Wounding the Messenger: The New Economy Makes Occupational Health Indicators Too Good to Be True

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.

Using a severity threshold to improve occupational injury surveillance: Assessment of a severe traumatic injury-based occupational health indicator across the International Classification of Diseases lexicon transition

BACKGROUND

Traumatic injury is a leading cause of death and disability among US workers. Severe injuries are less subject to systematic ascertainment bias related to factors such as reporting barriers, inpatient admission criteria, and workers' compensation coverage. A state-based occupational health indicator (OHI #22) was initiated in 2012 to track work-related severe traumatic injury hospitalizations. After 2015, OHI #22 was reformulated to account for the transition from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. This study describes rates and trends in OHI #22, alongside corresponding metrics for all work-related hospitalizations.

METHODS

Seventeen states used hospital discharge data to calculate estimates for calendar years 2012-2019. State-panel fixed-effects regression was used to model linear trends in annual work-related hospitalization rates, OHI #22 rates, and the proportion of work-related hospitalizations resulting from severe injuries. Models included calendar year and pre- to post-ICD-10-CM transition.

RESULTS

Work-related hospitalization rates showed a decreasing monotonic trend, with no significant change associated with the ICD-10-CM transition. In contrast, OHI #22 rates showed a monotonic increasing trend from 2012 to 2014, then a significant 50% drop, returning to a near-monotonic increasing trend from 2016 to 2019. On average, OHI #22 accounted for 12.9% of work-related hospitalizations before the ICD-10-CM transition, versus 9.1% post-transition.

CONCLUSIONS

Although hospital discharge data suggest decreasing work-related hospitalizations over time, work-related severe traumatic injury hospitalizations are apparently increasing. OHI #22 contributes meaningfully to state occupational health surveillance efforts by reducing the impact of factors that differentially obscure minor injuries; however, OHI #22 trend estimates must account for the ICD-10-CM transition-associated structural break in 2015.

Development and maturation of the occupational health services research field in the United States over the past 25 years: Challenges and opportunities for the future

Work is an important social determinant of health; unfortunately, work-related injuries remain prevalent, can have devastating impact on worker health, and can impose heavy economic burdens on workers and society. Occupational health services research (OHSR) underpins occupational health services policy and practice, focusing on health determinants, health services, healthcare delivery, and health systems affecting workers. The field of OHSR has undergone tremendous expansion in both definition and scope over the past 25 years. In this commentary, focusing on the US, we document the historical development and evolution of OHSR as a research field, describe current doctoral-level OHSR training, and discuss challenges and opportunities for the OHSR field. We also propose an updated definition for the OHSR field: Research and evaluation related to the determinants of worker health and well-being; to occupational injury and illness prevention and surveillance; to healthcare, health programs, and health policy affecting workers; and to the organization, access, quality, outcomes, and costs of occupational health services and related health systems. Researchers trained in OHSR are essential contributors to improvements in healthcare, health systems, and policy and programs to improve worker health and productivity, as well as equity and justice in job and employment conditions. We look forward to the continued growth of OHSR as a field and to the expansion of OHSR academic training opportunities.

Appraisal of Washington State workers' compensation-based return-to-work programs and suggested system improvements: A survey of workers with permanent impairments

BACKGROUND

Following a work-related permanent impairment, injured workers commonly face barriers to safe and successful return to work (RTW). Examining workers' experiences with the workers' compensation (WC) system could highlight opportunities to improve RTW outcomes. Objectives included summarizing workers': (1) appraisal of several WC-based RTW programs, and (2) suggestions for vocational rehabilitation and WC system improvements to promote safe and sustained RTW.

METHODS

In telephone interviews, 582 Washington State workers with work-related permanent impairments were asked whether participation in specified WC-based RTW programs helped them RTW and/or stay at work. Suggestions for program and system improvements were solicited using open-ended questions; qualitative content analysis methods were used to inductively code responses.

RESULTS

Most respondents reported positive impacts from RTW program participation; for example, 62.5% of vocational rehabilitation participants reported it helped them RTW, and 51.7% reported it helped them stay at work. Among 582 respondents, 28.0% reported that no change was needed to the WC system, while 57.6% provided suggestions or critiques. Reduce delays/simplify process/improve efficiency was the most frequent WC system theme-mentioned by 34.9%. Among 120 vocational rehabilitation participants, 35.8% reported that no change was needed to vocational rehabilitation, while 46.7% (N = 56) provided suggestions or critiques. More worker choice/input into the vocational retraining plan was the most frequent vocational rehabilitation theme-mentioned by 33.9%.

CONCLUSIONS

This study's findings suggest that there is substantial room for improvement in workers' experience with the WC system. In addition, injured workers' feedback may reflect opportunities to reduce administrative burden and to improve worker health and RTW outcomes.

Pregnant and undocumented: taking work into account as a social determinant of health

Purpose

It is well understood that women’s work situations are critical to their well-being during pregnancy and in terms of potential risks to the fetus. It has also long been known that undocumented women workers face particularly difficult work conditions and being undocumented precludes access to key social benefits (i.e. public health insurance, paid maternity leave, child benefits and subsidized daycare) that support pregnant women and new mothers. Yet, this paper aims to write about the intersection of undocumented women’s pregnancy with work experiences.

Design/methodology/approach

Drawing on the results of a broader qualitative study that was focussed on access to healthcare for undocumented (and therefore, uninsured) women who were pregnant and gave birth in Montreal, Canada, the authors begin this paper with a review of the relevant literature for this topic related to the work conditions of undocumented women, how work exacerbates barriers to accessing healthcare and the resulting health outcomes, particularly in relation to pregnancy. The authors highlight the social determinants of health human rights framework (Solar and Irwin, 2010), before presenting methodology. In conclusion, the authors discuss how an understanding of undocumented women’s work situations sheds light on their pregnancy experiences.

