Testing hypothesized psychosocial mediators: lessons learned in the MassBUILT study.

Only a few of the interventions that target blue-collar workers have conducted formal analysis to evaluate the specific attributes of their intervention that are associated with success or failure. This study examined the role of dual hazard and decisional balance in the MassBUILT smoking cessation intervention. The authors conducted sets of multivariable linear and logistic regressions that examined if (a) the intervention was associated with changes in the psychosocial variables and (b) increase in psychosocial variables was associated with increase in smoking cessation. As hypothesized by the theoretical basis of the study, higher scores on both of the psychosocial variables were significantly associated with smoking cessation. However, the intervention did not change decisional balance and decreased dual hazard. The variables examined were important but were not mediators of the MassBUILT intervention and this could have contributed to the significant relapse in smoking among study participants.

Occupational, social, and relationship hazards and psychological distress among low-income workers: implications of the 'inverse hazard law'.

BACKGROUND: Few studies have simultaneously included exposure information on occupational hazards, relationship hazards (eg, intimate partner violence) and social hazards (eg, poverty and racial discrimination), especially among low-income multiracial/ethnic populations. METHODS: A cross-sectional study (2003-2004) of 1202 workers employed at 14 worksites in the greater Boston area of Massachusetts investigated the independent and joint association of occupational, social and relationship hazards with psychological distress (K6 scale). RESULTS: Among this low-income cohort (45% were below the US poverty line), exposure to occupational, social and relationship hazards, per the 'inverse hazard law,' was high: 82% exposed to at least one occupational hazard, 79% to at least one social hazard, and 32% of men and 34% of women, respectively, stated they had been the perpetrator or target of intimate partner violence (IPV). Fully 15.4% had clinically significant psychological distress scores (K6 score ≥ 13). All three types of hazards, and also poverty, were independently associated with increased risk of psychological distress. In models including all three hazards, however, significant associations with psychological distress occurred among men and women for workplace abuse and high exposure to racial discrimination only; among men, for IPV; and among women, for high exposure to occupational hazards, poverty and smoking. CONCLUSIONS: Reckoning with the joint and embodied reality of diverse types of hazards involving how people live and work is necessary for understanding determinants of health status.

Implications of discrimination based on sexuality, gender, and race/ethnicity for psychological distress among working-class sexual minorities: the United for Health Study, 2003-2004.

This study investigated the distribution of demographic characteristics, the prevalence of discrimination based on sexuality, gender, and race, and relationships with psychological distress among 178 working-class sexual minorities (i.e., who identified as lesbian, gay, or bisexual (LGB) or had ever engaged in same-sex sexual behaviors) recruited to the United for Health Study (2003-2004). The results indicated considerable heterogeneity in responses to items assessing sexual orientation and sexual behavior, with a majority of sexual minority participants not identifying as LGB (74.2%). The authors found significant demographic differences in LGB identification by gender, race/ethnicity, nativity, and socioeconomic factors. In addition, LGB participants had higher levels of psychological distress than non-LGB-identified sexual minorities. Linear regression analyses revealed that reports of racial/ethnic discrimination and sexuality discrimination were associated with higher levels of psychological distress among sexual minority participants. The results underscore the need to collect multiple measures of sexuality in conducting research on racially diverse working-class communities; to consider demographic factors in collecting sexuality data; and to disaggregate information on sexuality by LGB identification. Findings also highlight the importance of addressing discrimination in ameliorating problematic mental health outcomes among working-class sexual minorities.

The association of workplace hazards and smoking in a U.S. multiethnic working-class population.

