Assessing the role of social determinants of health in health disparities: The need for data on work

BACKGROUND

Work is a key social determinant of health. Without the collection of work-related information in public health data systems, the role of social determinants in creating and reinforcing health disparities cannot be fully assessed.

METHODS

The Centers for Disease Control and Prevention (CDC) maintains or supports a number of public health surveillance and health monitoring systems, including surveys, case-based disease and exposure systems, vital status records, and administrative data systems. We evaluated a convenience sample of these systems for inclusion of information in three work-related domains: employment status, industry and occupation, and working conditions.

RESULTS

While 12 of 39 data systems were identified as collecting work-related data, this information was often minimal (e.g., only employment status), restricted to a subset of respondents, or only gathered periodically. Information on working conditions was particularly sparse.

CONCLUSION

Historically, the limited and inconsistent collection of work-related information in public health data systems has hindered understanding of the role work plays in health disparities. Current CDC data modernization efforts present opportunities to enhance the identification and mitigation of health disparities by prioritizing inclusion of an expanded set of work-related data elements.

Injuries That Happen at Work Lead to More Opioid Prescriptions and Higher Opioid Costs

OBJECTIVES

This study aimed to compare opioid prescription incidence, supply days, and cost associated with occupational injury and other injury-caused conditions.

METHODS

We used Medical Expenditure Panel Survey (MEPS) data for 2010-2019. The MEPS provides information on medical conditions and associated medical encounters, treatments, and treatment costs, as well as demographic, education, health, working status, income, and insurance coverage information. We used descriptive statistics and logistic and 2-part regressions.

RESULTS

Controlling for covariates and compared with other injury-caused conditions, occupational injury-caused conditions resulted in 33% higher odds of opioid prescribing, 32.8 more opioid prescription supply days, and $134 higher average cost.

CONCLUSIONS

Occupational injuries were associated with higher opioid incidence and costs, and more opioid supply days. These findings point to the need to focus on making work safer and the role employers may play in supporting worker recovery from injury and opioid use disorders.

Work Flexibility and Work-Related Well-Being

Work organization practices, including work flexibility, are changing and can affect worker well-being. Common work flexibility types include working at home, taking time off when needed, and changing one’s work schedule. Given the changes in and the importance of work flexibility, the study assesses its prevalence and association with worker well-being in the United States. We used 2002–2018 General Social Survey—Quality of Worklife (GSS-QWL) data, descriptive statistics, and regression analyses to assess the reported likelihood of job stress, job satisfaction, healthy days, and days with activity limitations among workers reporting work flexibility. The prevalence of work flexibility remained relatively stable during the period examined. Working at home increased the likelihood of job stress by 22% and job satisfaction by 65%. Taking time off decreased the likelihood of job stress by 56% and days with activity limitations by 24%, and more than doubled the likelihood of job satisfaction. Changing one’s schedule decreased the likelihood of job stress by 20% and increased the likelihood of job satisfaction by 62%. This study used all the available data from GSS-QWL and demonstrated the ongoing importance of work flexibility for well-being.

Employment arrangement, job stress, and health-related quality of life

OBJECTIVE

We aimed to understand the characteristics of U.S. workers in non-standard employment arrangements, and to assess associations between job stress and Health-related Quality of Life (HRQL) by employment arrangement.

BACKGROUND

As employers struggle to stay in business under increasing economic pressures, they may rely more on non-standard employment arrangements, thereby increasing the pool of contingent workers. Worker exposure to job stress may vary by employment arrangement. Excessive exposure to stressors at work is considered to be a potential health hazard, and may adversely affect health and HRQL.

