Rethinking the Paradigm and Practice of Occupational Health in a World Without Decent Work: A Perspective From East and Southern Africa.

The global political economy is generating new forms and growing shares of informal, insecure, and precarious labor, adding to histories of insecure work and an externalization of social costs. The COVID-19 pandemic has highlighted the consequences of ignoring such signals in terms of the increased risk and vulnerability of insecure labor. This paper explores how such trends are generating intersecting adverse health outcomes for workers, communities, and environments and the implications for breaking siloes and building links between the paradigms, science, practice, and tools for occupational health, public health, and eco-health. Applying the principle of controlling hazards at the source is argued in this context to call for an understanding of the upstream production and socio-political factors that are jointly affecting the nature of work and employment and their impact on the health of workers, the public, and the planet.

Impact of employment and insurance status on distress in gynecologic oncology patients.

OBJECTIVES: To study associations among employment, insurance status, and distress in gynecologic oncology patients; and to evaluate the impact of being unemployed or having no/Medicaid insurance on different distress problem areas. METHODS: In this single institution, cross-sectional analysis of gynecologic oncology patients, we screened for distress and problem areas using the National Comprehensive Cancer Network distress thermometer and problem list at outpatient appointments between 6/2017-9/2017. Primary outcome was self-reported high distress (score ≥ 5). The distress problem list included 5 categories-practical, family, emotional, physical, and other. Employment status included employed, unemployed, homemaker, and retired. Logistic regression was used to predict high distress from employment and insurance statuses, adjusting for relevant covariates. RESULTS: Of 885 women, 101 (11.4%) were unemployed, and 53 (6.0%) uninsured or had Medicaid coverage. One in five patients (n = 191, 21.6%) indicated high distress. Unemployed patients were more likely than employed to endorse high distress [adjusted odds ratio (aOR) = 3.5, 95% confidence interval (CI) 2.2-5.7, p < 0.001]. Compared to employed patients, a greater proportion of unemployed patients endorsed distress related to practical (p < 0.05), emotional (p < 0.001), physical (p < 0.01), and other (p < 0.05) problems. Uninsured/Medicaid patients were more likely to endorse high distress (aOR = 2.8, 95% CI 1.5-5.1, p < 0.001) and report family (p < 0.001), emotional (p < 0.001), and other (p < 0.01) problems than patients who had Medicare/commercial insurance. CONCLUSIONS: Gynecologic oncology patients who are unemployed or have no/Medicaid insurance face high distress that appears to arise from issues beyond practical problems, including financial and/or insurance insecurities.

Understanding the Mothers of Children with Spina Bifida and Hydrocephalus in Tanzania.

OBJECTIVE: To identify if there are cultural, medical, educational, economic, nutritional and geographic barriers to the prevention and treatment of spina bifida and hydrocephalus. METHODS: The mothers of infants with spina bifida and hydrocephalus admitted to Muhimbilli Orthopaedic Institute, Dar Es Salaam, Tanzania, between 2013 and 2014 were asked to complete a questionnaire. A total of 299 infants were identified: 65 with myelomeningoceles, 19 with encephaloceles, and 215 with isolated hydrocephalus. The questionnaire was completed by 294 of the mothers. RESULTS: There was a high variation in the geographic origin of the mothers. Approximately 85% traveled from outside of Dar Es Salaam. The mean age was 29 (15-45) years old with a parity of 3 (1-10). The rates of consanguinity, obesity, antiepileptic medication, HIV seropositivity, and family history were 2%, 13%, 0%, 2%, and 2%, respectively. A maize-based diet was found in 84%, and only 3% of woman took folic acid supplementation, despite 61% of mothers stating that they wished to conceive another baby. Unemployment was high (77%), a low level of education was common (76% not attended any school or obtaining a primary level only), and 20% were single mothers. Hospital only was the preferred method of treatment for 94% of the mothers, and 85% of the babies were born in a hospital. CONCLUSIONS: Our study highlights some of the cultural, educational, geographic, nutritional, and economic difficulties in the prevention and management of spina bifida and hydrocephalus in Tanzania.

Social Causation, Social Selection, or Common Determinants? Examining Competing Explanations for the Link Between Young Adult Unemployment and Nicotine Dependence.

