Political economy of US states and rates of fatal occupational injury

Forty-year trends in fatal occupational injuries in North Carolina

BACKGROUND

We describe progress in the control of deaths on-the-job due to fatal occupational injury in North Carolina over the period 1978-2017.

METHODS

Forty years of information on fatal occupational injuries in North Carolina has been assembled from medical examiners' reports and death certificates, supplemented by newspaper and police reports. Cases were defined as unintentional fatal occupational injuries among adults. Annual estimates of the population at risk were derived from US Census data, and rates were quantified using Poisson regression methods.

RESULTS

There were 4434 eligible deaths. The unintentional fatal occupational injury rate at the beginning of the study period was more than threefold the rate at the end of the study. The fatal occupational injury rate among men declined from 9.6 per 100,000 worker-years in the period 1978-1982 to 3.1 per 100,000 worker-years in the period 2013-2017. The fatal occupational injury rate among women declined from 0.3 per 100,000 worker-years in the period 1978-1981 to 0.1 per 100,000 worker-years in the period 2013-2017. Declines in rates were observed for young adults as well as older workers and were observed across all major industry categories. Average annual declines in rates were greatest in those industries and occupations that had the highest fatal injury rates at the start of the study period.

CONCLUSIONS

The substantial decline in fatal injury rates underscores the importance of injury prevention and demonstrates the ability to make meaningful reductions in unintentional fatal injury.

Health Power Resources Theory: A Relational Approach to the Study of Health Inequalities

Link and Phelan's pioneering 1995 theory of fundamental causes urged health scholars to consider the macro-level contexts that "put people at risk of risks." Allied research on the political economy of health has since aptly demonstrated how institutions contextualize risk factors for health. Yet scant research has fully capitalized on either fundamental cause or political economy of health's allusion to power relations as a determinant of persistent inequalities in population health. I address this oversight by advancing a theory of health power resources that contends that power relations distribute and translate the meaning (i.e., necessity, value, and utility) of socioeconomic and health-relevant resources. This occurs through stratification, commodification, discrimination, and devitalization. Resurrecting historical sociological emphases on power relations provides an avenue through which scholars can more fully understand the patterning of population health and better connect the sociology of health and illness to the central tenets of the discipline.

Union Burying Ground: Mortality, Mortality Inequities, and Sinking Labor Union Membership in the United States

BACKGROUND

Over the last several decades in the United States, socioeconomic life-expectancy inequities have increased 1-2 years. Declining labor-union density has fueled growing income inequities across classes and exacerbated racial income inequities. Using Panel Study of Income Dynamics (PSID) data, we examined the longitudinal union-mortality relationship and estimated whether declining union density has also exacerbated mortality inequities.

METHODS

Our sample included respondents ages 25-66 to the 1979-2015 PSID with mortality follow-up through age 68 and year 2017. To address healthy-worker bias, we used the parametric g-formula. First, we estimated how a scenario setting all (versus none) of respondents' employed-person-years to union-member employed-person-years would have affected mortality incidence. Next, we examined gender, racial, and educational effect modification. Finally, we estimated how racial and educational mortality inequities would have changed if union-membership prevalence had remained at 1979 (vs. 2015) levels throughout follow-up.

RESULTS

In the full sample (respondents = 23,022, observations = 146,681), the union scenario was associated with lower mortality incidence than the nonunion scenario (RR = 0.90, 95% CI = 0.80, 0.99; RD per 1,000 = -19, 95% CI = -37, -1). This protective association generally held across subgroups, although it was stronger among the more-educated. However, we found little evidence mortality inequities would have lessened if union membership had remained at 1979 levels.

CONCLUSIONS

To our knowledge, this was the first individual-level US-based study with repeated union-membership measurements to analyze the union-mortality relationship. We estimated a protective union-mortality association, but found little evidence declining union density has exacerbated mortality inequities; importantly, we did not incorporate contextual-level effects. See video abstract at, http://links.lww.com/EDE/B839.