Findings

The authors then present participants’ work conditions before becoming pregnant, working conditions while pregnant and employment options and pressures after giving birth.

Originality/value

The authors emphasize that attention to undocumented pregnant women’s work situations might help health and social service practitioners to better serve their needs at this critical point in a woman’s life and at the beginning of the life of their children, born as full citizens.

Coverage Gaps and Cost-Shifting for Work-Related Injury and Illness: Who Bears the Financial Burden?

The heavy economic burden of work-related injury/illness falls not only on employers and workers' compensation systems, but increasingly on health care systems, health and disability insurance, social safety net programs, and workers and their families. We present a flow diagram illustrating mechanisms responsible for the financial burden of occupational injury/illness borne by social safety net programs and by workers and their families, due to cost-shifting and gaps in workers' compensation coverage. This flow diagram depicts various pathways leading to coverage gaps that may shift the burden of occupational injury/illness-related health care and disability costs ultimately to workers, particularly the most socioeconomically vulnerable. We describe existing research and important research gaps linked to specific pathways in the flow diagram. This flow diagram was developed to facilitate more detailed and comprehensive research into the financial burden imposed by work-related injury/illness, in order to focus policy efforts where improvement is most needed.

Immigrant Respiratory Health: a Diverse Perspective in Environmental Influences on Respiratory Health

PURPOSE OF REVIEW

The aim of this review is to examine the prevalence of and impact of environmental exposures in the workplace and home on immigrant respiratory health in the USA.

RECENT FINDINGS

Few studies report levels of workplace and home environmental exposures for immigrant children and adults, and documenting these findings is an important first step to addressing their respiratory health concerns. Rates of respiratory disease are lowest upon first arrival and increase with duration of residency in the USA. Community Health Workers may be an efficacious intervention to reducing exposures and improving lung health among immigrant populations. Immigrant children and adults have a high risk of occupational and home environmental exposures that can negatively affect their respiratory health. While limited studies exist, more documentation of these exposures and their impact on immigrant person's respiratory health are needed to begin to tackle these disparities.

State Trauma Registries as a Resource for Occupational Injury Surveillance and Research: Lessons From Washington State, 1998-2009

OBJECTIVES

Work-related traumatic injury is a leading cause of death and disability among US workers. Occupational injury surveillance is necessary for effective prevention planning and assessing progress toward Healthy People 2020 objectives. Our objectives were to (1) describe the Washington State Trauma Registry (WTR) as a resource for occupational injury surveillance and research, (2) compare the WTR with 2 population-based data sources more widely used for these purposes, and (3) compare the number of injuries ascertained by the WTR with other data sources.

METHODS

We linked WTR records to hospital discharge records in the Comprehensive Hospital Abstract Reporting System for 2009 and to workers' compensation claims from the Washington State Department of Labor and Industries for 1998 to 2008. We assessed the 3 data sources for overlap, concordance, and case ascertainment.

RESULTS

Of 9185 work-related injuries in the WTR, 3380 (37%) did not link to workers' compensation claims. Use of payer information in hospital discharge records along with the WTR work-relatedness field identified 20% more linked injuries as work related (n = 720) than did use of payer information alone (n = 602). The WTR identified substantial numbers of work-related injuries that were not identified through workers' compensation or hospital discharge records.

CONCLUSIONS

Workers' compensation and hospital discharge databases are important but incomplete data sources for work-related injuries; many work-related injuries are not billed to, reported to, or covered by workers' compensation. Trauma registries are well positioned to capture severe work-related injuries and should be included in comprehensive injury surveillance efforts.

A Seven-Year Longitudinal Claim Analysis to Assess the Factors Contributing to the Increased Severity of Work-Related Injuries

BACKGROUND

In recent decades, the frequency of Medical Only (MO) and Lost Time (LT) workers' compensation claims has decreased, while average severity (medical and indemnity costs) has increased.

OBJECTIVE

The aim of this study was to compare claim frequency, mix, and severity (cost) over two periods using a claim cohort follow-up method.

METHODS

Sixty-two thousand five hundred thirty-three claims during two periods (1999 to 2002 and 2003 to 2006) were followed seven years postinjury. Descriptive analysis and significant testing methods were used to compare claim frequency and costs.

RESULTS

The number of claims per $1 M of premium decreased 50.4% for MO claims and 35.6% for LT claims, consequently increasing the LT claim proportion. The average cost of LT claims did not increase.

CONCLUSION

The severity increase is attributable to the proportional change in LT and MO claims. While the number of LT claims decreased, the inflation-adjusted average cost of LT claims did not increase.

Using emergency department surveillance data to assess occupational injury and illness reporting by workers

OBJECTIVE

Researchers from the National Institute for Occupational Safety and Health (NIOSH) share detailed methodologies from conducting two follow-back studies initiated in 2010 that were designed to assess whether workers reported their injuries and illnesses to their employers and to identify worker incentives and disincentives for reporting work-related injuries to employers.

METHODOLOGY

Study respondents were sampled from the National Electronic Injury Surveillance System occupational supplement (NEISS-Work), an emergency department-based surveillance system. Telephone interviews were used to collect information directly from workers.

OUTCOMES

Among persons treated in emergency departments who could be identified as working at the time of injury or illness, most reported their injury or illness to their employer. Our studies did not assess if these reported injuries and illnesses were recorded on the Occupational Safety and Health logs.

