Journal of Rural Medicine
Original article

Vulnerable groups and protective habits associatedwith the number of symptoms caused by pesticide
application in Kratie, Cambodia: a cross-sectionalquestionnaire study
Yurie Kobashi1, Lihorn Srou2, Masaharu Tsubokura3, Yoshitaka Nishikawa4,
Ngy Laymithuna5, Songhy Hok1, and Manabu Okawada6
1Sunrise Japan Hospital Phnom Penh, Cambodia
Cambodia International School, Cambodia
3
Department of Radiation Health Management, Fukushima Medical University School of Medicine, Japan
4
Department of Health Informatics, Kyoto University School of Public Health, Japan
5
University of Kratie, Cambodia
6
Department of Pediatrics, Sunrise Japan Hospital Phnom Penh, Cambodia
2

Abstract
Objective: The present study aimed to identify pesticide poisoning symptoms and related protective habits to effectively prevent
pesticide poisoning among farmworkers in Kratie, Cambodia, where pesticide poisoning is an urgent public health problem.
Materials and Methods: This cross-sectional study based on a questionnaire survey analyzing social demographics, number ofsymptoms, and protective behavior regarding pesticide application was conducted in Kratie Province from January 25 to 31, 2021.
In total, 210 farmworkers completed the survey. The effects of social demographics and pesticide-protective behavioral scores on
the number of symptoms were investigated using multivariable regression analysis.
Results: The observed number of symptoms was 1.16 times higher among women (P=0.004), increased with the duration of work,and decreased with age. In addition, we identified five significant pesticide-protective behaviors: 1) preparing using gloves, 2) using
protective equipment, 3) avoiding wiping sweat, 4) avoiding leaking, and 5) resting when feeling ill. Pesticide-protective behaviors
tended to decrease with the duration of working years in the low-education group (B=−0.04, SE=0.01), whereas no association wasobserved in the high-education group (B=0.01, SE=0.01).
Conclusion: Pesticide-protective behaviors significantly correlated with fewer symptoms. The female and aging groups required
continuous special education or instructions for implementing pesticide-protective actions, especially the aforementioned fiveprotective actions.
Key words: farmworker, vulnerable groups, occupational health, Cambodia(J Rural Med 2022; 17(4): 214–220)

Introduction
Received: April 23, 2022
Accepted: June 16, 2022
Correspondence: Yurie Kobashi, Sunrise Japan Hospital Phnom
Penh, Sangkat Chroy Changvar, Phnom Penh, Cambodia
E-mail: yurie-s@umin.ac.jp(Supplementary materials: refer to PMC https://www.ncbi.nlm.nih.
gov/pmc/journals/2669/)
This is an open-access article distributed under the terms of theCreative Commons Attribution Non-Commercial No Derivatives(by-nc-nd) License <http://creativecommons.org/
licenses/by-nc-nd/4.0/>.

©2022 The Japanese Association of Rural Medicine

Health disparity is thought to emerge from weaknesses
in health systems and individual factors such as race, sex,
sexual identity, age, disability, socioeconomic status, geographic location, environmental barriers, and stigmatization1). These conditions pose a crucial barrier to achieving
better health care for all patients. In addition, disparity andvulnerability are significantly related and cannot be separated from one another2). Specifically, individuals can become
vulnerable to disease, disability, and other personal conditions, or to societal and environmental conditions3), which
are factors with complex associations. Thus, identifying thedoi: 10.2185/jrm.2022-019 | 214

