Low back pain (LBP) is the most common musculoskeletal disorder among agricultural and horticultural workers [1-5], negatively impacting worker’s physical and mental health, increasing absenteeism, and shortening work longevity [6-11]. Further, LBP contributes to lower productivity, loss of experienced workers, and increased workman’s compensation costs. The financial impact of high out-of-pocket costs and lack of paid leave often drive agricultural and horticulture workers to seek pain relief from prescription medications and illicit substances [12-14]. In one study of farmers with LBP, 71% relied on pain medication without consulting a physician compared to only 35% of white-collar workers [15].

Viable alternatives to pharmacological management of LBP have never been more important [16,17]. Despite guidelines recommending nonpharmacologic management, opioids are commonly prescribed for work-related injury and pain more frequently than for nonoccupational musculoskeletal disorders [18-22]. Although opioid prescribing has declined gradually since 2010, opioid fatalities from prescription and illicit synthetic opioids have continued to rise [20,23]. The precipitous increase in opioid overdose associated with fentanyl manufactured in clandestine laboratories [23,24] has elevated the importance of highlighting and promoting uptake of nonpharmacological alternatives for management of LBP [20]. In rural areas, opioid prescription rates are particularly high [25], and access to nonpharmacologic treatment options is limited [16]. A preliminary study supporting this protocol found that over half of agricultural workers (n=129) reported using opioids at some point [14]. Of those who had used opioids, most (77%) reported they received a prescription for a work-related injury. Participants explicitly linked work hazards and chronic pain with increased risk of opioid dependence, citing the need to continue working and “live with pain” as a cultural norm contributing to the problem [14]. While progression to opioid use disorder is complex, opioid misuse has devastating effects on health and work. A systematic review of the impact of prescription medications for occupational musculoskeletal injuries found that opioid use was associated with slower return to work, longer duration of disability, poorer self-reported work function, and poorer functional improvements [26]. Opioid prescriptions within the first 2 weeks of a work-related injury, opioid use for longer than 7 days, and higher dose supplies are associated with subsequent work disability or delayed recovery and greater work loss [26]. Owners of nursery and landscaping businesses in Florida reported problems with turnover, frequent absences, and low productivity among workers who used opioids, resulting in decreased labor availability [14]. Landscape and nursery work characteristics including low skill discretion, job strain (low control and high demand), high physical effort, and heavy lifting are risk factors for opioid use disorder [27]. Few opioid prevention efforts have been focused on underlying work-related factors such as musculoskeletal pain [18,28]. The substantial worker and employer burden of LBP in the horticulture industry and the devastating effects of opioid dependency highlight the need for efforts to manage and limit LBP and reduce unwarranted opioid use for musculoskeletal injury. Strategies to (1) increase workers’ awareness of the risks and consequences of opioid use, (2) encourage workers to discuss options with health care providers after more acute injuries, and (3) provide alternatives for nonpharmacological strategies to manage pain or limit ergonomic stress [28] may increase knowledge and self-efficacy while reducing stigma [20,28].

Self-management is defined as the ability to manage pain, treatment, psychosocial, and lifestyle implications of a chronic condition [29,30], with the overall goal for individuals to safely manage symptoms and lifestyle without seeking unnecessary medical intervention [30-33]. Encouraging active involvement and empowering individuals to select options to manage work-related pain tailored to each worker’s circumstances and preferences encompasses the principles of self-management for chronic conditions [6]. Effective self-management strategies should optimize pain coping strategies to manage and reduce symptom exacerbation through problem-solving [30]. Self-management is recommended for the management of chronic LBP in a number of guidelines and strategic initiatives [16,34,35], with moderate effectiveness for pain, and small to moderate effectiveness for pain-related disability reported in a systematic review and meta-analysis [36]. Increasing self-management of chronic pain that frequently limits work activities is one of the Health People 2030’s targets [35]. However, most studies investigating effectiveness of self-management approaches have involved patients receiving clinical care rather than groups who continue to work in physically demanding occupations. Self-management skills such as problem-solving, action planning, self-tailoring, and self-monitoring may provide a worker-centered approach for horticulture workers to promote self-efficacy and coping skills for adjusting work activities and managing pain [29,30,37].