DISCUSSION

Our approach suggests that emergency department-based surveillance data are limited in their utility to investigate underreporting among workers. Am. J. Ind. Med. 59:600-609, 2016. © 2016 Wiley Periodicals, Inc.

Industrial Injury Hospitalizations Billed to Payers Other Than Workers' Compensation: Characteristics and Trends by State

OBJECTIVE

To describe characteristics of industrial injury hospitalizations, and to test the hypothesis that industrial injuries were increasingly billed to non-workers' compensation (WC) payers over time.

DATA SOURCES

Hospitalization data for 1998-2009 from State Inpatient Databases, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality.

STUDY DESIGN

Retrospective secondary analyses described the distribution of payer, age, gender, race/ethnicity, and injury severity for injuries identified using industrial place of occurrence codes. Logistic regression models estimated trends in expected payer.

PRINCIPAL FINDINGS

There was a significant increase over time in the odds of an industrial injury not being billed to WC in California and Colorado, but a significant decrease in New York. These states had markedly different WC policy histories. Industrial injuries among older workers were more often billed to a non-WC payer, primarily Medicare.

CONCLUSIONS

Findings suggest potentially dramatic cost shifting from WC to Medicare. This study adds to limited, but mounting evidence that, in at least some states, the burden on non-WC payers to cover health care for industrial injuries is growing, even while WC-related employer costs are decreasing-an area that warrants further research.

Urban occupational health in the Mexican and Latino/Latina immigrant population: a literature review

Mexican and Latino/Latina immigrants represent a rapidly growing population within the United States. The majority settle in urban areas. As a group, Mexican immigrants typically have low educational attainment and socioeconomic status, and limited English proficiency. These immigrants often find work in hazardous jobs, with high injury and fatality rates. They often have inadequate or no safety training, no personal protective equipment, limited understanding of workers' rights, job insecurity, fear of report of undocumented status and lack health care benefits. This review includes what has been published on the urban occupational health of this population. The findings suggest that Mexican and Latino/Latina immigrants experience higher rates of work-related fatalities and injuries compared to other populations, and may be less likely to report such incidents to employers or to apply for workers' compensation. There is a strong need to develop effective programs to address the health and safety of this vulnerable population.

Contrasting patterns of care for musculoskeletal disorders and injuries of the upper extremity and knee through workers' compensation and private health care insurance among union carpenters in Washington State, 1989 to 2008

BACKGROUND

Musculoskeletal symptoms and disorders (MSDIs) are common reasons for visits to medical providers in the general population and they are common work-related complaints. Prior reports raise concerns as to whether declines in workers' compensation (WC) rates represent true improvement in occupational health and safety or shifting of care to other payment systems.

METHODS

By linking administrative records, we compared patterns of WC claims and private health care utilization for disorders of the upper extremity (UE) and knee among a large cohort of union carpenters over a 20-year period.

RESULTS

As WC claim rates declined, private health care utilization increased. The increase was muted somewhat but sustained when adjusting for other patterns of health care utilization.

CONCLUSIONS

Findings suggest the decline of WC claim rates do not solely represent improved occupational safety in this population, but also a considerable shifting of care to their private insurance coverage over time.

Disparities in occupational injury hospitalization rates in five states (2003-2009)

BACKGROUND

Achievement of health equity and elimination of disparities are overarching goals of Healthy People 2020, yet there is a paucity of population-based data regarding race/ethnicity-based disparities in occupational injuries.

METHODS

Hospital discharge data for five states (Arizona, California, Florida, New Jersey, and New York) were obtained from the Healthcare Cost & Utilization Project (HCUP) for 2003-2009. Age-adjusted rates and trends for work-related injury hospitalizations were calculated using negative binomial regression (reference category: non-Latino white).

RESULTS

Latinos were significantly more likely to have a work-related traumatic injury hospitalization. The disparity for Latinos was greatest for machinery-related hospitalizations. Latinos were also more likely to have a fall-related hospitalization. African-Americans were more likely to have an occupational assault-related hospitalization, but less likely to have a fall-related hospitalization.

CONCLUSIONS

We found evidence of substantial multistate disparities in occupational injury-related hospitalizations. Enhanced surveillance and further research are needed to identify and address underlying causes.

Non-reporting of work injuries and aspects of jobsite safety climate and behavioral-based safety elements among carpenters in Washington State

BACKGROUND

Declining work injury rates may reflect safer work conditions as well as under-reporting.

METHODS

Union carpenters were invited to participate in a mailed, cross-sectional survey designed to capture information about injury reporting practices. Prevalence of non-reporting and fear of repercussions for reporting were compared across exposure to behavioral-based safety elements and three domains of the Nordic Safety Climate Questionnaire (NOSACQ-50).

RESULTS

The majority (>75%) of the 1,155 participants felt they could report work-related injuries to their supervisor without fear of retribution, and most felt that the majority of injuries on their jobsites got reported. However, nearly half indicated it was best not to report minor injuries, and felt pressures to use their private insurance for work injury care. The prevalence of non-reporting and fear of reporting increased markedly with poorer measures of management safety justice (NOSACQ-50).

CONCLUSIONS

Formal and informal policies and practices on jobsites likely influence injury reporting.

