Linda Forst

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.

The impact of OSHA recordkeeping regulation changes on occupational injury and illness trends in the US: a time‐series analysis

Objectives: The Survey of Occupational Injuries and Illnesses (SOII), based on Occupational Safety and Health Administration (OSHA) logs, indicates that the number of occupational injuries and illnesses in the US has steadily declined by 35.8% between 1992–2003. However, major changes to the OSHA recordkeeping standard occurred in 1995 and 2001. The authors assessed the relation between changes in OSHA recordkeeping regulations and the trend in occupational injuries and illnesses. Methods: SOII data available from the Bureau of Labor Statistics for years 1992–2003 were collected. The authors assessed time series data using join-point regression models. Results: Before the first major recordkeeping change in 1995, injuries and illnesses declined annually by 0.5%. In the period 1995–2000 the slope declined by 3.1% annually (95% CI −3.7% to −2.5%), followed by another more precipitous decline occurring in 2001–2003 (−8.3%; 95% CI −10.0% to −6.6%). When stratifying the data, the authors continued to observe significant changes occurring in 1995 and 2001. Conclusions: The substantial declines in the number of injuries and illnesses correspond directly with changes in OSHA recordkeeping rules. Changes in employment, productivity, OSHA enforcement activity and sampling error do not explain the large decline. Based on the baseline slope (join-point regression analysis, 1992–4), the authors expected a decline of 407 964 injuries and illnesses during the period of follow-up if no intervention occurred; they actually observed a decline of 2.4 million injuries and illnesses of which 2 million or 83% of the decline can be attributed to the change in the OSHA recordkeeping rules.

Ethnic disparities in traumatic occupational injury.

Objective: Workers of different ethnicities differ in patterns of employment and occupational risks. We use the Illinois Trauma Registry to evaluate ethnic disparities among the occupational traumatic injuries occurring in the State of Illinois between 1997 and 2003. Methods: We analyze incidence, severity, cause and place of injury, disability and in-hospital mortality. Results: The incidence rates of traumatic injuries among Hispanics were more than two times higher than whites, however, the risk of severe injury (Injury Severity Score ≥16) was more than 50% lower. Among African-American workers, the incidence and severity of traumatic injuries were lower than whites. Machinery was the primary external cause of injury among Hispanics. blacks were disproportionately injured in road accidents and homicides/assaults. Conclusion: There are substantial racial/ethnic differences in incidence, severity and outcome of work-related traumatic injuries treated in level I and II trauma centers in Illinois.

Occupational lead exposure and hearing loss

Studies of adults, children, and laboratory animals suggest an association between lead exposure and hearing loss. A causal relationship might direct mandated medical surveillance of lead-exposed workers to include audiometric testing. A cross-sectional, computerized dataset was obtained from a private occupational health screening company to examine the relationship between blood lead level and hearing loss. Audiometry and blood lead results were available for 183 workers. A statistically significant correlation was found between blood lead level and an elevated hearing threshold at 400 Hz (P = 0.03); no other frequencies showed such a correlation. This finding suggests either an interaction between nose exposure and lead, interaction of other exposure factors (such as cigarette smoking), or that factors other than biomechanical ones render the organ of Corti more susceptible at 4000 Hz. Further evaluation of these questions should be undertaken. Computerized databases created for worker surveillance may be a source for data useful for examining other causal connections in occupational settings.

Fatal falls in the US construction industry, 1990 to 1999.

The Occupational Safety and Health Administration’s (OSHA’s) Integrated Management Information System (IMIS) database allows for the detailed analysis of risk factors surrounding fatal occupational events. This study used IMIS data to (1) perform a risk factor analysis of fatal construction falls, and (2) assess the impact of the February 1995 29 CFR Part 1926 Subpart M OSHA fall protection regulations for construction by calculating trends in fatal fall rates. In addition, IMIS data on fatal construction falls were compared with data from other occupational fatality surveillance systems. For falls in construction, the study identified several demographic factors that may indicate increased risk. A statistically significant downward trend in fatal falls was evident in all construction and within several construction categories during the decade. Although the study failed to show a statistically significant intervention effect from the new OSHA regulations, it may have lacked the power to do so.