There are limited training initiatives to address musculoskeletal pain for horticulture workers and most workers rely on supervisor’s advice or learning by experience. Many studies have concluded that education can positively influence work-related musculoskeletal pain by promoting behavioral change, modifying health beliefs, and improving attitudes, although gaps in optimal implementation persist [38]. Although some studies reported additive effects of improving physical activity or ergonomic adjustments [38], none focused on agriculture, nursery, or landscape workers. Collectively, there is a crucial need to determine optimal implementation of effective self-management programs for workers, especially for those who do not have resources to receive treatment in typical health care settings [39,40]. Therefore, examining the effectiveness of training to assist workers with learning self-management and ergonomic strategies will provide valuable information, while studying implementation outcomes will help determine engagement, adoption, and feasibility.

This protocol builds from a preliminary study of streamlined individualized participatory ergonomic (PE) methods in clam aquaculture workers with similar physically challenging work [39,41]. Workers with chronic LBP were introduced to ergonomic concepts to reduce risk, selected 3 pertinent and acceptable strategies from a list, reviewed videos, and received text reminders. Significant improvements in disability, work-task pain, pain anxiety, and coping compared to baseline were observed (P<.05; n=19), with pain improvements greater than published minimal detectable change for 74% of the participants. The methods were both feasible and acceptable. These promising results led to recommendations to establish whether these approaches are effective in a larger cohort over longer timeframes, in different contexts, and with follow up [39].

We will investigate the effectiveness of self-management and ergonomic individual choices along with behavior change support for nursery and landscape workers. The first aim is to determine if self-management videos combined with multimodal personalized support is more effective than self-management videos alone for improving LBP management among horticulture workers. We hypothesize that compared to the video modules alone, the combined multimodal personalized support will result in (1) greater reductions in work task pain and disability, (2) lower prevalence of high-impact chronic pain, (3) greater reduction in substance use to manage pain, (4) greater reeducation in pain anxiety and depression, and (5) improved coping and self-efficacy. The second aim is to identify contextual factors that impact engagement, adoption, effectiveness, and implementation of nonopioid alternatives for LBP self-management. Understanding the external context and individual and team characteristics will help explain the results, provide important implementation perspectives, and inform translation.

The exploration and preparation phases of the study were started in 2023, with the video training module creation, evaluation, modifications, and production completed in June 2024. A 2-arm pragmatic randomized controlled hybrid type II effectiveness and implementation study [42-44] will be conducted using mixed methods and a within-subject control period. The Standards for Reporting Implementation Studies (StaRI) standards checklist is included in Multimedia Appendix 1.

The study was approved by the University of Florida Institutional Review Board (IRB202300756) and registered as a clinical trial through ClinicalTrials.gov (NCT06153199). Participants will be compensated for their time. Workers will receive US $25 for the baseline data collection and US $50 for subsequent steps for a possible total of US $225, while supervisors or owners will receive US $50 for the 2 data collection sessions for a possible total of US $100.

Employers will provide permission to discuss the study with workers and to conduct the study in the workplace. After determining eligibility, research staff will describe the purpose of the study, study-related procedures, risks, and benefits, and participants will sign an informed consent if they agree to participate. We will ensure that participants understand that participation is voluntary and that they can withdraw from the study at any time without consequences. A Certificate of Confidentiality (42 USC §241(d)) will protect participant privacy related to potentially sensitive information about the use of pain medication and other substances. If individual workers are not eligible or do not want to participate, they will be able to view the educational videos with their teams. If participants who are randomly assigned to the intervention enhanced with multimodal support are not comfortable being videotaped, we will provide deidentified video clips of other workers with blurred faces performing tasks similar to the tasks they have identified as difficult due to pain.