METHODS

We used the Quality of Worklife (QWL) module which supplemented the General Social Survey (GSS) in 2002, 2006, 2010, and 2014. GSS is a biannual, nationally representative cross-sectional survey of U.S. households that yields a representative sample of the civilian, non-institutionalized, English-speaking, U.S. adult population. The QWL module assesses an array of psychosocial working conditions and quality of work life topics among GSS respondents. We used pooled QWL responses from 2002 to 2014 by only those who reported being employed at the time of the survey. After adjusting for sampling probabilities, including subsampling for non-respondents and correcting for the number of adults in the household, 6005 respondents were included in our analyses. We grouped respondents according to their employment arrangement, including: (i) independent contractors (contractor), (ii) on call workers (on call), (iii) workers paid by a temporary agency (temporary), (iv) workers who work for a contractor (under contract), or (v) workers in standard employment arrangements (standard). Respondents were further grouped into those who were stressed and those who were not stressed at work. Descriptive population prevalence rates were calculated by employment arrangement for select demographic and organizational characteristics, psychosocial working conditions, work-family balance, and health and well-being outcomes. We also assessed the effect of employment arrangement on job stress, and whether job stress was associated with the number of reported unhealthy days and days with activity limitations. These two health and well-being outcomes capture aspects of worker HRQL.

RESULTS

Our results underscored the importance of employment arrangement in understanding job stress and associated worker health and well-being outcomes. Between 2002 and 2014, the prevalence of workers in non-standard employment arrangements increased from 19% to 21%; however, the observed trend did not monotonically increase during that period. Compared with workers in standard arrangements, independent contractors and on call workers were significantly less likely to report experiencing job stress. For workers in standard arrangements and for contractors, we observed significant association between perceived job stress and reported unhealthy days. We observed a similar association for reported days with activity limitations, for workers in standard and temporary arrangements.

CONCLUSION

The major contribution of our study was to highlight the differences in job stress and HRQL by employment arrangement. Our results demonstrated the importance of studying each of these employment arrangements separately and in depth. Furthermore, employment arrangement was an important predictor of job stress, and compared with non-stressed workers, stressed workers across all employment arrangements reported more unhealthy days and more days with activity limitations.

Potential Economic Benefits of Paid Sick Leave in Reducing Absenteeism Related to the Spread of Influenza-Like Illness

OBJECTIVE

Most U.S. employers are not required to provide paid sick leave (PSL), and there is limited information on the economic return of providing PSL. We estimated potential benefits to employers of PSL in reducing absenteeism related to the spread of influenza-like illness (ILI).

METHODS

We used nationally representative data and a negative binomial random effects model to estimate the impact of PSL in reducing overall absence due to illness or injury. We used published data to compute the share of ILI from the total days of absence, ILI transmission rates at workplaces, wages, and other parameters.

RESULTS

Providing PSL could have saved employers $0.63 to $1.88 billion in reduced ILI-related absenteeism costs per year during 2007 to 2014 in 2016 dollars.

CONCLUSION

These findings might help employers consider PSL as an investment rather than as a cost without any return.

Musculoskeletal disorders and associated healthcare costs among family members of injured workers

BACKGROUND

Research has infrequently looked beyond the injured worker when gauging the burden of occupational injury.

OBJECTIVES

We explored the relationship between occupational injury and musculoskeletal disorders (MSDs) among family members of injured workers.

DATA AND METHODS

We used 2005 and 2006 Truven Health Analytics databases, which contain information on workers' compensation and family healthcare claims. We used descriptive analyses, and negative binomial and two-part models.

RESULTS

Family members of severely injured workers had a 15% increase in the total number of MSD outpatient claims and a 34% increase in the mean cost of MSD claims compared to family members of non-severely injured workers within 3 months after injury. Extrapolating cost results to the national level implies that severe occupational injury would be associated with between $29 and $33 million additional cost of family member outpatient MSD claims.

CONCLUSION

Occupational injury can impose a formerly unrecognized health burden on family members of injured workers.

Profitability and occupational injuries in U.S. underground coal mines

BACKGROUND

Coal plays a crucial role in the U.S. economy yet underground coal mining continues to be one of the most dangerous occupations in the country. In addition, there are large variations in both profitability and the incidence of occupational injuries across mines.

OBJECTIVE

The objective of this study was to examine the association between profitability and the incidence rate of occupational injuries in U.S. underground coal mines between 1992 and 2008.

