of pesticides. However, the industry’s interests in profit makes

them willing to sell pesticides in developing countries that are already banned in industrialized countries

[5, 11, 16]. This results in products of the most toxic classes, like the ones mentioned above, being sold to

farmers in developing countries [17]. Moreover, if the pesticide industry keeps paying sales persons on a

commission basis, it is unlikely that the dealers will encourage the farmers to use fewer pesticides [4].

The Food and Agriculture Organisation of the United Nations (FAO) has, with its code of conduct, tried

to control the use of pesticides. This code of conduct was one of the first voluntary codes of conduct in

support of increased food security, while at the same time protecting human health and the environment.

The original FAO code of conduct was published in 1985, trying to encourage long-term efforts to

develop legislation, regulations, and infrastructure in order to enforce good pesticide practice [4, 8, 18].

FAO recommend Integrated Pest Management (IPM) to deal with the present pesticide issues. IPM can

reduce the use of agrochemicals, improve management and optimize ecosystem mechanisms for pest

control/soil enrichment, while also protecting both farmers and the environment [5]. Sustainability is

ensured by preparing the communities, building on available local resources and commitments, weaving

IPM into local community development planning processes and situating program concerns within the

local government system [4].

UGANDA AND PESTICIDES

Pesticide use in Africa accounts for 2-4% of the global pesticide market. This is in comparison to 30% in

North America and 16% in Asia [19, 20]. During the period 1993-94, FAO estimated that about 100,000

tons of pesticides were applied in developing countries, of which 20,000 tons were applied in Africa [8,

21]. In Africa, it is estimated that 11 million cases of pesticide overexposure occur annually [4].

Data gathering for the present study has taken place in Uganda. Uganda was one of the first countries to

be included in the Danish programme coordination identified in 1989 after the present Ugandan

government of the National Resistance Movement came to power in 1986. The BNI per capita is around

$350, and 31% live in extreme poverty. The size of the country is 241.551 km2, and the population

density is 123 persons/km2. The population size is about 28 million people, and the fertility rate is 6.5.

The life expectancy is 50 years. The most prevalent diseases are diarrhoea, airway tract infections,

malaria and HIV/AIDS. The illiteracy rate is 31%, and women account for 75% of this [22].

Agriculture plays a vital role of the Ugandan economy. It contributes to roughly 21% of the Gross

Domestic Product, and 85% of the population work either directly or indirectly in the agricultural sector

[21]. Uganda is currently reported to be among one of the countries in Africa with the lowest pesticide

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usage rate at only 17 kg/ha. However, with a growing population and thereby a growing crop production,

the import of pesticides are increasing. Exact numbers are difficult to acquire, but the import of pesticides

has risen with a factor 47 from 1980 to 2004. On top of that, it is estimated that at least another 25% of

the actual use is smuggled into the country over non-secured borders [21, 22].

SEARCH STRATEGY

To identify relevant articles in relation to pesticide use and poisoning in developing countries, literature

researches were done from September to November 2010, looking for relevant articles in both national

and international public health databases using SveMed+, Cochrane and PubMed.

The search strategy was the same in each database using ‖advanced search‖.

The main search words being used were ―pesticide‖ and ―poisoning‖ or ―toxic‖, all of them being

truncated. This resulted in only one relevant article in SveMed+.

Searching for reviews with the same words in Cochrane gave 34 hits. Many of these reviews dealt with

treatment of poisoning with organophosphate and were irrelevant for this study. Also, a lot of them were

references to the Cochrane Injuries Group (CIG). CIG is an editorial base with the purpose of preparing,

maintaining and promoting the accessibility of systematic reviews in the prevention field, including

poisoning. Eight reviews dealt with poisoning. However, all of these also concerned treatment of

pesticide poisoning which was not relevant for this study.

PubMed had 13437 hits. To narrow this number down, different combinations were made, with the

following words: ―Developing countries‖ or ―Africa‖ or ―Uganda‖. Also ―knowledge‖, ―practice‖ and

―attitude‖ were used, both combined and divided. Furthermore, the abbreviation ―KAP‖ was also used.

―Small-scale farmers‖, ―small scale farmers‖ and ―small holders‖ were used. All words were truncated

and combined with either AND or OR, according to the relevance. Relevant abstracts from the different

hits were read through, resulting in 48 articles with the criteria of being either; a cross sectional study,

looking at self-reported incident of pesticide poisoning, located in Africa or concerned with knowledge in

relation to pesticides.

Apart from these, relevant reports from the WHO or FAO were included.

THE FRAMEWORK OF THE PROJECT

The project is a collaboration between the Danish NGO, Dialogos and the Ugandan NGO, Uganda

National Association of Community and Occupational Health (UNACOH). UNACHO wishes to

promote a healthy and productive Ugandan population, and has been involved in several Ugandan

occupational health projects. Dialogos has worked with occupational health in developing countries since

1993. It wants to assist developing countries in their self-chosen pathway away from poverty.

The present project is called ―Pesticide use, health and environment in Uganda–. Project‖ and is a three

year intervention study of farmers´ pesticide use, health and environment in Uganda running from

7

summer of 2010 -2013. The general objective of the intervention project is to reduce negative health

effects of pesticides in humans and prevent pesticide pollution of the environment.

Moreover, Dialogos are working together with ICOEPH (International Centre for Occupational and

Environmental Medicine and Public Health) on this project. ICOEPH is a centre formed by professionals

and institutions with profound knowledge and experience in the fields of occupational medicine,

environmental medicine and public health. ICOEPH and Dialogos have been working together for the

past eight years on IPM and ―Pesticides, Health and Environment‖ in Bolivia, and have gained experience

in minimising pesticide problems in most developing countries.

In Denmark, a steering committee is responsible for the technical management and guidance of the

Ugandan project. The committee consists of volunteers from Dialogos, ICOEPH and the universities.

Dialogos is responsible for managing the funds for the project and the fundraising, monitoring and

reporting of the project, while UNACHO will be responsible for implementing and the day-to-day work

of the project [22].

The presented article is the final product of a research year in collaboration with Dialogos, ICOHEP,

Bispebjerg Hospital and Copenhagen University. The research year takes basis in gathering of the

―Pesticide, Health and Environment, Uganda. Project‖ baseline and has consisted of writing a project

description (appendix 1), typing of the questionnaire (appendix 2), gathering of data, typing of data,

analysis of data and writing an article. By agreement with Copenhagen University, the article will account

as a thesis (appendix 3).

Jane Frølund (JF), who is a member of ICOEPH and connected to Copenhagen University, is the main

supervisor of this thesis. JF is located at Bispebjerg Hospital Work and Occupational Medicine

Department, where I have been seated when not in Uganda. Erik Jørs (EJ), who is the secondary

supervisor of the thesis, is located at Odense University Hospital. JF was mainly supervising before and

after the data gathering in Uganda, while EJ was supervising during data gathering in Uganda.

Deo Sekimbi (DS), who is the project coordinator in Uganda, was also present during the data gathering,

and will be responsible for the future coordination of the project in Uganda. At the same time of the

baseline gathering observational studies were done, concerning the use of pesticides and protective

measures.

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ARTICLE

9

PESTICIDE USE AND HOW IT AFFECTS THE HEALTH OF SMALL SCALE

FARMERS IN UGANDA: A CROSS-SECTIONAL STUDY

ABSTRACT

Over the past years there has been an increase in the use of pesticides in developing countries, many of

them being listed as extremely and highly hazardous. Improper use of pesticides can cause acute pesticide

poisoning. A cross-sectional study was conducted using a standardized questionnaire. 319 small scale

farmers in the districts of Pallisa and Wakiso in Uganda were interviewed. The study showed that the

main pesticides used belonged to WHO class II pesticides, and that a majority of the farmers did not use

appropriate personal protective equipment (PPE). Also many farmers lacked adequate knowledge

concerning the colour coding of the pesticides.

There was no significant association between the number of times sprayed with pesticides and self

reported pesticide symptoms. However there was a significant association between using their mouth to

unblock the nozzle of the knapsack sprayer (OR 2,13 with a 95% CI 1,09 – 4,18) when spraying with

class II pesticides within the last year.

These findings suggest that an effort must be made to upgrade the farmers’ knowledge so that they keep

the most dangerous pesticides off the market. Additionally attention should be called to class III and U

pesticides, helping the farmers to understand the classification and labelling of the pesticides, and future

interventions also must focus on not using their mouth to unblock the nozzle.

Keywords: pesticides, poisoning, small scale farmers, health, knowledge, developing country.

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BACKGROUND

The balance between population increase and sufficient food production is one of the most important

challenges in many African countries, including Uganda [23]. The use of pesticides is an effective method

to protect crops from being damaged and to improve yields [24]. Over the past years there has been an

increase in the use of pesticides in developing countries, and the developing countries now account for

about 20% of the worlds expenditure [25]. However, improper use of pesticides can cause direct human

poisoning, accumulate as residues in food and environment and lead to the development of resistance in

pests [26, 27].

Approximately 300.000 workers die worldwide from pesticide exposure every year with the majority of

deaths occurring in developing countries [2, 5]. The main part of these deaths is due to self-poisoning. In

addition to this comes 3.000.000 cases of acute pesticide poisoning every year [16].

The Food and Agriculture Organisation of the United Nations (FAO) has tried to control the use of

pesticides with its code of conduct [5]. For instance, FAO recommend governments in developing

countries that small scale farmers should only be given access to pesticides that require little personal

protective equipment [3, 12, 28, 29]. Moreover The World Health Organisation (WHO) has made an

Essential Drug List (EDL) categorising the pesticides according to health hazard, going from extremely

hazardous to unlikely to present acute hazards. This is a useful tool, especially for developing countries,

for elimination of the most dangerous pesticides. However, many pesticides used in developing countries

are still listed as extremely and highly hazardous [3, 12]; for example, Jors et. al. have documented a

frequent use of the most toxic pesticides among farmers in Bolivia, who have had no introduction on how

to use pesticides and protect themselves against the dangers of intoxication [13]. Also, studies in four

African countries have shown use of unauthorised pesticides and a lack of advice on alternatives [20].

It is crucial that the use of pesticides is assessed to ensure that it does not harm humans or nature.