Does the Union Make Us Strong? Labor-Union Membership, Self-Rated Health, and Mental Illness: A Parametric G-Formula Approach

Union members enjoy better wages and benefits and greater power than nonmembers, which can improve health. However, the longitudinal union-health relationship remains uncertain, partially because of healthy-worker bias, which cannot be addressed without high-quality data and methods that account for exposure-confounder feedback and structural nonpositivity. Applying one such method, the parametric g-formula, to US-based Panel Study of Income Dynamics data, we analyzed the longitudinal relationships between union membership, poor/fair self-rated health (SRH), and moderate mental illness (Kessler 6-item score of ≥5). The SRH analyses included 16,719 respondents followed from 1985-2017, while the mental-illness analyses included 5,813 respondents followed from 2001-2017. Using the parametric g-formula, we contrasted cumulative incidence of the outcomes under 2 scenarios, one in which we set all employed-person-years to union-member employed-person-years (union scenario), and one in which we set no employed-person-years to union-member employed-person-years (nonunion scenario). We also examined whether the contrast varied by sex, sex and race, and sex and education. Overall, the union scenario was not associated with reduced incidence of poor/fair SRH (relative risk = 1.01, 95% confidence interval (CI): 0.95, 1.09; risk difference = 0.01, 95% CI: -0.03, 0.04) or moderate mental illness (relative risk = 1.02, 95% CI: 0.92, 1.12; risk difference = 0.01, 95% CI: -0.04, 0.06) relative to the nonunion scenario. These associations largely did not vary by subgroup.

Solidarity and disparity: Declining labor union density and changing racial and educational mortality inequities in the United States

BACKGROUND

Recently, United States life expectancy has stagnated or declined for the poor and working class and risen for the middle and upper classes. Declining labor-union density-the percent of workers who are unionized-has precipitated burgeoning income inequity. We examined whether it has also exacerbated racial and educational mortality inequities.

METHODS

From CDC, we obtained state-level all-cause and overdose/suicide mortality overall and by gender, gender-race, and gender-education from 1986-2016. State-level union density and demographic and economic confounders came from the Current Population Survey. State-level policy confounders included the minimum wage, the generosity of Aid to Families with Dependent Children or Temporary Assistance for Needy Families, and the generosity of unemployment insurance. To model the exposure-outcome relationship, we used marginal structural modeling. Using state-level inverse-probability-of-treatment-weighted Poisson models with state and year fixed effects, we estimated 3-year moving average union density's effects on the following year's mortality rates. Then, we tested for gender, gender-race, and gender-education effect-modification. Finally, we estimated how racial and educational all-cause mortality inequities would change if union density increased to 1985 or 1988 levels, respectively.

RESULTS

Overall, a 10% increase in union density was associated with a 17% relative decrease in overdose/suicide mortality (95% confidence interval [CI]: 0.70, 0.98), or 5.7 lives saved per 100 000 person-years (95% CI: -10.7, -0.7). Union density's absolute (lives-saved) effects on overdose/suicide mortality were stronger for men than women, but its relative effects were similar across genders. Union density had little effect on all-cause mortality overall or across subgroups, and modeling suggested union-density increases would not affect mortality inequities.

CONCLUSIONS

Declining union density (as operationalized in this study) may not explain all-cause mortality inequities, although increases in union density may reduce overdose/suicide mortality.

Psycho-socio-cultural factors and global occupational safety: Integrating micro- and macro-systems

Occupational health and safety varies greatly around the world. However, there is a dearth of information on contributing factors to global occupational safety at both micro- and macro-level. The aim of this study was to examine which psycho-socio-cultural factors including economic contexts are associated with occupational fatality rates in 51 countries from six continents (Study 1), as well as fatality rates and serious occupational injury rates in 31 European countries (Study 2). Multiple regression analysis showed that universal healthcare and individualism were significantly associated with lower occupational fatality rates in Study 1. To expand Study 1, additional variables regarding healthcare systems and occupational safety were utilized in Study 2 and it was shown that greater overall quality of healthcare system, greater quality of healthcare systems' prevention effort, and higher individualism were meaningfully linked with lower occupational fatality rates. Meanwhile, greater overall quality of healthcare and greater quality of healthcare systems' prevention efforts were meaningfully linked with higher serious occupational injury rates. To prevent workplace fatalities more effectively and to promote workplace safety and health at the global level, socioeconomic and cultural factors at micro- and macro-level need to be appropriately considered. Specifically, safety policies, regulations, procedures, and practices in countries with healthcare systems of greater quality can be benchmarked for other countries. Also, functional aspects of safety communication and participation in cultures with high individualism can be referenced by other countries.