INTRODUCTION: Unemployment has been related to smoking, yet the causal nature of the association is subject to continued debate. Social causation argues that unemployment triggers changes in smoking, whereas the social selection hypothesis proposes that pre-existing smoking behavior lowers the probability of maintaining employment. The present study tested these competing explanations while accounting for another alternative explanation-common liability. METHODS: Data were from the Christchurch Health and Development Study, a longitudinal cohort followed from birth to age 35. Odds were generated for having nicotine dependence in models for social causation and being unemployed in models for social selection. These models were extended to include possible common liability factors during childhood (eg, novelty seeking) and young adulthood (eg, major depression). RESULTS: In the model testing social causation, coefficients representing the impacts of unemployment on nicotine dependence remained statistically significant and robust (odds ratio [OR] = 1.55; 95% confidence interval [CI] = 1.20, 2.00), even after accounting for common determinant measures. In contrast, a reverse social selection model revealed that coefficients representing the impacts of nicotine dependence on unemployment substantially attenuated and became statistically nonsignificant as childhood factors were added (OR = 1.14; 95% CI = 0.90, 1.45). CONCLUSIONS: Unemployment may serve as inroads to nicotine addiction among young adults, not the other way, even in the context of nicotine dependence, a more impaired form of smoking that may arguably hold higher potential to generate social selection processes. This social causation process cannot be completely attributable to common determinant factors. IMPLICATIONS: It is critical to clarify whether unemployment triggers changes in smoking behaviors (ie, social causation) or vice versa (ie, social selection)-the answers to the question will lead to public health strategies with very different intervention targets to break the linkage. The current study findings favor social causation over social selection, regardless of gender, and support a needed shift in service profiles for unemployed young adults-from a narrow focus on job skills training to a more holistic approach that incorporates knowledge from addiction science in which unemployed young adults can find needed services to cope with job loss.

Role of age and health in perceptions of returning to work: a qualitative study.

BACKGROUND: People aged over 50 years form a growing proportion of the working age population, but are at increased risk of unemployment compared to other age groups. It is often difficult to return to work after unemployment, particularly for those with health issues. In this paper, we explored the perceptions, attitudes, and experiences of returning to work after a period of unemployment (hereafter RTW) barriers among unemployed adults aged over 50 years. METHOD: In-depth semi-structured interviews were conducted with a diverse sample of 26 unemployed individuals aged 50-64 years who were engaged with the UK Government's Work Programme. Data were thematically analysed. RESULTS: Age alone was not discussed by participants as a barrier to work; rather their discussions of barriers to work focused on the ways in which age influenced other issues in their lives. For participants reporting chronic health conditions, or disabilities, there was a concern about being unfit to return to their previous employment area, and therefore having to "start again" in a new career, with associated concerns about their health status and managing their treatment burden. Some participants also reported experiencing either direct or indirect ageism (including related to their health status or need to access healthcare) when looking for work. Other issues facing older people included wider socio-political changes, such as the increased pension age, were felt to be unfair in many ways and contradicted existing expectations of social roles (such as acting as a carer for other family members). CONCLUSION: Over-50s experienced multiple and interacting issues, at both the individual and societal level, that created RTW barriers. There is a need for employability interventions that focus on supporting the over-50s who have fallen out of the labour market to take a holistic approach, working across healthcare, employability and the local labour market, providing treatment and skills training for both those out of work and for employers, in order to create an intervention that that helps achieve RTW and its associated health benefit.

Relationship Between Opioid Analgesic Prescription and Unemployment in Patients Seeking Acupuncture for Chronic Pain in Urban Primary Care.

OBJECTIVE: The widespread use of opioid analgesics to treat chronic nonmalignant pain has contributed to the ongoing epidemic of opioid-related morbidity and mortality. Previous studies have also demonstrated a relationship between opioid analgesic use and unemployment due to disability. These studies have been limited to mainly white European and North American populations. The objective of this study is to explore the relationship between opioid analgesic use for chronic nonmalignant pain in an urban, mainly black and Hispanic, low-income population. DESIGN: This is a cross-sectional observational study. SETTING: Subjects were recruited from six urban primary care health centers. SUBJECTS: Adults with chronic neck, back, or osteoarthritis pain participating in an acupuncture trial were included. METHODS: Survey data were collected as a part of the Acupuncture Approaches to Decrease Disparities in Pain Treatment two-arm (AADDOPT-2) comparative effectiveness trial. Participants completed a baseline survey including employment status, opioid analgesic use, the Brief Pain Inventory, the global Patient Reported Outcomes Measurement Information Systems quality of life measure, the Patient Health Questionnaire-9 (PHQ-9), and demographic information. A multivariable logistic regression model was built to examine the association between opioid analgesic use and unemployment. RESULTS: Opioid analgesic use was associated with three times the odds of unemployment due to disability while controlling for potential confounders, including depression, pain severity, pain interference, global physical and mental functioning, and demographic characteristics. CONCLUSIONS: This study adds to the growing body of evidence that opioid analgesics should be used with caution in chronic nonmalignant pain.