Therefore the use of pesticides in developing countries should be further investigated and clarified, to

provide a guideline for governments and international organizations making appropriate policies [13, 24,

30].

Many farmers in Uganda are small scale farmers with less than a few acres per household. Often they

farm without the money or the knowledge to use pesticides appropriately [19]. Incorrect dosage, incorrect

timing and targeting, poorly maintained equipment, mixing with bare hands, lack of personal protective

equipment (PPE) and lack of precautions when spraying may result in acute pesticide poisoning (APP)

[20, 31, 32]. In the absence of appropriate handling with pesticides, not only the health of farmers, but

also their families´ health is at risk [23].

Studies have shown that it is beneficial to look at the knowledge, practice and attitude towards pesticide

use. Yassin et. al have made a study in the Gaza Strip pointing to the fact that even though the farmers

11

had high levels of knowledge on the health impact of pesticides they did not act according to this. It is

important to emphasize that clarifying these aspects makes it easier to take action where it is needed. This

will over time minimize the hazards of occupational pesticide exposure [23, 30, 31, 33].

The aim of this paper is to determine the extent and character of pesticide use by small scale farmers in

Uganda, and to examine the practise and impact of protective measures and the storage of pesticides.

Furthermore it assesses how the farmers’ knowledge affects the use of pesticides and analyses the

relationship and nature between use of pesticides and symptoms of acute pesticide poisoning.

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METHOD

STUDY DESIGN

This cross-sectional study constitutes the baseline of a three year intervention study of farmers´ pesticide

use, health and environment in Uganda. The project is in collaboration with the Danish NGO Dialogos

and the Ugandan NGO Uganda National Association of Community and Occupational Health

(UNACOH) and is funded by The Danish Ministry of Foreign Affairs.

The general objective of the intervention project is to reduce negative health effects of pesticides in

humans and prevent pesticide pollution of the environment. The elements of the intervention consist of

educating farmers, extension workers and pesticide dealers in integrated pest management (IPM), and by

educating health care workers in prevention, diagnosis and treatment of acute and chronic pesticide

poisonings. Through seminars and meetings, the project aims to help local key stakeholders to form a

pesticide committee. The effect of the intervention will be assessed in 2013.

SETTING

We conducted a cross-sectional study including 317 small scale farmers. The fieldwork was carried out

from January to February 2011 in two different districts in Uganda: Wakiso and Pallisa. According to the

research from the planning of the project Wakiso primarily grows vegetables (groundnuts, tomatoes,

green pepper etc.) and Pallisa primarily produce cotton. 40-90% of the farmers were expected to use

pesticides [22].

Wakiso is situated in the northern part of Uganda, approximately 20 kilometres northwest of the capital

Kampala, close to Lake Victoria, with an average elevation of one kilometre above sea level. 1.310.100

people is living in Wakiso.

Being close to Lake Victoria the Wakiso district is generally very fertile.

Pallisa is situated in the eastern part of Uganda, 170 kilometres from Kampala close to the border of

Kenya, also with an average elevation of one kilometre above sea level, with a population of 394.000

people.

Pallisa's climate is predominantly continental with a lot more sun and less rain. Unfortunately, the study

data was gathered in Pallisa’s dry season. This affected the outcome of our analyses as the spraying is

generally more frequent in the wet season due to higher pressure of insect pests, diseases and weeds.

PARTICIPANTS

In many African countries, farming is usually a business with all the family members engaged in the

agricultural activities. Hence the whole family appears to be at risk of pesticide exposure [23]. Therefore

we accepted subjects of different ages and both genders. Having enough women in the material to make

13

statistical analysis was a priority in the gathering of the study population, since the data on women and

pesticides are currently very limited.

The project team, consisting of the project manager (EJ), the day to day project leader (DS), the research

assistant (AH) and local assistants, visited and established contact to the local authorities in the two

districts before starting the data collection. During these meetings, time and dates of the interviews were

scheduled.

In each district a mid-level manager was connected to the project team. He or she was in charge of

making contact with the local farmers and of making arrangements for interviewing. Both farmers

organized in a farmers´ group and farmers outside a group were included in the study. At most times all

members of a farmer group would gather at the group leader’s house or at a village hall. At other times

they would gather in smaller numbers at different more convenient places, like member homes or in the

field. Meetings with farmers who were not a member of a farmer group would also be arranged by the

mid-level manager, these interviews were carried out in the home or in their field.

The interviewers were dropped off at the interviewing spot in the morning, picked up for lunch and then

again going out for more interviews in the afternoon. Several places were only accessible by foot or in a

four wheel drive truck and therefore transportation was a time-consuming factor.

The total number of small scale farmers´ in the visited areas is not available. Therefore it is not possible

to calculate how big a part the 317 farmers represent or how many chose not to be part of the study.

STANDARDIZED INTERVIEWS

All participants were interviewed individually with the use of a standardized questionnaire. The

questionnaire has been used successfully in other studies in Colombia and Bolivia. It was originally

written in Spanish but translated into English [13, 34].

Most questions were one of two types; either yes/no questions, offering a dichotomous choice, or multiple

choice questions, offering several fixed alternatives. In addition to demographics and crop production, the

questionnaire asked about type and amount of pesticides used, knowledge of pesticides, attitude and

practice during the mixing, application and storage of pesticides and toxicity symptoms.

A pre-test was carried out with 15 farmers in both Pallisa and Wakiso (not included in the sample) to

modify the questionnaire. The modification primarily included rephrasing to more understandable English

and focusing on more information about the training and handling of pesticides.

At each district 8-12 people interviewed the farmers. The interviewers were young Ugandan students or

recently graduated. The people interviewing in Pallisa were not the same as in Wakiso except for the

project team which was involved in both districts.

Each question was translated on the fly by the interviewer from English into the local language during the

interview. Consequently there might have been small differences in the translation. To minimise this and

other biases there was a two day introduction to the questionnaire before starting the interviews. An

14

important part of this training was to secure that the interviewers understood the meaning of the

questions, and to discuss possible ways to translate each question from English to the local languages.

The interviewers were also instructed on when only to choose one fixed answer and when it was possible

to tick multiple answers and when to read the fixed answers aloud and when not to. An additional part of

the training was that the project team or public health and agronomist teachers at Makerere University

reviewed the first couple of responses together with each interviewer, in an effort to minimise

misunderstandings.

All interviews were conducted face to face, and a trained interviewer would take approximately 30

minutes to complete an interview.

EXPOSURE VARIABLES

Exposure to pesticides may be by inhalation of vapour or direct dermal or oral contact. The main

exposure measure covering these routes of exposure were self-reported number of times sprayed.

There were two different time points measuring this exposure. The first one was number of times sprayed

in the last month, and the second was number of times sprayed in the last season.

Pesticides used within the last month were divided into three groups: sprayed 1 time, sprayed 2-3 times

and sprayed more than 3 times. People not spraying were left out of this part of the analysis, because they

were not asked about symptoms in the last month. Pesticides used last season were divided according to

the WHO classification of pesticides, making it possible to do analysis on class II, III and U pesticides.

Moreover for class II pesticides we divided the number of times spraying into tertiles; spraying 1-7 times,

8-12 times and more than 12 times, using ´not spraying´ as the reference group. Class III and U pesticides

were divided dichotomously into not spraying or spraying one or more times.

When using a knapsack sprayer to distribute pesticides the nozzle sometimes blocks. The second

exposure variable was whether the small scale farmer would use his mouth to blow or suck in order to

unclog the nozzle. This variable was divided dichotomous (yes/no).

OUTCOME VARIABLES

The questionnaire included three self-reported outcome measures in relation to pesticide poisoning. As

the first measure each farmer was asked if he or she had had any symptoms immediately after pesticide

spraying in the last year, spontaneously mentioning all the symptoms they could recall (―spontaneous last

year‖). Secondly the farmers were asked in the same way if they had experienced any symptoms

immediately after spraying pesticides within the last month (―spontaneous last month‖). Finally, as the

third measure, the farmers were once again asked if he or she had had any symptoms the last month, but

now 18 different symptoms were read aloud, allowing for the farmer to agree or disagree with each

symptom (―asked the last month‖). The reason for making both a ―spontaneous‖ and an ―asked‖ outcome

measure was to eliminate possible recall bias that could happen in a cross-sectional study.

15

Each symptom was aggregated into a dichotomous variable, with 0-1 symptom coded as 0 and more than

one symptom coded as 1. This was a choice made because many of the symptoms spontaneous and asked

are frequent in other diseases. For all three outcome measures only symptoms potentially related to class

II and III pesticides were included [35].

POTENTIAL CONFOUNDERS

The following set of explanatory and potential confounder variables were included in all analyses:

District (Wakiso/ Pallisa), age (continuous), gender (female/male), marital status (yes/no), farmer group

(yes/no), educational level (no education/ primary school/>primary school), PPE (yes/no) and precautions

(1-2/>2). Age was used as a continuous variable. We used both age and age squared in the analyses.

One might argue that it would have been better not to keep all the potential confounders in the analyses,

but these factors have previously shown to have an effect on pesticide symptoms and were therefore kept

in the analyses [13, 33, 36].

STATISTICAL METHOD

Descriptive statistics with means, standard deviation (SD) and range were used. The association between

exposure (number of times sprayed in previous month / season) and health outcome were analyzed using

logistic regression. Both crude and adjusted odds ratios are presented. The adjusted logistic regression

analyses included district, age and age squared, gender, marital status, farmers group, educational level,

PPE and precautions.

Sensitivity analyses were performed with different cut points for number of times sprayed with pesticides

and number of symptoms.

Earlier analyses have shown an association between gender and number of times spraying with pesticides

[37]. Therefore interactions were calculated for gender, with both the type of interaction and the main

effects in the analyses. Also there might be an association between the exposure variable and age so

interactions were also calculated for this variable [38]. As differences in the two districts turned out to be

significant, analyses with stratification was also carried out.

MISSING DATA

Because data was gathered by interviews, missing variables were kept to a minimum, less than 3% on

average. In the few cases of missing values, most of these are related to interviewers being unable to

translate the question, respondents not understanding the question or typing errors.

