Set When the Sun Rises, Rise When the Sun Sets: Climate Impact on Health, Safety, and Wellbeing of Smallholder Farmers in Vietnam

Abstract

Vietnam is a country most at risk for experiencing climate change effects, especially increasing temperatures. Agricultural production is one of the biggest contributors to Vietnam’s economy. Recent research has explored how climate change will impact agriculture in Vietnam. However, the impact of climate change to the health, safety, and wellbeing of Vietnamese farmers is often overlooked. In this study, we conducted five focus groups with 46 farmers representing three provinces of Vietnam. We used a convergent mixed-methods design and a Total Worker Health^® framework to assess how farmers in Vietnam experience climate-change-related hazards and describe how famers associate these hazards with impacts to their health, safety, and wellbeing. Multi-dimensional scaling suggests farmers conceptualize hazards separately from health, safety, and wellbeing outcomes, but a thematic analysis of our data indicated that farmers perceive both direct and indirect impacts of climate change to their health, safety, and wellbeing. Direct impacts of climate change described included physical health effects such as heat stress. Indirect impacts included mental health stressors due to productivity demands. Gaps in available health and safety trainings for farmers were also identified. This project demonstrates the need to co-develop safety and health trainings with farmers. System-level approaches both at the societal and community levels are needed. The local governments, cooperatives, Women’s Unions, and Farmers’ Unions are trusted sources of information that could implement and disseminate these trainings.

1. Introduction

Vietnam is ranked in the top 10 countries most vulnerable to climate change and climate-related events [1]. Currently, agriculture accounts for 20% of the nation’s GDP [2]. The World Bank projects that by 2050, the total GDP could be reduced by 0.7%–2.4% as a result of climate-change-related reductions in agriculture, including the distribution of agricultural production, food supply, and global markets [3]. To date, the focus on climate adaptation strategies within the agriculture sector have primarily focused on technical solutions to plant adaptations [4]. While it is understood that changing weather patterns and extreme climate events will have a great economic impact on the agriculture sector as a whole [5], the effect on the physical and mental wellbeing of those who rely on agriculture as their main source of livelihood is often overlooked.

Vietnam’s geography makes it especially susceptible to many climate-related hazards. These include drought, flooding, salinity intrusion, extreme weather events, vector-borne diseases and other biological hazards, and increasing temperatures [3]. In Vietnam, annual average temperatures have increased nearly 0.2 °C per decade since 1980 [6]. Looking forward, annual maximum and minimum temperatures are expected to increase at an even greater rate than annual average temperatures, which will likely amplify the consequences to human health, livelihoods, and ecosystems [3].

Climate change is expected to have negative health consequences worldwide [7]. This includes both physical and mental health effects. Climate change has been linked to increased mortality due to heatwaves [8,9,10], cardiovascular and respiratory disease exacerbated by air pollution [11], and vector-borne disease transmission [12]. Mental health effects linked to climate change include increased anxiety, depression, and post-traumatic stress disorder [13]. There are individual-, community-, and societal-level factors that affect how vulnerable an individual is to the health consequences of climate change [14,15]. One such vulnerability is work.

Workers, especially those who work outdoors, are extremely vulnerable to the negative health consequences of climate change [16]. Research has emerged showing the link between climate-change-related increases in temperature and the occupational safety, health, and wellbeing of agricultural workers. Climate-change-related increases in temperatures have been linked to an epidemic of chronic kidney disease in agricultural communities clustered around the equator [17]. Associations between increased temperatures and higher rates of traumatic occupational injuries in agricultural workers have also been shown [18].

Climate adaptation studies for agricultural workers are lacking, especially within low- and middle-income countries (LMICs) [19]. For example, while effective interventions to mitigate the effects of heat on physical performance have been developed, often within lab settings [20], these strategies are often not efficacious when applied to the work setting [21]. One potential reason for this discordance is the difficulty in implementing these strategies with consistency and ensuring adherence to the recommendations [22]. This is especially true for smallholder farmers. Smallholder farmers are a subpopulation of agricultural workers who are especially vulnerable to climate change due to their low capacity to adapt to change and their reliance on crops for subsistence and income [23]. There is a need to develop adaptation strategies specifically for smallholder farmers that address not only the health of their corps but their own health, safety, and wellbeing.

