Health, Access to Care, and Financial Barriers to Care Among People Incarcerated in US Prisons.

Importance: Decades-old data indicate that people imprisoned in the US have poor access to health care despite their constitutional right to care. Most prisons impose co-payments for at least some medical visits. No recent national studies have assessed access to care or whether co-pays are associated with worse access. Objective: To determine the proportion of people who are incarcerated with health problems or pregnancy who used health services, changes in the prevalence of those conditions since 2004, and the association between their state's standard prison co-payment and care receipt in 2016. Design, Setting, and Participants: This cross-sectional analysis was conducted in October 2023 and used data from the Bureau of Justice Statistics' 2016 Survey of Prison Inmates, a nationally representative sample of adults in state or federal prisons, with some comparisons to the 2004 version of that survey. Exposures: The state's standard, per-visit co-payment amount in 2016 compared with weekly earnings at the prison's minimum wage. Main Outcomes and Measures: Self-reported prevalence of 13 chronic physical conditions, 6 mental health conditions, and current severe psychological distress assessed using the Kessler Psychological Distress Scale; proportion of respondents with such problems who did not receive any clinician visit or treatment; and adjusted odds ratios (aORs) comparing the likelihood of no clinician visit according to co-payment level. Results: Of 1 421 700 (unweighted: n = 24 848; mean [SD] age, 35.3 [0.3] years; 93.2% male individuals) prison residents in 2016, 61.7% (up from 55.9% in 2004) reported 1 or more chronic physical conditions; among them, 13.8% had received no medical visit since incarceration. A total of 40.1% of respondents reported ever having a mental health condition (up from 24.5% in 2004), of whom 33.0% had received no mental health treatment. A total of 13.3% of respondents met criteria for severe psychological distress, of whom 41.7% had not received mental health treatment in prison. Of state prison residents, 90.4% were in facilities requiring co-payments, including 63.3% in facilities with co-payments exceeding 1 week's prison wage. Co-payments, particularly when high, were associated with not receiving a needed health care visit (co-pay ≤1 week's wage: aOR, 1.43; 95% CI, 1.10-1.86; co-pay >1 week's wage: aOR, 2.17; 95% CI, 1.61-2.93). Conclusions and Relevance: This cross-sectional study found that many people who are incarcerated with health problems received no care, particularly in facilities charging co-payments for medical visits.

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.

Results of a community-university partnership to reduce deadly hazards in hardwood floor finishing.

A community-university partnership used community-based participatory research (CBPR) to design, implement, and evaluate a multi-cultural public health campaign to eliminate flammable products and reduce use of products high in volatile organic compounds (VOCs) in hardwood floor finishing in Massachusetts. Leading participants were Vietnamese-American organizations and businesses. Following the public health campaign, a multi-lingual survey of self-reported experiences with fires, product use, exposure to outreach activities, and changes made, was conducted with floor finishers. One hundred nine floor finishers responded. Over 40% reported fires at their companies' jobs, mostly caused by lacquer sealers. Over one third had heard radio or TV shows about health and safety in floor finishing, and over half reported making changes as a result of outreach. Exposure to various outreach activities was associated with reducing use of flammable products, increasing use of low-VOC products, and greater knowledge about product flammability. However, most respondents still reported using flammable products. Outreach led by community partners reached large proportions of floor finishers, was associated with use of safer products, and adds to recent work on CBPR with immigrant workers. Continued use of flammable products supports the belief that an enforceable ban was ultimately necessary to eradicate them.

Barriers to Workplace Stress Interventions in Employee Assistance Practice: EAP Perspectives.

Occupational health literature links stressful working conditions with cardiovascular and other chronic diseases, injuries, and psychological distress. We conducted individual interviews with employee assistance professionals (EAPs) to understand opportunities and barriers for EAPs to address job stress through organization level interventions. EAPs described their primary role as assisting individual employees versus designing company wide interventions. The most salient barriers to organization level interventions cited were lack of access to company management and (for contracted EAPs) perceptions of contract vulnerability. Education about workplace stress interventions may be most effectively directed at EAPs who are already integrated with company level work groups.

