Experiences of insecurity among non-standard workers across different welfare states: A qualitative cross-country study.

In recent decades, economic crises and political reforms focused on employment flexibilization have increased the use of non-standard employment (NSE). National political and economic contexts determine how employers interact with labour and how the state interacts with labour markets and manages social welfare policies. These factors influence the prevalence of NSE and the level of employment insecurity it creates, but the extent to which a country's policy context mitigates the health influences of NSE is unclear. This study describes how workers experience insecurities created by NSE, and how this influences their health and well-being, in countries with different welfare states: Belgium, Canada, Chile, Spain, Sweden, and the United States. Interviews with 250 workers in NSE were analysed using a multiple-case study approach. Workers in all countries experienced multiple insecurities (e.g., income and employment insecurity) and relational tension with employers/clients, with negative health and well-being influences, in ways that were shaped by social inequalities (e.g., related to family support or immigration status). Welfare state differences were reflected in the level of workers' exclusion from social protections, the time scale of their insecurity (threatening daily survival or longer-term life planning), and their ability to derive a sense of control from NSE. Workers in Belgium, Sweden, and Spain, countries with more generous welfare states, navigated these insecurities with greater success and with less influence on health and well-being. Findings contribute to our understanding of the health and well-being influences of NSE across different welfare regimes and suggest the need in all six countries for stronger state responses to NSE. Increased investment in universal and more equal rights and benefits in NSE could reduce the widening gap between standard and NSE.

Non-Standard Employment and Unemployment during the COVID-19 Crisis: Economic and Health Findings from a Six-Country Survey Study.

The COVID-19 crisis is a global event that has created and amplified social inequalities, including an already existing and steadily increasing problem of employment and income insecurity and erosion of workplace rights, affecting workers globally. The aim of this exploratory study was to review employment-related determinants of health and health protection during the pandemic, or more specifically, to examine several links between non-standard employment, unemployment, economic, health, and safety outcomes during the COVID-19 pandemic in Sweden, Belgium, Spain, Canada, the United States, and Chile, based on an online survey conducted from November 2020 to June 2021. The study focused on both non-standard workers and unemployed workers and examined worker outcomes in the context of current type and duration of employment arrangements, as well as employment transitions triggered by the COVID-19 crisis. The results suggest that COVID-19-related changes in non-standard worker employment arrangements, or unemployment, are related to changes in work hours, income, and benefits, as well as the self-reported prevalence of suffering from severe to extreme anxiety or depression. The results also suggest a link between worker type, duration of employment arrangements, or unemployment, and the ability to cover regular expenses during the pandemic. Additionally, the findings indicate that the type and duration of employment arrangements are related to the provision of personal protective equipment or other COVID-19 protection measures. This study provides additional evidence that workers in non-standard employment and the unemployed have experienced numerous and complex adverse effects of the pandemic and require additional protection through tailored pandemic responses and recovery strategies.

Under-reporting of non-fatal occupational injuries among precarious and non-precarious workers in Sweden.

BACKGROUND: Under-reporting of occupational injuries (OIs) among precariously employed workers in Sweden challenges effective surveillance of OIs and targeted preventive measures. OBJECTIVE: To estimate the magnitude of under-reporting of OIs among precarious and non-precarious workers in Sweden in 2013. METHODS: Capture-recapture methods were applied using the national OIs register and records from a labour market insurance company. Employed workers 18-65 resident in Sweden in 2013 were included in the study (n=82 949 OIs). Precarious employment was operationalised using the national labour market register, while injury severity was constructed from the National Patient Register. Under-reporting estimates were computed stratifying by OIs severity and by sociodemographic characteristics, occupations and precarious employment. RESULTS: Under-reporting of OIs followed a dose-response pattern according to the levels of precariousness (the higher the precarious level, the higher the under-reporting) being for the precarious group (22.6%, 95% CI 21.3% to 23.8%), followed by the borderline precarious (17.6%, 95% CI 17.1% to 18.2%) and lastly the non-precarious (15.0%, 95% CI 14.7% to 15.3%). Under-reporting of OIs, decreased as the injury severity increased and was higher with highest level of precariousness in all groups of severity. We also observed higher under-reporting estimates among all occupations in the precarious and borderline precarious groups as compared with the non-precarious ones. CONCLUSIONS: This is the first register-based study to empirically demonstrate in Sweden that under-reporting of OIs is 50% higher among precariously employed workers. OIs under-reporting may represent unrecognised injuries that especially burden precariously employed workers as financial, health and social consequences shift from the employer to the employee.

COVID-19: US federal accountability for entry, spread, and inequities-lessons for the future.