Journal of Rural Medicine
related problems faced by vulnerable people is a vital publichealth issue. However, vulnerable people are last to be given
special consideration and administered surveys3).
To examine the conditions faced by vulnerable people,
focusing on a specific group is essential. In Asian countries,
the majority of residents in rural areas engage in agricultural work. In this context, farmworkers are exposed to highrisks of work injuries, and the farmworker occupation isconsidered one of the most dangerous ones4, 5). In particular,
various effects of chronic exposure to pesticides have beenreported, including deoxyribonucleic acid (DNA) damage,neurological disorders, respiratory effects, developmental
disorders, and sterility6–10). Consequently, farmworkers area potentially vulnerable population owing to a combinationof social and cultural risk factors as well as pesticide exposure6). Thus, surveying the health effects associated withpesticide poisoning among farmworkers, and identifying
the group that is most affected by these problems (particularly in rural Asia where the majority of poor individuals
work in agriculture), is urgently required. Nevertheless, incountries in the aforementioned area, these surveys have notbeen sufficiently conducted.
Cambodia, a country in Southeast Asia, is classified asa low- to middle-income country. The adult literacy rate is
84.1% for men and 76.1% for women11). The majority of residents are engaged in agriculture with 8.6% males and 5.2%
females located in urban areas, and 59% males and 52.2%
females located in rural areas. Moreover, 77.2% of male
farmworkers and 79% of female farmworkers are classified
in the lowest quantile of economic status, indicating that thepoorest people in Cambodia are mostly farmworkers11). The
main crops are grains, rice, vegetables, fruits, cassava, andcashew nuts12). A total of 70% of agricultural households use
inorganic fertilizers, whereas 50% use organic fertilizers12).
Notably, farmworkers reported several symptoms associated with pesticide application in Cambodia in a previous
survey conducted in Southeast Asia13). Furthermore, a previous study indicated that organochlorines greatly influenced
the health of pregnant women, especially in low-income
groups14). Thus, Cambodia is a suitable area for surveying the health effects associated with pesticide poisoning
among farmworkers and identifying groups highly affectedby these problems15).
The objective of this study was to identify the characteristics of several pesticide poisoning symptoms and to identify protective habits that effectively prevented these symptoms among farmworkers in Kratie, where such poisoning is
an urgent public health problem15).

Materials and Methods
Study design and participantsThis study had a cross-sectional design. Kratie Prov-

ince, located 270 km from the capital city, Phnom Penh, ismainly a rural area with a total population of approximately
340,000, of which about 80% are farmworkers. Specifically, 68.9% of males and 72.9% of females were classified as
farmworkers with a low standard of living. In 2019, Kratie
Province experienced a disaster caused by chemical substances. Therefore, this province was chosen as the survey
area because pesticide poisoning is an urgent problem.
The average area per agricultural holding in Kratie is
2.14 hectares12), and the main crops are grain, rice, cassava,
cashew nuts, lemongrass, citrus trees, pepper, rubber, andcoconut trees. These crops require a much higher pesticide
amount than grains. The province has a temperate climate,with wet and dry seasons, and the Mekong River frequently overflows during the rainy season. In this context, most
farmworkers do not prefer personal-protective equipment
use because of the hot climate.
Kratie Province is officially divided into six districts; ofthese, five are rural and one is urban. We gathered participants from five rural districts to reduce regional bias basedon district differences. The selection criterion for farmworkers was as follows: age between 30 and 70 years with an
exclusive engagement in agriculture for more than 5 years.
The proportion of male participants was two-thirds, which
was the same as in a previous survey16). The present study
was approved by the National Ethics Committee of Cambodia (approval number 001NECHR).

Procedure
A qualitative interview on pesticide-related symptoms
was conducted with 20 farmworkers in May 2020 to determine area-specific pesticide-associated symptoms, enabling
the development of a validated questionnaire to count the
number of symptoms. Twenty-nine pesticide-related symptoms were identified from the open-question interviews offarmworkers in Kratie and from a literature review13, 16).
Pesticide-related symptoms were examined using multiplechoice questions such as “What kind of symptoms have you
experienced when using pesticides or within 24 hours after
pesticide application?”. The number of symptoms was determined by researchers.
We used a questionnaire consisting of nine questions
from a previous large-scale survey in rural China to examine the protective behavior associated with pesticide
use16). Local and Japanese experts in health and pesticides
discussed the validity of this questionnaire for use in the
Kratie Province and deemed it appropriate for this study.
Participants answered questions on the frequency of protective behaviors by selecting from five options: always, often,
sometimes, rarely, and never. The sample size was calculated with a confidence level of 95%, precision of 0.75, andthe population of rural Kratie of 270,000. A 20% margin
sample size was set, and subsequently, the sample size was2022; 17(4): 214–220 | doi: 10.2185/jrm.2022-019 | 215