Recently, the Total Worker Health^® approach has emerged as a way to understand the complex interactions between individual-, workplace-, community-, and societal-level factors that influence the health, safety, and wellbeing of workers [24]. Similar to the social–ecological model [25], Total Worker Health (TWH) can guide adaptive strategies, recognizing that workers are nestled within their workplaces that operate within communities and societies. There is a need to understand the vulnerability factors that shape each individual farmer’s ability to adapt [26]. Using TWH as a framework, we are provided a holistic view of how work and nonwork factors influence smallholder farmers’ abilities to adapt to climate change. Local coping strategies and adaptive capacity can also be influenced by inequalities [5]. Inequalities make it difficult to develop one-size-fits-all approaches to addressing work in hot environments. The ability to adapt also depends on having the relevant skills and training to utilize adaptation strategies [27].

Including farmers’ opinions in the development of climate change adaptation strategies will better meet their health, safety, and wellbeing needs [4]. The goal of this study was to understand how farmers in Vietnam view climate-change-related hazards in terms of the impact to their health, safety, and wellbeing. Additionally, we wanted to understand how farmers are currently adapting to climate change and identify additional adaptive capacity needs.

2. Materials and Methods

2.1. Study Population

This study took place in three provinces in Vietnam from August to October 2023 (Figure 1). Convenience sampling was used for province selection with the goal of representation from each of the three main agricultural regions in Vietnam. The first province was Can Tho Province in the Mekong River Delta region, located in the southern part of the country. The primary crop grown in the Mekong River Delta region is rice, which comprises approximately 75% of the total agricultural production value in the country [28]. The second province was Ninh Binh Province, which is in the Red River Delta region and is in the northern part of the country. While the staple crop of the Red River Delta has historically been rice, as a climate-related adaptive strategy there have been recent efforts to increase fruit cultivation [29]. The final province was Lam Dong Province in the Central Highlands of Vietnam, which is located in the middle of the country. The primary crop of the Central Highlands is coffee, which is an important part of the rural economy of Vietnam [30].

Farmers in this study were all from rural areas and not considered part of the formal agricultural sector. All study participants were members of their local cooperatives. Farmers work within a cooperative structure to pool their harvested crop with other farmers to process and sell their product. Should the cooperative initiate it, the farmers within the cooperative will receive both technical and safety training from local organizations and authorities such as the Farmers’ Union, the Women’s Union, or the Department of Labor, Invalids, and Social Affairs (DOLISA). The Farmers’ Union, Women’s Union, and the cooperative are all considered important social organizations that provide livelihood support for farmers [1].

2.2. Methodological Approach

In this study, we used a convergent mixed-methods design [31] and a TWH framework. Focus group discussions were held with members of farming cooperatives in the study provinces. Local authorities provided written approval and facilitated the organization of the focus group discussions. Participants in the focus groups were recruited through coordination between the Vietnamese Chamber of Commerce and Industry (VCCI) and the Farmers’ Union, with the goal of two focus groups per province and 10 participants per focus group. Eligibility criteria for participants included (1) over the age of 18 and (2) primary occupation being agricultural work. This convenience sample resulted in five total focus groups: a Can Tho male focus group, a Can Tho female focus group, a mixed-gender Ninh Binh focus group, and separate male and female Lam Dong focus groups. At the start of each focus group, participants were provided with informed consent documents. All participants then provided verbal consent to participate. Verbal consent was also obtained to audio record and photograph the focus groups. Upon participation, participants were provided with a VND 155,000 (USD 7) incentive for their participation in the study. Ethics approval was provided by the Colorado Multiple Institutional Review Board (#23-1235) and the Institutional Review Board of the Hanoi University of Public Health (#023-371/DD-YTCC).

Focus groups were conducted in Vietnamese by native speakers. An interpreter was present and provided consecutive interpretation (Can Tho) and simultaneous interpretation (Ninh Binh) to the non-Vietnamese speaker of the research team. Detailed field notes were taken to capture non-verbal cues and other observations. Only native Vietnamese speakers were present at the Lam Dong focus groups. After spending time welcoming the participants, the focus groups were conducted in three main sections: (1) open discussion about climate change, in which the facilitator opened the focus group by asking, “if we talk about climate change now, what do you think about?”, (2) pile sorting, and (3) qualitative vignettes. Each focus group took between 60 and 90 min. In Can Tho, male and female focus group discussions were held in the local villages at the cooperatives’ headquarters. In Ninh Binh, the combined male and female focus group discussion was held in the city of Ninh Binh at the local Farmers’ Union office. In Lam Dong, the focus group with females took place at a local coffee shop in their commune. The focus group with males took place at the commune’s Farmers’ Union office. Representatives from the Farmers’ Union were present at all focus groups. The head of the cooperatives were present and participated in the Can Tho male focus group and the Ninh Binh focus group.