Barriers and benefits of protective eyewear use by Latino farm workers

Abstract Agricultural work is one of the riskiest occupations for the eyes. Protective eyewear can prevent eye injuries in upward of 90% of cases. Latino migrant and seasonal farm workers (LFWs) are at particular risk of eye injury because of economic, social, and cultural barriers to safe employment. The goal of this project was to determine the perceived benefits and barriers to use of protective eyewear during agricultural work among LFWs. In the year 2000, 55 workers who spent at least part of their time working in Illinois and Michigan as seasonal, hired farm workers were interviewed either individually (9) or in six focus groups (46) regarding their perceptions of eye hazards and the factors that encourage or discourage the use of protective eyewear. Subsequently, safety glasses and training on eye safety were delivered by promotores de salud to LFWs from the same cohort over two summer seasons. During the second season, the promotores observed the use of safety eyewear by farm workers at least once per week on 17 farms over a three-month period. At each point of observation, the promotores asked those wearing the glasses why they chose to wear them and those who were not wearing them, why not. At both points of the study (pre-intervention interviews and post-intervention observations), the reasons for use fell into the following categories: protection from hazards, appearance, whether it was mandated/provided by the employer, and whether others used it. The reasons for non-use include perceived lack of protection, discomfort, undesirable appearance, interference with visual acuity, slowing down the work pace, and no mandate from employers. Since eliminating the eye injury hazard is not possible in most agricultural settings, administrative strategies and use of personal protective equipment are critical. Perceptions of the target audience, LFWs, should be used to develop a comprehensive eye safety program; this should include allowing LFWs to select a style from effective prototypes, providing eyewear and promoting/mandating its use in hazardous job tasks, and implementing a comprehensive PPE program for eye safety. In addition, addressing functional problemsfalling off, fogging, loss and forgetting glasses, the pace slowdown that reduces production and leads to lower wages for workersshould be addressed.

Traumatic occupational injuries in Hispanic and foreign born workers.

BACKGROUND Hispanic and foreign-born workers suffer high rates of occupational fatality. Reasons for this are not well understood. Our aim was to gather information about the details related to severe, non-fatal occupational injuries in this vulnerable population. METHODS Eight years of data were obtained from an urban trauma center. In addition, medical consultations of individuals admitted for an occupational injury during an 8-month period are reported. RESULTS Hispanics were more highly represented than expected; their number of injuries steadily rose. Hispanics were more likely to be injured by machinery and hand tools. Workers reported hazardous working conditions, lack of workers compensation, short time in current employment, and not working in their usual job. CONCLUSION Trauma systems can provide a glimpse of risk factors for severe injuries in vulnerable workers. We recommend greater use of this data source, follow backs, long-term follow up of individuals, and improvement of surveillance of vulnerable working populations.

Preventing eye injuries among citrus harvesters: the community health worker model.

OBJECTIVES Although eye injuries are common among citrus harvesters, the proportion of workers using protective eyewear has been negligible. We focused on adoption of worker-tested safety glasses with and without the presence and activities of trained peer-worker role models on harvesting crews. METHODS Observation of 13 citrus harvesting crews established baseline use of safety eyewear. Nine crews subsequently were assigned a peer worker to model use of safety glasses, conduct eye safety education, and treat minor eye injuries. Safety eyewear use by crews was monitored up to 15 weeks into the intervention. RESULTS Intervention crews with peer workers had significantly higher rates of eyewear use than control crews. Intervention exposure time and level of worker use were strongly correlated. Among intervention crews, workers with 1 to 2 years of experience (odds ratio [OR] = 2.89; 95% confidence interval [CI] = 1.11, 7.55) and who received help from their peer worker (OR = 3.73; 95% CI = 1.21, 11.57) were significantly more likely to use glasses than were other intervention crew members. CONCLUSIONS Adaptation of the community health worker model for this setting improved injury prevention practices and may have relevance for similar agricultural settings.

More than training: Community-based participatory research to reduce injuries among hispanic construction workers

BACKGROUND Workplace mortality and severe injury are disproportionately distributed among foreign born and Hispanic construction workers. Worker Centers (WCs) provide services and advocacy for low-wage workers and a way for investigators to reach them. The goal of this project is to prevent occupational injuries by increasing awareness of hazards and self-efficacy among foreign born, Hispanic construction workers and by expanding the agenda of WCs to include occupational health and safety (H&S). METHODS Investigators partnered with eight WCs in seven cities to train worker leaders to deliver a modified OSHA 10-hr curriculum to their peers. RESULTS Thirty-two worker leaders trained 446 workers over 3 years. There was a demonstrated improvement in knowledge, hazard identification, self-efficacy, and sustainable H&S activities. CONCLUSIONS This study provides evidence for successful implementation of a training intervention for low wage, low literacy Hispanic construction workers using a community-based participatory research approach.

Adoption of Safety Eyewear Among Citrus Harvesters in Rural Florida

The community-based prevention marketing program planning framework was used to adapt an evidence-based intervention to address eye injuries among Florida’s migrant citrus harvesters. Participant-observer techniques, other direct observations, and individual and focus group interviews provided data that guided refinement of a safety eyewear intervention. Workers were attracted to the eyewear’s ability to minimize irritation, offer protection from trauma, and enable work without declines in productivity or comfort. Access to safety glasses equipped with worker-designed features reduced the perceived barriers of using them; deployment of trained peer-leaders helped promote adoption. Workers’ use of safety glasses increased from less than 2% to between 28% and 37% in less than two full harvesting seasons. The combination of formative research and program implementation data provided insights for tailoring an existing evidence-based program for this occupational community and increase potential for future dissemination and worker protection.