8

Communications, Training, and Education Gaps and Strategies

The seventh session of the workshop explored strategies to improve health education for farmworkers, highlighted effective personal protective equipment (PPE) education programs, and identified gaps in current education efforts. Bethany Boggess Alcauter, director of research and public health programs at the National Center for Farmworker Health (NCFH), moderated the session.

HEALTH COMMUNICATIONS AND INFORMATION ACCESSIBILITY

California Public Health Department H5N1 Outreach Response

Sara Floor, creative unit supervisor for the California Department of Public Health (CDPH), highlighted CDPH’s efforts to partner in collaborative outreach, strengthen local public health, communicate effectively with the public, and develop effective response plans. In 2022, CDPH began responding to Influenza A(H5N1) outbreaks at poultry and egg farms. These outbreaks have not led to any identified cases in poultry farmworkers or in owners of backyard birds in California. She noted that although commonly called “bird flu,” H5N1 can infect humans and other mammals and represents a strong public health concern. The top producing milk state in the nation, California has over 1,100 dairy farms with almost 2 million cows. As outbreaks in cattle were detected in other states in the spring of 2024, CDPH began building an H5N1 dairy response team

with over 200 employees. Initial detections of infected cows in California occurred on three dairy farms in late August 2024. Less than a year later in July 2025, over 771 California farms had confirmed cases of H5N1 in dairy cows. Moreover, 38 human cases were identified, most of whom were dairy farmworkers, in addition to one probable case (Zhu et al., 2024). Their symptoms were mild, primarily consisting of conjunctivitis, and they did not require intensive treatment. These cases informed CDPH outreach efforts, said Floor.

Farmworker Outreach

Outreach goals included (1) effectively and equitably communicating health information to at-risk populations; (2) supporting local health department response efforts; (3) supporting distribution of PPE to farmworkers; and (4) increasing access to testing and seasonal flu vaccine through mobile clinics, Floor outlined. The COVID-19 pandemic demonstrated the importance of effective communication and tailoring the response approach to each audience. She emphasized that distinct communication strategies apply to dairy farmworkers, dairy farm owners, and local health departments conducting outreach, and that messages differ across these groups. Moreover, outreach activities should consider the current social climate. According to Floor, pertinent social dynamics include distrust of the government and public health, lack of public health relationships with and/or access to farms, farmworker fear that expressing concern or asking for PPE could result in retaliation such as deportation or job loss, and uncertainty about the effects of the virus on human health.

To contend with these challenges, CDPH took a collaborative approach to outreach by partnering with state agencies involved in the H5N1 response, Floor stated. Prior to joining CDPH’s communication team in October 2023, she worked at the Dairy Council of California, a dairy industry-funded marketing order under the auspices of California Department of Food and Agriculture. She used her connections within the dairy industry to establish a partnership with Western United Dairies the state’s largest membership-based dairy farmer trade organization, and this relationship helped her communicate to dairy farm owners and state agencies about the nature of the H5N1 outbreaks and their ramifications at the farm level. State agency partners included the California Division of Occupational Safety and Health (Cal/OSHA), the California Department of Food and Agriculture (CDFA), and Listos California, an emergency preparedness agency. The collaborative outreach effort also incorporated community benefit organizations such as NCFH; the Western Center for Agricultural Health and Safety (WCAHS) at the University of California (UC), Davis;

and the UC Merced Community and Labor Center. These organizations leveraged established communication lines with dairy farmworker communities to distribute information and to guide the refinement of materials to ensure they were as useful as possible. The various agencies and organizations involved assisted in hosting 87 outreach events for dairy owners and farmworkers. She noted that participants felt more comfortable asking questions at events hosted by organizations trusted by the dairy industry. For instance, one outreach event was offered at the Western United Dairies supervisor seminar. These outreach activities featured PPE distribution and clear, confirmed information about the developing H5N1 outbreaks. In partnership with NCFH, CDPH offered a training for health care personnel that Floor described as effective in disseminating information to target audiences.