2.2.1. Pile Sorting

The goal of the pile-sorting activity was to understand how participants link climate-change-related hazards to impacts on occupational safety and health. In the past, this activity has been successfully employed to understand how individuals detect and attribute climate change impacts [32]. To conduct the pile-sorting activity, each participant was provided with a set of 26 cards contained in a small plastic bag during the focus group. Each card represented one item, with the item written in Vietnamese on one side and English on the other (

Table 1. List of items provided to participants for the pile-sorting activity.

Environmental Conditions Relating to Climate Change	Theorized Occupational Safety and Health Conditions Relating to Climate Change
Salt intrusion	Injury to people
Drought	Personal illness
Flood	Income
Extreme weather phenomena	Human health
Rising temperatures	Animal health
Heatwaves	Stress
Pollution	Depression
Climate change	Concern
Season change	Job needs
Water pollution	Labor productivity
Pesticide leaks	Type of work
Amount of rain	Diseases in animals
Sea level rise	Disease outbreak in humans

). The items were broadly classified by the research team based on environmental conditions and occupational safety and health conditions. The included items were selected based on background literature review of the most common climate change concerns in Vietnam [1] and published theoretical frameworks for the impact of climate change on occupational health and safety [33,34,35,36].

At the start of the activity, participants were instructed to individually group their pile of cards together based on similarities or differences. It was emphasized that there was no right or wrong answer. There was no limit on the number of piles a participant could create. Once participants finished grouping their cards, they were asked to label each pile with a short name to describe the group. The facilitators then invited each participant to explain a little about their reasoning underlying their groupings. At the end of the activity, participants were instructed to rubber band together each of their labeled piles and to place them back in the plastic bag. Each pile label was translated to English after the conclusion of the focus group.

2.2.2. Qualitative Vignettes

The goal of the qualitative vignettes was to assess participants’ knowledge and attitudes towards adaptation strategies and to identify potential barriers. We created qualitative vignettes [37,38,39] to present a hypothetical story to participants. Participants were then asked a series of questions regarding the fictional characters’ behaviors. The story was provided to participants in written form and also read aloud by the facilitator. The choice to use fictional characters rather than ask participants to share their own stories was made to alleviate any potential stigma participants may have felt by sharing their own stories. The vignettes presented were context-specific based on the participants’ home province but had an overarching theme of heat-related illness (

Table 2. English translation of vignettes presented to focus group participants.

Province	Vignette
Can Tho	In recent years, due to the effects of drought and saltwater intrusion, hundreds of thousands of hectares of rice, crops and fruit trees in the Mekong Delta are at risk of being lost. Mai’s house is also in a similar situation, Mai is extremely worried and tries to pump water day and night to save her rice field. Her husband works away from home, so in addition to farming, Mai also has to take care of the housework and take care of the children. Mai has a small child of kindergarten age, so every morning she has to get up early to prepare breakfast for her family, take her child to school, and then go to the fields to work. Mai tries not to drink too much water while working because she is afraid that it will affect her work. Her co-worker saw that Mai looked tired and told her to rest and then continue working. Mai explained that she tried to finish her work, then she also had to buy fresh water to take home to use for eating and living. Because this whole week, tap water has been contaminated with salt, so it cannot be used. After finishing pumping water to irrigate, she went to buy fresh water for cooking and then had to pick up her child. The road was far and it was starting to get dark. She was worried that she would not be able to come back in time to pick up her child. She felt tired and worried. Mai started to cry. She felt lonely and confused, not knowing how to cope without her husband’s support.
Ninh Binh	In recent years, many households in the commune are gradually escaping poverty by converting traditional rice cultivation to high-value fruit trees. Mr. Tuan also learned to transfer 3 sao of his family’s field to the new Le Guava variety. In the past two years, the weather has been erratic, rainy, and pestilent, so there is no experience in the guava garden of Mr. Tuan’s house. He is looking forward to this year’s crop to rotate capital. However, yesterday the weather forecast announced that a strong 11-level storm was about to make landfall in the Gulf of Tonkin. This year, the weather is also erratic, with storms coming early. Mr. Tuan was very worried, so early in the morning, he mobilized the whole family to wrap the guavas before the storm came. Before the big storm, it was hot and humid with sweat, but Mr. Tuan did not dare to rest his hands because by noon there was still more than a third of the garden unfinished. His wife and children were worried that he would have a high blood pressure, and advised him to take a break for lunch, but he did not listen. After working for about an hour, Mr. Tuan felt dizzy, could not stand and fainted.
Lam Dong	Vinh has been growing coffee for 5 years, each year Vinh finds that the number of workers who come to apply for the job of harvesting coffee beans is less and less. Coffee is ripe, lack of collectors, so he has to work hard from early morning until late at night hoping to harvest. This morning he went to the field to harvest coffee, it was unusually hot in the morning. He felt more tired than usual while working, but he also got a short break before lunch. During the break, Vinh sat outside in the sun. He brought a bottle of water from home to work and drank it all, but when it ran out, he didn’t take any more. After that, Vinh had lunch in the sun. After lunch, Vinh started to have a headache and felt weaker but he still managed to keep working. Vinh just worked and talked with Huy. Huy is not aware of Vinh’s bad health, so the two still try to harvest the coffee fields. About twenty minutes later Vinh fainted.