Production lost due to cervical cancer in Poland in 2012.

BACKGROUND: Poland has one of the highest cervical cancer mortality rates in Europe. It is related to the problem of late diagnosis and low attendance rate in screening programs. The objective of the study has been to assess the annual production loss due to the cervical cancer morbidity and mortality in Poland in 2012. The outcomes have been to provide comprehensive information on cervical cancer's influence on population's ability to work and its overall economic burden for the society. The study has also provided the methodological framework for disease-related production losses in Polish settings. MATERIAL AND METHODS: The human capital method was used. The production losses were calculated in both monetary and quantitative terms (working days lost) due to 4 following reasons: 1) temporary disability to work, 2) permanent disability, 3) informal care, and 4) mortality. RESULTS: Cervical cancer resulted in approx. 702 964 working days lost in 2012 due to absence at work for both patients and care givers and a total number of 957 678 working days lost due to patients' mortality. The total value of production lost was assessed at 111.4 million euros. More than 66% of this value was attributed to women's mortality. CONCLUSIONS: The calculation of production lost due to cervical cancer burden provides strong evidence to support adequate health promotion and disease prevention actions. Actions promoting cervical cancer screening should be intensified including workplace health promotion activities. Med Pr 2016;67(3):289-299.

Sickness absence, moral hazard, and the business cycle.

The procyclical nature of sickness absence has been documented by many scholars in literature. So far, explanations have been based on labor force composition and reduced moral hazard caused by fear of job loss during recessions. In this paper, we propose and test a third mechanism caused by reduced moral hazard during booms and infections. We suggest that the workload is higher during economic booms and thus employees have to go to work despite being sick. In a theoretical model focusing on infectious diseases, we show that this will provoke infections of coworkers leading to overall higher sickness absence during economic upturns. Using state-level aggregated data from 112 German public health insurance funds (out of 145 in total), we find that sickness absence due to infectious diseases shows the largest procyclical pattern, as predicted by our theoretical model.

Exploring maternal mortality in relation to socioeconomic factors in Iran.

INTRODUCTION: Maternal mortality is a tragic death, and is perceived as a sensitive indicator of the socioeconomic status and healthcare services in a given country. In this study, the relationship between maternal deaths and factors such as socioeconomic development and the proportion of medical professionals in Iran was examined. METHODS: This was an ecological study, where three main groups of data based on different provinces were applied. Data included maternal mortality ratio, the proportion of medical professionals and socioeconomic variables, such as urban residency, unemployment and literacy. Data were obtained from various sources, including census returns, the Family Unit at the Ministry of Health and Medical Education, Tehran and the Iran Medical Council. Data were analysed using univariate and multivariate methodologies. RESULTS: Multivariate analysis showed a significant inverse relationship between maternal deaths and variables of male literacy (p < 0.001) and unemployment (p = 0.04). A marginally significant association was also found between maternal deaths and the proportion of midwives (p = 0.09). CONCLUSION: Our findings underscore the role of literacy, particularly male literacy, in the prevention of maternal deaths. Iran, as a male-dominated society, could benefit from targeting men for training programmes to enhance the health of their families, and ultimately, that of the society. As economic status does play a role in maternal deaths, there is a need to strengthen the financial situation of families. The number of skilled medical personnel available in a population also plays a key role in reducing maternal deaths.

Who was using dental services just prior to the recession and how do we plan for the recovery?

Since the start of the current economic recession in December 2007, the number of unemployed persons has increased by 7.6 million to 15.1 million (as of October 2009), and the unemployment rate has doubled to 9.8 percent. The economics of dentistry during the 2007-2009 recession are considered from the perspective of earlier recessions. The eventual turnaround in the economy is considered in terms of the need for dental practices to be extended to serve the multitude of underserved individuals in our communities.