The California dairy industry contains numerous multigenerational family farms and is highly relationship-driven, said Floor. However, relationships between local health departments and nearby dairy farms were lacking. When local health departments began reaching out to farms about H5N1, many farm owners conveyed apprehension about attempted contacts and visits from people not affiliated with their dairies, she noted. Deeply concerned about saving their herds from H5N1, dairy owners were focused on the intensive interventions necessary to protect their cows. Meanwhile, CDPH and local health department staff were contacting them about dairy worker health, with some farmers being contacted by multiple individuals. Miscommunication was common, and some owners had concerns about the logistics and potential ramifications of health checks, symptom monitoring, and reporting. To combat these challenges, CDPH held weekly meetings with Western United Dairies. The department asked for guidance on how to effectively communicate to farm owners that CDPH is not an enforcement entity and that local health jurisdictions are contacting them to protect the health of dairy workers and the local community. Floor suggested that in addressing any future outbreaks, local health departments should assign one individual as a point of contact to each farm to establish relationships and build trust. Although CDPH distributed over 5 million units of PPE, the department received reports that some farmworkers were resistant to wearing it. In the Central Valley of California, temperatures often reach 100 degrees Fahrenheit in the summer, with readings sometimes as high as 110 degrees. Many dairy workers found wearing PPE to be very uncomfortable in such hot weather. To help address these concerns, CDPH sought out the most effective PPE for farmworkers and collaborated with CDFA and Cal/OSHA to increase worker awareness of the risk of H5N1 and the importance of seeking treatment, said Floor.

Developing Effective Communications

Given that the human health risk of H5N1 to the general public is relatively low, CDPH targeted communications efforts to dairy farmworkers, Floor noted. In this effort, the CDPH worked to identify effective communication channels, use literacy levels appropriate for the intended audience, and balance Cal/OSHA regulations with the realities of farm work. Collaborating closely with community benefit partners, CDPH crafted the communications response, and farmworker focus groups and committees at NCFH and WCAHS reviewed educational materials and provided feedback. From this feedback, CDPH learned that many dairy farmworkers respond to appeals to protect their families and coworkers more than to other PPE messaging approaches. Additionally, they learned that the WhatsApp messaging application is widely used among farmworkers due to its popularity in other countries and that farmworker communities often appreciate printed educational materials. Incorporating input from farmworkers and partner groups, CDPH lowered the literacy level of their materials, used a large number of photos, retooled materials for WhatsApp, and developed several handouts printed in Spanish on one side and English on the other for distribution within farmworker communities, said Floor.

To disseminate educational materials, CDPH compiled a H5N1 communications toolkit and made it available to agencies, local health departments, and the public via their website, Floor highlighted.¹ The department met with local county health public information officers in the affected counties on a weekly basis to understand the needs, concerns, and gaps transpiring at the local level. The CDPH media team worked continuously to answer questions about the outbreaks. They developed videos in Spanish and English that could easily be uploaded and forwarded to contacts within WhatsApp. Floor noted that WhatsApp is an instant messaging platform that enables users to create groups and send materials, audio files, and videos to individuals or groups. Leveraging this capability, CDPH transformed all social media assets to a WhatsApp format. Additionally, CDPH partnered with NCFH in utilizing their multilingual information and helpline, a partnership that Floor described as a tremendous asset.

Planning for Future Emergencies

Floor stated that the aforementioned efforts took place from April 2024 to February 2025. The department lacked emergency funding and relied heavily on community benefit organizations and internal resources

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¹ The toolkit is available at https://www.cdph.ca.gov/Programs/OPA/Pages/Communications-Toolkits/Bird-Flu.aspx (accessed November 12, 2025).

for Spanish translation services. When limited emergency funding became available, it carried the stipulation that funds must be expended by June 30, 2025, giving the department 2.5 months to use the funds. In working with a marketing agency, CDPH prioritized projects that would aid future responses and could be completed in a short timeframe. These projects included a PPE photo and video library, Indigenous language transadaptation, and a response plan. She highlighted a gap in available images depicting PPE for aerosol transmissible disease that meets California standards. Noting that images from the Centers for Disease Control and Prevention (CDC) issued helpful materials, she said they do not match state regulations. To fill this gap, CDPH determined to create a library of photos and videos of farmworkers correctly using PPE. Filmed in both Spanish and English, the videos are tailored to dairy and poultry settings. The dairy videos were filmed on a working dairy to realistically portray hazards and tasks, and the CDPH Occupational Health Branch was on site to ensure that all footage displayed PPE use in accordance with California standards. Floor commented that CDPH collected footage for PPE aside from that needed for H5N1, creating images available for future responses to other threats, and CDPH is currently working to make the library public-facing.