). Prior research on the impact of climate change on safety and health in Vietnam has shown heat-related illness to be a common theme, and we assumed it would be the climate hazard participants were most concerned with [40]. Initial drafts of the vignette were developed in English and later edited to the specific contexts and translated by Vietnamese members of the research team. Once the vignette was presented, a discussion was facilitated by asking the following: (1) In this situation, what should Mai/Mr. Tuan/Vinh do to ensure safety and health?; (2) Why do you think Mai/Mr. Tuan/Vinh does not do these things?

At the conclusion of the focus group, any follow-up questions from the non-Vietnamese-speaking researcher were asked through an interpreter. Follow-up questions were guided by the researcher’s previous findings and experiences. At the end of the focus groups, participants were thanked for their time and asked to complete a brief survey to collect information on demographics (Vietnam Demographic and Health Survey [41]), work information (Agricultural Health Study Farmer Applicator Questionnaire [42]), general health (RAND SF 36 [43]), mental wellbeing (WHO-5 [44]), occupational health (Workplace Health and Safety Survey [45]), and climate change knowledge and beliefs [46].

2.3. Data Analysis

First, we analyzed the quantitative data from the survey. Summary statistics were stratified by province. Numerical responses were summarized as mean and standard deviation (SD), and categorical responses were categorized as count (N) and percent (%). Fisher’s exact test and ANOVA were used to statistically compare responses.

To analyze the quantitative data generated by the pile-sorting activity, we quantified the number of piles that were created by each participant. The number of piles reflects the number of concepts that participants grouped the items into. Multi-dimensional scaling (MDS) was used to compare the “sameness” of the pile-sorted items [47]. In this study, sameness can be thought of as how often two items were grouped in the same pile. A distance matrix was created in Excel to facilitate the analysis. The distance matrix is analogous to a correlation matrix, with each cell populated by the count of the co-occurrence of two items in a pile. The R functions “dist”, “cmdscale”, and “seqmds.stress” were used to calculate the underlying data for the MDS plots and fit statistics. The results from the MDS analysis were presented as a 2-dimensional graph. The 2-dimensional graph was examined to identify conceptual clusters with common themes. The stress measure, how well the MDS analysis fits the data, was calculated.

The goal of the qualitative data analysis was to further contextualize the findings of the MDS. The qualitative data analysis followed best practices, including a deductive, theory-driven approach and an inductive, data-driven approach [48,49]. First, the audio recordings from each of the focus groups was transcribed verbatim by a native Vietnamese speaker (T.T.). Then, the transcriber translated the transcripts into English. Once the English transcripts were received by the coder (M.D.), they were read into MAXQDA 2022 (VERBI Software, Berlin, Germany) to facilitate coding. Each transcript was read in three stages. A priori, we identified 26 codes corresponding to the items provided in the pile-sorting activity. Then, during the first reading of the full transcripts, we used inductive coding to identify and add to the original 26 codes in the code book. This resulted in an additional 19 codes. During the second full reading, we applied the codes to each of the relevant passages. To identify thematic areas, in the third stage, we examined similarities and differences between passages with a given code applied. We also examined the co-occurrence of codes within and between the transcripts. This third stage of analysis lead to the development of the identified themes. A code for “quote” was applied to any passage that exemplified an identified theme. Finally, we examined how the identified themes corresponded to the conceptual clusters identified in the MDS analysis.

2.4. Data Quality and Analysis Safeguards

We used detailed written notes taken at the time of the focus group discussion to supplement our analyses. Upon completion of the analysis, we debriefed with the team who conducted the focus groups. Finally, preliminary results were presented to a group of representatives from the Ministry of Labor, Invalids, and Social Assistance, the Ministry of Health, the Farmers’ Union, and the Women’s Union to assess the cultural appropriateness of our interpretations.