OBJECTIVE: We investigated the extent to which smoking status was associated with exposure to occupational (e.g., dust, chemicals, noise, and ergonomic strain) and social (e.g., abuse, sexual harassment, and racial discrimination) workplace hazards in a sample of U.S. multiethnic working-class adults. METHODS: United for Health is a cross-sectional study designed to investigate the combined burden of occupational and social workplace hazards in relation to race/ethnicity, gender, and wage and to evaluate related health effects in a working-class population. Using validated measures, we collected data from 1,282 multiethnic working-class participants using audio computer-assisted interviews. We used multiple imputation methods to impute data for those missing data. Crude and adjusted logistic odds ratios (ORs) were modeled to estimate ORs and 95% confidence intervals (CIs). RESULTS: The prevalence of smoking was highest among non-Hispanic white workers (38.3%) and lowest for foreign-born workers (13.1%). We found an association between racial discrimination and smoking (OR = 1.12, 95% CI 1.01, 1.25). The relationship between smoking and sexual harassment, although not significant, was different for black women compared with men (OR = 1.79, 95% CI 0.99, 3.22). We did not find any associations by workplace abuse or by any of the occupational hazards. CONCLUSION: These results indicate that racial discrimination might be related to smoking in working-class populations and should be considered in tobacco-control efforts that target this high-risk population.

MassBuilt: effectiveness of an apprenticeship site-based smoking cessation intervention for unionized building trades workers.

OBJECTIVE: Blue-collar workers are difficult to reach and less likely to successfully quit smoking. The objective of this study was to test a training site-based smoking cessation intervention. METHODS: This study is a randomized-controlled trial of a smoking cessation intervention that integrated occupational health concerns and was delivered in collaboration with unions to apprentices at 10 sites (n = 1,213). We evaluated smoking cessation at 1 and 6 months post-intervention. RESULTS: The baseline prevalence of smoking was 41%. We observed significantly higher quit rates in the intervention versus control group (26% vs. 16.8%; p = 0.014) 1 month after the intervention. However, the effects diminished over time so that the difference in quit rate was not significant at 6 month post-intervention (9% vs. 7.2%; p = 0.48). Intervention group members nevertheless reported a significant decrease in smoking intensity (OR = 3.13; 95% CI: 1.55-6.31) at 6 months post-intervention, compared to controls. CONCLUSION: The study demonstrates the feasibility of delivering an intervention through union apprentice programs. Furthermore, the notably better 1-month quit rate results among intervention members and the greater decrease in smoking intensity among intervention members who continued to smoke underscore the need to develop strategies to help reduce relapse among blue-collar workers who quit smoking.

The inverse hazard law: blood pressure, sexual harassment, racial discrimination, workplace abuse and occupational exposures in US low-income black, white and Latino workers.

Research on societal determinants of health suggests the existence of an "inverse hazard law," which we define as: "The accumulation of health hazards tends to vary inversely with the power and resources of the populations affected." Yet, little empirical research has systematically investigated this topic, including in relation to workplace exposures. We accordingly designed the United for Health study (Greater Boston Area, Massachusetts, 2003-2004) to investigate the joint distribution and health implications of workplace occupational hazards (dust, fumes, chemical, noise, ergonomic strain) and social hazards (racial discrimination, sexual harassment, workplace abuse). Focusing on blood pressure as our health outcome, we found that among the 1202 low-income multi-racial/ethnic working class participants in our cohort - of whom 40% lived below the US poverty line - 79% reported exposure to at least one social hazard and 82% to at least one high-exposure occupational hazard. Only sexual harassment, the least common social hazard, was associated with elevated systolic blood pressure (SBP) among the women workers. By contrast, no statistically significant associations were detectable between the other additional highly prevalent social and occupational hazards and SBP; we did, however, find suggestive evidence of an association between SBP and response to unfair treatment, implying that in a context of high exposure, differential susceptibility to the exposure matters. These results interestingly contrast to our prior findings for this same cohort, in which we found associations between self-reported experiences of racial discrimination and two other health outcomes: psychological distress and cigarette smoking. Likely explanations for these contrasting findings include: (a) the differential etiologic periods and pathways involving somatic health, mental health, and health behaviors, and (b) the high prevalence of adverse exposures, limiting the ability to detect significant associations. As clarified by the "inverse hazard law," to understand health inequities, research is needed that contrasts exposures and health status population-wide, not just among those most inequitably exposed.