Administering the cost of death: organisational perspectives on workers' compensation and common law claims following traumatic death at work in Australia

Quite apart from its devastating human and psychological effects, the death of a worker can have significant, life-changing effects on their families. For many affected families, workers' compensation entitlements represent the primary financial safeguard. Where the worker was self-employed, the family will generally be excluded from this remedy and have to take the more problematic option of claiming damages at common law. Despite the centrality of workers' compensation, little attention has been given to how effectively workers' compensation agencies address the needs of bereaved families or the views of other organisations involved, such as safety inspectors, unions, employers and victim advocates. Based on interviews with forty eight organisational representatives in five Australian states, this study examines how workers' compensation regimes deal with work-related death from the perspective of those organisations involved directly or indirectly in the process. The study highlighted a number of problems, including the exclusion of self-employed workers and dealing with 'mixed families'.

Industry contributions to aggregate workplace injury and illness rate trends: 1992-2008

BACKGROUND

Aggregate workplace injury and illness rates have generally declined over the past quarter century. Assessing which industries contributed to these declines is hampered by industry coding changes that broke time series data.

MATERIALS AND METHODS

Ratios were estimated to convert older incidence rate data to current industry codes and to create long industry time series from data of the BLS Survey of Occupational Injuries and Illnesses. These data were used to assess contributions to aggregate trends from within-industry incidence rate trends and across-industry hours shifts.

RESULTS

Hours shifts toward safer industries do not explain aggregate incidence rate declines. Rather declines resulted from within-industry declines. The top 20 contributors out of 307 industries account for 40 percent of the decline and include both goods-producing and service-providing industries.

CONCLUSION

These data help focus future research on industries responsible for rate declines and factors hypothesized as contributing to declines.

Use of multiple data sources for surveillance of work-related amputations in Massachusetts, comparison with official estimates and implications for national surveillance

BACKGROUND

Accurate surveillance of work-related injuries is needed at national and state levels. We used multiple sources for surveillance of work-related amputations, compared findings with Survey of Occupational Injuries and Illnesses (SOII) estimates, and assessed generalizability to national surveillance.

METHODS

Three data sources were used to enumerate work-related amputations in Massachusetts, 2007-2008. SOII eligible amputations were compared with SOII estimates.

RESULTS

787 amputations were enumerated, 52% ascertained through hospital records only, exceeding the SOII estimate (n = 210). The estimated SOII undercount was 48% (95% CI: 36-61%). Additional amputations were reported in SOII as other injuries, accounting for about half the undercount. Proportionately more SOII estimated than multisource cases were in manufacturing and fewer in smaller establishments.

CONCLUSION

Multisource surveillance enhanced our ability to document work-related amputations in Massachusetts. While not feasible to implement for work-related conditions nationwide, it is useful in states. Better understanding of potential biases in SOII is needed.

Using injury severity to improve occupational injury trend estimates

BACKGROUND

Hospitalization-based estimates of trends in injury incidence are also affected by trends in health care practices and payer coverage that may differentially impact minor injuries. This study assessed whether implementing a severity threshold would improve occupational injury surveillance.

METHODS

Hospital discharge data from four states and a national survey were used to identify traumatic injuries (1998-2009). Negative binomial regression was used to model injury trends with/without severity restriction, and to test trend divergence by severity.

RESULTS

Trend estimates were generally biased downward in the absence of severity restriction, more so for occupational than non-occupational injuries. Restriction to severe injuries provided a markedly different overall picture of trends.

CONCLUSIONS

Severity restriction may improve occupational injury trend estimates by reducing temporal biases such as increasingly restrictive hospital admission practices, constricting workers' compensation coverage, and decreasing identification/reporting of minor work-related injuries. Injury severity measures should be developed for occupational injury surveillance systems.

Effects of social, economic, and labor policies on occupational health disparities

BACKGROUND

This article introduces some key labor, economic, and social policies that historically and currently impact occupational health disparities in the United States.

METHODS

We conducted a broad review of the peer-reviewed and gray literature on the effects of social, economic, and labor policies on occupational health disparities.

RESULTS

Many populations such as tipped workers, public employees, immigrant workers, and misclassified workers are not protected by current laws and policies, including worker's compensation or Occupational Safety and Health Administration enforcement of standards. Local and state initiatives, such as living wage laws and community benefit agreements, as well as multiagency law enforcement contribute to reducing occupational health disparities.

CONCLUSIONS

There is a need to build coalitions and collaborations to command the resources necessary to identify, and then reduce and eliminate occupational disparities by establishing healthy, safe, and just work for all.

Promoting integrated approaches to reducing health inequities among low-income workers: applying a social ecological framework

BACKGROUND

Nearly one of every three workers in the United States is low-income. Low-income populations have a lower life expectancy and greater rates of chronic diseases compared to those with higher incomes. Low- income workers face hazards in their workplaces as well as in their communities. Developing integrated public health programs that address these combined health hazards, especially the interaction of occupational and non-occupational risk factors, can promote greater health equity.

METHODS

We apply a social-ecological perspective in considering ways to improve the health of the low-income working population through integrated health protection and health promotion programs initiated in four different settings: the worksite, state and local health departments, community health centers, and community-based organizations.

RESULTS

Examples of successful approaches to developing integrated programs are presented in each of these settings. These examples illustrate several complementary venues for public health programs that consider the complex interplay between work-related and non work-related factors, that integrate health protection with health promotion and that are delivered at multiple levels to improve health for low-income workers.

CONCLUSIONS

Whether at the workplace or in the community, employers, workers, labor and community advocates, in partnership with public health practitioners, can deliver comprehensive and integrated health protection and health promotion programs. Recommendations for improved research, training, and coordination among health departments, health practitioners, worksites and community organizations are proposed.

Occupational health policy and immigrant workers in the agriculture, forestry, and fishing sector

BACKGROUND

Immigrant workers make up an important portion of the hired workforce in the Agricultural, Forestry and Fishing (AgFF) sector, one of the most hazardous industry sectors in the US. Despite the inherent dangers associated with this sector, worker protection is limited.