Journal of Rural Medicine
determined to be 210.
The questionnaire survey was conducted in the Khmer
language by local surveyors between 25 May and 31 May,
2021. The surveyors were trained in advance of the survey
by researchers. Additionally, the researchers contacted thehead of the village each district to obtain permission for thesurvey and negotiated the gathering of eligible farmworkers. Some of the participants were interviewed in groups
using the previously mentioned gathering methods. The
surveyors went door-to-door of the participants, and one
participant from each household was selected. Convenient
sampling was performed in each district. First, the surveyors explained the objectives and methods of the survey andinformed consent was obtained from each participant. Subsequently, participants were interviewed on social demographic information, number of symptoms, and protective
behavior regarding pesticide application.
The frequency of protective behavior—classified as always, often, sometimes, rarely, and never—was scored as
10, 6.5, 4.5, 2, and 0, respectively, and named the “pesticideprotective behavioral score” (Supplementary Table 1). For
questions on protective behavior (e.g., “Did you read labels
about the pesticides before application?”), the score was assigned according to the aforementioned methods. For questions on risky behaviors (e.g., “Did you prepare pesticides
without gloves?”), the frequency of the corresponding protective behavior was assigned scores of 0, 3.5, 5.5, 8, and 10,
respectively (Supplementary Table 1). The protective behaviors were as follows: “read labels, prepare with gloves, use
protective equipment, avoid eating during an application,
avoid wiping sweat, avoid leaking, avoid physical contact,take rest when feeling ill, and take a shower” (Supplementary Table 1).

Outcomes
The primary outcome measure was the number of symptoms experienced. The effects of social demographics andpesticide-protective behavioral scores on the number ofsymptoms were investigated.
Data analysis
First, the social demographics of the participants weresummarized based on sex. The χ2 test or Mann–Whitney U
test were used to determine differences between the sexes.
Second, the proportion of participants with each symptom
associated with pesticide application was summarized basedon sex. The median pesticide-protective behavioral score
was then determined for each of the nine categories, and theaverage was calculated. The average pesticide-protective
behavioral scores and the number of symptoms according
to the main variables were described. A multivariate linear
regression model was constructed to determine the effect ofsocial demographics on the sum of the pesticide-protective

behavioral scores. Sex, age, years of education, and district
were used as explanatory variables. The same multivariate
linear regression model was performed for years of education (less than 3 years or more than 4 years). Finally, multivariable Poisson regression analysis was used to determine
the effect of social demographics and each pesticide-protective behavioral score on the primary outcome. After comparing the predictive power of the outcome variables, theparticipant sex, age, years of education, working experience, instructed experience, and all pesticide- protective behavioral scores were added as explanatory variables. A literature review and Akaike information criterion were used
to choose the appropriate multipliable models. Statisticalsignificance was set at P<0.05. All analyses were performed
using STATA IC15 (Lightstone, TX, USA, version 15).

Results
A total of 210 farmworkers provided consent, completed
the survey, and were included in the analysis. Of the total,
142 individuals were male, the median (interquartile range)
age was 45.4 (IQR=38–55) years, and the number of years ofeducation was lower among women than among men. Only
30 individuals (14.3%) had previously received instructions
on pesticide application (Table 1).
A total of 206 individuals experienced at least one symptom during pesticide application or within 24 h of pesticide
application. The major symptoms were neurological andincluded dizziness, muscular pain, headache, fatigue, andweakness. In addition, mucous membrane irritation symptoms, including eye problems, were frequently found among
farmworkers. However, the appearance of dermatologicalsymptoms was comparatively low among Kratie farmworkers (Table 2).
We also found that farmworkers frequently exhibited
protective behavior, avoided eating during applications,avoided leaking of pesticides, rested when they felt ill,and showered after an application. However, they rarely
used personal-protective equipment (Table 3). The number of symptoms was higher among women, aging adults,
and those who had lower pesticide-protective scores (Table4). We also found that the pesticide-protective behavioral
scores did not differ according to sex and age. However, thefarmworkers in the high-education group and those froma prominent rural area in the Prek Prosorb, Sambour, andSnuol districts frequently exhibited protective behaviors
regarding pesticide applications (Supplementary Table 2).
The multivariable linear regression model for pesticideprotective behavioral scores according to years of education
showed that the protective behavior decreased with working
years only in the low-education group, whereas no association was found in the high-education group (Table 5).
Moreover, the number of symptoms was 1.16 times