Another initiative addresses the wide diversity of languages spoken by dairy farmworkers, said Floor. In collaboration with community organizations, CDPH selected numerous Indigenous languages to translate public service announcements into, such as K’iche’, Mam, Nahuatl, Q’anjob’al, Zapotec, Purépecha, and Mixtec. Given that some of these languages lack written form, CDPH created recordings to reach speakers of these languages and to create accessibility for all literacy levels. She noted that these materials are linked in the communication toolkit. Lastly, CDPH developed a detailed response plan tailored to H5N1 that provides an applicable framework for any zoonotic response. She indicated that despite extensive crisis training on zoonotic diseases, the emergence of “bird flu” in cattle was surprising. Floor suggested that this resource would be helpful in the event of another zoonotic disease or the spread of H5N1 to a different industry, and it can be adapted for unknown emergencies.

National Center for Farmworker Health H5N1 Response

Lisbeth Gall, associate director of population health programs at NCFH, outlined the process of creating educational materials in a variety of media and languages that feature farmworker photos and illustrations. As a nonprofit organization based in Texas, NCFH works toward the mission of improving the health of farmworker families. The organization responded to H5N1 outbreaks with a multipronged approach featuring local farmworker outreach, network building, health education, training and capacity

building, data collection for action, and evaluation and feedback. In these efforts, NCFH partnered with 22 organizations across 11 states, enabling extensive farmworker outreach and collaboration with experts in various fields, Gall highlighted.

Health educators play an essential role in communicating with various populations and providing health education to raise awareness and ultimately change workplace practices and behaviors, said Gall. As the H5N1 outbreaks first emerged, NCFH identified the importance of understanding farmworker challenges, work circumstances, demographics, beliefs, priorities, and potential barriers. Additionally, NCFH identified challenges that outreach workers would likely encounter, essential information with which to prepare them, and a protocol for maintaining their safety during outreach farm visits. The organization also considered the health education and communication strategies most likely to be effective with animal farmworker populations. Gall clarified that although farmworker health is NCFH’s focus, employees working in animal production are a subpopulation with needs and challenges that can differ from those working in crop agriculture.

Creating health education materials for dairy workers begins with message development by NCFH staff, Gall outlined. They consider key information and guidelines in drafting content about awareness, prevention, and a call to action while following plain language principles. Farmworker committees review and offer feedback on all materials that NCFH creates. She remarked that because NCFH is not embedded within the community, feedback from farmworker committees helps the organization understand perceptions of its messaging and improve clarity. For H5N1, NCFH formed a review committee from seven dairy workers living in different areas of Texas and other U.S. states. Once the organization incorporates feedback and finalizes design, the materials are published in both Spanish and English using a variety of media types. Most commonly, NCFH creates outreach flyers that can easily be discussed with workers during health education activities. Outreach workers create or join existing social media and messaging groups, and NCFH creates custom graphics and messages to share on WhatsApp, Facebook, and Instagram. Public service announcements are issued via local radio stations, said Gall, adding that NCFH produces audio recordings in English, Spanish, and Indigenous languages that are linked to printed materials via quick-response (QR) codes.

Translation of materials to multiple languages is key in reaching farmworkers, Gall stated. Data collection conducted by NCFH’s research team informs understanding of farmworker demographics and the languages spoken within specific farmworker populations. A NCFH survey of 708 dairy workers found that on average, farmworkers completed 8 years of

schooling and had been working in the United States for 8 years. Additionally, 15 percent of participants were Indigenous, and 21 different languages were currently spoken among those surveyed. To address this broad linguistic diversity, NCFH works with contractors who specialize in translating content into Indigenous languages. This process requires farmworker origin data that, at minimum, provide country of origin and ideally specify the state or town of origin, enabling the translators to identify the best language match for the population. She noted that most of the languages are from Mexico, and some are from Guatemala. Many Indigenous languages are not traditionally written, making audio files essential in providing access to educational materials for speakers of these languages. Gall remarked that linking audio files of health messages via QR codes to educational materials has proven effective in increasing accessibility.

