The fishing industry includes a wide variety of commercial operators, ranging from small, independent fishing operators using a mix of traditional and modern techniques, through to large ocean going vessels that are highly mechanized. Although fishing has been noted as an occupation with a high risk of traumatic occupational injury since 1713,¹ the literature on fishing related injury relates mainly to deep sea fishing and/or large scale industrialized operations.^2–7 Relatively little is known about injuries in small scale independent fishers who are less industrialized and fish in coastal areas and inland waterways.

Commercial fishers in eastern North Carolina are small scale independent commercial fishers who work the coastal areas and inland sounds and rivers along North Carolina’s coast.⁸ They mainly conduct finfishing and crabbing, followed by shrimping, clamming, and oystering. These fishers operate small and medium size vessels with typical crew sizes of one to three people.^9,10 There are over 7000 such independent operators in North Carolina. In 2002, the fishing industry was North Carolina’s highest earning agricultural industry, with over $94 million dollars in revenue.

We established a prospective cohort study of fishing related injury in this fishing community. This initial report uses baseline data from that cohort to describe the nature and circumstances of the work related injuries sustained by this group of small scale, independent commercial fishers, based on a 12 month retrospective recall of injury.

METHODS

For logistical efficiency, this study utilized a cohort of volunteer participants established as part of a previous study of exposure to a toxic marine micro-organism and possible impairments in neurological function (the “parent study”). At baseline assessment, the subjects completed a self administered questionnaire during a clinic visit. The questionnaire asked details of their worst traumatic injury in the 12 months before baseline. We obtained detailed information on the type of fishing they were engaged in, whether the injury was on-water or off-water, their activity immediately before the injury, the contact that caused the injury, the type and site of injury, level of care received, and impact on work.

The target population for the parent study was individuals 18–65 years of age who worked on the inland sounds and rivers, or on the ocean, for at least 20 hours per week for at least six months of the year. Subjects were recruited through a wide variety of mechanisms during the period April 1999 to May 2000.⁸

During August 2000 to May 2002, two ethnographers from our research team conducted extensive fieldwork in order to characterize the nature of fishing work in eastern North Carolina. They conducted interviews, took photographs and video footage, and studied patterns of communication in the community.¹¹ Selected quotes from the field interviews are included here in order to provide an anthropologic context for the epidemiologic results.

Results from the ethnographic research demonstrate that fishers have a low level of utilization of medical services, and are traditionally reluctant to take time off work to get care for, and recover from, injuries. We therefore used a very inclusive definition of injury in order to fully characterize the injury experience of these workers. We asked about the circumstances and natures of the “worst” injury event in the previous 12 months that “damaged your body” and required “first aid at the time of injury, or medical care at some later time, or time away from work”. “Work related” injury events were defined as any injury event in the course of fishing work, where fishing work was defined to include off-water activity such as fishing related maintenance (for example, boat repair) or fishing related transportation (for example, driving to the dock), as well as the actual work of harvesting catch on the water.

We also collected data on multiple injuries resulting from a single event. For example, a fall from a ladder might result in both a fracture and a concussion. In analyses dealing with circumstances of the event, we used the injury event as the unit of analysis. In analyses dealing with the nature of the injuries—that is, the physical damage—we used the injury as the unit of analysis.

The parent study enrolled 238 subjects. Of these, 230 consented to participate in the injury component of the study. We excluded 11 individuals were not actively engaged in commercial fishing, and a further four individuals who either did not complete the injury questionnaire as part of their baseline testing session or did not attend a baseline testing session that included the injury questionnaire. The final study size was 215.

RESULTS

Table 1 presents selected quotes from the ethnographic interviews. Themes of reluctance to seek medical care, injury from contact with marine animals, and issues around lifting emerged from some interviews, although it should be noted that the predominant themes of the interviews were related to the economic realities of making a day-to-day living from fishing and concerns about state regulations pertaining to the fisheries. Note that the respondents to the field interviews were not members of the cohort, but were other commercial fishers in eastern North Carolina.