Geography of underweight and overweight among women in India: a multilevel analysis of 3204 neighborhoods in 26 states.

We investigated the geographic distribution and the relationship with neighborhood wealth of underweight and overweight in India. Using multilevel modeling techniques, we calculated state-specific smoothed shrunken state residuals of overweight and underweight, neighborhood and state variation of nutritional status, and the relationships between neighborhood wealth and nutritional status of 76,681 women living in 3204 neighborhoods in 26 Indian states. We found a substantial variation in overweight and underweight at the neighborhood and state levels, net of what could be attributed to individual-level factors. Neighborhood wealth was associated with increased levels of overweight and decreased levels of underweight, and was found to modify the relationship between personal living standard and nutritional status. These findings suggest that interventions to address the double burden of undernutrition and overnutrition in India must take into account state and neighborhood characteristics in order to be successful.

Racial and ethnic disparities in smoking-cessation interventions: analysis of the 2005 National Health Interview Survey.

BACKGROUND: Recent national surveys document racial and ethnic disparities in receipt of smoking-cessation advice. This study updates and expands prior analyses using survey data for 2005, and evaluates the association between smokers' race and ethnicity and three separate measures of healthcare-encounter-based tobacco interventions: screening, smoking-cessation advice, and use of smoking-cessation aids. METHODS: Analyses are based on 4756 smokers (aged 18 and older) reporting a healthcare encounter within the past year who participated in the 2005 National Health Interview Survey (NHIS). Multivariate-adjusted OR and 95% CI for receipt of tobacco interventions in non-Hispanic black and Hispanic smokers were compared to those of non-Hispanic white smokers, adjusted for smokers' characteristics (sociodemographics, health status, and healthcare-utilization factors, and smoking-related characteristics). Analyses were done in 2006. RESULTS: Results show that compared to white smokers, black and Hispanic smokers had significantly lower odds of (1) being asked about tobacco use (AOR=0.70 and AOR=0.69, respectively); (2) being advised to quit (AOR=0.72 and AOR=0.64, respectively); or (3) having used tobacco-cessation aids during the past year in a quit attempt (AOR=0.60 and AOR=0.59, respectively). Compared to 2000 NHIS published data, the prevalence of receipt of advice to quit from a healthcare provider increased from 52.9% in 2000 to 61.2% in 2005, with increases across racial and ethnic groups. CONCLUSIONS: Despite progress in smokers' being advised to quit during healthcare encounters in the past 5 years, black and Hispanic smokers continue to be less likely than whites to receive and use tobacco-cessation interventions, even after control for socioeconomic and healthcare factors. Further actions are needed to understand and eliminate this disparity.

Effects of individual and proximate educational context on intimate partner violence: a population-based study of women in India.

OBJECTIVES: We examined the role of women's education and proximate educational context on intimate partner violence (IPV). METHODS: We examined a sample of 83627 married women aged 15 to 49 years from the 1998 to 1999 Indian National Family Health Survey. We used multilevel multiple logistic regression modeling to estimate the relative effect of women's and their husband's levels of education, spousal education differential, and community-level literacy on women's risk of recent and lifetime IPV. RESULTS: In adjusted models, odds of recent IPV among women without any education were 5.61 times (95% confidence interval [CI] = 3.53, 8.92) those of college-educated women, and odds among wives of uneducated men were 1.84 times (95% CI=1.44, 2.35) those of wives of college-educated men. Women with more education than their husbands were more likely than those with educational parity to report recent IPV (odds ratio [OR]=1.18; 95% CI=1.05, 1.33). The results were similar for lifetime IPV. After we controlled for individual factors, as community male and female literacy levels increased, likelihood of IPV declined. CONCLUSIONS: Although increasing women's levels of education is crucial to reducing IPV for women, proximate educational context is also an important factor in reducing this public health burden.

Unfair treatment, racial/ethnic discrimination, ethnic identification, and smoking among Asian Americans in the National Latino and Asian American Study.

