Heat stress is associated with numerous health effects that potentially harm workers, especially in a warming world. This investigation occurred in a setting where laborers are confronted with occupational heat stress from physically demanding work in high environmental temperatures. Collaboration with a major Nicaraguan sugarcane producer offered the opportunity to study interventions to prevent occupational heat-stress-related kidney disease. Two aims for this study of a rest-shade-water intervention program were: (1) describe the evolving intervention, summarize findings that motivated proposed improvements, assess impact of those improvements, and identify challenges to successful implementation and (2) extract primary lessons learned about intervention research that have both general relevance to investigations of work-related disease prevention and specific relevance to this setting. The learning curve for the various stakeholders as well as the barriers to success demonstrate that effectiveness of an intervention cannot be adequately assessed without considerations of implementation. Designing, effectively implementing, and assessing both health impacts and implementation quality is a resource-intensive endeavor requiring a transdisciplinary approach. Both general and specific lessons learned are presented for decisions on study design and study elements, implementation assessment, and management engagement in understanding how productivity and health can be successfully balanced and for building effective communication between investigators and all levels of management.

Background: Chronic kidney disease of non-traditional origin (CKDnt) is an ongoing epidemic that has taken the lives of tens of thousands of people in Mesoamerica, also affecting other tropical geographies. Occupational heat stress, which will increase worldwide as climate change persists, has been identified as a primary trigger of kidney injury and reduced renal function. At Nicaragua's largest sugarcane mill, the water, rest, and shade (WRS) intervention has proven to reduce the risk of heat stress and kidney injury effectively as assessed by the research and policy NGO La Isla Network (LIN) and their academic partners, who have worked with the sugar mill to improve the design of their intervention system. However, discrepancies between intervention design and implementation have been found. This study explores the perceptions of the WRS intervention in the company from the perspective of positions responsible for the workers' environment and heat stress prevention implementation.Methods: A qualitative design was used in the study. Twenty-one key informants of low and middle management, field assistants, and two members from LIN took part in the study. Semi-structured interviews were used to collect the data. Interviews' transcriptions were analyzed using interpretative phenomenological analysis (IPA).Results: Four main themes were developed in the analysis of the data: “A worthwhile struggle,” “Culture of care”, “Traditional production culture Vs. Culture of care,” and “The importance of the formalization of care.” Each theme contained sub-themes, all of which were further discussed in the light of organizational psychology.Conclusion and Implications: Discretionary differences resulting in low and middle management prioritizing production over health protection appeared to relate to a fair part of the implementation challenges and indicate that more efforts are needed to align operations' production and health goals. Education enhancement might be necessary, while further focus on health metrics for performance assessment might offer an opportunity to level perceived incentives and value of health and production.

Burned cane cutting and seed cutting in industrial sugarcane production are very physically demanding jobs that expose workers to heat strain. Women performing these jobs tend to work at higher workload intensities than male co-workers. Workers' health protections in industrial sugarcane production should consider work intensity as a risk factor when assessing heat stress.