The United States (US) has been among those nations most severely affected by the first-and subsequent-phases of the pandemic of COVID-19, the disease caused by SARS-CoV-2. With only 4% of the worldwide population, the US has seen about 22% of COVID-19 deaths. Despite formidable advantages in resources and expertise, presently the per capita mortality rate is over 585/million, respectively 2.4 and 5 times higher compared to Canada and Germany. As we enter Fall 2020, the US is enduring ongoing outbreaks across large regions of the country. Moreover, within the US, an early and persistent feature of the pandemic has been the disproportionate impact on populations already made vulnerable by racism and dangerous jobs, inadequate wages, and unaffordable housing, and this is true for both the headline public health threat and the additional disastrous economic impacts. In this article we assess the impact of missteps by the Federal Government in three specific areas: the introduction of the virus to the US and the establishment of community transmission; the lack of national COVID-19 workplace standards and enforcement, and lack of personal protective equipment (PPE) for workplaces as represented by complaints to the Occupational Safety and Health Administration (OSHA) which we find are correlated with deaths 16 days later (ρ = 0.83); and the total excess deaths in 2020 to date already total more than 230,000, while COVID-19 mortality rates exhibit severe-and rising-inequities in race/ethnicity, including among working age adults.

Disparities in the Deaths of Despair by Occupation, Massachusetts, 2000 to 2015.

OBJECTIVE: To explore mortality rates and trends according to the occupation of workers who died from the deaths of despair (DoD). METHODS: Death certificates for deaths due to poisonings (including opioid-related overdoses), suicides, and alcoholic liver disease occurring in Massachusetts from 2000 to 2015 were collected and coded according to the occupation of the decedent. Mortality rates and trends in mortality were calculated for each occupation. RESULTS: DoDs increased by more than 50% between 2000 to 2004 and 2011 to 2015. There were substantial differences in mortality rates and trends according to occupation. Blue collar workers were at a particularly elevated risk for DoD and had elevated trends for these deaths, notably: construction and farming, fishing, and forestry workers. CONCLUSIONS: Interventions should be targeted to occupations with elevated mortality rates and trends. Occupational risk factors that may contribute to these disparities should be explored.

Impact of differential injury reporting on the estimation of the total number of work-related amputations.

BACKGROUND: A capture-recapture analysis was performed to estimate the total number of work-related amputations. We examined the impact of misclassification due to differential injury reporting on the estimate of total number of work-related amputations. METHODS: Bureau of Labor Statistics' Survey of Occupational Injuries and Illnesses (SOII) samples and workers' compensation records (WC) were used to estimate the total number of work-related amputations. Some of the amputation cases in one data source matched with injuries other than amputations in the other data source. We performed sensitivity analyses reassigning such cases as matched amputations. RESULTS: Depending on how we treated the cases matched with other injuries, the total number of work-related amputations ranged from 276 to 442 cases, yielding dramatically different capture rates (35-87%). CONCLUSION: Due to differential classification, estimates of work-related amputations would be biased. Our findings highlight the importance of accurately reporting and classifying work-related injuries and illnesses.

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.

Gender differences in work-related asthma: surveillance data from California, Massachusetts, Michigan, and New Jersey, 1993-2008.

OBJECTIVE: To characterize work-related asthma by gender. METHODS: We analyzed state-based sentinel surveillance data on confirmed work-related asthma cases collected from California, Massachusetts, Michigan, and New Jersey during 1993-2008. We used Chi-square and Fisher's Exact Test statistics to compare select characteristics between females and males. RESULTS: Of the 8239 confirmed work-related asthma cases, 60% were female. When compared to males with work-related asthma, females with work-related asthma were more likely to be identified through workers' compensation (14.8% versus 10.6%) and less likely to be identified through hospital data (14.2% versus 16.9%). Moreover, when compared to males, females were more likely to have work-aggravated asthma (24.4% versus 13.5%) and less likely to have new-onset asthma (48.0% versus 56.5%). Females were also more likely than males with work-related asthma to work in healthcare and social assistance (28.7% versus 5.2%), educational services (11.8% versus 4.2%), and retail trade (5.0% versus 3.9%) industries and in office and administrative support (20.0% versus 4.0%), healthcare practitioners and technical (13.4% versus 1.6%), and education training and library (6.2% versus 1.3%) occupations. Agent groups most frequently associated with work-related asthma were miscellaneous chemicals (20.3%), cleaning materials (15.3%), and indoor air pollutants (14.9%) in females and miscellaneous chemicals (15.7%), mineral and inorganic dusts (13.2%), and pyrolysis products (12.7%) in males. CONCLUSIONS: Among adults with work-related asthma, males and females differ in terms of workplace exposures, occupations, and industries. Physicians should consider these gender differences when diagnosing and treating asthma in working adults.

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.

Healthy workplaces? A survey of Massachusetts employers.