2022; 17(4): 214–220 | doi: 10.2185/jrm.2022-019 | 216

Journal of Rural Medicine
Table 1 Participant characteristics

Age (median (IQR))
Years of education (median (IQR))
Years spent working (median (IQR))
District address n (%)
Chet Borey
Prek Prosorb
Sambour
Snuol
Chhlong
Experience of having received instructions previously n (%)

Male (n=142)

Female (n=68)

P value

46.5 (38–55)
4 (3–7)20 (10–30)

45 (37–52.5)
3 (1.5–5)
20 (20–32.5)

0.246
0.009
0.188
0.204

68 (66.0)
21 (77.8)
20 (80.0)
16 (53.3)
17 (68.0)
19 (63.3)

35 (34.0)
6 (22.2)
5 (20.0)
14 (46.7)
8 (32.0)
11 (36.7)

0.588

IQR: interquartile range.

Table 2 Symptoms associated with pesticide application; n (percentage to the whole)

Unpleasant smell
Dizziness
Eye problems
Muscular pain
Headache
Fatigue
Weakness
ThirstPoor appetite
Hyperhidrosis
Taste change
Dyspnea/short breath
Arrhythmia or tachycardia
Numbness
Chest pain or chest stuffiness
Hot sensation
Cough
Laryngeal itch and pain
Pruritus
Fever
Vomiting and nausea
Urticaria
Diarrhea
Swelling
Blister
Dermatitis
Allergy
Syncope
Other

Male
n (%)

Femalen (%)

117 (82.4)
83 (58.5)
86 (60.6)
82 (57.8)
75 (52.8)
77 (54.2)
79 (55.6)
66 (46.5)
56 (39.4)
55 (38.7)
48 (33.8)
45 (31.7)
46 (32.4)
46 (32.4)
41 (28.9)
36 (25.4)
42 (29.6)
36 (25.4)
30 (21.1)
31 (21.8)
27 (19.0)
23 (16.2)
16 (11.3)
13 (9.2)
11 (7.8)
13 (9.2)
3 (2.1)7 (4.9)1 (0.7)55 (80.9)
43 (63.2)
35 (51.5)
38 (55.9)
46 (67.7)
43 (63.2)
40 (58.8)
26 (38.2)
31 (45.6)
29 (42.7)
28 (41.2)
25 (36.8)
23 (33.8)
23 (33.8)
25 (36.8)
23 (33.8)
17 (25.0)
27 (39.7)
31 (45.6)
22 (32.4)
19 (27.9)
20 (29.4)
14 (20.6)
10 (14.7)
10 (14.7)
4 (5.9)10 (14.7)
2 (2.9)1 (1.5)higher among women, increased with work duration,and decreased with age. Pesticide-protective behavioral
scores—based on factors including preparing using gloves,using protective equipment, avoiding wiping sweat, avoiding leaking, and resting when feeling ill—significantly de-Table 3 Pesticide-protective behavioral score during
pesticide application (10=always, 0=never)
Score nameMedian (IQR)

Read labels
Prepared using gloves
Used protective equipment
Avoided eating during application
Avoided wiping sweat
Avoided leaking
Avoided physical contact
Rested when feeling ill
Took a shower
Average

4.5 (0, 6.5)
5.5 (0, 10)
0 (0, 4.5)
10 (10, 10)
5.5 (3.5, 10)
10 (5.5, 10)
4.5 (2, 6.5)
10 (8, 10)
10 (10, 10)
6.4 (5.3, 7.2)

IQR: interquartile range.

creased with the number of symptoms (Table 6). The same
Poisson analysis model with the complete score is shownin Supplementary Table 3 and shows that the results were
almost consistent with the model in Table 6.

Discussion
Research on the health effects associated with pesticide
poisoning among farmworkers (who comprise a potentiallyvulnerable population) and identification of the highly affected group are urgently required in rural Asia. This issue
has been studied in rural Cambodia.
Using multivariate analysis, this study found that the
number of symptoms was 1.16 times higher among women(P=0.004), increased with the duration of work, and decreased with age. These findings are consistent with those ofa previous study in Southeast Asia13). It is worth noting thatthe effects of pesticides might be more significant in womenthan in men because of physical features; therefore, the side
effects of pesticide application could be an issue among fulltime female farmers. Hence, educating these populations on
pesticide protection should be prioritized.