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ETHICAL CONSIDERATIONS

The Helsinki declaration of ethical principles for medical research were followed [39]. The study was

approved by the local leaders in each district, before starting the data collection. It was voluntary to

participate in the study and the participants were encouraged, but not forced, to be part of the interview.

All respondents were explained the purpose of the study, and after informed oral consent, written consent

was obtained from each participant. Illiterates provided a thumb print as an indication of their consent.

17

RESULTS

PARTICIPANTS

The total number of responses was 317. Tables 1 and 2 provide demographic details of the participants.

The majority of the farmers were males (61%), a total of 155 (49%) were from Wakiso and 161 (51%)

were from Pallisa. The average age was 42 years, and 216 (68%) of the farmers were organised in farmers

groups.

Analysis of the educational level showed that 42 (13%) had no education, 143 (45%) had finished

primary school and 116 (37%) had an education level of secondary school or above. The range of land

used for crops was from 0,25 – 38 acres. This measure is self reported, and may be quite imprecise since

many of the farmers were unsure of how much an acre was. However, with a mean of 4,15 acre, the

presumption that most farms are small scale is being confirmed.

CROPS

Figure 1 shows the crops grown in the two districts, on which the farmers use pesticides. The Figure

illustrates that different crops are grown in the two districts. In Wakiso there is a greater diversity of what

is being grown. The main crops grown in Wakiso are tomatoes, nakati (a kind of eggplant), cabbage and

green pepper. In Pallisa the main crops are cotton, green peas and cowpeas. The figure also shows that

many of the farmers grow more than one crop.

PESTICIDES

A total of 306 (96%) interviewed farmers were using pesticides and had been doing so with a mean

average of 17,5 years.

The 14 self-reported pesticides used by the farmers in the last month are shown according to the WHO

classification, and chemical family in Table 3.

No pesticides were registered as extremely hazardous (Ia) or highly hazardous (Ib). Moderately hazardous

(class II) were the most frequently used pesticides according to the questionnaire with cypermethrin and

cypermethrin-profenofos being used by the largest number of farmers. To some degree slightly hazardous

pesticides (class III) and pesticides unlikely to present any harm in normal use (class U) were used,

mainly Glyphosphate and Mancozeb [12]. Figure 2 shows the number of times the farmers sprayed with

the different pesticides within the last season in Wakiso and Pallisa. Unfortunately it is not possible to say

anything about the amount of pesticides used when spraying. However it is possible to say that pesticides

were sprayed more often in Pallisa than Wakiso in the last season.

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SYMPTOMS

The prevalence of self-reported symptoms is shown in Figure 3. The symptoms shown are divided into

the three outcome categories: Symptoms immediately after spraying in the last year (―spontaneous last

year‖), symptoms immediately after spraying in the last month (―spontaneous last month‖) and symptoms

immediately after spraying in the last month (―asked last month‖). Skin irritation, headache, extreme

tiredness, blurred vision and dizziness are the most commonly reported symptoms. The table shows - not

surprisingly - a tendency to more symptoms being reported in the last year and when asked.

KNOWLEDGE

Levels of knowledge among the farmers are described in Table 4. 289 (92%) of the farmers think

pesticides can have a negative effect on their health, 276 (90%) know that the pesticide containers have

marks showing the toxicity and 228 (74%) say that they are able to read and understand these

instructions. Despite these facts only 69 (22%) know that red color indicates the most dangerous

pesticides. Even more farmers (64%) do not know which sign marks the least dangerous pesticides.

Approximately one third (31%) of the farmers have had training on how to use and handle pesticides.

PRACTICE AND ATTITUDE

Table 5 illustrates the practice and attitude for small scale farmers towards pesticides.

The majority of the farmers (93%) use a knapsack sprayer to distribute and mix the pesticides. More than

80% of the small scale farmers take less than 3 hours to spray their field. 22% of the males and 12% of

the females take more than three hours to spray their field.

Questions relating to personal protective equipment and precautions after using pesticides show that a

high percentage (73%) use ordinary clothing when spraying. The most commonly used PPE were boots

(51%), followed by long-sleeved t-shirts (24%). Most of the farmers take precautions after spraying

pesticides, but only 80 (26%) take precautions after mixing pesticides. More than one third of the farmers

(39%) mixed several pesticides in one mixture. A total of 170 (56%) farmers stored the pesticides inside

the house, 39 (13%) stored them outside the house, 72 (23%) in a storehouse and 17 (5%) stored them in

the field.

ASSOCIATION BETWEEN SYMPTOMS AND PESTICIDE USAGE

To clarify the association between self-reported symptoms and pesticide usage, logistic regression

analyses were conducted. Table 6 lists the association between spontaneously reported and asked

symptoms the previous month and number of times sprayed with a pesticide the last month. The analyses

were conducted on 171 of the 309 participants (62 from Pallisa and 109 from Wakiso). The crude odds

ratios showed no significant association between numbers of times sprayed and symptoms of pesticide

19

poisoning. There was an increased crude OR of 2,45 (95% CI of 1,12 - 5,36) for spontaneously self-

reported pesticide symptoms in Pallisa. After adjusting for potential confounders there was still no

association between the number of times sprayed and self-reported pesticide symptoms, and the potential

confounder district became non-significant.

Precautions (continuous) showed a significant association with an OR of 1,46 (95% CI 1,02-2,09) for

asked symptoms in the last month.

Table 7 shows the association between symptoms immediately after spraying the last year for class II,

class III and class U pesticides. These analyses include the whole population of 317 participants. The

analyses show that there is no significant association between self-reported symptoms and the amount of

times sprayed with each pesticide class. However, the results show that district is a potential confounder

with and an increased OR of 2,56 for Pallisa (95% CI 1,34 – 5,24) when spraying with class II pesticides.

The same tendencies are shown for class III and U pesticides, decreasing when using less dangerous

pesticides.

Gender and farmers group were shown also to have a significant association as confounders, increasing

the risk of pesticide poisoning if you are in a farmers´ group (class II: OR = 2,22, 95% CI = 1,18 – 4,19)

(class III: OR 2,17, 95%. CI 1,16 – 4,08) (class U: OR 2,17, 95% CI 1,15 – 4,06 ) and decreasing the

risk when being a woman (class II: OR 0,49, 95% CI = 0,26 – 0,92; class III: OR 0,49. 95% CI 0,26 –

0,89; class U: OR 0,49. 95% CI = 0,27 – 0,90).

Again the analysis show that those taking more precautions (continuous) have a significantly higher risk

of more than 1 symptom with an 95% OR of 1,32 and a CI 1,02 – 1,79 for class II pesticides (class III:

OR 1,34, 95% CI 1,03 – 1,75; class U: OR 1,36, 95% CI 1,04 – 1,78) than those not taking

precautions.

Since several of the previous analyses showed that there was a significant difference between the two

districts we decided to make logistic regression analyses stratified on the two districts for class II

pesticides (Table 8). However, this did not change the association between the number of times sprayed

and symptoms or the unexpected directions of the ORs in some of the confounder variables. Again, a

significant protective effect was shown for females (OR = 0,34, 95% CI = 0,13 – 0,84) and an increased

risk when taking precautions (OR = 1,75, 95% CI = 1,17 – 2,63) for Pallisa. Significant associations were

found for spraying 1-7 times (OR= 0,17, 95% CI = 0,03 – 0,99) compared to not spraying and farmers

group (OR = 3,6, 95% CI = 1,23 – 10,45) was found in Wakiso.

When testing for interaction there were no significant findings. Also when changing the cut points for

number of times sprayed and number of symptoms this did not influence the odds ratios significantly. As

well as age squared did not have any significant effect on the outcome.

20

SUPPLEMENTARY ANALYSES To look at the symptoms in another perspective we divided them into four categories: Neurological

symptoms, abdominal symptoms, skin symptoms and respiration symptoms. Doing the analysis again for

each symptom group controlling for the confounders none of the groups had significant values, neither in

the last month or in the last year. Also we did not find any significant values when we examined the two

most reported pesticide poisoning symptoms, skin irritation and headache, one at a time.

Analysis performed with use of mouth to unblock the nozzle (either blowing or sucking) as the exposure

variable showing a significantly higher risk of getting acute pesticide poisoning within the last year with a

crude OR of 2,46 (95% CI 1,36 -4,33). After adjusting for the potential confounders keeping number of

times sprayed in the analysis the OR for class II pesticides was 2,13 with a 95% CI 1,09 – 4,18. When

calculation the adjusted OR the last month spontaneous and asked it is still elevated being 1,32 (0,45 –

3,88) and 1,56 (0,53 – 4,55) respectively, but not significant.

21

DISCUSSION

Our findings show that class II pesticides, mainly cypermethrin and cypermethrin-profenofos, are the

most frequently used pesticides for small scale farmers in Wakiso and Pallisa, Uganda.

This is an important finding, as other studies have shown extended use of class I pesticides in developing

countries. In a cross sectional study by Jors et al. in Bolivia for small scale farmers, it was shown that one

of the frequently used pesticides is Methamidophos, which is classified as highly hazardous class Ib [13].

Also in Vietnam there has been an increased use of class I pesticides even though many of them are

banned [40]. However a study made by Ngowi et. al. in Northern Tanzania, close to the border of

Uganda, has shown a low quantity of class I pesticides; also a study made in Ghana indicates that small

scale farmers

mainly used class II and III pesticides [26, 36]. These studies suggest that African small scale farmers are

not as exposed to class I pesticides as Asian and Latin American farmers. A study made in Kenya found

that mainly large scale farmers and not small scale farmers used class I pesticides [41].

Nevertheless class II pesticides are still known to have a moderate hazardous effect on humans, and there

are other less dangerous alternatives [12, 29]. In addition, we expected that 40-90 % of the farmers used

pesticides, but the data showed that 97% did. This supports the fact that the use of pesticides is increasing

in Africa, and will probably continue to do so as long as the population increases. Effective interventions

needs to be introduced to help the farmers get a sustainable relationship to pesticides [19]. Another focus

of this study was to examine the practice and impact of protective measures and the storage of pesticides.