OBJECTIVES: We examined the relations of self-report of general unfair treatment and self-report of race/ethnicity-specific discrimination with current smoking among Asian Americans. We investigated whether ethnic identification moderated either association. METHODS: Weighted logistic regressions were performed among 1977 Asian Americans recruited to the National Latino and Asian American Study (2002-2003). RESULTS: In weighted multivariate logistic regression models including both general unfair treatment and racial/ethnic discrimination, odds of current smoking were higher among Asian Americans who reported high levels of unfair treatment (odds ratio [OR]=2.80; 95% confidence interval [CI]=1.13, 6.95) and high levels of racial/ethnic discrimination (OR=2.40; 95% CI=0.94, 6.12) compared with those who reported no unfair treatment and discrimination, respectively. High levels of ethnic identification moderated racial/ethnic discrimination (F(3) =3.25; P =.03). High levels of ethnic identification were associated with lower probability of current smoking among participants reporting high levels of racial/ethnic discrimination. CONCLUSIONS: Our findings suggest that experiences of unfair treatment and racial/ethnic discrimination are risk factors for smoking among Asian Americans. Efforts to promote ethnic identification may be effective in mitigating the influence of racial/ethnic discrimination on smoking in this population.

Exposure to domestic violence associated with adult smoking in India: a population based study.

OBJECTIVE: To investigate the relation between domestic violence and tobacco use among adults in India. DESIGN: Multilevel cross sectional analyses of a nationally representative population based sample from the 1998-9 Indian national family health survey. PARTICIPANTS: 278,977 individuals aged 15 or older; and 89,092 ever married women aged 15-49. MAIN OUTCOME: Dichotomous variables for smoking and chewing tobacco. RESULTS: Women who reported being abused more than one year ago and those who reported being abused in the past year were more likely to smoke and chew tobacco than women who have never experienced domestic violence. Compared to individuals who lived in homes where no abuse was reported, those who lived in homes where a woman reported experiencing domestic violence were more likely to smoke and chew tobacco. CONCLUSION: Domestic violence is associated with higher odds of smoking and chewing tobacco in India. Efforts to control tobacco use need to consider the larger psychosocial circumstances within which individuals who practise such harmful health behaviours reside.

Social disparities in the burden of occupational exposures: results of a cross-sectional study.

BACKGROUND: Most occupational studies evaluate a single exposure in relation to a particular disease. However, workers typically experience multiple exposures simultaneously. There is also increasing evidence of disparities in health by sociodemographic characteristics, mostly related to social position such as gender, race/ethnicity, immigration status, income, and education. Little information exists on the worker experience of multiple occupational exposures as they vary among social groups. The objectives of this article were to: assess the burden of exposures reported within 1 year by a socially diverse population working in a range of industries; and evaluate whether sociodemographic characteristics affected the patterns of these exposures. METHODS: Study participants were from 14 unionized worksites in meat processing, electrical lighting manufacturing, retail grocery stores, and school bus driving. A cross-sectional study design used a self-administered, computer-assisted questionnaire (English and Spanish) to assess sociodemographic characteristics and nine workplace exposures, within the past year. An interviewer-administered job history also was collected. RESULTS: Twelve hundred eighty-two workers (72%) completed the survey: 36% women, 23% Latino, 39% black, 24% white, and 48% born outside the US. The prevalence of high exposures ranged from 21% (chemicals) to 39% (neck strain). Forty-six percent reported three or more high exposures. Exposure reporting varied among sociodemographic groups. Some of the disparities were explained by the jobs held by different groups, but after statistically controlling for job, many disparities remained. CONCLUSIONS: Sociodemographic characteristics should be considered when conducting exposure assessments using questionnaires. More research is needed to understand how social characteristics may influence exposures.

The influence of social context on changes in fruit and vegetable consumption: results of the healthy directions studies.