2022; 17(4): 214–220 | doi: 10.2185/jrm.2022-019 | 217

Journal of Rural Medicine
Table 4 Average pesticide-protective behavioral score and number of symptoms by main valuables
Average pesticide protective
behavioral score (Median (IQR))

The number of symptoms(Median (IQR))

6.2 (5.3, 7.1)
6.7 (5.4, 7.4)

7.5 (4, 14)
10 (7, 14)

6.4 (5.3, 7.1)
6.4 (5.4, 7.4)

8.5 (5, 13.5)
10 (3, 14)

6.2 (5.2, 6.9)
6.7 (5.6, 7.4)

9 (4, 14)9 (5, 14)

Sex
Male
FemaleAge
Under 50 years old
50 and over 50 years old
Education
Under 4 years
4 and over 4 years
Pesticide protective behavioral score
Under 6.5
6.5 and over 6.5

11 (7, 16)
6.5 (3, 11)

IQR: interquartile range.

Table 5 Multivariable liner regression model for pesticide-protective behavioral scores by education years

Sex (ref. male)Age (years)
Working years
Instruction (ref. none)
District address (ref. Chet Borey)
Prek Prosorb
Sambour
Snuol
Chhlong

More than four education years (n=117)

Less than three education years (n=93)

B

SE

β

P valueBSEβ

P value

0.07
−0.02
0.01
−0.74

0.31
0.02
0.01
0.39

0.023
−0.1620.105−0.177

0.809
0.221
0.415
0.063

0.46
0.03
−0.04
0.40

0.29
0.02
0.01
0.37

0.163
0.236
−0.356
0.105

0.108
0.068
0.009
0.280

0.59
0.45
0.93
0.00

0.38
0.43
0.40
0.40

0.157
0.105
0.236
0.001

0.124
0.292
0.021
0.994

1.57
1.74
0.79
−0.89

0.49
0.45
0.40
0.54

0.313
0.400
0.195
−0.178

0.002
0.000
0.051
0.101

B: unstandardized regression coefficient; SE: standard error; β: standardized coefficient.

Table 6 Poisson regression model (adjusted incidence-rate ratios) for number ofsymptoms associated with pesticide application

Sex (ref. male)Age (years)
Working years
Education years
Instruction (ref. none)
Pesticide protective behavioral score
Read labels
Prepared using gloves
Used protective equipment
Avoided eating during application
Avoided wiping sweat
Avoided leaking
Avoided physical contact
Rested when feeling ill
Took a shower

IRR

SE

P value

1.16
0.99
1.01
0.99
1.01

0.058
0.003
0.003
0.008
0.067

0.004
0.019
0.002
0.338
0.922

1.01
0.97
0.98
1.01
0.96
0.98
1.00
0.98
1.00

0.007
0.005
0.006
0.008
0.008
0.010
0.007
0.007
0.007

0.122
<0.001<0.001
0.062<0.001
0.018
0.720
0.008
0.970

IRR: incidence-rate ratios; SE: standard error.