Representative images are important in farmworker outreach, said Gall, noting that farmworkers want to see themselves reflected in the health education materials provided by NCFH. The organization strives to do this in a culturally sensitive way, seeking feedback from farmworkers about whether images are appropriate and realistic. She commented that NCFH uses photographs when possible and contracts an illustrator to create images when necessary. For instance, a photo of a farmworker realistically depicted the dairy setting and work task, but some of the PPE the employee was wearing was not aligned with the recommendations NCFH sought to represent. Referencing the photo, the illustrator captured many of its elements while changing the PPE depicted. Gall highlighted that all illustrations are reviewed by the NCFH farmworker committee before incorporation into educational materials.

Outreach workers connect directly with farmworkers, and NCFH conducted training to update staff on key information about H5N1 and steps to prevent transmission, said Gall. The organization created illustrations, activities, discussions, and PPE recommendations for outreach workers to share with farmworkers, and they reviewed protocols for outreach workers to follow to remain safe while conducting farm visits. Research on the media habits of farmworkers informs NCFH outreach efforts. In a survey of preferred social media platforms, 76 percent of farmworkers participating indicated that they use Facebook, 59 percent use WhatsApp, and 46 percent use TikTok. Gall noted that TikTok usage was a surprising change from previous assessments and indicates the platform’s increasing popularity among farmworkers. The organization also surveyed farmworkers about their top sources of health information. Sixty percent of respondents cited the internet, including social media, as their most utilized source. Community health centers and family or friends were less popular sources, each selected by 11 percent of participants. Few farmworkers used additional media sources such as television, radio, and newspapers for health

information. Gall emphasized that substantial majorities of the survey participants rely on social media and the internet for information, and this understanding is important in planning health information dissemination strategies.

TRAINING AND EDUCATION PROGRAMS

Carolyn Sheridan, executive director and founder of Ag Health and Safety Alliance (AHSA), and Jenna Gibbs, director of operations at AHSA, outlined agriculture-focused PPE training strategies and materials. As a nonprofit organization, AHSA offers health and safety training for the next generation of agricultural workers, with a focus on farmworkers aged 18–25 years in the United States and Canada. Gibbs noted that although these workers are young adults, many grew up on farms and have established safety habits. Emphasizing the value of engaging, hands-on training, she noted that people unfamiliar with PPE sometimes find it intimidating. During AHSA trainings, educators guide farmworkers in proper donning, doffing, and use of PPE. They use shaving cream to represent a pathogen in activities focused on protection against contamination. After handling items covered in shaving cream, participants are guided though doffing PPE in the correct order. Gibbs highlighted that in post-training follow-up, participants indicated that the training increased their confidence in using PPE on the farm, and many purchased additional PPE after learning about its benefits and proper use.

In addition to in-person training, AHSA offers engaging media to reach young adults, said Gibbs. Underscoring the value of representative imagery in health materials, she noted feedback from the target audience indicating a preference for images depicting agricultural, rather than clinical, work settings. In recent years, AHSA has partnered with a graphic novel illustrator to create materials that describe the importance of PPE in a format similar to a comic book. Gibbs clarified that not all these materials are specific to H5N1, but they encourage proper use of PPE to guard against any airborne pathogen. Sheridan highlighted that many of the young farmworkers in their target audience are relatives working on family-owned farms, therefore they often have substantial leeway in making decisions about their safety practices. In partnership with the Central States Center for Agricultural Safety and Health, AHSA recently produced a series of videos on proper techniques for donning, doffing, cleaning, and storing PPE that was made possible by a grant from the National Institute for Occupational Safety and Health (NIOSH); these videos are specific to poultry and dairy work settings and feature young adults. Sheridan remarked that in-person trainings offer insight on the questions and challenges some young people have as they begin to use PPE, and the videos address these. She added that

proper cleaning and storage of PPE is important to the economic feasibility of investing in reusable protection. The videos, each 3 to 4 minutes in length, are now being incorporated into AHSA Gear Up for Ag programming and other training opportunities. Moreover, ASHA is experimenting with training young people through immersive, virtual reality (VR) technology. Wearing VR headsets to view 360 videos, participants can explore and interact with farm settings and situations, allowing them to feel immersed in the environment even if they are unfamiliar with agricultural workspaces. The 360 videos feature scenarios of donning and doffing PPE. Emphasizing that the next generation of agricultural workers learn in diverse ways, Sheridan highlighted that offering a variety of entertaining educational media provides participants with opportunities to learn by listening, watching, and/or moving.