METHODS

This article describes the current occupational health and safety policies and regulatory standards in the AgFF sector and underscores the regulatory exceptions and limitations in worker protections. Immigration policies and their effects on worker health and safety are also discussed. Emphasis is placed on policies and practices in the Southeastern US.

RESULTS

Worker protection in the AgFF sector is limited. Regulatory protections are generally weaker than other industrial sectors and enforcement of existing regulations is woefully inadequate. The vulnerability of the AgFF workforce is magnified by worker immigration status. Agricultural workers in particular are affected by a long history of "exceptionalism" under the law as many regulatory protections specifically exclude this workforce.

CONCLUSIONS

A vulnerable workforce and high-hazard industries require regulatory protections that, at a minimum, are provided to workers in other industries. A systematic policy approach to strengthen occupational safety and health in the AgFF sector must address both immigration policy and worker protection regulations.

Occupational and Environmental Medicine in the United States: A Proposal to Abolish Workers' Compensation and Reestablish the Public Health Model

The workers' compensation model of occupational and environmental medicine should be converted to a public health model. Occupational and environmental medicine, as a part of the public health infrastructure,could play a much more substantive part in bringing about a national program to deal with occupational and environmental health. The workers' compensation insurance system could be discontinued at any time,but it will be vital to do so when national health insurance is adopted in the United States. Abolishing workers' compensation would remove the perverse incentives that currently undermine the practice of occupational medicine. Medical care for workers should be provided by health care professionals who are not subject to influence by employers or insurers. Eligibility for benefits should not be determined by health and safety professionals. Wage-replacement benefits for workers should be determined by guidelines established by government and industry that prevent manipulation of health and safety professionals by employers and insurers. A nationwide comprehensive system to track work-related injury and illness, superior to the current reliance on records provided by employers and collated by government agencies, should be adopted. When unusually high rates of injuries, illnesses,and fatalities occur, government inspectors ought to respond and regulate the industry accordingly. Occupational health and safety professional strained in public health can and should participate in these activities, but not when they are in the employ of industry or insurers.

Who pays for work-related traumatic injuries? Payer distribution in washington state by ethnicity, injury severity, and year (1998-2008)

BACKGROUND

Acute work-related trauma is a leading cause of death and disability for U.S. workers but it is difficult to obtain information about injured workers not covered by workers' compensation (WC). This study aimed to: (1) describe trends in expected payer and linkage to WC claims, (2) compare characteristics of injured workers who did and did not have a linked WC claim, and (3) describe variation in expected payer and linkage to WC claims by ethnicity and injury severity.

METHODS

Data for injuries occurring from 1998 through 2008 were obtained from the Washington State Trauma Registry and linked to WC claims.

RESULTS

We found that 27% of work-related traumatic injuries did not have WC listed as a payer, while 37% did not link to a WC claim. Among those with WC listed as a payer, the odds of having a linked WC claim were 57% lower for workers with other non-WC insurance compared with the otherwise uninsured. Latinos were more likely to have a linked WC claim compared with non-Latinos, but there was no significant difference after partially controlling for WC-covered employment and other insurance.

CONCLUSIONS

This study demonstrated the importance of considering differential access to other insurance coverage and adaptation by health care settings to financial pressures when assessing trends in occupational injury incidence and reporting, especially when using WC as a proxy for work-relatedness. The addition of occupation, industry, and work status to trauma registries and hospital discharge databases would improve surveillance, research, policy and prevention efforts.

Twenty years of work-related injury and illness among union carpenters in Washington State

BACKGROUND

Individuals who work in the construction industry are at high risk of occupational injury. Robust surveillance systems are needed to monitor the experiences of these workers over time.

METHODS

We updated important surveillance data for a unique occupational cohort of union construction workers to provide information on long-term trends in their reported work-related injuries and conditions. Combining administrative data sources, we identified a dynamic cohort of union carpenters who worked in Washington State from 1989 through 2008, their hours worked by month, and their workers' compensation claims. Incidence rates of reported work-related injuries and illnesses were examined. Poisson regression was used to assess risk by categories of age, gender, time in the union, and calendar time contrasting medical only and paid lost time claims.

RESULTS

Over the 20-year study period, 24,830 carpenters worked 192.4 million work hours. Work-related injuries resulting in medical care or paid lost time (PLT) from work occurred at a rate of 24.3 per 200,000 hr worked (95% CI: 23.5-25.0). Medical only claims declined 62% and PLT claims declined 77%; more substantive declines were seen for injuries resulting from being struck and falls to a lower level than from overexertion with lifting. Differences in risk based on union tenure and age diminished over time as well.

CONCLUSIONS

Significant declines in rates of reported work-related injuries and illnesses were observed over the 20-year period among these union carpenters. Greater declines were observed among workers with less union tenure and for claims resulting in PLT.

Evaluating goals in worker health protection using a participatory design and an evaluation checklist

Spanish-speaking immigrant workers in construction are considered hard to reach and at high risk for work-related injury and fatality. This evaluation study describes the use of participatory methods and an evaluation checklist to consider a health and safety (H&S) training program for these workers. A previously developed training manual and model were disseminated to eight worker centers (WCs) through participatory research collaboration. It incorporated H&S training for workers while strengthening the role of WCs as sources for leadership development and worker empowerment. Design, delivery, reaction, application, and extension were assessed through individual interviews with participants, trained trainers, and center staff and through observation of training sessions and partner debriefs; pre- and post-training tests assessed participant learning. Results indicate moderate learning and application by participants and strong evidence for structural gains in and among WCs. We conclude that such partnerships and models are valuable tools for collaborating with hard-to-reach workers.