3. Results

There were 46 participants across the five focus groups. Focus groups 1 and 2 were rice farmers from Can Tho (7 males, 10 females); focus group 3 comprised 5 male and 5 female guava farmers from Ninh Binh; and focus groups 4 and 5 were coffee farmers from Lam Dong (10 males, 9 females). A total of 41 participants (89%) completed the demographic survey.

Table 3. Demographics for participants in 5 focus groups from Can Tho, Ninh Binh, and Lam Dong Provinces, Vietnam.

	Can Tho (N = 17) Mean (SD) Or N (%)	Ninh Binh (N = 10) Mean (SD) Or N (%)	Lam Dong (N = 14) Mean (SD) Or N (%)	p-Value
Gender				0.675
Male	7 (41%)	5 (50%)	8 (57%)
Female	10 (59%)	5 (50%)	6 (43%)
Age	43 (10)	62 (7)	50 (12)	<0.001
Married	16 (94%)	12 (100%)	10 (86%)	0.758
Head of household	11 (65%)	3 (38%)	10 (77%)	0.216
Vietnamese	15 (100%)	10 (100%)	10 (71%)	0.036
Religion				<0.001
No religion	0	6 (67%)	5 (36%)
Buddhist	3 (19%)	2 (22%)	5 (36%)
Catholic	9 (56%)	0	3 (21%)
Protestant	0	0	1 (7%)
Hoa Hao	4 (25%)	0	0
Other	0	1 (1%)	0
Education				0.944
Primary (passed grade 5)	1 (6%)	0	0
Secondary (grades 6–9)	9 (53%)	7 (70%)	7 (54%)
High school (grades 10–12)	5 (29%)	2 (20%)	3 (23%)
Vocational/college/university	2 (12%)	1 (10%)	3 (23%)
Weekly sources of news
Newspaper	13 (81%)	7 (78%)	10 (71%)	0.888
Radio	11 (79%)	7 (88%)	6 (55%)	0.329
TV	16 (100%)	8 (100%)	13 (100%)	1
Farming as main source of income	16 (100%)	9 (90%)	14 (100%)	0.25
Works on their family farm	14 (88%)	7 (100%)	12 (86%)	0.822
Average size of farm (hectares)	186 (131)	29 (40)	109 (53)	0.002
Number of years in agriculture				0.36
5–10 years	4 (25%)	4 (50%)	1 (8%)
11–20 years	4 (25%)	1 (13%)	5 (39%)
21–30 years	1 (6%)	1 (13%)	3 (23%)
Over 30 years	7 (44%)	2 (25%)	4 (31%)

Note: 5 participants from Lam Dong did not complete a survey. Not all participants responded to all questions.

provides a summary of participant demographics by province. We observed a statistically significant difference in the age of study participants by province (p-value: <0.001). While 100% of participants from Can Tho and Ninh Binh were Vietnamese, participants from Lam Dong were more ethnically (p-value: 0.04) and religiously diverse (p-value: <0.001). There was a significant difference in the average farm size. Participants in Can Tho on average worked on the largest farms, while workers in Ninh Binh worked on significantly smaller farms (p-value: 0.002). While not statistically different, 50% of participants from Can Tho and Lam Dong had worked in agriculture for more than 20 years, while 50% of participants from Ninh Binh had worked in agriculture for 5–10 years (p-value: 0.36).

3.1. Pile-Sort Clusters

There were 44 participants who provided labeled piles. The two missing piles were from Lam Dong. There were 171 pile-sort piles created across the five focus groups. The median count of piles created per participant was four, with the number of piles ranging from two to seven. There was no observable difference in the number of piles created by province (p-value: 0.06). The median number of items per pile was 6, with the number of items per pile ranging from 2 to 20.

Figure 2 shows the 2-dimensional model resulting from the MDS analysis of the 171 piles from all participants. There were five primary conceptual clusters identified. These included clusters related broadly to (1) climate, weather, and the environment; (2) pollution and pesticides; (3) the physical health of humans and animals; (4) psychological effects; and (5) work demands and livelihood. A third (37%; n = 64) of the sorted piles were related to the cluster of climate, weather, and the environment. Example pile names for this cluster included “weather conditions” and “climate change”. The physical health of humans and animals cluster was applied to 28% (n = 48) of piles, and work demands and livelihood was applied to 16% (n = 27) of piles (

Table 4. Concepts identified in the 2-dimensional multi-dimensional scaling (MDS) based on the 171 piles created by the full participant sample and corresponding pile name examples. Note: 4 piles were not given a label by participants.