In this paper, we present the protocol for a randomized within-subject controlled hybrid intervention study with coprimary aims to examine the effectiveness of self-management videos combined with multimodal personalized support compared to self-management videos alone for improving LBP and disability in nursery and landscape workers, as well as to identify contextual factors that impact implementation including engagement, adoption, effectiveness, and feasibility. Improving self-management strategies to reduce transition from intermittent to high-impact chronic LBP will contribute to important Healthy People 2030 objectives [35] while addressing research and practice gaps to mitigate musculoskeletal pain.

In nursery and landscape businesses, prevention of musculoskeletal injuries has not typically received high priority. Despite the size and growth of the industry, horticulture has rarely been included with other agriculture sectors in studies addressing musculoskeletal injury prevalence [5] or risk factors [5,6]. There is a death of intervention studies to prevent or mitigate LBP in agriculture [2,10,66], with few intervention studies specifically targeting nursery and landscape populations [5]. Feasible, easily implemented interventions to manage pain and reduce risk factors are essential for small businesses in the horticulture industry who face major challenges with labor availability. Variability in work environments, seasonal fluctuation in workloads, weather constraints, and productivity requirements make the adaptability, efficiency, and ease of adoption paramount for any training intervention. Current “training on the-job” from more experienced workers and supervisors is challenging with turnover and difficulty retaining experience workers who can pass on best practices. Efficient delivery methods providing structured evidence-based information and strategies would provide consistency. Short videos tailored for both sectors are a pragmatic option to address the needs while remaining flexible for work priorities and productivity. This study will contribute to knowledge about the effectiveness of interventions specifically tailored to the characteristics, work tasks, and work settings for these workers.

Awareness of the risks and consequences will highlight the importance of nonopioid alternatives [14]. Opioid education is not effectively integrated into workplace safety training but embedding discussion of opioid risk within a more holistic approach to prevention and mitigation of LBP may promote help-seeking behavior and reduce stigma and communication barriers [20]. Introducing the risk of opioids along with options to manage pain using self-management and ergonomic alternatives is likely to be received more positively than opioid education alone.

Awkward postures, repetitive actions, and intermittent lifting, digging, or shoveling have been identified as inherent ergonomic risk factors for landscape workers [5]. Similar risks are present in nursery work with awkward stooped trunk postures, repetitive low load lifting, and intermittent heavy lifting [10,11]. Larger companies often have more access to mechanical equipment, while small work units seldom have sufficient resources for major engineering redesign recommended in the NIOSH hierarchy of controls [6]. Modifying the way people work or reinforcing the use of available equipment in small businesses is, therefore, more realistic than major equipment modifications. Typically, smaller companies do not have access to ergonomic and safety experts, and may not provide health care benefits. Feasible, easily implemented interventions to manage pain and reduce risk factors are, therefore, needed for businesses in the nursery and landscape industry.

PE approaches involve workers in identifying possible solutions to reduce work-related stress and have been used in a variety of ways in large manufacturing, construction, and health care settings [83-86]. The evidence for effectiveness of PE in large corporations is mixed for group changes for time off work, return to work, self-assessed productivity, and prevalence of LBP [85,87-94]. In contrast, PE has been found to improve overall perceived health, decrease back pain intensity, and reduce absences due to back pain [94]. Comprehensive PE interventions are often time-consuming and challenging to implement across large corporations. Solutions suggested by workers may be feasible, but changing organizational processes can be difficult. Thus, PE has been suggested to be especially beneficial for small teams, enterprises with restricted finances, and rural or less developed areas [86,95,96]. Although PE has not been studied extensively in agricultural settings [39,41,86,95,96], there is some evidence of lowered ergonomic risk and improved management of symptoms among farmers [86]. In another study, construction workers reported significantly less general fatigue after a typical workday, and increased influence on their work compared to controls [81]. A modified approach to encourage workers to choose relevant options for changing their work activities to minimize ergonomic stresses may be feasible to empower nursery and landscape workers to manage back pain [40].