Over the course of training thousands of students and other audiences, AHSA educators have learned that hands-on practice is essential, Sheridan stated. Coupling the practice with individual coaching enables participants to try different types of PPE, determine the correct size for their bodies, experiment with donning and doffing techniques, and ask questions. She emphasized the importance of training that is relatable and relevant to farmworker experiences, needs, and interests. Engaging methods include modern video tools, such as VR 360 videos or multi-modal videos that combine text, visuals, voiceover, and closed captioning. Given that PPE access is a common barrier to safe farmworker practices, Sheridan underscored the importance of PPE distribution. In the absence of PPE provision by a safety officer or employer, many farmworkers lack access. Gibbs highlighted feedback from farmworkers that PPE is often difficult to access in stores or other locations in their communities. She described a frustrating scenario in which a farmworker is encouraged to wear four different types of PPE, but only one type is available at the local store and the size does not fit the worker. To address this barrier, AHSA provides PPE free of charge to all training participants, said Gibbs. Sheridan highlighted follow-up survey findings that indicate that farmworkers provided with PPE are more likely to purchase it for themselves in the future. Combining PPE availability with education leads to use, Sheridan stated, and ensuring access to both is important to outbreak response efforts.

DISCUSSION

California Farmworker Ethnic Subpopulations

Noting that the CDPH communications toolkit is available in Dutch, a participant asked whether the California population of Dutch-speaking farmworkers is sizable. Floor replied that a number of Dutch dairy farmers

immigrated in the 1960s and 1970s and settled in Los Angeles County and the California Central Valley. With a mission to protect the health of all Californians, CDPH strives to provide materials in all languages spoken by California dairy farm owners and workers. Highlighting the diversity within California’s dairy farm community, Floor noted that CDPH materials are also available in languages spoken in the Middle East and Asia, including Dari, Pashto, Punjabi, and Hmong.

Farmworker Education Success Stories

In response to a call for PPE education success stories, Sheridan commented that young people in AHSA trainings sometimes ask for PPE to share with parents or grandparents or ask for tips on how to explain the importance of PPE to others. She remarked that an individual’s desire to spread a message of safety throughout a multigenerational farm signifies that the training made a difference for that person. Alcauter recalled seeing dairy workers on a New York farm wearing waterproof, reusable sleeves that clip in the back. Having heard farmworkers in other locations complain about the lack of protective sleeves that met their needs, she asked the dairy workers to strike model poses for photos. Alcauter shares these photos on farm visits to make workers aware that this option is available. Gibbs remarked that training participants have commented that PPE is for people who work in hospitals, not on farms. Highlighting shifts in understanding about the current risk of infectious disease in nonclinical settings, Gibbs emphasized the role of imagery depicting people using PPE in farm environments.

Lessons Learned from H5N1 Outbreak Response

Alcauter asked the panelists what they would do differently in their outbreak responses if equipped with more resources and the knowledge about H5N1 that they have today. Floor recalled how time consuming it was for CDPH graphic designers to search for clip art and accessible licensed photos and to edit these images to reflect California standards. The lack of relevant, representative photos spurred CDPH to use funds—once they became available—to fill this gap. They collected photo and video footage of farmworkers in a wide variety of PPE, creating an image library that not only meets H5N1-related needs, but can also be used for future threats that may require different PPE than that necessitated by H5N1. Floor suggested that establishing this library and making it widely available would serve future outbreak responses. Gibbs described how AHSA applied for a grant through the U.S. Department of Agriculture (USDA) to conduct a statewide PPE availability survey in Iowa focusing on infectious disease emergency

response. However, the USDA grant is no longer available. Gibbs stated that better understanding of PPE access and availability could inform future responses. Sheridan expressed her surprise at discovering how difficult it can be for farmworkers to obtain PPE, particularly PPE that fits their bodies properly. The availability of respirator fit testing is extremely limited, and ensuring proper fit is challenging in the absence of a safety officer or other professional providing expert guidance. Sheridan added that depopulations sometimes require assistance from USDA or other organizations, and employees from these groups may have PPE that farmworkers do not have access to. Gall remarked on the utility of having educational materials that depict farmworkers correctly using and disinfecting PPE in a realistic farm setting, and she stated that such materials would have been helpful at the onset of H5N1 outbreaks on farms.

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