Theme	Number of Piles (%) N = 171	Pile Name Examples
Climate, weather, and environment	64 (37%)	“Weather conditions”, “Climate change”, and “Extreme weather events”
Pollution and pesticides	18 (11%)	“Water pollution”, “Environment hygiene”, and “Climate change impacts, plant protection, chemicals and pollution”
Physical health of humans and animals	48 (28%)	“Effects on human health”, “Effects on animal health”, and “Feeling unwell leading to being tired”
Psychological effects	10 (6%)	“Mental stress”, “Human psychological needs”, “Climate affects psychology”, and “Anxiety income”
Work demands and livelihood	27 (16%)	“Weather effects to labor, workers’ daily life”, “Decreasing work hours leads to decreasing income”, and “What farmers need”

).

Figure 2 suggests that farmers were conceptualizing climate-change-related factors distinctly from health and wellbeing factors. However, discussions with farmers highlighted an integrated approach to thinking about climate change and its impact on work and health. As one female worker from Lam Dong noted, “weather changes affect every aspect of human life and health.” A male participant from Lam Dong expanded by suggesting implications for mental wellbeing, stating that “the issues of worry and anxiety are related to the psychological well-being of farmers when their crop yields are not met”. This was echoed throughout each of the focus groups. As a female participant from Ninh Binh stated, “First, our health, second our crop, are all affected by weather, so it is not very good”.

3.2. Climate Change Impact on TWH

Smallholder farmers in Vietnam acutely recognize the influence of climate change on their health. As women in Can Tho described, “our health has been negatively impacted since the weather is extremely hot and we suffer from severe dehydration”. Women in Lam Dong suggested chronic effects of working in the heat, noting that “if the weather is very hot, the elderly are more likely to experience an increase in high blood pressure. Many people have high blood pressure”. Infectious diseases were also of concern, with one participant noting that “heavy rainfall also brings about many diseases, such as dengue fever. With the increased rainfall, mosquitoes thrive, and this year, dengue fever has been spreading rapidly”.

Notably, the effect of climate on health and safety is not just at work, but within the community as well. Workers who live in low-lying areas and near riverbanks are especially concerned about the risk of landslides. As one participant in Lam Dong noted, “Heavy rain, slippery conditions, landslides. The terrain here is steep, making transportation difficult. Safety issues arise such as slipping, falling, traffic accidents, etc.”.

While we speculated heat would be the hazard of greatest concern, workers in Lam Dong stated they have not yet experienced the effects of heat as drastically as other regions. Changing rainfall patterns were their biggest concern. Across all five focus groups, changes in temperature were mentioned 53 times, 18 of which came from farmers in Lam Dong (34%, often regarding how they have not yet experienced it). Comparatively, of the 39 total mentions of changing rainfall patterns, 23 came from farmers in Lam Dong (59%). Of these, over half (n = 12) were in relationship to productivity, focusing on “the consequence is a reduction in crop yields”. This is an important indication of how climate influences work productivity and what that means for the wellbeing of the worker, a concept that is explored further in the next section.

Only females from Lam Dong mentioned the relationship between unpredictable rain and human health. The major disease of concern was dengue fever. Secondary health effects due to the increased use of pesticides were described: “Excessive rainfall leads to more plant diseases, which means that farmers have to use more pesticides. This requires more effort and increases exposure to farmers, especially women, who contact with harmful chemicals, affecting their health, particularly their reproductive health”. Further, the runoff of pesticides into streams and rivers has adverse consequences on those community members who rely on those water sources.

3.3. Climate Change Impact on Livelihood

The impact of climate change on the livelihood of farmers was a common theme throughout the focus groups. Male farmers in Can Tho spent a lot of time discussing how climate change has impacted their productivity (33 of 101 coded segments; 33%), highlighting that “farmers struggle to meet their needs when working”. This concept was expanded in Ninh Binh where a farmer explained that “[changing weather] affects all stages: planting, caring for the crops, harvesting, and even transporting guavas for sale”.

Reduction in crop yields as it relates to income was a specific concern of men in Can Tho. Income concerns were mentioned 14% of the time in their focus group compared to 8% of the time in the mixed-sex Ninh Binh focus group and 3% of the time in the remaining focus groups. In speaking about the market value of rice, one male in Can Tho described that “the prices are also unstable and fluctuating. Sometimes, more loss than gain”, which ultimately leads to a loss of livelihood and “farmers [having] to abandon farming”. In Can Tho, both men and women noted the government’s role in assisting farmers with their economic standing. While discussions with the males focused on market stabilization, females suggested that “the government could provide support and arrange additional jobs for women to earn extra income and reduce free time”.