Right-to-Work-for-Less: How Janus v. AFSCME Threatens Public Health

In February 2018, the Supreme Court heard oral arguments in Janus v. AFSCME, a case poised to make right-to-work (or, as some call it, right-to-work-for-less) the law in the public sector. At issue is the constitutionality of requiring non-union members, who benefit from collective bargaining, to pay fees that support contract negotiations on the terms and conditions of their employment. We argue that a win for Janus would threaten public health by eroding organized labor's power to improve working conditions. Furthermore, we critique the dubious legal theory underpinning Janus's case and describe the moneyed political interests backing his legal representation. Finally, we chart a path forward for labor organizing in a post- Janus world, drawing inspiration from the winter 2018 educators' strike in West Virginia. Regardless of how Janus itself is decided, the issues raised in this article remain crucial because the ongoing weakening of unions by legislative and judicial means undermines workers' health and exacerbates inequities.

Protecting labor rights: roles for public health

Federal, state, and local labor laws establish minimum standards for working conditions, including wages, work hours, occupational safety, and collective bargaining. The adoption and enforcement of labor laws protect and promote social, economic, and physical determinants of health, while incomplete compliance undermines these laws and contributes to health inequalities. Using existing legal authorities, some public health agencies may be able to contribute to the adoption, monitoring, and enforcement of labor laws. We describe how routine public health functions have been adapted in San Francisco, California, to support compliance with minimum wage and workers' compensation insurance standards. Based on these experiences, we consider the opportunities and obstacles for health agencies to defend and advance labor standards. Increasing coordinated action between health and labor agencies may be a promising approach to reducing health inequities and efficiently enforcing labor standards.

Multiple jobholder mortality patterns in Kentucky: an examination of occupational fatalities

BACKGROUND

The percentage of multiple jobholders was elevated in Kentucky compared to the US from 2002 to 2010.

METHODS

Kentucky Fatality Assessment and Control Evaluation (FACE) multiple jobholder fatality data were analyzed to identify contributing injury factors from 2002 to 2010.

RESULTS

Kentucky's total occupational fatality rates were higher than US rates for all years (2002-2010). Kentucky multiple jobholder fatalities averaged 8.4 deaths per 100,000 employees compared to the total average occupational fatality rate of 6.5. Almost half of multiple jobholder fatalities (47%) occurred in the agricultural industry and management occupation as the primary industry and occupation; 67% were tractor-related. The most prevalent secondary industry and occupation were the construction industry and management occupation.

CONCLUSIONS

Increased surveillance of multiple jobholder injuries is needed to improve safety and health on the job. Future investigations should include the relationship between multiple jobholding and agricultural employment as farm owners.

The proportion of work-related emergency department visits not expected to be paid by workers' compensation: implications for occupational health surveillance, research, policy, and health equity

OBJECTIVE

To examine trends in the proportion of work-related emergency department visits not expected to be paid by workers' compensation during 2003-2006, and to identify demographic and clinical correlates of such visits.

DATA SOURCE

A total of 3,881 work-related emergency department visit records drawn from the 2003-2006 National Hospital Ambulatory Medical Care Surveys.

STUDY DESIGN

Secondary, cross-sectional analyses of work-related emergency department visit data were performed. Odds ratios and 95 percent confidence intervals were modeled using logistic regression.

PRINCIPAL FINDINGS

A substantial and increasing proportion of work-related emergency department visits in the United States were not expected to be paid by workers' compensation. Private insurance, Medicaid, Medicare, and workers themselves were expected to pay for 40 percent of the work-related emergency department visits with this percentage increasing annually. Work-related visits by blacks, in the South, to for-profit hospitals and for work-related illnesses were all more likely not to be paid by workers' compensation.

CONCLUSIONS

Emergency department-based surveillance and research that determine work-relatedness on the basis of expected payment by workers' compensation systematically underestimate the occurrence of occupational illness and injury. This has important methodological and policy implications.

Association between perceived union connection and upper body musculoskeletal pains among unionized construction apprentices

BACKGROUND

Several studies show varying associations between unionization and workers' health and well-being. This study investigated the association between individual worker's perceived union connection and musculoskeletal pains (MSPs).