Cost-effectiveness of a participatory return-to-work intervention for temporary agency workers and unemployed workers sick-listed due to musculoskeletal disorders: design of a randomised controlled trial.

BACKGROUND: Within the working population there is a vulnerable group: workers without an employment contract and workers with a flexible labour market arrangement, e.g. temporary agency workers. In most cases, when sick-listed, these workers have no workplace/employer to return to. Also, for these workers access to occupational health care is limited or even absent in many countries. For this vulnerable working population there is a need for tailor-made occupational health care, including the presence of an actual return-to-work perspective. Therefore, a participatory return-to-work program has been developed based on a successful return-to-work intervention for workers, sick-listed due to low back pain.The objective of this paper is to describe the design of a randomised controlled trial to study the (cost-)effectiveness of this newly developed participatory return-to-work program adapted for temporary agency workers and unemployed workers, sick-listed due to musculoskeletal disorders, compared to usual care. METHODS/DESIGN: The design of this study is a randomised controlled trial with one year of follow-up. The study population consists of temporary agency workers and unemployed workers sick-listed between 2 and 8 weeks due to musculoskeletal disorders. The new return-to-work program is a stepwise program aimed at making a consensus-based return-to-work implementation plan with the possibility of a (therapeutic) workplace to return-to-work. Outcomes are measured at baseline, 3, 6, 9 and 12 months. The primary outcome measure is duration of the sickness benefit period after the first day of reporting sick. Secondary outcome measures are: time until first return-to-work, total number of days of sickness benefit during follow-up; functional status; intensity of musculoskeletal pain; pain coping; and attitude, social influence and self-efficacy determinants. Cost-benefit is evaluated from an insurer's perspective. A process evaluation is part of this study. DISCUSSION: For sick-listed workers without an employment contract there can be gained a lot by improving occupational health care, including return-to-work guidance, and by minimising the 'labour market handicap' by creating a return-to-work perspective. In addition, reduction of sickness absence and work disability, i.e. a reduction of disability claims, may result in substantial benefits for the Dutch Social Security System. TRIAL REGISTRATION NUMBER: NTR1047.

Psychosocial, demographic, and treatment-seeking strategic behavior, including faith healing practices, among patients with epilepsy in northwest India.

The data on sociocultural, demographic, and psychosocial aspects and types of treatment strategies adopted by families of patients with epilepsy in northwestern India were collected by the interview schedule method from 400 patients (200 idiopathic and 200 symptomatic) at the outpatient department of the Neurology and Epilepsy Clinic of the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Epilepsy was classified as idiopathic or symptomatic on the basis of clinical tests (EEG, CT scan, and MRI). It was observed that socioeconomic factors had no bearing on epilepsy in the present sample. Early onset, that is, before 20 years of age, reduced the chances of patients' finding a spouse among those who disclosed the disease information, thereby impacting the nuptial and fertility rates of patients with epilepsy. The present sample of patients was well informed about and sensitized to the efficacy of the modern system of medicine, as 80% of patients sought medical treatment on the very same day as or within a week of onset of seizures. The data were compatible with the framed hypothesis that well-being and safety of the patient would override the stigma burden factor, as 94% of the affected families made no attempt to hide the disease from their neighbors, friends, and colleagues, and teachers of the affected patients. Surprisingly, only 7.5% of the families admitted that they consulted a faith healer. Families did adopt some culturally prevalent methods to control involuntary movements during seizures. It can be concluded that trust in faith healers exists strongly as an undercurrent, but is not overtly admitted by the majority of patients. Some families concurrently visited modern hospitals and occult healers seeking a cure for the disease. The fear of having a child with epilepsy or other abnormalities discouraged married patients from becoming pregnant after developing epilepsy.

[Black Africans' compliance to antihypertensive treatment]. / L'observance thérapeutique et ses facteurs chez l'hypertendu noir africain.