Less than one of six uses any of the four protective measures: Gloves, overalls, masks or hats. And more

than half of the farmers store pesticides inside their house. This puts the environment and the health of the

farmer and his family at risk [19, 20, 23, 26]

Moreover many of the farmers in Pallisa and Wakiso do not know enough about how to use and handle

pesticides. As seen in other studies the small scale farmers have some knowledge of the names and

effects of the pesticides they use but lack knowledge about mixing and of the color coding of pesticides

[13, 23, 33]. These findings show lacking knowledge, and unhealthy practices and attitudes concerning

the use of pesticides. Without adequate knowledge, practice and attitude on pesticide classification

systems, application rates, inefficiency of combining pesticides, re-entry periods, mixing and storage of

pesticides farmers are unable to make good crop decisions and exercise proper practices [2, 26].

Integrated Pest Management has shown to have an effect on minimizing the use and improper practice of

pesticides. IPM emphasizes the importance of the growth of healthy crops and encourages natural pest

controls systems. It keeps the use of pesticides to a level that is affordable for the farmers and reduces the

risk to humans and the environment while still yielding the expected outcome [20, 29, 30, 42].

This study also hypothesized that there would be an association between use of pesticides and pesticide

poisoning symptoms. The result of the comparison does not support this hypothesis. After adjusting for

22

gender, age, marital status, member of a farmers group, district, PPE and precautions, the OR did not

show a significant association between number of times sprayed and symptoms of acute pesticide

poisoning.

The lack of associations between number of times sprayed and pesticide poisoning symptoms could be

due to numerous reasons.

Firstly confirming an association in a cross sectional design can easily lead to overestimation of the

assumption between outcome and exposure, because of recall bias [43]. In the present study we made an

effort to avoid this by making numerous outcome measures. First of all the farmers were asked to mention

symptoms both within the last year and the last month, because we assumed that the last month would be

less sensible of recall bias hence making it the strongest association between number of times sprayed and

APP. However, because of the dry season in Pallisa, symptoms within the last year turned out to be the

most reliable measure.

Secondly we assumed that we could remove some reporting bias by having the farmers spontaneously

mention symptoms in relation to pesticides, and then afterwards asking about specific symptoms both

related and un-related to pesticide poisoning. However we did not encounter this kind of bias. The main

symptoms reported were skin irritation, headache, extreme tiredness, blurred vision and dizziness which

are consistent with other studies [44]. Many of these symptoms could be due to other factors like hot

climate, long exposure to sunlight or other diseases [26]. This might also affect the outcome as the farmer

might be exposed to these factors simultaneously. We could have eliminated some of this by focusing

more on physical signs, making health care personal observe the farmers. Another possible way to obtain

better information in relation to symptoms could be to ask the farmer to keep a diary and write down

symptoms occurring up to 48 hours after spraying; this could eliminate some recall bias [10]. S. Dasgupta

et al. calls attention to the point that self-reported symptoms is a weak indicator for pesticide poisoning,

and recommend AChE testing instead [40]. However AChE can be insufficient as there is a big variation

within people and would make the study much more costly [15].

It is also possible that the amount of pesticide sprayed was insufficient for an exposure to be detected,

supported by the fact that majority of the farmers took less than three hours to spray their field and only

used class II pesticides.

Thirdly conduction of the interviews might have had an influence on the missing association between

number of times spraying pesticides and pesticide poisoning symptoms. Even though interviews were

carried out by trained groups, and the training emphasized understanding the questionnaire, it was not

possible to ensure that the translation of the questionnaire was clear and understandable, as we couldn’t

fully control the translation. With up to 14 people doing the interviews it is almost impossible to secure

stringency and homogeneity. By a written translation of the questionnaire into the local language we

might have been able to eliminate some interview bias. Also the study population itself could encounter

some bias as we didn´t know the overall number of farmers in the two districts. However it seemed like

the farmers gladly participated and that they were representative of the general population in the two

23

districts and all the farmers who had the opportunity to participate did so. The only farmers not

participating were the ones who did not know about the study.

We did find a constant increased risk of getting pesticide poisoning when living in Pallisa (OR 2,7) when

using class II pesticides in the last year. When stratifying in the two districts there was still no association

between number of times sprayed and pesticide poisoning symptoms. The reason for the increased risk

could be that the main crop grown in Pallisa is cotton, which is a high growing vegetable, and thereby the

pesticides are closer to the breathing zone posing more danger. Another reason could be that Pallisa is a

more remote area, not having the same access to knowledge as Wakiso.

Also male farmers seemed to have an increased risk of getting pesticide poisoning. There has been

expressed concern about female farmers spraying and the need for more data [38, 45]. Therefore it was a

priority in this study to interview both males and females farmers. However when it comes to spraying of

pesticides, the knapsack sprayer (which was used by 93% of the farmers) is very heavy. Other studies

have shown that it is mostly men carrying the knapsack sprayer, where women are more involved in

transporting, weeding and harvesting [36]. If men carry the knapsack sprayer for a longer time than

women, men will have a longer exposure time. This is consistent with the fact that 22% of the men, and

only 12% of the women, carry the knapsack sprayer for more than three hours in this study, and could be

one of the reasons for the elevated OR for men [46]. Very few studies look at both genders in relation to

pesticide exposure. The number of women participating in this study is a strengthening, and may help

clarify women’s exposure to pesticides, but more studies would help to clarify this relationship.

We found that farmers organized in groups had an increased risk of reporting pesticide poisoning

symptoms. We were aware of these associations, since the purpose of the groups is to strengthen its

members. This finding could also be caused by group members influencing each other in a negative way.

The group seems to be of significant importance to the farmers when it comes to distribution and selling

of pesticides, and must therefore be taken into consideration when doing interventions. There is a lack of

studies looking at how the organization of farmers in groups affects the correlation between the use of

pesticides and pesticide poisoning. It would therefore be recommended that other studies take this into

account.

Furthermore we looked at the exposure of blowing or sucking a clogged nozzle of the knapsack sprayer.

This analysis showed a significant increased risk of reporting pesticide poisoning symptoms within the

last year, controlling for potential confounders. These results suggest that this routine performed by one

fifth of the farmers should be targeted in the intervention. In the study referred to earlier by Jors et. al.

49% of the farmers would either blow or suck the nozzle of the knapsack sprayer if it clogged, but the

study does not examine the association between this practice and pesticide poisoning symptoms [13].

24

CONCLUSION

As this study is a baseline in a three year intervention program, the present findings makes it possible to

specify the coming interventions where it is really needed. The study shows that the pesticides used in

Uganda are far and foremost class II pesticides and that the most dangerous pesticides are rarely found in

the market. It also shows that many of the farmers do not use the proper PPE. Moreover an effort to

upgrade the farmers’ knowledge about labelling and classification of pesticides must be made, enabling

them to stay away from the most dangerous pesticides and raising awareness of class III and U pesticides.

No association between the number of times sprayed with pesticides and symptoms of acute pesticide

poisoning was found. We found that farmers using their mouth to unblock their nozzle have an increased

risk of pesticide poisoning, making this parameter important in an intervention.

25

TABLES FOR PESTICIDE USE BY UGANDAN SMALL SCALE FARMERS:

A CROSS SECTIONAL STUDY.

TABLE 1

Distribution on district, gender, farmers group, educational level and pesticide use of small scale farmers

in Uganda.

Wakiso Pallisa %

District: N % N % N

Wakiso 155 49

Pallisa 161 51

Gender:

Female 123 39 64 43 58 36

Male 190 61 87 57 102 64

Farmers´ group*:

Yes 216 68 101 66 113 70

No 101 32 53 34 48 30

Educational level:

No education 42 13 16 10 26 16

Primary School 143 45 76 49 66 41

Secondary school 112 36 54 35 57 36

University 4 1 4 3 0 0

Other tertiary 16 5 4 3 12 7

Use of pesticides

No 11 3 9 6 1 1

Yes 306 97 145 94 160 99

* Farmers´ groups are characterized by 10 – 30 farmers organizing to help each other with transportation and selling of crops to save money on

distribution expenditures, but also with the purpose of exchanging knowledge on farming.

26

TABLE 2

Demographic details (self-reported) on small scale farmers working with pesticides, Wakiso and Pallisa,

Uganda.

n Mean

Standard Deviation Range

Age 318 42 12,74 13 – 76 years

Acres of land cultivated 316 4,15 4,54 0,25 – 38 acres

Acres of rented land for small scale farmers 316 1,35 1,80 0 – 12 acres

Years of engagement in agriculture 316 22,46 13,28 0 – 69 acres

Years of utilizing pesticides 311 17,55 12,51 0 – 69 yeas

27

FIGURE 1

Crops, on which the small scale farmers use pesticides, grown in Wakiso and Pallisa. Only crops reported

by five or more farmers are included.

0

20

40

60

80

100

120

140

160

banana

beans

cabbage

cass

avaco

tton

cow

peas

groundnuts

green p

eas

maiz

e

mille

t

nakati

orange

potato

essa

lad

soya

beans

spin

ach

sweet p

otato

es

tom

ato

chill

ies

eggplant

green p

epper

num

ber

of f

arm

ers

Pallisa

Wakiso

28

TABLE 3

Classification of pesticides used by small scale farmers, in Wakiso and Pallisa, Uganda. January 2011

Pesticide Number of farmers Pallisa Wakiso Toxicological class by WHO Chemical class

Glyphosate 14 1 13 III Phosphonomethyl

2,4 D 2 0 2 II Phenoxy-carboxylic-acid

Paraquat 2 0 2 II Bipyridylium

Cypermethrin-profenofos 47 13 34 II Pyrethroid

Cypermethrin 52 24 28 II Pyrethroid

Endosulfan 1 0 1 II Organochlorine

Dimethoate 16 6 10 II Organophosphate

Malathion 1 1 0 III Organophosphate

Fenvalerate 1 1 0 II Pyrethroid

Alpha-cypermethrin 1 0 1 II Pyrethroid

Mancozeb 19 2 17 U Dithiocarbamate

Lamda cyhalothrin 11 6 5 II Pyrethroid

DDT 1 1 0 II Organochlorine

Dimethylcyclopropanecarboxylic 1 1 0 II Unclassified

Unknown 28 8 20

29

FIGURE 2

Pesticide use from January 2011, previous season.