Occupational health and safety experiences among self-identified immigrant workers living or working in Somerville, MA by ethnicity, years in the US, and English proficiency

In this community based research initiative, we employed a survey instrument predominately developed and administered by Teen Educators to assess occupational health risks for Haitian, Salvadoran, and Brazilian immigrants (n = 405) in Somerville, MA, USA. We demonstrate that a combined analysis of ethnicity, years in the US, and English proficiency better characterized the occupational experience of immigrant workers than considering these variables individually. While years in the US (negatively) and English proficiency (positively) explained the occurrence of health risks, the country of origin identified the most vulnerable populations in the community. Brazilians, Salvadorans, and other Hispanic, all of whom who have been in the US varying length of time, with varying proficiency in English language had twice the odds of reporting injuries due to work compared to other immigrants. Although this observation was not significant it indicates that years in the US and English proficiency alone do not predict health risks among this population. We recommend the initiation of larger studies employing c community based participatory research methods to confirm these differences and to further explore work and health issues of immigrant populations. This study is one of the small number of research efforts to utilize a contemporaneous assessment of occupational health problems in three distinct immigrant populations at the community level within a specific Environmental Justice context and social milieu.

Preserving workers' dignity in workers' compensation systems: an international perspective

BACKGROUND

Workers' compensation systems are among the most generous disability insurance systems in North America, although they are also known to be potentially adversarial and may have iatrogenic effects on claimants. This article examines issues to be considered to ensure fair compensation provided in a way that respects the dignity of workers.

METHODS

An overview of the literature on characteristics and effects of workers' compensation systems is followed by an analysis based on classic legal methods, including those of comparative law, complemented with interview data to examine three models of disability compensation.

RESULTS

The first part of the article identifies cross cutting issues to be considered in the examination of the equity of compensation systems and the protection of the dignity of claimants. These include three underpinnings of workers' compensation: the links between a "no-fault" system and the adversarial process, the appropriate use of medical and scientific evidence in the determination of compensability and the application of appropriate measures for promoting return to work. The second part looks at accident compensation in New Zealand, where compensation is available regardless of the cause of the accident, and disability insurance in the Netherlands, where compensation is available regardless of the cause of the disability. It then describes a composite of characteristics favorable to equity drawn from the thirteen workers' compensation systems in Canada.

CONCLUSION

Systems that succeed in reducing opportunities for adversarial interactions and that provide substantive protection could better promote the dignity of claimants.

Use of statewide electronic emergency department data for occupational injury surveillance: a feasibility study in Massachusetts

BACKGROUND

Statewide datasets of emergency department (ED) visits may be useful for occupational injury surveillance. Using data from 12 hospitals, we evaluated two indicators of work-relatedness in reported ED data and the availability of employment information in medical charts.

METHODS

Workers' compensation as payer and/or "yes" in an injury-at-work field were used to define probable work-related (PWR) injury visits in the Massachusetts ED dataset. Charts were reviewed for a sample of 1,002 PWR and 250 probable nonwork-related (PNWR) cases.

RESULTS

Using chart information as the gold standard, indicators of work-relatedness had a sensitivity of 82%, specificity of 97%, and predictive value positive of 86%. Employer name was in charts for 89% of PWR and 42% of PNWR cases. Occupation was available for 34% of PWR cases.

CONCLUSION

Electronic ED data are useful for state surveillance of occupational injuries. Improvements in attribution of work-relatedness and collection of available employer identifiers and occupational information would enhance its usefulness. The performance of indicators of work-relatedness in ED datasets should be examined in different states.

Health situation of migrants with precarious status: review of the literature and implications for the Canadian context--Part A

Migrants with precarious status (MPS) are an understudied population. Yet there are indications that they could be particularly vulnerable and confronted to health inequalities. This review of Canadian and international literature highlights that MPS, like other migrants, are confronted with deleterious living conditions and multiple obstacles to access healthcare. However, their status brings additional challenges and harmful health determinants. The situation of MPS may well be similar in Canada, where they could be numerous. Therefore it is crucial to better document this issue within the Canadian context. Part B of this article, reported elsewhere, further explores this topic.

Health of migrants with precarious status: results of an exploratory study in Montreal--Part B

Increasingly, migrants with precarious status (MPS) are recognized as being particularly vulnerable. This exploratory study assesses whether the health of MPS in Montreal, Canada, is similar to that reported in the international literature (see Health situation of migrants with precarious status: Review of the literature and implications for the Canadian context--Part A, Social Work in Public Health, 27 (4), 330-344). The results of this study show that, as in other parts of the world, MPS in Canada appear to be confronted by multiple obstacles to health, many of which are linked to their precarious migration status and its impact on living conditions and access to health care. To reduce health inequalities, therefore, it is crucial to better understand and address the specific needs of this highly vulnerable population.

Objective measures of adoption of patient lift and transfer devices to reduce nursing staff injuries in the hospital setting

BACKGROUND

Interventions to reduce patient-handling injuries in the hospital setting are often evaluated based on their effect on outcomes such as injury rates. Measuring intervention adoption could address how and why observed trends in the outcome occurred.

METHODS

Unit-level data related to adoption of patient lift equipment were systematically collected at several points in time over 5 years on nursing units at two hospitals, including hours of lift equipment use, equipment accessibility, and supply purchases and availability.

RESULTS

Various measures of adoption highlighted the adoption process' gradual nature and variability by hospital and between units. No single measure adequately assessed adoption. Certain measures appear well-correlated.

