Work-Related Factors Associated With Health and Well-Being of Early Care and Education Workers.

OBJECTIVE: We assessed and examined relationships between the health and working conditions of early care and education workers. METHODS: We surveyed early care and education workers ( n = 2242) about their socioeconomic characteristics; work organization; psychosocial, physical, and ergonomic exposures; coping behaviors; and health. RESULTS: Nearly half of respondents reported chronic health conditions. Most worked full time, half earned less than $30,000 a year, and many reported unpaid hours or inability to take breaks. One-quarter reported economic strain. Numerous exposures were prevalent. Workers' general health was poorer than normed averages, although their physical functioning was slightly better. Sixteen percent of workers reported work-related injuries, and 43% reported depressive symptoms. Factors associated with health included socioeconomic characteristics, having a chronic condition, job type, access to benefits, eight psychosocial stressors, four physical exposures, sleep, and alcohol consumption. CONCLUSIONS: Findings support the need for attention to this workforce's health.

Presence of Any Medical Debt Associated With Two Additional Years of Homelessness in a Seattle Sample.

Although medical debt has been associated with housing instability, almost no research has connected homelessness to medical debt. We interviewed 60 individuals experiencing homelessness in Seattle, selected from those participating in self-governed encampments organized by a homeless advocacy organization. Most respondents reported having at least one kind of debt, with two-thirds reporting current medical debt. Almost half reported trouble paying medical bills for themselves or family members. Almost one-third believed medical debt was in part responsible for their current housing situation. More than half with medical debt incurred this debt while they were covered under insurance. People who had trouble paying medical bills experienced a more recent episode of homelessness 2 years longer than those who did not have such trouble, even after controlling for race, education, age, gender, and health status. People of color who had trouble paying medical bills reported almost 1 year more homelessness than whites.

The Culture Of Health In Early Care And Education: Workers' Wages, Health, And Job Characteristics.

Little is known about the health of the 2.2 million early care and education (ECE) workers responsible for the care, well-being, and success of the approximately ten million children younger than age six enrolled in ECE, or the extent to which ECE environments and employers play a role in workers' health. The purpose of this analysis was to describe the health of an ECE worker sample by wage and by job and center characteristics and to begin to explore the relationships between these factors and workers' health. Our data indicate that ECE workers earn low wages and experience poor mental well-being and high rates of food insecurity. Lower-wage workers worked at centers with more children enrolled in subsidy programs and were more likely to work at centers that did not offer health insurance, paid sick leave, or parental or family leave. Policies and programs that raised workers' wages or mandated the provision of meals to both children and workers could better support teacher health and the quality of ECE for children. Our results suggest that the culture of health in ECE settings and equity-related outcomes could be improved by helping centers provide support and flexibility to teachers (for example, offsetting workers' benefit costs or reducing teacher-to-child ratios to reduce stress) who are managing their own health in the context of demanding work.

District Health Officer Perceptions of PEPFAR's Influence on the Health System in Uganda, 2005-2011.

BACKGROUND: Vertically oriented global health initiatives (GHIs) addressing the HIV/AIDS epidemic, including the President's Emergency Plan for AIDS Relief (PEPFAR), have successfully contributed to reducing HIV/AIDS related morbidity and mortality. However, there is still debate about whether these disease-specific programs have improved or harmed health systems overall, especially with respect to non-HIV health needs. METHODS: As part of a larger evaluation of PEPFAR's effects on the health system between 2005-2011, we collected qualitative and quantitative data through semi-structured interviews with District Health Officers (DHOs) from all 112 districts in Uganda. We asked DHOs to share their perceptions about the ways in which HIV programs (largely PEPFAR in the Ugandan context) had helped and harmed the health system. We then identified key themes among their responses using qualitative content analysis. RESULTS: Ugandan DHOs said PEPFAR had generally helped the health system by improving training, integrating HIV and non-HIV care, and directly providing resources. To a lesser extent, DHOs said PEPFAR caused the health system to focus too narrowly on HIV/AIDS, increased workload for already overburdened staff, and encouraged doctors to leave public sector jobs for higher-paid positions with HIV/AIDS programs. CONCLUSION: Health system leaders in Uganda at the district level were appreciative of resources aimed at HIV they could often apply for broader purposes. As HIV infection becomes a chronic disease requiring strong health systems to manage sustained patient care over time, Uganda's weak health systems will require broad infrastructure improvements inconsistent with narrow vertical health programming.

Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level.