0

50

100

150

200

250

Glyphosa

te

2,4 D

Paraq

uat

Ametry

ne

Cyper

met

hrin-p

rofe

nofos

Cyper

met

hrin

Dichlo

rvos

Endosu

lfan

Dimeth

oate

Malat

hion

Fenv

alera

te

Alpha

-cyp

ermet

hrin

Manc

ozeb

Butani

l

Lam

da cy

haloth

rin

Pyret

hroid

DDT

Dimeth

ylcy

clopro

paneca

rboxy

lic

Unknow

n

Nu

mb

er

of

tim

es

spra

yed

Pallisa

Wakiso

30

FIGURE 3

Symptoms relevant for class II and III pestecides. January 2011 and january 2010 – january 2011.

0

10

20

30

40

50

60

70

80

90

Nause

a

Blurr

ed v

ision

Dizzin

ess

Saliv

ation

Skin

irrit

atio

n

Musc

ular w

eakn

ess

Heada

che

Respira

tory

diff

iculti

es

Extr

eme

tired

ness

Vomiti

ng

Abdomin

al p

ain

Loss

of a

ppetit

e

Lack

of c

oordin

atio

n

Exce

ssive

swea

ting

Nu

mb

er

of

farm

ers

Spontaneous symptoms January 2011.

Asked symptoms january 2011.

Spontaneous symptoms January 2010 -

2011.

31

TABLE 4

Knowledge on pesticide handling and toxicity.

All Wakiso Pallisa

n % n % N %

Have you ever had any training on how to use and handle pesticides

No 213 69 97 67 114 71

Yes 96 31 50 34 60 29

Do you know of any alternatives to pesticides?

No 183 58 90 59 92 57

Yes 132 42 63 41 68 43

Do you think pesticides can have a negative effect on your health?

No 7 2 1 1 6 4

Yes 289 92 144 95 143 89

don’t know 18 6 6 4 12 12

Can you read and understand instructions on the pesticide containers?

No 70 23 27 18 43 27

Yes 228 74 114 78 113 71

Do the pesticide containers have any signs marking their toxicity

No 16 5 9 6 7 4

Yes 276 90 136 93 139 87

Sometimes 3 1 1 1 1 1

Don’t know 12 4 12 8

Which sign marks the most dangerous pesticide?

I don’t know 122 40 75 51 47 30

Blue color coding 5 2 0 0 5 3

Red color coding 69 22 23 16 46 29

Yellow color coding 23 8 5 3 18 11

Green color coding 7 2 3 2 4 3

Skull and bones pictorials 75 24 42 29 31 20

The smell indicates the danger 70 23 22 15 48 30

Which sign marks the least dangerous pesticides?

I don’t know 196 64 115 78 80 51

Blue color coding 6 2 1 1 4 3

Red color coding 9 3 3 2 6 4

Yellow color coding 13 4 9 6 4 3

Green color coding 32 10 6 4 26 16

Skull and bones pictorials 8 3 4 3 4 3

The smell indicates the danger 50 16 11 7 39 25

32

TABLE 5

Safety practice and attitude during pesticide mixing and application.

All Wakiso (0) Pallisa (1)

N % n % n %

What do you wear doing pesticide spraying (PPE):

Ordinary clothing 229 73 105 70 123 77

Gloves 38 12 24 16 14 9

Overall 26 8 14 9 12 8

Boots 160 51 109 73 49 31

Mask 39 13 34 23 5 3

Hat 26 8 19 13 7 4

Long-sleeved shirt 76 24 35 23 41 26

Do you take precautions immediately after handling pesticides?

Yes 304 98 145 97 157 99

No 6 2 4 3 2 1

Which ones?

Wash hands immediately after mixing 80 26 34 24 46 29

Wash hands immediately after spraying 188 62 113 78 74 47

Wash hands before eating in the field

when spraying

34 11 21 15 13 8

Wash hands before smoking when

spraying pesticides

11 4 3 2 8 5

Wash whole body immediately after

spraying pesticides

240 79 95 66 143 92

Shift clothes after spraying 215 71 110 76 103 66

How long does it take you to spray the field

< 1 hour 93 30 23 16 70 44

1-3 hour 153 50 76 52 76 48

> 3 hours 58 19 46 31 11 7

Unknown 2 1 1 1 1 1

How long does it take you to return to the same field after spraying?

Hours 51 17 31 21 19 12

Days 158 51 79 53 78 49

Weeks 100 32 38 26 62 39

Do you use a knapsack sprayer:

Yes 287 93 131 89 154 96

No 21 7 15 11 6 4

In case you get a blockage of your sprayer nozzle what do you do?

Use mouth to blow to unblock 61 20 26 18 35 23

Use a sharp object to unblock 160 53 92 64 66 42

Replace with another nozzle and take to

technician for repair

74 25 22 15 52 33

Where do you mix your pesticides:

In the house 4 1 0 0 4 3

Outside the house 138 53 42 33 95 72

In the field 111 42 73 57 38 29

Beside a water source 39 15 29 22 10 8

33

Do you mix several different pesticides in one mixture?

No 187 61 47 32 140 89

Yes 121 39 101 68 18 11

Where do you store your pesticides?

Inside the house 170 56 79 53 91 57

Outside the house 39 13 20 13 19 12

Storehouse 72 23 39 26 3 19

Locked up 97 34 19 13 14 9

Free access 4 1 1 1 3 2

Hidden in the field 17 5 16 11 1 1

Box for pesticides 34 11 4 3 30 19

34

TABLE 6

Association between self reported pesticide poisoning symptoms and pesticide spraying in Wakiso and

Pallisa, Uganda. January 2011 (n= 173).

Symptoms immediately after spraying. January 2011.

Spontaneous by the farmer.

Symptoms immediately after spraying. January 2011.

Asked by the interviewer.

Crude Adjusted * Crude Adjusted *

n OR CI OR CI OR CI OR CI

Number of times sprayed the last month

1 time 53 1,00 - 1,00 - 1,00 - 1,00 -

2-3 times 67 0,56 0,23 - 1,36 0,43 0,14 - 1,34 0,74 0,34 - 1,63 0,76 0,29 - 2,00

> 3 times 53 0,52 0,20 - 1,37 0,57 0,20 - 1,59 0,81 0,35 - 1,87 0,70 0,28 - 1,78

Continuous 173 0,95 0,82 - 1,09 0,95 0,82 - 1,10 1,00 0,95 - 1,06 0,98 0,91 - 1,06

District

Wakiso = 0, 109 1,00 - 1,00 - 1,00 - 1,00 -

Pallisa = 1 62 2,45 1,12 - 5,36 1,79 0,69 - 4,69 1,31 0,66 - 2,61 1,31 0,55 - 3,10

Age continuous 173 0,99 0,96 - 1,02 0,98 0,94 - 1,02 0,98 0,96 - 1,01 0,99 0,96 - 1,02

Gender 173

Male =1 109 1,00 - 1,00 - 1,00 - 1,00 -

Female = 2 62 0,74 0,33 - 1,68 0,67 0,25 - 1,77 0,72 0,36 - 1,40 0,75 0,34 - 1,66

Marital status

No = 0 38 1,00 - 1,00 - 1,00 - 1,00 -

Yes = 1 135 3,43 0,99 - 11,94 3,20 0,82 - 12,52 0,93 0,43 - 2,03 0,99 0,40 - 2,44

Farmers group

No = 0 46 1,00 - 1,00 - 1,00 - 1,00 -

Yes = 1 127 0,95 0,40 - 2,24 0,98 0,37 - 2,63 0,68 0,32 - 1,44 0,69 0,29 - 1,61

Education level

No education 22 1,00 - 1,00 - 1,00 - 1,00 -

Primary school 80 1,63 0,43 - 6,22 1,51 0,36 - 6,32 0,53 0,18 - 1,61 0,47 0,15 - 1,50

More then primary 71 1,58 0,41 - 6,12 1,36 0,31 - 5,99 0,60 0,20 - 1,83 0,60 0,17 - 2,07

PPE

0 PPE

> = 1 PPE

43 1,00 - 1,00 - 1,00 - 1,00 -

130 1,03 0,43 - 2,50 1,27 0,43 - 1,27 0,81 0,38 - 1,74 0,95 0,39 - 2,33

Continuous 173 0,99 0,77 - 1,27 1,15 0,85 - 1,56 0,92 0,75 - 1,13 0,92 0,71 - 1,81

Precautions after using pesticides

1-2 precautions 85 1,00 - 1,00 - 1,00 - 1,00 -

> 2 precautions 84 0,53 0,43 - 2,50 0,56 0,23 - 1,37 1,34 0,70 - 2,59 1,87 0,88 - 3,94

Continuous 169 0,90 0,64 - 1,27 0,96 0,66 - 1,40 1,25 0,93 - 1,67 1,46 1,03 - 2,09

*The adjusted analyses include the following potential confounders: district, age gender, farmer group, education level, use of PPE and

precautions.

35

TABLE 7

Associations between self reported pesticide poisoning symptoms and pesticide spraying January 2010 -

2011. Class II, III and U pesticides. Wakiso and Pallisa, Uganda (n=317)

Symptoms immediately after spraying.

January 2010 -11. Previous year.

Symptoms immediately after spraying.

January 2010 -11.

Symptoms immediately after

spraying. January 2010 -11. Previous

year

Crude Adjusted* Crude Adjusted* Crude Adjusted*

n OR CI OR CI n OR CI OR CI n OR CI OR CI

Number of times sprayed with class 2 pesticides. Number of times sprayed with class 3 pesticides.

Number of times sprayed with

class U pesticides.