PURPOSE: This study examines worksite health promotion (WHP) and occupational health and safety (OHS) activities by Massachusetts employers, and the extent to which workplaces with programming in one domain were more likely to have the other as well. DESIGN: In 2008, the Massachusetts Department of Public Health surveyed a stratified sample of Massachusetts worksites. SETTING: A mailed questionnaire to be completed by workplace representatives. SUBJECTS: Massachusetts worksites returning the questionnaire. MEASURES: Questionnaire items about worksite characteristics, WHP, and some OHS practices. ANALYSIS: We scored levels of WHP and OHS activity; examined the relationship between activities in the two domains by employer characteristics; and assessed self-reported coordination between them. RESULTS: The 890 responding worksites had higher scores for OHS (mean = 48% of practices, SD = 24%) than WHP (mean = 20%, SD = 12%). The difference between these scores varied by a factor of two across industry sectors and was smallest for workforces of 100+ employees (p = .001). Employers with no unionized workers reported fewer activities in both domains (p < .0001). Only 28% of respondents reported always/often coordinating OHS and WHP efforts; these organizations had more activities overall in both domains. CONCLUSION: Larger and unionized workplaces in Massachusetts were more likely to offer both WHP and OHS programming. Self-reported coordination was somewhat associated with more activity in both domains, although levels of WHP activity varied widely.

Barriers to use of workers' compensation for patient care at Massachusetts community health centers.

OBJECTIVES: To examine barriers community health centers (CHCs) face in using workers' compensation insurance (WC). DATA SOURCES/STUDY SETTING: Leadership of CHCs in Massachusetts. STUDY DESIGN: We used purposeful snowball sampling of CHC leaders for in-depth exploration of reimbursement policies and practices, experiences with WC, and decisions about using WC. We quantified the prevalence of perceived barriers to using WC through a mail survey of all CHCs in Massachusetts. DATA COLLECTION/EXTRACTION METHODS: Emergent coding was used to elaborate themes and processes related to use of WC. Numbers and percentages of survey responses were calculated. PRINCIPAL FINDINGS: Few CHCs formally discourage use of WC, but underutilization emerged as a major issue: "We see an awful lot of work-related injury, and I would say that most of it doesn't go through workers' comp." Barriers include lack of familiarity with WC, uncertainty about work-relatedness, and reliance on patients to identify work-relatedness of their conditions. Reimbursement delays and denials lead patients and CHCs to absorb costs of services. CONCLUSION: Follow-up studies should fully characterize barriers to CHC use of WC and experiences in other states to guide system changes in CHCs and WC agencies. Education should target CHC staff and workers about WC.

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.

Indicators for occupational health surveillance.

Each year, millions of the estimated 140 million U.S. workers are injured on the job or become ill from exposure to hazards at work. These work-related injuries and illnesses result in substantial human and economic costs for workers, employers, and society; estimated direct and indirect costs of work-related injuries and illnesses are approximately $170 billion annually. In 1998, the Council of State and Territorial Epidemiologists (CSTE) and CDC's National Institute for Occupational Safety and Health (NIOSH) convened a work group that identified priority occupational health conditions to be placed under surveillance, addressed cross-cutting surveillance concerns, and made recommendations regarding the role of states in a comprehensive nationwide surveillance system for work-related disease, injuries, and hazards. CSTE recommendations led to the generation of 19 occupational health indicators (OHIs) and one Employment Demographic Profile, which were developed during 2001-2003. The OHIs complement other guidelines for state-based occupational health surveillance to address overall state and national goals to improve public health. These OHIs are intended to help states build occupational health capacity by providing them with tools to collect and generate important, basic information concerning the occupational health status of the state population and to identify areas in which to focus prevention efforts. In 2005, CSTE released a report compiling OHI data from 13 states. NIOSH provides funding for the OHIs because they are now a required component of state-based cooperative agreements for occupational health surveillance. This report introduces the OHIs and describes CSTE's approach to developing this new occupational health surveillance tool.

Work-related carpal tunnel syndrome (WR-CTS) in Massachusetts, 1992-1997: source of WR-CTS, outcomes, and employer intervention practices.

BACKGROUND: The Massachusetts Sentinel Event Notification System for Occupational Risks (MASS SENSOR) receives reports of work-related carpal tunnel syndrome (WR-CTS) cases from (1) workers' compensation (WC) disability claims for 5 or more lost work days; and (2) physician reports (PR). METHODS: From 1992 through 1997, 1,330 WC cases and 571 PR cases completed follow-back surveys to provide information on industry, occupation, attributed source of WR-CTS, outcomes, and employer intervention practices. RESULTS: Sixty-four percent of the respondents had bilateral CTS and 61% had surgery, both of which were proportionally more frequent among WC cases. Office and business machinery was the leading source of WR-CTS (42% of classifiable sources) in every economic sector except construction, followed by hand tools (20%). Managers and professional specialty workers were the most likely to report employers' interventions and were up to four times more likely to report equipment or work environment changes than higher risk groups. CONCLUSIONS: State-based surveillance data on the source of WR-CTS provided valuable information on how and where to implement interventions. New occurrences of WR-CTS are likely, especially in the highest risk industries where very few cases reported primary prevention measures (e.g., changes to equipment or work environment) implemented by their employers.