OBJECTIVES : PEPFAR's initial rapid scale-up approach was largely a vertical effort focused fairly exclusively on AIDS. The purpose of our research was to identify spill-over health system effects, if any, of investments intended to stem the HIV epidemic over a 6-year period with evidence from Uganda. The test of whether there were health system expansions (aside from direct HIV programming) was evidence of increases in utilization of non-HIV services-such as outpatient visits, in-facility births or immunizations-that could be associated with varying levels of PEPFAR investments at the district level. METHODS : Uganda's Health Management Information System article-based records were available from mid-2005 onwards. We visited all 112 District Health offices to collect routine monthly reports (which contain data aggregated from monthly facility reports) and annual reports (which contain data aggregated from annual facility reports). Counts of individuals on anti-retroviral therapy (ART) at year-end served as our primary predictor variable. We grouped district-months into tertiles of high, medium or low PEPFAR investment based on their total reported number of patients on ART at the end of the year. We generated incidence-rate ratios, interpreted as the relative rate of the outcome measure in relation to the lowest investment PEPFAR tertile, holding constant control variables in the model. RESULTS : We found PEPFAR investment overall was associated with small declines in service volumes in several key areas of non-HIV care (outpatient care for young children, TB tests and in-facility deliveries), after adjusting for sanitation, elementary education and HIV prevalence. For example, districts with medium and high ART investment had 11% fewer outpatient visits for children aged 4 and younger compared with low investment districts, incidence rate ratio (IRR) of 0.89 for high investment compared with low (95% CI, 0.85-0.94) and IRR of 0.93 for medium compared with low (0.90-0.96). Similarly, 22% fewer TB sputum tests were performed in high investment districts compared with low investment, [IRR 0.78 (0.72-0.85)] and 13% fewer in medium compared with low, [IRR 0.88 (0.83-0.94)]. Districts with medium and high ART investment had 5% fewer in-facility deliveries compared with low investment districts [IRR 0.95 for high compared with low, (91-1.00) and 0.96 for medium compared with low (0.93-0.99)]. Although not statistically significant, the rate of maternal deaths in high investment district-months was 13% lower than observed in low investment districts. CONCLUSIONS : This study sought to understand whether PEPFAR, as a vertical programme, may have had a spill-over effect on the health system generally, as measured by utilization. Our conclusion is that it did not, at least not in Uganda.

Longitudinal assessment of noise exposure in a cohort of construction workers.

OBJECTIVES: To address questions surrounding noise-induced hearing loss (NIHL) from variable noise, we have been evaluating noise exposures and changes in hearing in a prospective cohort of construction workers (representing eight trades) and controls. In this paper, we develop and explore several long-term exposure estimates for cohort members. METHODS: We followed cohort members between 1999 and 2009 and interviewed them approximately annually to obtain a detailed work history for the previous subject-interval while also collecting tests of hearing sensitivity. Over the same period, we also collected a sample of full-shift average noise measurements and activity information. We used data from these two sources to develop various exposure estimates for each subject for specific subject intervals and for the duration of the study. These estimates included work duration, trade-mean (TM)-equivalent continuous exposure level (L(EQ)), task-based (TB) L(EQ), a hybrid L(EQ) combining TB and subjective information, and an estimate of noise exposure 'peakiness'. RESULTS: Of the 456 subjects enrolled in the study, 333 had at least 2 interviews and met several inclusion criteria related to hearing sensitivity. Depending on the metric used, between one-third and three-quarters of 1310 measured full-shift noise exposures exceeded permissible and recommended exposure limits. Hybrid and TB exposure estimates demonstrated much greater variability than TM estimates. Work duration and estimates of exposure peakiness showed poor agreement with average exposures, suggesting that these metrics evaluate different aspects of exposure and may have different predictive value for estimating NIHL. CONCLUSIONS: Construction workers in the cohort had subject-interval and study-average exposures which present a substantial potential risk of NIHL. In a subsequent paper, we will use these estimates to evaluate the exposure-response relationship between noise and NIHL.

Predictors of hearing protection use in construction workers.

OBJECTIVES: Although noise-induced hearing loss is completely preventable, it remains highly prevalent among construction workers. Hearing protection devices (HPDs) are commonly relied upon for exposure reduction in construction, but their use is complicated by intermittent and highly variable noise, inadequate industry support for hearing conservation, and lax regulatory enforcement. METHODS: As part of an intervention study designed to promote HPD use in the construction industry, we enrolled a cohort of 268 construction workers from a variety of trades at eight sites and evaluated their use of HPDs at baseline. We measured HPD use with two instruments, a questionnaire survey and a validated combination of activity logs with simultaneous dosimetry measurements. With these measurements, we evaluated potential predictors of HPD use based on components of Pender's revised health promotion model (HPM) and safety climate factors. RESULTS: Observed full-shift equivalent noise levels were above recommended limits, with a mean of 89.8 +/- 4.9 dBA, and workers spent an average of 32.4 +/- 18.6% of time in each shift above 85 dBA. We observed a bimodal distribution of HPD use from the activity card/dosimetry measures, with nearly 80% of workers reporting either almost never or almost always using HPDs. Fair agreement (kappa = 0.38) was found between the survey and activity card/dosimetry HPD use measures. Logistic regression models identified site, trade, education level, years in construction, percent of shift in high noise, and five HPM components as important predictors of HPD use at the individual level. Site safety climate factors were also predictors at the group level. CONCLUSIONS: Full-shift equivalent noise levels on the construction sites assessed were well above the level at which HPDs are required, but usage rates were quite low. Understanding and predicting HPD use differs by methods used to assess use (survey versus activity card/dosimetry). Site, trade, and the belief that wearing HPD is not time consuming were the only predictors of HPD use common to both measures on an individual level. At the group level, perceived support for site safety and HPD use proved to be predictive of HPD use.

Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort.

STUDY DESIGN: Prospective, population-based cohort study. OBJECTIVE: To examine whether prescription of opioids within 6 weeks of low back injury is associated with work disability at 1 year. SUMMARY OF BACKGROUND DATA: Factors related to early medical treatment have been little investigated as possible risk factors for development of long-term work disability among workers with back injuries. We have previously shown that about 1 of 3 of workers receive an opioid prescription early after a low back injury, and a recent study suggested that such prescriptions may increase risk for subsequent disability. METHODS: We analyzed detailed data reflecting paid bills for opioids prescribed within 6 weeks of the first medical visit for a back injury among 1843 workers with lost work-time claims. Additional baseline measures included an injury severity rating from medical records, and demographic, psychosocial, pain, function, smoking, and alcohol measures from a worker survey conducted 18 days (median) after receipt of the back injury claim. Computerized database records of work disability 1 year after claim submission were obtained for the primary outcome measure. RESULTS: Nearly 14% (254 of 1843) of the sample were receiving work disability compensation at 1 year. More than one-third of the workers (630 of 1843) received an opioid prescription within 6 weeks, and 50.7% of these (319 of 630) were received at the first medical visit. After adjustment for pain, function, injury severity, and other baseline covariates, receipt of opioids for more than 7 days (odds ratio = 2.2; 95% confidence interval, 1.5-3.1) and receipt of more than 1 opioid prescription were associated significantly with work disability at 1 year. CONCLUSION: Prescription of opioids for more than 7 days for workers with acute back injuries is a risk factor for long-term disability. Further research is needed to elucidate this association.

Early predictors of chronic work disability associated with carpal tunnel syndrome: a longitudinal workers' compensation cohort study.

BACKGROUND: The study objectives were to identify early predictors of chronic work disability associated with carpal tunnel syndrome (CTS) and to test the hypothesis that variables from each of several domains (sociodemographic, clinical, work-related, and psychosocial) would add unique predictive information. METHODS: Washington State workers were interviewed 18 days (median) after submitting a new workers' compensation claim for CTS. Baseline predictors of chronic work disability (> or =180 days of work disability compensation in the year after claim submission) were examined for workers who had at least 1 day of disability compensation (N = 899). RESULTS: Baseline demographic variables, symptom severity, functional limitations, lack of job accommodation, job physical demands, job psychosocial conditions, and worker psychosocial characteristics predicted chronic disability bivariately. Each domain of variables added significantly to the prediction of chronic disability. The final multivariable model had fair ability to discriminate individuals with versus without chronic disability (cross-validated area under the ROC curve = 0.76). CONCLUSIONS: Sociodemographic, clinical, work-related, and worker psychosocial factors early in a claim contribute unique information to the prediction of subsequent work disability associated with CTS.

Prognostic factors of long-term disability in a workers' compensation system.

OBJECTIVE: We identified predictive factors of long-term disability in new workers' compensation claims to guide secondary prevention research and target interventions for high-risk claims. METHODS: Workers with 4 or more days of work disability resulting from workplace injuries were followed for approximately 6 years in a population-based retrospective inception cohort study of 81,077 workers. RESULTS: Predictors of long-term disability included delay between injury and first medical treatment, older age, construction industry, logging occupation, longer time from medical treatment to claim filing, back injury, smaller firm size, female gender, higher unemployment rate, and having dependents. We used logistic and quantile regression to investigate predictors of disability. These models produced consistent information regarding predictors. CONCLUSION: These factors can be used to identify jobs or workers at increased risk for long-term disability that warrant prevention intervention.

Factors associated with early opioid prescription among workers with low back injuries.

UNLABELLED: Prescription of opioids for nonmalignant musculoskeletal pain has increased substantially in recent years, but there is little information on the incidence of, or factors associated with, such prescription for work-related back pain. In a prospective cohort study (N = 1,067), we examined associations between worker sociodemographic and other characteristics and opioid prescription within six weeks of the first medical visit for workers' compensation claims for work loss due to back injury. We examined administrative, pharmacy, and worker-reported data. In bivariate logistic regression models, Hispanics were less likely than non-Hispanic whites to receive opioid prescriptions, and very high body mass index, daily tobacco use, greater pain and physical disability, pain radiating below the knee, injury severity categorizations (from medical records) of major sprain and radiculopathy, and worse mental health were associated with opioid prescription. Adjusting for demographics, pain intensity, and physical disability, opiate prescription was significantly associated with daily tobacco use, pain radiating below the knee, and injury severity categories (major sprain and radiculopathy). Knowledge of worker characteristics associated with early opioid prescription may be useful in future studies of the role of early pain treatment in influencing subsequent course of pain and disability among workers with back injuries. PERSPECTIVE: Little is known about patient characteristics that may influence physicians' decisions concerning prescription of opioids for acute back pain. Not surprisingly, workers with more severe back injuries are more likely to be prescribed opioids, but reasons for prescription disparities based on ethnicity and tobacco use warrant further study.