Didn’t spray 51 1,0 - 1,0 - Didn´t spray 290 1,0 - 1,0 - 265 1,0 - 1,0 -

1-7 times 52 0,9 0,3 - 2,3 0,5 0,2 - 1,6 > 1 time 29 0,6 0,2 - 1,5 0,5 0,2 - 1,5 54 0,7 0,4 - 1,4 0,7 0,3 - 1,7

8-12 times 113 1,5 0,7 - 0,3 0,6 0,2 - 1,6 Continuous 317 0,9 0,7 - 1,0 0,7 0,5 - 1,1 317 1,0 0,9 - 1,0 1,0 0,9 - 1,0

> 12 times 103 1,7 0,8 - 3,8 0,9 0,3 - 2,2

Continuous 317 1,0 0,9 - 1,0 1,0 0,9 - 1,0

District District

Wakiso 155 1,0 - 1,0 - Wakiso 155 1,0 - 1,0 - 155 1,0 - 1,0 -

Pallisa 161 2,3 1,4 - 3,9 2,7 1,3 - 5,2 Pallisa 161 2,3 1,4 - 3,9 2,3 1,2 - 4,4 161 2,3 1,4 - 3,9 2,2 1,1 - 4,3

Age 317 1,0 0,9 -0,9 1,0 0,9 - 1,0 Age 317 1,0 0,9 - 0,9 1,0 0,9 - 1,0 1,0 0,9 - 0,9 1,0 0,9 - 1,0

Gender Gender

Male = 1 190 1,0 - 1,0 - Male 190 1,0 - 1,0 - 190 1,0 - 1,0 -

Female = 2 123 0,5 0,3 - 0,9 0,5 0,3- 0,9 Female 123 0,5 0,3 - 0,9 0,5 0,3 - 0,9 123 0,5 0,3 - 0,9 0,5 0,2 - 0,9

Marital status Marital status

No = 0 55 1,0 - 1,0 - No 55 1,0 - 1,0 - 55 1,0 - 1,0 -

Yes = 1 262 2,0 0,9 - 4,1 1,3 0,6 - 2,6 Yes 262 2,0 0,9 - 4,1 1,3 0,6 - 3,3 262 2,0 0,9 - 4,1 1,4 0,6- 4,1

Farmers group Farmers group

No = 0 101 1,0 - 1,0 - No 101 1,0 - 1,0 - 101 1,0 - 1,0 -

Yes = 1 216 1,8 1,0 - 3,1 2,2 1,2 - 4,2 Yes 216 1,8 1,0 - 3,1 2,2 1,2 - 4,1 216 1,8 1,0 - 3,1 2,2 1,2 - 4,1

Education level Education level

No education 42 1,0 - 1,0 - No education 42 1,0 - 1,0 - 42 1,0 - 1,0 -

Primary school 134 2,2 0,9 - 5,2 2,0 0,8 - 5,0 Primary sc. 134 2,2 0,9 - 5,2 2,1 0,8 - 5,0 134 2,2 0,9 - 5,2 2,1 0,9 - 5,2

> primary 132 1,6 0,7 - 3,8 1,2 0,5 - 3,2 > primary 132 1,6 0,7 - 3,8 1,3 0,5 - 3,2 132 1,6 0,7 - 3,8 1,3 0,5 - 3,2

PPE PPE

0 PPE 102 1,0 - 1,0 - 0 PPE 102 1,0 - 1,0 - 102 1,0 - 1,0 -

> 1 PPE 209 1,1 0,6 - 1,8 1,3 0,7 - 2,5 > 1 PPE 209 1,1 0,6 - 1,8 1,3 0,7 - 2,4 209 1,1 0,6 - 1,8 1,3 0,7 - 2,4

Continuous 311 1,0 0,8 - 1,2 1,1 0,9 - 1,3 Continuous 311 1,0 0,8 - 1,2 1,1 0,9 - 1,3 1,0 0,8 - 1,2 1,0 0,8 - 1,3

Precautions after using pesticides Precautions after using pesticides

1-2 prec. 140 1,0 - 1,0 - 1-2 prec. 140 1,0 - 1,0 - 140 1,0 - 1,0 -

>2 prec. 162 1,3 0,8 - 2,2 1,5 0,9 - 2,7 > 2 prec. 162 1,3 0,8 - 2,2 1,6 0,9 - 2,7 162 1,3 0,8 - 2,2 1,6 0,9 - 2,7

Continuous 302 1,2 1,0 - 1,6 1,3 1,0 - 1,8 Continuous 302 1,2 0,9 - 1,6 1,3 1,0 - 1,8 1,2 0,9 - 1,6 1,4 1,0 - 1,8

* The adjusted analyses include the following potential confounders: district, age gender, farmer group, education level, use of PPE and

precautions.

36

TABLE 8

Association between self reported pesticide symptoms and pesticide spraying January 2010-11. Divided

in the two districts Wakiso and Pallisa, Uganda (n=317).

Pallisa Wakiso

Symptoms immediately after spraying.

January 2010 - 2011.

Symptoms immediately after spraying.

January 2010 - 2011.

Crude Adjusted * Crude Adjusted *

n OR CI OR CI n OR CI OR CI

Number of times sprayed with class 2 pesticides. Number of times sprayed with class 2 pesticides.

Didn´t spray 9 1,00 - 1,00 - 41 1,00 - 1,00 -

1-7 times 19 3,15 0,52 - 19,27 2,71 0,35 - 20,34 33 0,21 0,04 - 1,08 0,17 0,03 - 0,99

8-12 times 81 1,95 0,38 - 10,02 0,90 0,15 - 5,67 31 0,63 0,18 - 2,17 0,79 0,18 - 3,44

> 12 times 52 2,19 0,41 - 11,60 0,84 0,12 - 5,79 50 1,39 0,51 - 3,77 1,33 0,41 - 4,23

Continuous 152 0,99 0,95 - 1,03 0,96 0,92 - 10,1 114 1,00 0,98 - 1,02 1,00 0,97 - 1,02

Age 161 1,00 0,97 - 1,02 0,98 0,94 - 1,01 155 0,99 0,96 - 1,02 0,99 0,95 - 1,03

Gender

Male 102 1,00 - 1,00 - 87 1,00 - 1,00 -

Female 58 0,46 0,23 - 0,93 0,34 0,13 - 0,84 64 0,60 0,25 - 1,44 0,55 0,20 - 1,51

Marital status

No 14 1,00 - 1,00 - 41 1,00 - 1,00 -

Yes 147 1,08 0,34 - 3,38 0,45 0,11 - 1,78 113 2,02 0,72 - 5,72 2,09 0,62 - 7,05

Are you in a farmers group

No 48 1,00 - 1,00 - 53 1,00 - - -

Yes 113 1,47 0,71 - 2,98 2,07 0,86 - 4,97 101 2,29 0,87 - 6,05 3,60 1,23 - 10,45

Education level

No education 26 1,00 - 1,00 - 16 1,00 - 1,00 -

Primary school 66 2,95 1,05 - 8,29 2,53 0,79 - 8,09 76 2,13 0,44 - 10,30 1,38 0,22 - 8,60

More then primary 57 1,67 0,57 - 4,84 1,10 0,33 - 3,55 54 1,93 0,38 - 9,78 0,97 0,15 - 6,53

PPE

0 PPE 79 1,00 - 1,00 - 23

> 1 PPE 81 1,07 0,56 - 2,03 0,80 0,37 - 1,72 126 >999 0,00 – 999** >999 0,00 – 999

Continuous 160 1,00 0,79 - 1,28 0,90 0,65 - 1,27 149 1,15 0,89 - 1,48 1,20 0,87 - 1,66

Precautions after using pesticides

1-2 precautions 75 1,00 - 1,00 - 64 1,00 - 1,00 -

> 2 precautions 81 2,16 1,11 - 4,21 2,72 1,24 - 5,92 80 0,75 0,34 - 1,69 0,63 0,24 - 1,62

Continuous 156 2,00 1,2 - 2,4 1,75 1,17 - 2,63 144 1,00 0,65 - 1,37 0,96 0,60 - 1,53

* The adjusted analyses include the following potential confounders: district, age gender, farmer group, education level, use of PPE and

precautions.

**The huge CI for binominal PPE in Wakiso are due to the fact that no farmers are having more then 1 symptom and not using any PPE.

37

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APPENDIX

41

APPENDIX 1

Projektbeskrivelse

Viden, holdning og praksis studie, i ugandiske småbønders brug af pesticider.

Følgende projektbeskrivelse skildrer baggrunden, formålet, metoden, tidsplanen og rammerne for at

gennemføre et studie om pesticidbrug blandt bønder i Uganda studieåret i 2010-11.

BAGGRUND

Brugen af pesticider er kraftigt stigende i flere afrikanske lande. Øget efterspørgsel på fødevarer,

ændringer i klima og en stor befolkningstilvækst betyder, at de oprindelige dyrkningsmetoder ikke

længere er tilstrækkelige (Williamson, Ball & Pretty, 2007; Ntow et. al., 2006; Abate, Huis & Ampofo,

2000). Derfor har der gennem de seneste mange år været store fordele ved at bruge pesticider. Ikke blot

for dem der sælger pesticider og bonden selv, men også for de afrikanske regeringer, der lettere kan

brødføde deres befolkning (Abate et. al., 2000).

Men forkert brug af pesticider kan føre til miljøforurening og have svære helbredsmæssige konsekvenser

for de mennesker, der arbejder med dem (Sam et. al. 2007; Wesseling, Corriols & Bravo, 2005; Salameh

et. al. 2002). Hvert år dør cirka 300.000 mennesker på grund af pesticider. Hovedparten af disse dødsfald

er selvmord, der skyldes en let adgang til de meget giftige stoffer.

Hertil kommer omkring 3 millioner akutte pesticidforgiftninger pr år (Acute Pesticide Poisoning (APP))

samt et endnu større antal bønder, der rammes af kroniske forgiftningssymptomer og følgesygdomme

som hovedpine, svimmelhed, søvnløshed, øget forekomst af kræft, udslet med videre.

UN Food and Agricultral Organisation (FAO) har med sin International Code of Conduct forsøgt at

kontrollere brugen af pesticider. Blandt andet anbefaler FAO, at de pesticider, der sælges til småbønder,

kræver minimalt med beskyttelsesudstyr (Eddleston, et. al. 2002; FAO 2010). Flere studier har netop

dokumenteret en klar sammenhæng mellem manglende brug af beskyttelsesudstyr (Personal protective

equitment (PPE)) og manglende personlig hygiejne som en indikator for APP (MacFarlane et.al., 2010;

Ntow et. al., 2006; Yassin, Mourad & Safi, 2002). Anbefalingen er derfor særdeles aktuel. Endvidere har

WHO med sin Essential Drug List (EDL) - der senest blev opdateret i år 2009 - en optegnelse over de

mest farlige pesticider. Listen er et nyttigt værktøj til eliminering af de mest farlige pesticider (Eddelston

et. al, 2000, WHO 2009). Fulgte de enkelte afrikanske lande anbefalingerne kunne man sandsynligvis

sænke antallet af APP.