The cohort itself was predominantly white (only one African-American) and male, with an age range of 18–65 years. The two main types of fishing conducted during the previous 12 months were finfishing and crabbing (table 2), followed by shrimping, oystering, and clamming. Seventy seven percent had engaged in more than one type of fishing during the previous 12 months.

Eighty three of respondents reported at least one injury in the previous year. The 12 month retrospective recall incidence proportion was therefore 83/215 or 38.6 per 100 workers (95% confidence interval (CI) 32.1 to 45.1). The fishers who reported an injury event were generally similar, in terms of demographics and the type of fishing, to the uninjured (table 2).

Fourteen percent of the injury events (12/83) resulted in time lost from work, and 25% (21/83) interfered with work but did not result in time lost. Nineteen percent of injury events (16/83) required care from a medical professional. The 12 month retrospective recall incidence proportion for lost time and medical care injuries was therefore 5.6 per 100 workers (exact 95% CI 2.9 to 9.6) and 7.4 per 100 workers (exact 95% CI 4.3 to 11.8), respectively.

The majority of the injury events (54/82 or 65%) took place between 7:00 am and 1:59 pm, when fishers are generally on the water harvesting catch. A further 16% (13/82) occurred between 2:00 pm and 6:59 pm, typical times for selling catch and equipment maintenance. Time of day was missing for one injury event.

The majority of the injury events occurred on the water (table 3). The most common activity before injury for on-water injury events was hauling up nets, pots, or lines. More than half of the on-water injury events involved contact with marine animals (see table 1 for more on the hazards posed by marine animals). The most common type of fishing conducted on the day of injury event, for both on-water and off-water injuries, was crabbing followed by finfishing.

Off-water injury events accounted for 18% of all injury events (table 3). The majority of these occurred on the dock and many involved lifting or moving a heavy object. The most common activity for off-the-water injury events was maintaining equipment or boat, trailering the boat, or working with equipment.

The 83 injury events resulted in 94 injuries. In 74 events there was one injury, seven events resulted in two injuries, and two events resulted in three injuries. Injuries to the hand, wrist, and digits accounted for half the total (47/94), followed by back injury (12/93 or 13%) and injuries to the upper extremities (9/94 or 10%) and shoulders (8/94 or 9%).

The most common type of injury was penetrating wound (44/94 or 47%) followed by sprains and strains (23/94 or 25%). Of the penetrating wounds, 87% (39/44) were to the hand/wrist/digits, 32% (14/44) became infected, and 80% (35/44) were associated with contact with finfish, shellfish, or other marine animal. Of the 94 injuries, a total of 19% (18/94) became infected. All penetrating wounds that became infected were reportedly due to contact with finfish, shellfish, or other marine animal.

Of the strains/sprains, 48% (11/23) were to the back and 26% (6/23) were to the shoulder. Seventy percent (16/23) of strains/sprains were associated with moving heavy objects. Finally, there were two cases of sunburn and one of concussion.

We also asked about general safety behaviors and attitudes in an effort to elicit preliminary information about beliefs and attitudes that might be useful for designing prevention programs. There was no difference in reported swimming ability, seatbelt use, belief in the preventability of injuries between injured and uninjured (table 4).

Because this was a retrospective recall study, we examined the data for evidence of recall effects, such as memory decay (tendency to forget minor injuries that are distant in time). Figure 1 is a histogram of the recall period (the number of days between the date of administration of the injury questionnaire and the self reported date of the injury event) and indicates no memory decay (memory decay would create clustering of data towards the left hand side of the chart). If anything, the frequency distribution was shifted towards the right hand side of the chart, suggesting the possibility of memory telescoping (tendency to falsely remember major injuries as occurring recently in time).

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Figure 1

 Recall bias plot: elapsed time since reported injury (n = 83).

DISCUSSION

This group of 215 commercial fishers self reported 83 injury events over the previous 12 months. The most common types of injuries were penetrating wounds to the hand/wrist/digits resulting from contact with marine animals and sprains/strains while moving heavy objects. The fishers who reported an injury event were generally similar, in terms of demographics and the type of fishing, to the uninjured, indicating that these injuries arise are part of the typical workday experience for these workers.