Getting to Know You: Occupational Health Researchers Investigate Employee Assistance Professionals' Approaches to Workplace Stress.

Workplace stress is strongly associated with health problems, including cardiovascular disease. The occupational health field is developing partnerships with a variety of health professions to prevent and address job stress at the organizational level. A review of literature for and about employee assistance professionals was conducted to explore their perspectives on these issues. Results show high awareness regarding the health effects of job stress and a wide range of approaches to address this problem. EAPs appear to be a potential strong partner in efforts to prevent workplace stress, but face obstacles to intervening at the level of the work environment.

Reducing hazardous cleaning product use: a collaborative effort.

Workplace hazards affecting vulnerable populations of low-wage and immigrant workers present a special challenge to the practice of occupational health. Unions, Coalition for Occupational Safety and Health (COSH) groups, and other organizations have developed worker-led approaches to promoting safety. Public health practitioners can provide support for these efforts. This article describes a successful multiyear project led by immigrant cleaning workers with their union, the Service Employees International Union (SEIU) Local 615, and with support from the Massachusetts COSH (MassCOSH) to address exposure to hazardous chemicals. After the union had identified key issues and built a strategy, the union and MassCOSH invited staff from the Massachusetts Department of Public Health's Occupational Health Surveillance Program (OHSP) to provide technical information about health effects and preventive measures. Results included eliminating the most hazardous chemicals, reducing the number of products used, banning mixing products, and improving safety training. OHSP's history of public health practice regarding cleaning products enabled staff to respond promptly. MassCOSH's staff expertise and commitment to immigrant workers allowed it to play a vital role.

Results from a community-based occupational health survey of Vietnamese-American nail salon workers.

A community-university collaborative partnership assessed self-reported work-related health effects and environmental factors in Boston's Vietnamese immigrant community via an interviewer-assisted survey. Seventy-one nail technicians responded. Musculoskeletal disorders, skin problems, respiratory irritation and headaches were commonly reported as work-related, as were poor air quality, dusts and offensive odors. The reporting of a work-related respiratory symptom was significantly associated with the reporting of exposure factors such as poorer air quality. Absence of skin disorders was associated with glove use and musculoskeletal symptoms were associated with years worked as a nail technician. Work-related health effects may be common in nail salon work. Chemical and musculoskeletal hazards should be reduced through product and equipment redesign.

The Boston-area HASWIC Research Circle: an innovative participatory method for coloring in the picture of a special work environment.

Recent qualitative studies have investigated some of the hazards affecting women in non-traditional trades such as construction. However, one-time interactions among researcher participants, and between researchers and participants, in standard settings such as focus groups and interviews, cannot provide the time, space, and relationships to fully explore tradeswomen's in-depth knowledge of their work environment. This study applied a Scandinavian method called the Research Circle to convene a group of experienced women construction workers repeatedly over a period of two years so they could collaborate with researchers in explaining workplace issues. The results both validated and expanded upon previous findings about health and safety for women in construction, including gender discrimination, lack of access to sanitary facilities, retaliation for reporting hazards and injuries, and inadequate training and equipment. Especially important, findings illustrate some of the complex hierarchical social structures involved in both female and male construction workers responding to hazardous conditions.

Factors influencing ergonomic intervention in construction: trunkman case study.

This case study examines factors affecting the use of equipment designed to prevent lower back strain in laborers who pour concrete on major highway construction sites. Qualitative methods of organizational analysis were used to characterize factors identified from interviews and participant observation. The major obstacles to the use of the control on site were 1. Managers placing a low priority on ergonomics. 2. Safety officers' limited power in organizational hierarchies. 3. Rationalizing, rather than challenging, resistance to change. 4. Lack of a forum to share knowledge about interventions. Several organizational factors impeded the adoption of a technically effective, low-cost safety control on the site studied. The implementation of the control ultimately resulted from actions taken by the investigators, suggesting that safety programs present at the site are not always adequate to realize feasible interventions.