2022; 17(4): 214–220 | doi: 10.2185/jrm.2022-019 | 218

Journal of Rural Medicine
Moreover, we observed several preventive behaviors
that were effective in reducing the health effects of pesticides. In particular, five of the nine behaviors (preparing
using gloves, using protective equipment, avoiding wiping
sweat, avoiding pesticide leakage, and resting when feelingill) significantly suppressed the number of pesticide poisoning symptoms. Additionally, four of the five behaviors havebeen correlated with pesticide poisoning in previous studies16). However, many farmworkers do not engage in these
protective behaviors, and our study found that it is necessary to educate farmers on these practices. Specifically,
particular groups—women and those who have worked forlong durations—could be prioritized for these educational
interventions.
The protective behaviors for pesticide use might decrease during the working year only among the low-education group, as we found no association on multivariable
analysis in the high-education group. The low-educationgroup required special and longer instructions for pesticideprotective actions; therefore, further research is required on
this issue.
In the present study, most of the symptoms related topesticide application were neurological. A total of 98% of
the farmworkers in Kratie had at least one pesticide poisoning symptom after pesticide application or within 24 h. In
this context, many other diseases and neurological symptoms have been reported in previous studies, including
cancer, DNA damage, respiratory effects, developmental
disorders, and sterility8). However, some of these symptoms
are silent and often not apparent until the disease worsens.
The number of non-communicable diseases that are also silent diseases has been increasing in Cambodia. Thus, healthcheckups should be widely conducted in vulnerable populations to identify these silent diseases in the early stages.
Verifying the credibility of pesticide effects is difficult without an evaluation of the baseline health status determined bywidespread health checkups among farmworkers.
Several limitations of this study should be consideredwhen interpreting the findings. First, the frequency of
symptoms was not measured in this study, and informationon the frequency of each symptom is needed to more accurately understand symptoms related to pesticide application. Second, we did not obtain important information about
economic disparities in the study population (e.g., economic
status and family structure). Third, while we selected fiverural districts in Kratie, convenience sampling was conducted in each district. Fourth, there are wide variations inagricultural products, soils, and climates within Cambodia;
hence, the generalization of these results to all of Cambodia
requires caution. Fifth, the Cronbach’s score for pesticideprotective behavior was 0.4519; thus, the reliability of pesticide-protective behavior was not confirmed. The reason forthis finding might be that the questionnaire was minimal.

Nevertheless, the questionnaire was created after discussions between medical staff, specialists in pesticide use, andlocal staff. Further improvement of the questionnaire is required. Finally, we did not obtain information on the type of
pesticides used. Although the present study had these limitations, it is the first to identify groups with several symptoms associated with pesticide application and to determine
associated protective behavior in rural Cambodia, where
pesticide poisoning is a significant problem.

Conclusions
The present study identified a group vulnerable to pesticide poisoning as well as significant protective behaviors
associated with self-reported symptoms caused by pesticide
application. Women and those with longer work durations
might have to be prioritized for education regarding pesticide protection. We also found that using gloves, using protective equipment, avoiding wiping sweat, avoiding pesticide leakage, and resting when feeling ill were significant
protective behaviors. Moreover, further research is required
to investigate objective health effects and self-reported
symptoms to protect the health of farmworkers, a vulnerable, hard-working population.
Author contributions: The author contributions wereas follows: conceptualization, Y.K. and L.S.; methodology,
Y.K. and L.S.; software, Y.K.; validation, Y.K. and L.S.; formal analysis, Y.K.; investigation, L.S. and S.H.; resources,
Y.K. and M. T.; data curation, L.S.; writing and originaldraft preparation, Y.K.; writing and review and editing,M.T., Y.N., N.L., and M.O.; visualization, Y.K.; supervision,
M.T., Y.N., N.L., and M.O.; project administration, Y.K.,
L.S., M.T., and N.L.; funding acquisition, Y.K. All authors
read and agreed to the published version of the manuscript.
Funding: YK received a personal research fee from the
National Mutual Insurance Federation of Agricultural Cooperatives for research titled “Health survey among farmers
in rural Asian developing countries”. This research did notreceive any other specific grants from any funding agency
in the public, commercial, or not-for-profit sectors.
Conflict of interest: YK received a personal researchfee from the National Mutual Insurance Federation of Agricultural Cooperatives. This funding source had no role inthe design, practice, or analysis of this study. The other authors declare no conflicts of interest.

Acknowledgements
We thank Dr. Hiroshi Nagami and Prof. Kayako Sakisaka for providing constructive advice to support the dis-

2022; 17(4): 214–220 | doi: 10.2185/jrm.2022-019 | 219

Journal of Rural Medicine
cussion in this research. We would like to thank Miss Peng
Sithy, Mr. Chhen Senny, Mr. Chheang Rathana, and Mr.
Heng Bunnara who provided critical data for this study.
Since the corresponding author received a personal researchfee for the research entitled “Health survey among farmer
in rural Asian developing countries” from the National Mutual Insurance Federation of Agricultural Cooperatives, apreliminary report was presented in the Kyosai-Examiner-

Tsuushin (a non-peer reviewed Japanese journal publishedby National Mutual Insurance Federation of Agricultural
Cooperatives). The National Mutual Insurance Federationof Agricultural Cooperatives approved the publication of
papers using data obtained through a research grant fromthe National Mutual Insurance Federation of Agricultural
Cooperatives in 2020.

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