Health-related quality of life within agriculture in England and Wales: results from a EQ-5D-3L self-report questionnaire

There has long been concern over high rates of mental and physical health problems among agricultural populations across the world [1‐3]. In the United Kingdom (UK), national data has consistently identified agriculture as one of the poorest performing sectors in terms of suicide and physical injury. Between 2016/17 and 2020/21 Agriculture, Forestry and Fishing had the highest rate of work-related musculoskeletal disorders, fatal injuries and non-fatal injuries of all sectors in Great Britain [4]. Latest estimates for England suggest that males in elementary agricultural occupations have a suicide risk 1.9 times higher, and those in skilled agricultural occupations 1.7 times higher, than the national average [5].

Research on these issues across different international contexts has identified a range of factors that contribute to poor health among farming populations. In the developed world, these include financial difficulties [6, 7]; pressures associated with paperwork, regulation and inspection [8, 9]; loneliness and isolation [10‐12]; work demands/long working hours [13, 14]; impacts of climate change and extreme weather [15‐17]; pesticide exposure [18, 19]; and animal disease [20, 21]; as well as social, cultural and practical barriers around seeking help for health issues [22‐24]. Mental and physical health problems are clearly concerning for the wellbeing of the individual, but they can also have wider impacts on the farm business and family. They can, for instance, be difficult for close family members to deal with (10) and can lead to the neglect of business responsibilities such as animal welfare [25, 26].

The COVID-19 pandemic has helped highlight the role of farmers as essential workers. In addition, in the UK radical changes to the policy environment in which farmers operate are being implemented following withdrawal from the European Union (EU). High rates of health problems could inhibit the ability of individual farming businesses to adapt and plan for the future. A detailed analysis of the health and well-being status of the agricultural community is, therefore, more timely than ever.

In 2021 we conducted a survey of people living and working in agriculture (n = 15,296) to investigate the overall health status and quality of life of this population, identify common sources of stress and explore perceptions of current farm business performance, challenges and opportunities. This article presents results from one survey instrument, the EQ-5D-3L,¹ which provides a standardised measure of health-related quality of life (HRQOL) [27]. The EQ-5D-3L comprises a descriptive system questionnaire and a visual analogue scale (EQ-VAS). The descriptive system asks the respondent to indicate whether they have no, some or extreme problems in relation to five health dimensions (mobility; self-care; performing usual activities; pain/discomfort; and anxiety/depression), thereby enabling focused analysis regarding these particular health issues. Responses to the descriptive system can also be converted into index values, which provide a single aggregated measure of health for each individual based on their reported level of problems with the five health dimensions. The index value is calculated “according to a set of [country or region-specific] weights that reflect, on average, people’s preferences about how good or bad the state is” [27] (p21) and represents the societal perspective on health. The EQ-VAS, on the other hand, requires the respondent to self-rate their health on a vertical visual scale (with 0 being the worst and 100 being the best health they can imagine) and, as such, represents the person’s own perspective on the overall state of their health. Analysis of the EQ-5D-3L responses in our survey provides a broad indication of HRQOL within the agricultural population of England and Wales, including sub-group variations according to age and gender.

The primary methodology was a questionnaire survey (described below), which was distributed across the agricultural community in England and Wales for completion between January and April 2021. The research set out to remedy the paucity of data on the health and wellbeing of the agricultural community by establishing a baseline on this topic using standardised and replicable measures, including the EQ-5D-3L.² A license to use the EQ-5D-3L questions was obtained from the EuroQol Research Foundation and all guidelines regarding the use and analysis of this instrument, as set out in the official user guide [27], were adhered to.

As far as we are aware, this is the first time that the HRQOL of farmers, farm families and other agricultural workers in England and Wales has been assessed on a large scale. The results reveal concerning levels of reported health problems among people living and/or working in agriculture. The findings that over half (52%) of respondents reported having moderate or extreme pain/discomfort and almost a third (31%) reported some or severe problems with anxiety/depression at the time of completing the survey are striking. The timing of the survey (i.e. during the COVID-19 pandemic and partially in a period of national lockdown) to some extent restricts the conclusions that can be made about respondents’ health in relation to non-pandemic conditions or historical national population data, as it is possible that increased levels of social isolation and restricted access to routine healthcare at this particular point in time would have negatively impacted HRQOL. There are, however, a number of considerations that lead us to contend that such impacts are unlikely to account for all of the disparities observed between our sample and national data.

First, a growing body of literature has already highlighted significant mental and physical health problems among farmers both within the UK and internationally [3, 35‐38] and has established links between these and a variety of personal, family and business-related challenges commonly faced by members of this community. The renowned high rates of both suicide and work-related injuries within agriculture compared to other occupations [1, 4, 39‐41] are conspicuous indicators of such issues. Previous studies using the EQ-5D among farming populations have also found farmers to have lower EQ-5D index scores than non-farmers both at a local level within England [42] and elsewhere (e.g. Finland [43] and China [44].