DATA AND METHOD

We used mine-specific data on annual hours worked, geographic location, and the number of occupational injuries suffered annually from the employment and accident/injury databases of the Mine Safety and Health Administration, and mine-specific data on annual revenue from coal sales, mine age, workforce union status, and mining method from the U.S. Energy Information Administration. A total of 5669 mine-year observations (number of mines×number of years) were included in our analysis. We used a negative binomial random effects model that was appropriate for analyzing panel (combined time-series and cross-sectional) injury data that were non-negative and discrete. The dependent variable, occupational injury, was measured in three different and non-mutually exclusive ways: all reported fatal and nonfatal injuries, reported nonfatal injuries with lost workdays, and the 'most serious' (i.e. sum of fatal and serious nonfatal) injuries reported. The total number of hours worked in each mine and year examined was used as an exposure variable. Profitability, the main explanatory variable, was approximated by revenue per hour worked. Our model included mine age, workforce union status, mining method, and geographic location as additional control variables.

RESULTS

After controlling for other variables, a 10% increase in real total revenue per hour worked was associated with 0.9%, 1.1%, and 1.6% decrease, respectively, in the incidence rates of all reported injuries, reported injuries with lost workdays, and the most serious injuries reported.

CONCLUSION

We found an inverse relationship between profitability and each of the three indicators of occupational injuries we used. These results might be partially due to factors that affect both profitability and safety, such as management or engineering practices, and partially due to lower investments in safety by less profitable mines, which could imply that some financially stressed mines might be so focused on survival that they forgo investing in safety.

Incidence and costs of family member hospitalization following injuries of workers' compensation claimants

BACKGROUND

The consequences of occupational injuries for the health of family members have rarely been studied. We hypothesized that non-fatal occupational injury would increase the incidence and costs of hospitalization among workers' families, and that family members of severely injured workers would be likely to experience greater increases in hospitalizations than family members of non-severely injured workers.

DATA AND METHODS

We used the MarketScan databases from Thomson Reuters for 2002-2005, which include workers' compensation and inpatient medical care claims data for injured workers' families. We used a before-after analysis to compare the odds and costs of family hospitalization 3 months before and after the index occupational injury among 18,411 families. Severe injuries were defined by receipt of indemnity payments and at least 7 days of lost work. Family hospitalizations were measured by the incidence of hospitalization of at least one family member.

RESULTS

Among families of all injured workers, the odds of at least one family member being hospitalized were 31% higher [95% confidence intervals (CI) = 1.11-1.55] in the 3 months following occupational injury than in the 3 months preceding injury. Among the families of severely injured workers, the odds of hospitalization were 56% higher [95% CI = 1.05-2.34] in the 3 months following injury. Hospitalization costs were found to rise by approximately the same percentage as hospitalization incidence.

CONCLUSION

The impact of occupational injury may extend beyond the workplace and adversely affect the health and inpatient medical care use of family members.

Paid sick leave and nonfatal occupational injuries

OBJECTIVES

We examined the association between US workers' access to paid sick leave and the incidence of nonfatal occupational injuries from the employer's perspective. We also examined this association in different industries and occupations.

METHODS

We developed a theoretical framework to examine the business value of offering paid sick leave. Data from the National Health Interview Survey were used to test the hypothesis that offering paid sick leave is associated with a reduced incidence of occupational injuries. We used data on approximately 38 000 working adults to estimate a multivariate model.

RESULTS

With all other variables held constant, workers with access to paid sick leave were 28% (95% confidence interval = 0.52, 0.99) less likely than workers without access to paid sick leave to be injured. The association between the availability of paid sick leave and the incidence of occupational injuries varied across sectors and occupations, with the greatest differences occurring in high-risk sectors and occupations.

CONCLUSIONS

Our findings suggest that, similar to other investments in worker safety and health, introducing or expanding paid sick leave programs might help businesses reduce the incidence of nonfatal occupational injuries, particularly in high-risk sectors and occupations.

The business cycle and the incidence of workplace injuries: evidence from the U.S.A

INTRODUCTION

The current study explored the association between the business cycle and the incidence of workplace injuries to identify cyclically sensitive industries and the relative contribution of physical capital and labor utilization within industries.