42

Det er det enkelte lands eget ansvar at overholde FAO anbefalingerne og WHO´s liste, men manglende

resurser og politisk vilje i udviklingslande, har desværre ofte betydet, at de ikke bliver gennemført

(Eddelston et. al, 2000; Naidoo et. al., 2010; Wesseling et. al., 2005). Endvidere har pesticid industrien

også et ansvar for fornuftig brug af pesticider. Flere firmaer påtager sig også dette ansvar, men det ser ud

til at tiltagene ikke har nogen egentlig effekt (Konradsen et. al, 2003; Murray and Tayler, 2000).

Således tegner dagens billede af pesticidbrugen i flere afrikanske lande sig ikke positivt. Flere pesticider,

som afrikanske bønder bruger, er i strid med EDL og forbudt i industrilandene. Det vurderes, at op til 25

% af de pesticider, der bruges, bliver smuglet ind i landene, og pesticidernes afmærkninger og

brugsanvisninger er ofte fraværende, mangelfulde eller skrevet på et fremmed sprog for bonden.

Endvidere har bønderne ofte hverken adgang eller råd til beskyttelsesforanstaltninger (Kondradsen et. al.,

2003; Maroni, Fait, Colosio, 1999;).

Små landbrug er essentielle for overlevelsen af flere afrikanske familier (Naidoo et. al, 2002; Abate, et. al.

2000). Uganda er ikke anderledes, her bor 28 millioner mennesker. Af disse 28 millioner bor 85 % på

landet, og de er på den ene eller anden måde afhængige af indtægter fra landbruget. En survey gennemført

af Ugandan National Association of Community and Occupational Health (UNACOH) og International

Centre for Occupational, Environmental and Public Health (ICOEPH) viser, at 90 % af bønderne bruger

pesticider. Denne survey viser også, at meget få har fået undervisning i, hvordan pesticider bruges og

opbevares korrekt, samt at flere undlader at bruge de korrekte beskyttelsesforanstaltninger og ofte har

forgiftningssymptomer (Pesticide Use, Health and Enviroment –Uganda, 2010).

Andre studier ser på den samme problematik. De viser, at problemer typisk opstår, når bonden ikke har

tilstrækkelige viden, holdning eller praksis (knowledge, attitude and praksis, KAP) omkring brugen af

pesticider. Studierne ser derfor på sammenhængen mellem de tre faktorer i relation til brug af pesticider

(Sam et al, 2007;Wesseling, Corriols & Bravo, 2005). I et studie af Ngowi, Maeda og Paranen (2002)

påpeger de eksempelvis, at bønderne ofte ikke er bevidste om deres manglende viden. Andre KAP-studier

har fundet frem til, at hvis følgevirkningerne af pesticider skal undgås, så er undervisning i brug af

pesticider vigtig. Ikke kun for bønderne, men også for resten af befolkningen (Sam et. al, 2008). Dog har

andre studier vist, at øget viden ikke nødvendigvis fører til bedre praksis (Yassin, Mourad & Safi, 2002).

Viden, holdning og praksis er også primærfokus i dette studie af pesticidbrug og forgiftningssymptomer

blandt bønder i Uganda. Endvidere er projektet en del af et større interventionsstudie om bæredygtighed,

der ønsker at mindske de negative effekter af pesticider på mennesker og i naturen blandt andet gennem

undervisning i korrekt brug af pesticider (Pesticide Use, Health and Environment –Uganda, 2010).

43

Formål

Formålet med studiet er at undersøge småbønders brug af pesticider i Uganda. Der fokuseres på fire

problemstillinger i projektet:

1. At indsamle baselinedata i det overordnede interventionsprojekt, herunder beskrivelse af

bøndernes viden, holdning og praksis omkring pesticider.

2. At klarlægge hvorledes viden har en effekt på APP, PPE, hygiejne ved sprøjtning og opbevaring

af pesticider (se figur 1).

3. At belyse hvordan selvrapporterede symptomer på APP påvirkes af PPE, hygiejne ved sprøjtning

og opbevaring af pesticider (se figur 1).

4. At observere bøndernes opbevaring og brug af pesticider.

Figur 1.

Der arbejdes således ud fra følgende hypoteser:

Viden har betydning for tilfældene af selvrapporterede symptomer på pesticidforgiftning.

Viden har betydning for holdning og praksis ved håndtering af pesticider, forstået som brugen af

PPE, hygiejne ved sprøjtning og eventuelt opbevaring af pesticider.

Holdning og praksis (PPE, hygiejne ved sprøjtning og opbevaring af pesticider) har betydning for

selvrapporterede symptomer på pesticidforgiftning.

Eksponering:

Pesticider. Hvor ofte, hvilke

typer og hvor meget?

Viden om pesticider?

Viden omkring den akutte

og kroniske effekt af

pesticider?

Udfald:

Selvrapporterede

symptomer på

pesticidforgiftning.

Brug af PPE

Hygiejne ved sprøjtning.

Opbevaring af pesticider.

Potentielle confoundere:

Alder, køn, skolegang, antal år som

landmand, størrelse på farmen, afgrøder,

område, rygning, alkoholindtagelse,.

Brug af PPE

Hygiejne ved sprøjtning.

Opbevaring af pesticider.

Selvrapporterede symptomer på

pesticidforgiftning.

44

Metode og materiale

Design

Studiet gennemføres som et epidemiologisk tværsnitsstudie, hvor både eksponering og udfald klarlægges

samtidigt. Data vil senere blive brugt som baseline i et interventionsstudie, der blandt andet undersøger

effekten af undervisning til ugandiske bønder i brug af pesticider.

Dataindsamling

Størstedelen af dataindsamlingen vil være 300 interviews med småbønder i Uganda. Public health

studerende fra Makerere Universety, danske studerende fra Københavns Universitet samt UNACHO

personale vil være med til at udføre interviewene. Alle vil følge den samme strukturerede interviewguide

med både åbne og lukkede spørgsmål. Hvert enkelt interview vil blive foretaget ansigt til ansigt, og det vil

være intervieweren, der udfylder interviewguiden. Hvert interview forventes at tage omkring en time

inklusiv transport, så der kan gennemføres cirka otte interviews om dagen. Data vil formentlig være

indsamlet i løbet af en periode på fire uger.

Interviewguiden har fokus på viden, attitude og praksis i relation til brug af pesticider. Bøndernes viden

omkring brug af pesticider bliver sat i relation til tre faktorer: i) Symptomer på forgiftning, ii)

Beskyttende foranstaltninger og iii) Opbevaring af pesticider (se figur 1).

Symptomer på forgiftning forstås som symptomer, der er opstået umiddelbart efter, at bonden har sprøjtet.

Svarmuligheder i forbindelse med dette indføres på en allerede specificeret liste i spørgeskemaet.

Beskyttende foranstaltninger dækker både over personlig hygiejne og brug af PPE.

Information omkring opbevaring af pesticider vil blive indsamlet både via interviews, men også via

observationer. Det er dog uvist, om det kan lade sig gøre at observere opbevaringen, da det endnu er

usikkert, om interviewet kommer til at foregå i den enkelte bondes hjem eller udenfor. Hvis interviewet

foregår udenfor den enkelte bondes hjem vil det være selvrapporterede data fra spørgeskemaet, der tages

med i analysen.

Svarene fra interviewguiden vil blive indtastet i løbet af opholdet i Uganda, så eventuelle tvivlsspørgsmål

kan blive opdaget.

Foruden interviewguiden og observationsdata vil der i løbet af perioden også blive foretaget

videooptagelser. De mange besøg hos småbønder på forskellige gårde og i forskellige distrikter giver

gode muligheder for at belyse forholdene visuelt. Lignende materiale vil blive lavet i Bolivia, og

optagelserne fra de to steder vil danne grundlag for undervisningsmateriale på universitetsniveau.

45

Videomaterialet vil desuden indgå som observationer af de arbejdsforhold, bønderne har, og vil også

blive inddraget i en diskussion af baselinedata.

Population

Der er omkring 300 småbønder i områderne Wakiso og Pallisa. Bønderne i Wakiso er kendt for at dyrke

grøntsager, mens de i Pallisa især dyrker bomuld. For at blive inkluderet i studiet skal bønderne have

brugt pesticider indenfor det sidste år og givet skriftligt samtykke om deltagelse. I tilfælde af analfabeter

vil mundtligt samtykke være tilstrækkeligt. Bønderne identificeres i samarbejde med UNACOH, der

kender området og har mulighed for at lave et repræsentativt udsnit. I udvælgelsen vil der indgå et

repræsentativt antal kvinder.

Fejlkilder

Da både eksponering og udfald indsamles på samme tidspunkt, vil der være risiko for over- og

underrapportering. Endvidere vil der i forbindelse med interviews altid være mulighed for

informationsbias. Det forsøges elimineret med korte og så vidt muligt faktuelle spørgsmål og ved at

gennemgå interviewguiden med både tolk og samarbejdspartnere først. Alle henvendelser til bønder vil

blive registeret, så antallet af bønder, der ikke ønsker at deltage, kan opgøres. Endvidere vil der kunne

opstå fejlkilder i relation til selve setting. Uganda er meget anderledes kulturelt og strukturelt

sammenlignet med Danmark, og det vil have betydning for de data, der indsamles.

Dataanalyse

Der vil blive brugt logistisk regressionsanalyse til at analysere data, så der tages højde for eventuelle

modificerende faktorer. Data analyseres i det statistiske program SAS efter hjemrejse.

Potentielle confoundere vil blive analyseret én for én og sammen for at se, om de har indflydelse på

resultatet. Ligeledes tages der hensyn til eventuelle effektmodifikatorer.

Tidsplan

Oktober – november Udarbejdelse af spørgeskema.

Etablering af kontakt med studerende ved Makerere universitet.

Primo december Afrejse til Uganda.