Second (and in line with national health and safety statistics [4]), the findings from other questions included in our survey suggest that farm work has a negative impact on health. For example, 64% of respondents said that they had experienced farm-related ‘pain in muscles/joints etc.’, and 16% had sustained a non-fatal injury, in the past 5 years [28]. Respondents also cited a wide range of farming-related factors as significant sources of stress and there were significant associations between poor perceptions of economic performance/farm viability and low mental health [28].

Finally, there are certain age-related patterns in our results that indicate unusually high levels of health problems among working-aged people in agriculture, which we examine further below.

The index values derived from the responses to the EQ-5D-3L descriptive system are lower than population norms within the age groups below 55 years old, indicating that these groups in our sample have a slightly lower health status than the general population from a societal perspective. The lower mean index values for females aged 18-24 and 25-34 compared to the wider population were particularly notable, exceeding the MID threshold established by Walters and Brazier [34] and suggesting that young female adults in agriculture deserve particular attention in efforts to improve HRQOL. Although the differences in index values observed for older females and all males in relation to the wider population were less significant (and even potentially positive in the case of the oldest age groups), the more notable variations in the 5 health dimensions indicate that the types of health issues experienced by farming are appreciably distinct and deserve further scrutiny. The results from the EQ-VAS indicate that self-perceptions of overall health are also poorer among our sample than among the wider population for both females and males, and this is the case across all except the oldest age groups (65 years old and over). It is notable that in both the index and VAS measures, disparities between the survey and UK populations were greatest among those of working age, which is when participation in farm work and business-related stress is likely to be at its most intense (both for primary farmers and other members of their families). Analysis of self-reported health problems from the EQ-5D-3L also revealed disparities between the survey sample and wider UK population among working-aged people in terms of i) pain/discomfort and ii) anxiety/depression, and it is plausible that the above health issues are at least partially influencing the lower levels of overall self-rated health. The gender analysis suggests that pain/discomfort is a particular issue for men, whereas anxiety/depression is a particular issue for women (although neither gender is immune from either health problem).

These findings are perhaps unsurprising when considered in the context of the nature of farming occupations. Farm work can involve considerable, at times intensive, manual labour and long-working hours with increased risks of physical injuries [41] and musculoskeletal disorders [14, 45, 46] that would be expected to lead to pain and discomfort. Notoriously long working hours and difficulties in taking time off from farm work [9] are only likely to exacerbate such health issues, as there is little opportunity for rest and recuperation. Although divisions of labour on farms are gradually changing [47], traditionally men have carried out more manual labour than women [48] and this might account for the higher levels of reported problems with pain/discomfort (and the other physical health dimensions) among men.

The high levels of self-reported anxiety/depression among working-aged people in our sample might similarly be explained by the likely occurrence of farm and business-related stress at this point in the life-course. Pressures and concerns associated with factors such as regulatory demands, paperwork, bad weather, disease, and maintaining economic viability may all be felt most acutely by those most involved in the everyday running of the farm. For working-aged women in farming in particular, these pressures are often accompanied by others relating to childcare responsibilities and/or involvement in diversified enterprises and off-farm work [10], with potential negative implications for mental health. Evidence suggests that the COVID-19 pandemic had a greater impact on mental health for younger compared to older people in the UK, particularly in terms of social isolation [49, 50], and this might have contributed to the heightened levels of anxiety/depression among this group. However, results from elsewhere in the survey suggest that it is unlikely to be the sole reason. Whilst COVID-19 was one of the top three sources of stress across the sample as a whole, it was more likely to be a source of significant stress for respondents over the age 65 (51% of 65-74 year olds and 53% of 75+ year olds 44% said it caused stress ‘quite a lot’ or ‘to a large extent’ compared to 44% of all respondents; (χ² (6, n = 14,297) = 281.45, p < .001, Cramer’s V = .14)),. Furthermore, other stressors (including concerns about the future of the farm/farming, workload pressures/long working hours and financial pressures) were found to be better predictors of anxiety than the pandemic [28].

More positively, respondents reported fewer problems with mobility and self-care than the wider population, particularly in the older age groups (45+). EQ-5D index values also appear higher than the wider population for those aged 75 and over. The reasons for this are, however, difficult to determine. It could suggest that farm work positively contributes to physical fitness later in life, keeping people active for longer, but it could also be a consequence of the requirement for a certain level of fitness in order to stay in agriculture (i.e. those with poorer mobility may already have left farming life). This demands further investigation. It is also interesting to note that, despite these better mobility levels, more respondents aged 75 or over (and to a lesser extent those aged 65-74) reported problems with performing their usual activities than the wider population. Given the tendency for farmers to retire (sometimes considerably) later than the state retirement age [51, 52], it is conceivable that this might be indicative of farmers trying to do more in their old age compared to their non-farming counterparts in spite of physical limitations. However, further research is required to affirm or refute such a supposition.

The findings presented here serve as compelling evidence of the need to understand and address physical and mental health issues among people living and working in agriculture, as well as providing a baseline for future investigation into the health status of UK food producers. The results should be seen as an imperative for action as, ultimately, a sustainable and resilient food system requires healthy agricultural workers who are able to maintain and improve production without detriment to themselves and their families.