3.4. Adaptive Strategies, Farmers’ Needs, and Trusted Sources of Information

During the focus groups, workers noted adaptive strategies that they have used to address the impacts they are currently experiencing due to climate change. The most described adaptive strategy was based on the principle “mặtmate trời lên thì mình lặn, mặt trời lặn thì mình lên”, which is the concept of setting when the sun rises and rising when the sun sets. As workers described, it simply becomes too hot to work. In multiple instances (10 of 28 segments; 36%), farmers reflected on the fact that they now must leave the fields earlier in the day because it is too hot. As a female participant in Can Tho reflected, “in the past, I left my house at 7 am and went back home at 10 to 11 am, now we have to start at 6 am and stop at 10 am because of the sun, it is too hot, I can’t stand it”, which results in a reduction in the total workable hours in a day. In this case, removing the hazard is the adaptive solution; as one farmer noted, “there aren’t many other options available”.

Workers in every focus group mentioned hydration as a type of adaptive strategy. A female in Ninh Binh described the importance of hydration by explaining that “the hot weather still has an impact, and the heat is still very tiring…when we’re done, we go back to rest, drink water to recover our health”. However, farmers also emphasized the importance of electrolyte rebalancing. Of the nine passages mentioning rehydration, 56% (n = 5) noted the use of sugared lemonade, tea, or milk instead of water. Responses to the vignettes demonstrated that farmers are aware of the signs of heat stress. In Lam Dong, a female participant explained that “when during harvesting, if farmers feel tired or have headaches, normally they would try to keep working, it, hence, affects their health, we should change this habit, should think about long-term goals”. Males in Lam Dong and Ninh Binh both demonstrated knowledge of how to address heat stroke, explaining that “in the above situation, there is a phenomenon of workers suffering from sunstroke, heat exhaustion, and fatigue. The handling method is to immediately stop working, move the affected person to a cool area, provide light fan ventilation, and offer them green tea with sugar. Loosen clothing if needed. If the person recovers within 5–15 min, that’s normal. However, if they remain unresponsive, it is advisable to call a doctor for hospitalization”. When asked if they had ever received formal training on handling these situations, they responded “we listen to the radio and have witnessed it a few times, on TV and the radio, they also provide instructions on how to handle it. I’ve also observed a few times when someone fainted, and they provided first aid like that, and the person recovered afterward”.

A common theme that emerged among all focus groups is that occupational safety and health knowledge was commonly gained through personal experience. As a female in Lam Dong summarized, “[formal] knowledge about occupational safety is often lacking among farmers, leading to their negligence”. As a female in Can Tho noted, while “there are also occupational safety classes, when applying them in practice, it’s quite different from the theory”. This was highlighted when discussing the proper use of personal protective equipment (PPE) when applying pesticides. While workers understand the need to use PPE, two issues were mentioned. The first is that the cost of PPE is prohibitive for farmers. The second is that the use of PPE negatively affects the ability to work. As a female in Can Tho described, “in outdoor conditions, it can get very hot, and it becomes exhausting and difficult to breathe with a mask on. We wear long-sleeved shirts and gloves, but we can only wear them for a while, then it becomes too hot, and we can’t breathe, so we have to take them off.” Farmers identified a “need [for] more suitable personal protective clothing”.

When discussing where farmers obtain their information, radio, TV, and social media were mentioned 33% of the time (10 of 30 coded segments). Other important sources of information include the government, specifically the Department of Agriculture, cooperatives, and communal farmers’ associations. While farmers feel that “we cannot address this on an individual scale”, it was well established that information sharing between those with experience is one of the best sources of information, as “experience and knowledge can [only] be gained from working process”.

4. Discussion

In this study, we explored how agricultural workers in Vietnam experience climate change in relation to their health, safety, and wellbeing. These links were described as both direct and indirect associations. Direct impacts of climate change included physical health effects such as fatigue and dehydration. Indirect impacts included mental health stressors due to productivity demands. While occupational safety and health training has been developed for farmers in Vietnam, this training may not be distributed equitably. For example, it is unclear who is responsible for informal farmers’ occupational health and safety, making this group more vulnerable to climate-change-related hazards.