METHODS

We conducted a cross-sectional survey of 1,757 unionized construction apprentices. Perceived union connection is a psychosocial scale measured by six questions that assessed individual worker's connection to their union (range 10-24) at unionized workplaces. We measured the prevalence of four MSPs (neck, shoulder, arm, and back pain) and difficulty in daily home activities, job activities, and sleeping caused by each of the four MSPs.

RESULTS

We found that a one score increase in perceived union connection was associated with 5% decreased odds of reporting neck pain (OR: 0.95, 95% CI: 0.91-1.00) and back pain (OR: 0.95, 95% CI: 0.91-0.99) after adjusting for confounders including self-reported ergonomic strain. We also found significant associations between perceived union connection and MSPs causing difficulty in daily activities. For a one score increase in perceived union connection, the odds of reporting back pain causing difficulty in home activities, job activities, and sleeping was 9% (95% CI: 0.87-0.96), 8% (95% CI: 0.88-0.96), and 7% (95% CI: 0.89-0.98) lower, respectively.

CONCLUSIONS

Although our findings are limited by the cross-sectional nature of the data, these results suggest that workers' perceived union connection can vary even within unionized workplaces, and it may be associated with the prevalence of MSPs and MSPs causing difficulty in daily activities.

Leveraging health capital at the workplace: an examination of health reporting behavior among Latino immigrant restaurant workers in the United States

This article examines the choices made by a sample of Latino immigrant restaurant workers in regard to their health management, particularly in response to illness and injury. I draw on 33 interviews with kitchen staff employed in the mainstream restaurant industry in San Jose, California, and Houston, Texas, in 2006 and 2007. I argue that workers must consider complex power relationships at work in weighing the advantages of calling in sick, using protective equipment, seeking medical care, or filing a workers' compensation claim. These decisions implicate direct and opportunity costs, such as risk of job loss and missed opportunities for advancement. Workers consequently leverage their health capital to meet their economic needs, to assert their autonomy at the workplace, and to ultimately reject the stigma of illness and injury.

Evaluation of a nationally funded state-based programme to reduce fatal occupational injuries

BACKGROUND

The Fatality Assessment and Control Evaluation (FACE) programme was established by the National Institute for Occupational Safety and Health to help prevent occupational traumatic fatalities by funding states to conduct targeted fatality investigations within cause-specific focus areas and associated prevention efforts.

PURPOSE

To investigate the impact of the state-based FACE programme on two previous focus areas.

METHODS

A longitudinal time-series analysis spanning 22 years compared state fatality rates for occupational falls and electrocutions before and after FACE programme funding with states not receiving FACE programme funding. Lag periods were utilised to allow time for the programme to have an effect, and rates were adjusted for a variety of covariates. Separate analyses were conducted for each injury outcome.

RESULTS

A reduction in fall fatality rates that was of borderline significance (1-year lag adjRR=0.92 (0.84 to 1.00)) and a non-significant reduction in electrocution fatality rates (3-year lag adjRR=0.92 (0.82 to 1.03)) were observed in states with FACE programme funding, Best-fit models presented two separate lag periods.

CONCLUSIONS

While it is challenging to quantitatively evaluate effectiveness of programmes such as FACE, the data suggest the FACE programme may be effective in preventing occupational injury deaths within its outcome focus areas throughout the state. It is important to look for ways to measure intermediate effects more precisely, as well as ways to maintain effects over time.

The impact of public employment on health and health inequalities: evidence from China

Because the public and private sectors often operate with different goals, individuals employed by the two sectors may receive different levels of welfare. This can potentially lead to different health status. As such, employment sector offers an important perspective for understanding labor market outcomes. Using micro-level data from a recent Chinese household survey, this study empirically evaluated the impact of employment sector on health and within-sector health inequalities. It found that public sector employment generated better health outcomes than private sector employment, controlling for individual characteristics. The provision of more job security explained an important part of the association between public sector employment and better health. The study also found less health inequality by social class within the public sector. These findings suggest that policymakers should think critically about the "conventional wisdom" that private ownership is almost always superior, and should adjust their labor market policies accordingly.