As part of the Harvard Cancer Prevention Program Project, we used a social contextual model of health behavior change to test an intervention targeting multiple risk-related behaviors in working-class, multiethnic populations. We examined the relationships between the social contextual factors in our conceptual model and changes in fruit and vegetable consumption from baseline to completion of intervention in health centers and small business studies. We analyzed change in fruit and vegetable consumption, measured at baseline and final assessments by self-report, in 2 randomized controlled prevention trials: 1 in small businesses (n = 974) and 1 in health centers (n = 1954). Stronger social networks, social norms that were more supportive, food sufficiency, and less household crowding were associated with greater change in fruit and vegetable intake. We also observed differences between our intervention sites. Social context can play an important role in promoting changes in fruit and vegetable consumption.

Methods for recruiting white, black, and hispanic working-class women and men to a study of physical and social hazards at work: the United for Health study.

Despite research on work and health having a long-standing concern about unjust exposures and inequitable burdens of disease, there are few studies that document the joint distribution and health effects of physical and psychosocial hazards (e.g., noise, dusts, fumes, and job strain) and social hazards (e.g., racial discrimination and gender harassment) encountered at work. Also, there is a paucity of data on how these exposures, singly and combined, are distributed in relation to sociodemographic characteristics including race/ethnicity, gender, socioeconomic position, and nativity. This article presents a conceptual model for redressing these knowledge gaps and describes recruitment strategies and the characteristics of study participants in the United for Health study. Working with labor unions, the authors recruited 14 (67%) of 21 worksites from manufacturing, meat processing, retail, and transportation, and 1,282 workers (72% response rate), of whom 62 percent were men, 36 percent were women, 39 percent were black, 23 percent were Hispanic, 25 percent were white, 31% earned less than a living wage, 40 percent were below the poverty level, and 23 percent had less than a high school education.

A decade of work on organized labor and tobacco control: reflections on research and coalition building in the United States.

Labor unions can and should make strong allies in tobacco control efforts. Through much of the 1980s and 1990s, however, the organized labor and tobacco control communities rarely formed coalitions to achieve mutual gains. Recently, labor unions and tobacco control organizations have begun to work together on smoking cessation programs, smoke-free worksite policies, and increased insurance coverage for cessation treatments. This paper explores the historic and present-day intersections among organized labor and tobacco control advocates. We summarize research in this area and report on our recent programmatic efforts to promote collaboration between the labor and tobacco control communities. We discuss lessons learned with the aims of promoting deeper understanding among tobacco control and labor advocates of how each views tobacco control issues, and most importantly, stimulating further collaboration toward mutual gains in protecting workers' health.

Work-to-family spillover and fruit and vegetable consumption among construction laborers.

PURPOSE: Spillover is the effect of one role on another as working adults attempt to integrate demands from work and family. We conducted a survey to understand how worker, job, and family characteristics were related to negative work-to-family spillover and how spillover was related to fruit and vegetable consumption to inform intervention design. DESIGN: A combined mail and telephone survey. SETTING: A national random sample in the United States. SUBJECTS: 1108 (44% response) unionized construction laborers. MEASURES: Personal characteristics, job factors, family factors, work-to-family spillover, and fruit and vegetable consumption. ANALYSIS: Multivariable logistic and least-squares regression. RESULTS: A range of 20% to 50% of respondents reported negative work-to-family spillover, agreeing that work demands, time, fatigue, and stress interfered with family meals or food choices. Higher spillover was associated with job factors, being of white race/ethnicity, and having children at home. Lower fruit and vegetable consumption was associated with higher work-to-family spillover (p = .002), being of white race or ethnicity (p < .0001), and working the graveyard or day shift (p = .02). CONCLUSION: Negative experience of work-to-family spillover may link employment to fruit and vegetable consumption and thus to worker health. Understanding the contribution of spillover to fruit and vegetable consumption aids understanding of how work experience affects health.

Tools for health: the efficacy of a tailored intervention targeted for construction laborers.