De første 14 dage bruges på introduktion, planlægning og logistisk arbejde.

Indsamling af data, observationer om opbevaring af pesticider og videooptagelse.

Indtastning af data i SAS udføres løbende under opholdet.

Primo marts Ankomst Danmark.

Statistisk behandling og analyse af data.

Udarbejdelse af videnskabelig artikel.

46

September Artikel færdig.

Projektets rammer

Projektet er et samarbejde mellem UNACOH (Uganda National Association of Community and

Occupational Health) og Dialogos. UNACOH er en NGO fra Uganda, der ønsker at fremme en sund og

produktiv ugandisk befolkning. Dialogos er en dansk NGO, der blandt andet ønsker at bistå

befolkningsgrupper i ulande på deres selvvalgte vej væk fra fattigdom. Dialogos har desuden stor erfaring

i arbejdet med pesticider. Begge organisationer har en frivillig og demokratisk arbejdsgang.

UNACOH er ansvarlige for implementering og daglig drift af projektet, mens Dialogos står for

fundraising, implementeringskontrol og rapportering fra projektet (Pesticide use, Health and Enviroment

– Uganda 2010). Projektet skal løbe over flere år og på sigt gøres bæredygtigt (Pesticide use, Health and

Enviroment – Uganda 2010). Derudover er blandt andet ICOEPH og Københavns Universitet tilknyttet

projektet. ICOEPH arbejdede sammen med Dialogos i Bolivia-projektet ‖Plagbol‖ med stor succes, og

Københavns Universitet har et samarbejde med Makerere Universitet i Uganda.

Endvidere er der et samarbejde med Bispebjerg Arbejds- og Miljømedicinske afdeling, hvor undertegnede

har fået tildelt en specialeplads og vejleder.

Finansiering

Projektet har støtte fra Dialogos, der betaler vaccination, flyrejse og løn i Uganda, vurderet til cirka

48.000.

Budgettet er foruden støtten fra Dialogos vurderet til:

Pr. måned Varighed DKK

Tilskud til boligudgifter i

Uganda

3000 3 måneder 9.000

Løn efter Uganda 11.000 7 måneder 77.000

I alt 86.000

47

APPENDIX 2

PESTICIDE USE, HEALTH AND ENVIRONMENT PROJECT:

FARMER’S BASELINE SURVEY TOOL

Informed consent:

The Pesticides Use, Health and Environment Uganda Project is being carried out by UNACOH (

Uganda) and Dialogos (Denmark) in collaboration with Makerere University Faculty of Agriculture

(MUFA) and Makerere University School of Public Health (MUSPH), in the districts of Pallisa and

Wakiso.

The project aims at making the use of pesticides safer for human health, more friendly to the

environment, while maintaining and improving agricultural productivity.

The baseline survey is being carried out to inform, the project at present in the above regards, so that we

can be able to measure later on the effects of the project interventions.

Your participation therefore is useful to the project, but more importantly to the people handling

pesticides, to the environment and to the economic activities of farmers. Therefore your giving answers

to the questionnaire, attached, will help all the stakeholders referred to above.

We thank you for your cooperation.

-------------------------------------------------------------------------------------------------------------------------

Are you willing to participate in this interview?

If not, why?

Date and signature:

48

PESTICIDE USE, HEALTH AND ENVIRONMENT PROJECT BASELINE SURVEY TOOL

Number _____________

Name of interviewer: _____________________Supervisor: _____________________________

Date of interview: __________________________

District: __________________________________ Sub-county__________________________

Parish:_______________________________ Village _____________________________

A. Personal data:

Name___________________________

Age: ______________

Sex:

If female do you use contraceptive pills:

Marital status:

Are you in a farmers group?

Name of head of household? ________________________________________

Who makes the final decisions in agricultural production:

Who is living in your household, family relations and age (begin with eldest):

S/N Sex Age Family relationship.

Can you read?

Can you write?

What is your highest attained education level?

university

How many years have you been engaged in agriculture? ____________

49

How many acres of land does the head of household own? _________________________

How many acres of land do you use for agriculture? ___________________

How many acres do you rent from other people? ____________________

In the past month, which diseases did you suffer from?

ular weakness

fficulties

B. Agricultural Aspects:

Do

Do you use pesticides (insecticides, fungicides, herbicides, acaricides, etc) in agriculture?

yes

Do you use pesticides for other purposes?

fy: __________________________________

How long have you been using pesticides? (Years)

____________________________________

Who helps you with the daily work at the farm?

Pesticide use on crops

Important Crops sprayed Pesticides used Types of pesticides

(Herbicides, Fungicides,

Insecticides, Acaricides)

No. of times

sprayed until

harvest

1.

2.

3.

50

Do you think you can reduce on the amount of pesticides you use in agriculture without

affecting the expected yield?

alternative

Do you know of any alternatives to pesticides for controlling pests?

If yes, which methods do you know? List

1. _________________________________________________

2. ___________________________________________________

3. ____________________________________________________

What do you wear during pesticide spraying? (Tick all mentioned)

-sleeved

shirt ___________________________

Do you take precautions immediately after handling pesticides in your field?

If yes, which ones?

field when spraying pesticides

How long does it take you to spray the field daily?

-3 hours

How long does it take you to return to the same field after spraying?

Do you spray your products after harvesting, but before taking them to the market?

no

If yes, on what crops: ______________________________________________________

Who does the spraying in the household?

kids

51

Do you follow a particular schedule when spraying?

What determines the frequency of spraying?

Other: _________________________

How many times have you sprayed in the last month? ___________

Which pesticides did you use the last month? ___________________

What do you use for applying the pesticide?

________________________________________

In case you get a blockage of your sprayer nozzle, what do you do?

Do you clean or wash your knapsack/ sprayer after use?

If yes, where do you clean it?

Where do you mix your pesticides?

field

How do you measure the dosage of pesticides needed when mixing?

___________________

Do you mix several different pesticides in one mixture?

If yes, why

If not, why not ___________________________________________________

Training, handling and management of pesticides:

Where do you normally get pesticide information?

-dealers

What advice do you get from any above (do not mention)?

52

-harvest / entry period

Do the pesticide containers have labels on them when you buy from the dealers?

If not, why ___________________________________________

Can you read and understand instructions on pesticide labels?

If not, why? ______________________________________

Have you ever had any training on how to use and handle pesticides?

no

If yes, how many times have you participated in such training? ____________________

How long did the training on pesticide use and handling take?

When did you receive the last training?

th ago

-6 month ago

From which organisation did you receive this training?

Do the pesticide containers have any signs indicating their toxicity (how poisonous they are)?

Which signs mark the most dangerous pesticide?

Which signs mark the least dangerous pesticides?

53

Do you observe the weather condition when going to spray?

If yes, in which weather do you not spray?

Where do you store your pesticides?

up.

What do you do with the empty pesticide containers?

bage pit

What do you do in case you don’t use up all the pesticide mixed?

field

Health effects:

Do you think pesticides can have any bad/ negative effect on your health?

How do pesticides enter your body?

Have you, in the last year, felt ill immediately after handling pesticides.

If yes what symptoms did you suffer (do not mention the symptoms)?

ular weakness

ulties

ss

How long did the pesticide symptoms last on you?

54

Have you in the last month felt ill immediately after spraying pesticides?

If yes, which symptoms did you suffer? (do NOT mention any symptoms , tick if the farmer

mentions himself ) – Acute signs and symptoms

ular weakness

ss

etite

71B. (Now mention the symptoms and tick if the farmer agrees).

iness

ular weakness

ss

uth

What did you do to address the above problems?

If yes what kind of treatment did you receive? (Specify)

_____________________________

What pesticide caused you the biggest danger? _______________________________

Do you try to avoid these pesticides?

If yes, how? ___________________________________________________________

Mention the least dangerous pesticides you know?

1. ___________________________

2. __________________________

3. _________________________

Do you know of any pesticide poisonings in your village or family that happened during last

year?

55

What was the reason for the poisoning?

Do you know of any fatal pesticide poisonings that happened in your village or family last

year?

What was the reason for the fatal poisoning?

Do you think pesticides could have a negative effect on the environment?

Apart from the effects of pesticides on health, what other negative effects do they cause to the

environment? (Tick. DO NOT mention)

-target organisms / animals

Observations done by the interviewer - only if possible

What is the name (trade and active ingredient) of the pesticides stored?

1. ____________________________________________________

2. ______________________________________________________

3. _____________________________________________________

Where are the pesticides containers kept:

How are they stored:

Does the knapsack sprayer leak:

What protective equipment are present in the house:

rall wear

What is the condition of the protective equipment:

not effective

56

APPENDIX 3

Fra: Signild Vallgårda <siva@sund.ku.dk>

Til: Anna Hobolth <anna_hobolth@yahoo.dk>

Cc: Rie Laurine Rosenthal Johansen <rijo@sund.ku.dk>

Sendt: 12:16 onsdag den 4. maj 2011

Emne: Re: SV: SV: Specialekontrakt

Kære Anna.

Rie har nok bare ikke nået at svare dig. Det jeg skrev til Rie om dit spørgsmål, og som jeg har sagt til

Emina er:

1. Det er kun den studerende som kan være forfatter på artiklen, ikke vejledere eller andre. 2. Det er en

god idé, at skrive en slags indledning eller kappe, hvor man redegøre grundigere for teori, metode og

måske øvrig forskning, da der jo ikke er så meget plads at skrive om dette i en artikel.

Som jeg også fortalte Emina, er der ikke nogen retningslinjer nu, men de vil blive udarbejdet.

Du behøver ikke at tale med Susanne. Du skal bare sørge for at få din kontrakt udfyldt.

Mange hilsener

Signild

On 04/05/11 12.12, "Anna Hobolth" <anna_hobolth@yahoo.dk> wrote:

Mange tak for hjælpen.

Jeg har lige snakket med Emina idag, omkring muligheden for at skrive en artikel som speciale (vi

sidder på samme kontor).

Jeg har spurgt studierådgivningen men har ikke rigtig fået noget svar.

Er der nogen retningslinjer? -og hvor kan jeg evt. finde dem. Og skal jeg også snakke med Susanne

om det?

Undskyld alle spørgsmålene.

Kh Anna