UNLABELLED: Hypertension is increasing in sub-Saharan Africa. It is difficult to follow a correct treatment in this environment. PURPOSE: Assessing the compliance of the drug therapy and identifying the characteristics of poor observant patients. METHODS: A study was carried out over one month at the outpatient department of the Abidjan Heart Institute among 200 sub-Saharan African hypertensives. Their compliance was estimated with the Compliance Evaluation Test of Girerd. RESULTS: The average age of the patients was 59 years and 59.5% of them were women. Most patients (60%) had a monthly pay lower than 100,000 CFA (Euros 152). Sixty two percent had no medical insurance. So 175 patients (87.5%) had difficulties to follow their treatment. Among them 55% had a very bad compliance and 32.5% had minor difficulties. Only 12.5% of them had a right compliance. A bad compliance was frequent between 30 and 70 years, in women (60.5%), in unemployed patients (93.7%), in married women (68.7%) and in executives (50%). Other factors of a poor compliance was a monthly income lower than 100,000 FCFA (64%), a number of daily tablets higher than three (77.3%), a number of daily administration >or= $ 3 (95.7%) and the high cost of drugs. A bad compliance is more frequent when herbal treatment is associated with medical drugs or used separately. CONCLUSION: The compliance of the antihypertensive treatment was poor. The causes are numerous, but they are very often related with the growing poverty in the black society.

[Older female employees in Germany - structures of employment and perspectives of the future]. / Altere Arbeitnehmerinnen in Deutschland - Erwerbsstrukturen und Zukunftsperspektiven.

This contribution presents an overview to the structures and conditions of employment of older female employees in Germany. Based on information about the labor force participation rates, rates of unemployment and occupational patterns the conditions of female employment beyond midlife are examined. Relating to the standard of living, the meaning of employment for older women is discussed. Furthermore, the effects of regulations of welfare state, i. e., pension systems, on future life of the employed women are highlighted. Further topics are the completion of working life and the transition to retirement of female employees, the issue of the future working conditions of older female employees related with demographic change und future reduction of the potential of labor force. Finally the contribution stresses the importance of a holistic approach to investigate the living and working conditions of older female employees.

Hospital admissions after transition into unemployment.

OBJECTIVE: It was examined whether the rate of hospital admissions change after transition into unemployment. METHODS: Data from a German statutory health insurance comprising 105,554 individuals (70.9% men, 29.1% women) with documented employment periods were used. Unemployment periods were divided into three intervals: up to eight months, more than eight up to 16, and more than 16 up to 24 months. RESULTS: The overall "risks" of hospital admissions dropped after transition into unemployment. The relative risk (RR) in men and women for unemployment up to eight months was RR = 0.31 (95% CI: 0.28-0.34), for periods of more than eight up to 16 months it was RR = 0.35 (95% CI: 0.32-0.39) and for more than 16 up to 24 months it was RR = 0.27 (95% CI: 0.23-0.33). In contrast, for myocardial infarction they increased with length of unemployment: up to eight months: RR = 1.49 (95% CI: 1.04-2.13), more than eight up to 16 months; RR = 1.82 (95% CI: 1.21-2.74), more than 16 up to 24 months: RR = 3.08 (95% CI: 1.84-5.17). CONCLUSION: For myocardial infarction the findings may reflect increased morbidity, for occupational diseases they may reflect a decrease following ceasing expositions at the workplace. For the remaining diagnostic groups decreasing health care utilisation may apply without morbidity having changed.

Socio-economic status and risk of conotruncal heart defects and orofacial clefts.

Studies of socio-economic status (SES) have figured prominently in research related to a variety of health outcomes, although the question remains as to whether SES contributes to the aetiologies of congenital anomalies. This study examines the association of SES with risks of conotruncal heart defects and orofacial clefts, using interview data from 696 case mothers (86% of eligible) and 734 (78%) control mothers from a population-based case-control study. Socio-economic measures from maternal interview included mother's education and employment. Reported addresses were linked with the US census to characterise six measures of neighbourhood SES (education, poverty, unemployment, occupation, crowding and rental occupancy). Results were adjusted for race-ethnicity, multivitamin/mineral supplement intake, cigarette smoking and binge drinking. Results for individual and neighbourhood measures suggested that low SES was associated with increased risk of d-transposition of the great arteries (dTGA), reduced risk of tetralogy of Fallot (TOF), but was not associated with risk of orofacial clefts. For example, when examining odds ratios (OR) that compared risks among women whose neighbourhoods were in the lowest vs. highest quartile of the census-based SES measures, ORs for five of the six measures were> 1.4 for dTGA, and ORs for all six measures were < 0.7 for TOF. ORs for clefts tended to be closer to 1. This study suggests that SES risks are birth defect specific.