Protecting workers and residents from wood floor-finishing hazards.

The recent deaths of three hardwood floor finishers in the Boston area have highlighted the urgency of addressing hazards in this industry. Among other dangers to health and safety, fire is a constant threat in a work setting that combines highly flammable solvents, large quantities of airborne wood dust, electrical equipment, heat, and friction inside old homes. Immigrant workers, who perform a large proportion of this work, are at special risk. An Environmental Justice partnership of community-based organizations, community health centers, and environmental health researchers funded by the National Institute of Environmental Health Sciences (the "Dorchester Occupational Health Initiative") had been studying the occupational health of hardwood floor finishing when these workers died. This preparation enabled community, health, labor, business, and political leaders to mobilize a response and release recommendations within weeks of the second fatal fire. Their report, adapted below, contains important information for health and labor activists in all areas where wood flooring is common. Most notably, the use of less flammable (higher flash point) products can help reduce the risk of more fatal fires. For further information, please contact the Massachusetts Coalition for Occupational Safety and Health, masscosh.org.

Wounding the messenger: the new economy makes occupational health indicators too good to be true.

The U.S. Bureau of Labor Statistics and workers' compensation insurers reported dramatic drops in rates of occupational injuries and illnesses during the 1990s. The authors argue that far-reaching changes in the 1980s and 1990s, including the rise of precarious employment, falling wages and opportunities, and the creation of a super-vulnerable population of immigrant workers, probably helped create this apparent trend by preventing employees from reporting some injuries and illnesses. Changes in the health care system, including loss of access to health care for growing numbers of workers and increased obstacles to the use of workers' compensation, compounded these effects by preventing the diagnosis and documentation of some occupational injuries and illnesses. Researchers should examine these forces more closely to better understand trends in occupational health.

The occupational health of Southeast Asians in Lowell: a descriptive study.

To assess the occupational health of a group of vulnerable workers, Southeast Asians, in Lowell, Massachusetts, researchers surveyed 160 residents of Cambodian or Lao ethnicity regarding working conditions, health problems, and use of medical services. Over 40% reported work in electronics and computer assembly. A fourth of those currently employed held temporary jobs. Workplace hazards included soldering fumes; inadequate ventilation; prolonged sitting or standing; awkward postures; unguarded machinery; shift work; long hours; and pressure to produce quickly. Common work-related health problems included sprains and strains, headache, dizziness, and flu-like symptoms. Less than a third of the respondents knew about workers' compensation. Household surveys can provide otherwise unavailable occupational health data for defined populations.

Occupational health of Southeast Asian immigrants in a US city: a comparison of data sources.

OBJECTIVES: This study sought to characterize occupational injury and illness cases identified through 3 different sources of data on a population of immigrant workers. METHODS: Participants were Cambodian and Lao workers living in Lowell, Mass. A household survey allowed comparisons between characteristics of work-related cases documented in workers' compensation wage replacement records and hospital records and characteristics of self-reported cases. RESULTS: The household survey captured types of cases missing from existing data, particularly illnesses self-reported to be associated with chemical exposures. Injuries and illnesses affecting the study population appeared to be significantly underrepresented in workers' compensation wage replacement data. CONCLUSIONS: Community-based methods can supplement available occupational health data sources.

Occupational injury and illness surveillance: conceptual filters explain underreporting.

Occupational health surveillance data are key to effective intervention. However, the US Bureau of Labor Statistics survey significantly underestimates the incidence of work-related injuries and illnesses. Researchers supplement these statistics with data from other systems not designed for surveillance. The authors apply the filter model of Webb et al. to underreporting by the Bureau of Labor Statistics, workers' compensation wage-replacement documents, physician reporting systems, and medical records of treatment charged to workers' compensation. Mechanisms are described for the loss of cases at successive steps of documentation. Empirical findings indicate that workers repeatedly risk adverse consequences for attempting to complete these steps, while systems for ensuring their completion are weak or absent.