This volunteer cohort cannot be considered a random sample of the community of fishers in eastern North Carolina. However, the parent study was related to a non-injury topic, so it is possible that their injury experience did not differ in some systematic fashion from the fishers who choose not to participate. Workers who experienced very disabling injuries before the initiation of this study, and were forced to leave the fishing workforce before our study started, would not be included here. Disabling injuries during the course of the study would have been captured.

These fishers are largely self employed or working for small operations, and are therefore unlikely to have health insurance coverage through their employment or to be covered by workers’ compensation plans. Therefore, our incidence proportion estimates for lost time and medical care injuries (5.6 and 7.4 per 100 workers, respectively) may considerably understate the true injury morbidity of this population. Seeking medical care and taking time off work may involve out-of-pocket expenses that these workers are unable to recoup, resulting in a high proportion of injuries receiving self care. Because the proportion of self employed, uninsured workers in this workforce is high, we advise caution when comparing the incidence estimates for lost time and medical care injuries with other industries.

Nearly half of the injury events occurred during crabbing. However, it does not necessarily follow that crabbing is particularly dangerous activity. Crabbing is one of the main types of fishing currently conducted in eastern North Carolina, and it reasonable to assume that the cohort spent more time crabbing than any other type of fishing during the recall period. Data on both injury incidence and time spent fishing is required in order to make inferences about the relative risk of the different types of fishing.

The recall period used in this study—12 months—was selected because we considered a priori that these workers would be able to reliably recall their work related injuries over this period. Some methodologic studies have identified strong recall decay effects for injuries over a 12 month period,^12,13 however, we did not observe any evidence of recall decay in this study. Given the highly physical nature of fishing work, and dependence of this workforce on a routine daily catch to generate a steady income, it is plausible that they have good recall of their work related injuries. In addition, we asked only about “worst” injury event over the previous 12 months, and this may have minimized recall decay, although this type of question presumably introduces the potential for increased memory telescoping. We also attempted to elicit information about off-water injury events, however, it must be noted that fishers may regard off-water work (for example, boat maintenance) as less directly related to their economic livelihood than on-water activity.

Like traditional farmers, these fishers live and work in communities that are geographically dispersed but socially close knit.^9,10 In such communities, diffusion of innovation can be rapid when new techniques or technologies have a clear commercial advantage. This suggests successful injury interventions should not only be effective in preventing injury, they should also be affordable and able to be readily implemented within the framework of existing fishing work activities.

Given the large of proportion of injuries that were penetrating wounds to the hand resulting from contact with marine wildlife, there would seem to be considerable opportunity for increased hand protection. The hand protection typically used by these workers consists only of cloth or rubber gloves, which offer limited protection but do not interfere with dexterous manual tasks such as removing fish from nets, shaking a crab pot, removing crabs from pots, and rebaiting pots. The meat processing industry, which also requires hand protection that minimally restricts manual dexterity, has developed chain mesh gloves with plastic wrist protectors that extend upwards over wrist area. These appear to have been effective in reducing hand injury in that industry.¹⁴

Fishing work imposes stressful loads on the musculoskeletal system.¹⁵ Heavy containers filled with bait or catch must be loaded and unloaded from the boat at the beginning and end of each workday, and moved around within the confined quarters of the boat during the workday. Maintenance of equipment, such as trailers and boats, also involves lifting of heavy, bulky loads under challenging environmental conditions. Increased use of overhead lift cranes on the dock and ramp, and possibly the boat, could do much to reduce the ergonomic stresses of this work. However, innovative engineering solutions are needed to ensure that such equipment can be seamlessly integrated into current work practices. Our ethnographic team learned of only two fishers who routinely employed mechanical aids for lifting or moving catch. Both were over the age of 70 years, and were unable to perform this lifting without assistance.

This cross sectional survey identified penetrating wounds to the hand/wrist/digits from marine animals and strains/sprains to the back while moving heavy objects as the most common injuries in this type of small scale, independent commercial fishing. Interventions for these injuries may include increased use of hand protection and lifting equipment, however, in order to be effective, these interventions probably need to be economically feasible and well integrated into existing work activities.