CONCLUSION

Future evaluation of primary preventive efforts designed to prevent patient-handling injuries would be strengthened by objective data on intermediate measures that reflect intervention implementation and adoption.

Results of a community-university partnership to reduce deadly hazards in hardwood floor finishing

A community-university partnership used community-based participatory research (CBPR) to design, implement, and evaluate a multi-cultural public health campaign to eliminate flammable products and reduce use of products high in volatile organic compounds (VOCs) in hardwood floor finishing in Massachusetts. Leading participants were Vietnamese-American organizations and businesses. Following the public health campaign, a multi-lingual survey of self-reported experiences with fires, product use, exposure to outreach activities, and changes made, was conducted with floor finishers. One hundred nine floor finishers responded. Over 40% reported fires at their companies' jobs, mostly caused by lacquer sealers. Over one third had heard radio or TV shows about health and safety in floor finishing, and over half reported making changes as a result of outreach. Exposure to various outreach activities was associated with reducing use of flammable products, increasing use of low-VOC products, and greater knowledge about product flammability. However, most respondents still reported using flammable products. Outreach led by community partners reached large proportions of floor finishers, was associated with use of safer products, and adds to recent work on CBPR with immigrant workers. Continued use of flammable products supports the belief that an enforceable ban was ultimately necessary to eradicate them.

National trends in occupational injuries before and after 1992 and predictors of workers' compensation costs

OBJECTIVE

Numbers and costs of occupational injuries and illnesses are significant in terms of morbidity and dollars, yet our understanding of time trends is minimal. We investigated trends and addressed some common hypotheses regarding causes of fluctuations.

METHODS

We pulled data on incidence rates (per 100 full-time employed workers) for injuries and illnesses from the U.S. Bureau of Labor Statistics and on costs and benefits from the National Academy of Social Insurance for 1973 through 2007. Rates reflected all injury and illness cases, lost work-time cases, and cases resulting in at least 31 days away from work. We adjusted dollar costs (premiums) and benefits for inflation and measured them per employed worker. We plotted data in time-trend charts and ran linear regressions.

RESULTS

From 1973 to 1991, there was a weak to nonexistent downward trend for injury and illness rates, and rates were strongly and negatively correlated with the unemployment rate. From 1992 to 2007, there were strong, consistent downward trends, but no longer were there statistically significant correlations with unemployment. Significant predictors (and signs) of workers' compensation premiums for 1973-2007 included medical price inflation (positive), number of lost-time injuries (positive), the Dow Jones Industrial Average (negative), and inflation-adjusted interest rate on U.S. Treasury bonds (negative). Dollars of benefits were positively and significantly predicted by medical inflation and number of lost-time cases. For 1992-2007, the Dow Jones variable was the only robust predictor of premiums; the number of injuries was not a significant positive predictor.

CONCLUSION

We had two major conclusions. First, the year 1992 marked a sharp contrast in trends and correlations between unemployment and incidence rates for occupational injuries and illnesses. Second, for the entire time period (1973-2007), insurance carriers' premiums were strongly associated with returns on investments.

Mexican urban occupational health in the US: a population at risk

Mexicans are the largest immigrant group in the US. Little is known about their urban occupational health status. We assess occupational illness, injury, and safety training among New York City Mexican immigrants. This study is a consecutive sample of the Mexican immigrant population utilizing Mexican Consulate services in New York City over two weeks in March 2009. Bilingual research assistants approached persons waiting in line at the Consulate and administered an occupational health questionnaire. 185 people agreed to participate. Most work in restaurants (37%), cleaning (18%), construction (12%), babysitting/nanny (7%), retail (9%), and factories (5%). 22% had received safety training. 18% reported work-related pain or illness. 18% suffered from a job-related injury since immigrating. Most injuries were in construction, factories, and restaurants. 29% had not reported their injury. This study provides evidence that the urban Mexican immigrant population is at high risk for work-related illness and injury, is not receiving adequate safety training, and is under-reporting occupational injury. Culturally and linguistically responsive community outreach programs are needed to provide occupational health and safety information and resources for urban Mexican workers.

Work-relatedness of selected chronic medical conditions and workers' compensation utilization: National health interview survey occupational health supplement data

BACKGROUND

An occupational health supplement (OHS) to the 1988 National Health Interview Survey (NHIS) bypassed many limitations of traditional occupational health surveillance systems, but the data collected about chronic work-related conditions have not yet been reported.

METHODS

We calculated the prevalence and proportion of cases related to work for the aggregation of 13 chronic conditions included in the NHIS-OHS, and for 11 conditions individually. For each of nine conditions, and for the aggregation of all conditions, we also calculated the prevalence of workers' compensation claims filed.

RESULTS

The overall prevalence of work-related chronic conditions was 7.5% (SE = 0.16). The work-related conditions with the highest prevalence were repeated trouble with the back/neck/spine (4.91%; SE = 0.13) and trouble hearing (1.14%; SE = 0.06). Overall, workers' compensation claims were filed for 39.0% (SE = 1.00) of work-related cases.

CONCLUSIONS

The burden of work-related illnesses in the US is substantial, and the workers' compensation system is underutilized.

Occupational injuries and illnesses in the solid waste industry: a call for action

Work-related injuries and illnesses are multi-factorial and remain major problems of public health magnitude requiring the attention of all stakeholders in the solid waste industry. The objective of this article was to describe the patterns of occupational injury and illness (OII) reporting incidence among workers in a major private U. S. solid waste management company. A five-year (2003-2007) retrospective review of the corporate Occupational Safety and Health Administration (OSHA) logs 300/300A/301 was conducted and employee OII reports (n = 1895) were analyzed from 37 establishments across 11 different states. The OII reporting rates were compared to industry average.