4.1. Health, Safety, and Wellbeing Impacts

Heat stress is the most uniformly reported health concern related to climate hazards between provinces in Vietnam [50]. While it is estimated that nearly 85% of farmers have experienced symptoms of heat-related illness, only 22% sought healthcare services related to the issue [40]. This is consistent with our findings, where fatigue and dehydration were commonly noted in our focus group discussions. Additionally, we found that workers seemed acutely aware of other potential health outcomes related to climate change, including the increase in chronic and infectious diseases. This is consistent with the World Health Organization’s statements that climate change and the epidemic of non-communicable diseases are intertwined and that climate change has led to increases in vector-borne diseases [51].

The WHO also notes that mental health issues have been a climate-change-related health outcome [51]. Farmers in Vietnam described anxiety due to income uncertainty that has been amplified by climate change. Research into climate change’s impact on the productivity of agricultural plants is extensive [52]. One of the most common adaptive strategies to address this within Vietnam has been agricultural transition, where farmers move from their traditional crop of harvest to a new type of crop. This was demonstrated in our study by the participants in Ninh Binh who participated in a transition from rice to guava over the last seven years. Farmers are often provided technical assistance through their provincial government during such a transition. What our study found is that training on how to address new occupational safety and health hazards resulting from the transition is lacking. This supports other findings in Vietnam that suggest access to safety training is limited [1]. Coupled with our findings that farmers are experiencing negative health and safety consequences of climate change, there is a need to work with farmers, their unions, and government agencies to develop and implement job-related health and safety protective measures.

4.2. Adaptation Needs

Participants in our study suggested that existing occupational safety and health trainings often do not provide practical advice. This can be said of current heat adaptation recommendations as well. While many solutions are well intended and grounded in science, they often fail to consider how they will be implemented in practice [53]. In the recommendations provided by Morrissey et al. in 2021, they suggest that medical examination results should be used to educate workers about how their health conditions may affect their heat tolerance, that health status checks should be conducted before work-shifts, that physiological monitoring should be conducted throughout the workday, and that an emergency action plan should be in place [53]. The differential access to medical care in Vietnam may affect the efficacy of such solutions, highlighting within the TWH framework how societal-level factors can influence individual health outcomes [54]. While it is estimated that 83% of farmers in Vietnam have experienced heat-related illness symptoms, only 22% sought medical care [40]. There is a need to further engage with farmers in Vietnam to identify their needs and to co-develop trainings and interventions to address occupational safety and health issues. By taking a community-based participatory approach [55], situation-specific limitations, such as housing conditions and access to medical care, are taken into account.

Farmers in Vietnam have used their experiences to develop ways to cope with changing temperatures. Workers commonly mentioned a reduction in work hours due to the temperature being too hot. This supports both modelling [56,57,58,59] and empirical studies [60,61] that have suggested that increased temperatures will reduce the ability to work. This loss of productivity was an additional stressor our participants described. There is a need to develop solutions to ensure decent work and economic growth for all [62]. To do so, a system-level approach, targeting interventions at the societal and community level, is needed. As suggested by our participants, government intervention in market stabilization and job transition training are two such approaches.

4.3. Limitations

Our study was limited by the number of focus groups we were able to conduct. While the three main agricultural areas of Vietnam were represented, we were only able to conduct a total of five focus groups. As this was a convenience sample, we were limited in our ability to generalize more broadly, even within the participating provinces. Our limited sample size also had implications for the fit of our MDS analysis. Generally, a stress statistic of 0.15 indicates a good fit. Our analysis reached that threshold around the six-dimension solution. This suggests a much more complex association of concepts than we presented in the two dimensions shown. We attempted to address this by providing an in-depth analysis of the focus group discussion to explain the results. While the Farmers’ Unions and Cooperatives support the farmers’ interests, the presence of these representatives may have influenced responses in our focus group discussions.

5. Conclusions

Climate-change-related hazards are associated with direct and indirect effects on the health, safety, and wellbeing of farmers in Vietnam. As a result of this study, we observed a need to co-develop trainings with agricultural workers in Vietnam to address occupational safety and health needs, ensure they are reflective of the needs and vulnerabilities of each province, and ensure they are delivered equitably. While farmers in Vietnam face a diversity of climate-related hazards, the results from our focus group discussions suggest that heat-stress-related trainings should be prioritized, including how to prevent and respond to heat stress. As farmers in our study noted, they will not be able to solve this problem alone, suggesting that a system-level approach is needed to address the impacts of climate change felt by farmers in Vietnam. The local governments, Women’s Unions, and Farmers’ Unions are trusted sources of information that could lead these efforts.