OBJECTIVES: Novel approaches to worksite health promotion are needed for high-risk workers who change job sites frequently, and thus may have limited access to worksite health promotion efforts. The objective of this study was to test a behavioral intervention among construction laborers. METHODS: Using a randomized-controlled design, we tested the efficacy of a tailored telephone-delivered and mailed intervention to promote smoking cessation and increased fruit and vegetable consumption (n = 582). RESULTS: At baseline, 40% of control group participants and 45% of intervention group participants reported using any tobacco in the last seven days. At final, 8% of baseline cigarette smokers in the control group had quit, compared to 19% in the intervention group (p = 0.03). In both groups, the mean consumption of fruits and vegetables at baseline was over five servings per day. At final, the intervention group had increased consumption by approximately one and one-half servings, compared to a slight decrease in consumption in the control group (p < 0.001). CONCLUSIONS: A tailored intervention can be efficacious in promoting tobacco use cessation and increased fruit and vegetable consumption among construction laborers, a high-risk, mobile workforce.

Process evaluation results from the Healthy Directions-Small Business study.

The Healthy Directions-Small Business randomized, controlled study aimed to reduce cancer risk among multiethnic workers in small manufacturing businesses by increasing fruit and vegetable consumption, physical activity, and daily multivitamin in take and decreasing consumption of red meat. The intervention incorporated participatory strategies and was built on a social-contextual framework that addressed people with varying cultural backgrounds and literacy levels. In addition, the intervention aimed to reduce worker exposure to occupational hazards. Process evaluation was conducted using quantitative and qualitative research methods. Quantitative results showed high levels of worker awareness of and participation in programs. Qualitative findings suggested that management support, worker input, and a history of social interaction between workers and management may have contributed to high participation rates. Future studies need to examine characteristics associated with participation and nonparticipation of both managers and nonmanagers to increase the likelihood of participation and ultimately improve health behavior.

Social influences, social context, and health behaviors among working-class, multi-ethnic adults.

Little research has explored the relationship between social influences (e.g., social networks, social support, social norms) and health as related to modifying factors that may contribute to health disparities. This is a cross-sectional analysis of fruit and vegetable intake and physical activity, using baseline data from two cancer prevention studies with working-class, multi-ethnic adults. Several social influence and social contextual variables were associated with fruit and vegetable intake and physical activity in both samples. Fruit and vegetable consumption was associated with social norms and social networks, although different contextual variables also were related to intake across the two samples. Physical activity was associated with social networks, social norms, and competing demands. By examining how key social influence and contextual mediating variables relate to health behaviors, we can learn more about the types of interventions that might be needed to promote sustained health behavior change in this population.

Integrating occupational health, safety and worksite health promotion: opportunities for research and practice.

BACKGROUND: There is emerging evidence that coordinating and integrating worksite health promotion and occupational health and safety enhances the effectiveness of efforts to promote and protect worker health, and growing attention internationally to the importance of integrating worksite health promotion and occupational health and safety. OBJECTIVES: (1) To present the rationale and scientific evidence for coordinating and integrating worksite health promotion and occupational health and safety as a means of enhancing the effectiveness of efforts to promote and protect worker health; and (2) to discuss recommendations for research priorities and future directions. METHODS: Review of the literature, drawing mainly on studies from the United States and Europe. RESULTS: The strongest evidence available supports the efficacy of this intervention model in promoting smoking cessation, particularly among blue-collar workers; some evidence additionally indicates significant effects for other health behaviors. Little evidence is available to date documenting the impact of these programs on occupational health and safety outcomes. CONCLUSIONS: Priority research directions include: social epidemiological research to identify key work-related factors associated with hazardous occupational exposures and risk-related behaviors, and to identify the underlying causes of social disparities in worker health; methods development research aimed at developing both appropriate measurement tools and new intervention approaches; efficacy and effectiveness studies to examine the effects of integrated interventions on both occupational health and safety outcomes as well as health behavior changes; assessments of the process of intervention implementation, including intervention implementation evaluation, cost assessments, and process-to-outcome assessments; and dissemination and durability studies, to identify strategies to promote the sustainability and dissemination of evidence-based programs.