Working poor in Germany: Dimensions of the problem and repercussions for the health-care system

The 'working poor' may not exceed the poverty threshold despite full-time (or even double) employment. The general relationship between poverty and illness is understood, but little is known about specific health implications of the 'working poor' status. The proportion of 'working poor' is increasing in Germany. Poverty-related health problems occur because of a lower standard of nutrition and housing, financial restraints, bad labour conditions, high-risk behaviours, and lack of access to health services. Impaired health status, in turn, adversely affects incomes and wages, raising concern about a vicious circle. Limited health-care resources demand preventive policies to improve employment status and income. Health and economic policy demand specific research on the health implications of precarious employment. In some areas, swift action is required.

Work-related injuries among Hispanic construction workers-evidence from the medical expenditure panel survey

BACKGROUND

Although a large number of Hispanic workers have entered the construction industry, few studies have estimated non-fatal work-related injuries for Hispanic construction workers at a national level. This study examines work-related injury conditions among Hispanic construction workers and assesses disparities between Hispanic and white, non-Hispanic workers.

METHODS

Pooled data were analyzed from a large national population survey, the Medical Expenditure Panel Survey (MEPS), between 1996 and 2002. More than 7,000 construction workers were identified from the MEPS data including 1,833 Hispanic workers and 4,533 white, non-Hispanic workers. Univariate and multivariate analyses were conducted using SAS-callable SUDAAN.

RESULTS

Hispanic workers differ from white, non-Hispanic workers in demographic and socioeconomic status. After controlling for major risk factors, Hispanic construction workers were more likely than their white, non-Hispanic counterparts to suffer non-fatal work-related injury conditions (OR = 1.28, 95% CI: 1.00-1.64).

CONCLUSIONS

This study provides important evidence concerning Hispanic workers' safety on construction sites. Enhanced safety and health programs for Hispanic construction workers and improved occupational injury data systems are recommended.

Occupational injury disparities in the US hotel industry

BACKGROUND

Hotel employees have higher rates of occupational injury and sustain more severe injuries than most other service workers.

METHOD

OSHA log incidents from five unionized hotel companies for a three-year period were analyzed to estimate injury rates by job, company, and demographic characteristics. Room cleaning work, known to be physically hazardous, was of particular concern.

RESULTS

A total of 2,865 injuries were reported during 55,327 worker-years of observation. The overall injury rate was 5.2 injuries per 100 worker-years. The rate was highest for housekeepers (7.9), Hispanic housekeepers (10.6), and about double in three companies versus two others. Acute trauma rates were highest in kitchen workers (4.0/100) and housekeepers (3.9/100); housekeepers also had the highest rate of musculoskeletal disorders (3.2/100). Age, being female or Hispanic, job title, and company were all independently associated with injury risk.

CONCLUSION

Sex- and ethnicity-based disparities in injury rates were only partially due to the type of job held and the company in which the work was performed.

Who is paying the bills? Health care costs for musculoskeletal back disorders, Washington State Union Carpenters, 1989-2003

OBJECTIVE

Factors associated with private health insurance payment rates for musculoskeletal back disorders were examined among a 15-year cohort of union carpenters. Payment patterns were contrasted with work-related back injury rates over time.

METHODS

Negative binomial regression was used to assess payment rates; generalized estimated equations accounted for multiple observations per person and cost correlation within subjects.

RESULTS

Payment rates increased after work-related injury and with the number of injuries. Increasing private payments and deductibles (inflation-adjusted and discounted) were observed in contrast with a marked decline in reported work-related injuries.

CONCLUSIONS

Private insurance payments do not appear to be independent of work-related back injury. Findings suggest cost-shifting from workers' compensation to the union-provided health insurance and to the worker; they also provide a warning regarding reliance on workers' compensation statistics for surveillance of work-related disorders or disease.

The Vida Verde Women's Co-Op: Brazilian immigrants organizing to promote environmental and social justice

We reviewed the key steps in the launch of the Vida Verde Women's Co-Op among Brazilian immigrant housecleaners in Somerville, MA. The co-op provides green housecleaning products, encourages healthy work practices, and promotes a sense of community among its members. We conducted in-depth interviews with 8 of the first co-op members, who reported a reduction in symptoms associated with the use of traditional cleaning agents and a new sense of mutual support. Critical to the co-op's success have been the supportive roles of its academic partners (Tufts University and the University of Massachusetts, Lowell), effective media outreach, and a focus on advancing social justice. Next steps include implementing a formal business plan and assessing the appropriateness of cooperatives in other industries.

A conceptual framework for integrating workplace health promotion and occupational ergonomics programs

Musculoskeletal, cardiovascular, and mental health are all associated with the physical and psychosocial conditions of work, as well as with individual health behaviors. An integrated approach to workplace health-promotion programs should include attention to the work environment, especially in light of recent findings that work organization influences so-called lifestyle or health behaviors. Macroergonomics provides a framework to improve both physical and organizational features of work and, in the process, to empower individual workers. The Center for the Promotion of Health in the New England Workplace (CPH-NEW) is a research-to-practice effort examining the effectiveness of worksite programs that combine occupational safety and health--especially ergonomics--with health promotion, emphasizing the contribution of work organization to both. Two intervention studies are underway in three different sectors: health care, corrections, and manufacturing. Each study features participatory structures to facilitate employee input into health goal-setting, program design and development, and evaluation, with the goal of enhanced effectiveness and longer-term sustainability.