METHOD

Bureau of Labor Statistics nonfatal injury rates from 1976 through 2007 were examined across five industry sectors with respect to several macroeconomic indicators. Within industries, injury associations with utilization of labor and physical capital over time were tested using time series regression methods.

RESULTS

Pro-cyclical associations between business cycle indicators and injury incidence were observed in mining, construction, and manufacturing but not in agriculture or trade. Physical capital utilization was the highest potential contributor to injuries in mining while labor utilization was the highest potential contributor in construction. In manufacturing each effect had a similar association with injuries.

CONCLUSION

The incidence of workplace injury is associated with the business cycle. However, the degree of association and the mechanisms through with the business cycle affects the incidence of workplace injuries was not the same across industries.

IMPACT ON INDUSTRY

The results suggest that firms in the construction, manufacturing, and mining industries should take additional precautionary safety measures during cyclical upturns. Potential differences among industries in the mechanisms through which the business cycle affects injury incidence suggest different protective strategies for those industries. For example, in construction, additional efforts might be undertaken to ensure workers are adequately trained and not excessively fatigued, while safety procedures continue to be followed even during boom times.

Cost-effectiveness of roll-over protective structures

BACKGROUND

Roll-over protective structures (ROPS) are proven to prevent fatalities from agricultural tractor overturns, accounting for more than one-third of all production agriculture-related fatalities in the United States. In 1997, there were approximately 1.2 million ROPS-retrofittable tractors in the United States.

METHODS

A decision analysis is used to compare the health outcomes of installing ROPS on retrofittable tractors, relative to doing nothing. A cost-effectiveness analysis builds on these results to assess the costs and benefits of installing ROPS on retrofittable tractors.

RESULTS

Doing nothing would result in 1,450 fatalities and 1,806 nonfatal injuries, while installing ROPS would prevent 1,176 fatalities and 957 nonfatal injuries. Installing ROPS would cost $489,373 per injury prevented.

CONCLUSIONS

Installing ROPS on retrofittable tractors would reduce fatalities from tractor overturns by more than 80% and nonfatal injuries by about 53%. The cost per injury prevented would be similar to that of other injury-preventing interventions. ROPS would help prevent additional injuries from falling off tractors and tractor collisions with motor vehicles.

Prevention effectiveness of rollover protective structures--Part II: Decision analysis

This is the second of three articles that evaluate the consequences of using rollover protective structures (ROPS) on agricultural tractors. It presents the results of a decision analysis that compares three strategies for preventing injuries when agricultural tractors without ROPS overturn. The three strategies examined are "do nothing", "install ROPS", and "replace tractor". The strategies are implemented over a five-year period and health outcomes expressed as fatal and nonfatal injuries are calculated over a 23-year period. The "do nothing" strategy would result in 1,450 fatalities and 1,806 nonfatal injuries, while the "install ROPS" strategy would prevent 1,176 fatalities and 957 nonfatal injuries, and the "replace tractor" strategy would prevent 1,188 fatalities and 967 nonfatal injuries. The latter two strategies reflect more than an 80% reduction in fatalities and about 53% reduction in nonfatal injuries. The study does not consider overturn injuries that result from tractors lacking ROPS and for which ROPS are unavailable.

Prevention effectiveness of rollover protective structures--Part III: Economic analysis

The purpose of this part of the study is to assess the costs and benefits of either installing rollover protective structures (ROPS) on tractors lacking ROPS and for which ROPS are available or replacing the tractors with newer ROPS-equipped ones, relative to doing nothing. The methods used are cost-effectiveness and cost-benefit analyses. The cost-effectiveness analysis shows that compared to the "do nothing" strategy, the "install ROPS" strategy would cost $489,373 per injury averted and the "replace tractor" strategy would cost $14.3 million per injury averted over a 23-year period. The cost-benefit analysis shows that compared to the "do nothing" strategy, the "install ROPS" strategy would save society $1.5 billion while the "replace tractor" strategy would cost society $18.7 billion. While both the "install ROPS" and the "replace tractor" strategies are effective at saving lives and preventing injuries, this study has concluded that the preferred strategy in terms of cost-effectiveness is to "install ROPS" on tractors lacking them and for which ROPS are available.