In this study, changes in the primary (pain, disability, and medication use) and secondary (pain-related anxiety, coping, self-efficacy) measures from the preintervention to postintervention timepoints will be compared to a within-subject baseline within-subject period. We will also compare 2 forms of training implementation—video modules alone and video enhanced with multimodal personalized support. We hypothesize that the video + support will facilitate greater engagement, and increased adoption, thereby contributing to greater reductions in work task pain and disability compared to a baseline control period than the video alone. If either intervention is effective, mitigating pain and enhancing knowledge, skills, and attitudes to manage pain successfully is likely to impact quality of life, productivity, and retention. Improvements in pain and disability could result in decreased use of pain medication and other substances, important outcome public health priorities. Even if observed differences are not significant, identifying characteristics of those who respond will contribute evidence for preventing the transition from low to high-impact chronic pain. The mixed methods will help explain results and surrounding inner and outer contextual factors, facilitators and barriers contributing to implementation success for individuals, teams, and specific strategy choices [44]. Qualitative analysis will also inform recommendations and provide ideas for sustainability of effective interventions. Analysis from multiple perspectives will also help explain emerging or complex factors inherent with the dynamic workplace environment and business models, to guide decisions for others considering these approaches. If self-management is effective for horticulture workers (or specific subgroups), simultaneously studying implementation outcomes (engagement, adoption, and feasibility) will facilitate translation of the intervention from research to practice and scaling to the workforce. Potential limitations that may impact the success of this study are consistent with other hybrid effectiveness implementation studies. First, although we anticipate that our recruitment goals are achievable, external factors such as productivity requirements may impact owner and supervisor willingness to allow workers to participate. As attrition is expected, we plan to enroll additional participants to achieve adequate power. We will emphasize benefits for employers such as limiting absenteeism, improving retention, and reducing potential risks of medication or substance use to manage pain while working. Second, we also anticipate that owners and supervisors who agree to participate are already committed to supporting workers. This may result in a sample of workers associated with positive contextual factors that may not be generalizable to all employers. However, these factors will be documented to help interpret results from an implementation perspective. Third, weather and seasonal variations are likely to impact productivity and, therefore, willingness to participate, particularly for landscape companies. These factors will also impact scheduling for data collection, for example, hurricane or weather delays. We have built in a 2-week window for data collection to accommodate the scheduling but there may be a need for additional flexibility. Finally, cultural, language, and educational literacy variations are expected. All instruments and materials have been translated and checked thoroughly while research assistants who speak Spanish fluently are essential.

Interventions to reduce the burden of LBP that consider the unique characteristics and business models within the nursery and landscape sectors are lacking. Given the high incidence of LBP, the risk of opioid use, impact on labor availability and productivity, and the limited attention to musculoskeletal disorders in these sectors, this study will provide valuable information to address both employer and worker needs. The hybrid type II effectiveness and implementation study will investigate the effectiveness of self-management interventions for pain and disability, along with the engagement, adoption, and feasibility, for 2 forms of implementation while also documenting the context, facilitators, and barriers for nursery and landscape businesses [44]. Increased awareness of opioid risk and options for alternate nonpharmacological strategies to manage pain will also provide an important contribution to a high priority public health challenge. We anticipate self-management will result in reduced pain and disability. Further, targeting self-management can empower workers and improve pain coping, reducing pain anxiety, depression, and associated use of pain medications. Short video training modules presenting realistic strategies to manage pain and limit work stress are likely to be feasible in the workplace while multimodal personalized support is likely to facilitate engagement and adoption of context-specific solutions. The qualitative methods used will help elucidate whether these options are feasible for small- to medium-sized horticulture businesses, document barriers and facilitators, and describe the inner and outer contextual factors influencing adoption and effectiveness. If the video and multimodal personalized support intervention is more effective than viewing training modules alone, this knowledge will inform best practices and may be easily adapted for other physically challenging agricultural sectors.