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.

Early Care and Education Workers' Experience and Stress during the COVID-19 Pandemic.

Early care and education (ECE) workers experience many job-related stressors. During the COVID-19 pandemic, ECE programs either closed or remained open while workers faced additional demands. We deployed a survey of the center-based ECE workforce in Washington State (United States) one year into the COVID-19 pandemic to assess impacts and workers' perceived stress levels. We describe the prevalence of reported impacts, including workplace closures; job changes; COVID-19 transmission; risk factors for severe COVID-19; the use of social distancing practices; satisfaction with workplace responses; perceptions of worker roles, respect, and influence; and food and financial insecurity. Themes from open-ended responses illustrate how workers' jobs changed and the stressors that workers experienced as a result. Fifty-seven percent of ECE workers reported moderate or high levels of stress. In a regression model assessing unique contributions to stress, work changes that negatively impacted home life contributed most to stress. Feeling respected for one's work and feeling positive about one's role as an "essential worker" contributed to lower levels of stress. Experiencing financial insecurity, caring for school-aged children or children of multiple ages, being younger, and being born in the United States also contributed to higher stress. Findings can inform policies designed to support the workforce.

Advocates Make a Difference in Duration of Homelessness and Quality of Life.

Social support is known to protect against homelessness and improve the wellbeing of people experiencing homelessness, but the role of professional versus informal advocates has not been studied in relation to the duration of homelessness and quality of life. We measured the effect of the presence and quality of formal (professional) and informal (family or friend) advocates on these outcomes. Our team interviewed 67 adults experiencing homelessness at tiny house villages and self-organized encampments in Seattle/King County, Washington in 2018-2019. The duration of homelessness was 19.6 months shorter for those with a high-quality informal advocate, compared to those without, while controlling for race, age, gender, and sexuality. However, this difference did not reach statistical significance at the alpha 0.05 level (p = .069). Additionally, those with high-quality informal advocates had 5.3 times the odds (p = .010) of reporting high quality of life compared to those without. The effect of at least one high-quality, professional advocate was insignificant in our model. Our results suggest social workers and other professional advocates integrate methods that strengthen clients' informal relationships into their practice.

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.

Court-imposed fines as a feature of the homelessness-incarceration nexus: a cross-sectional study of the relationship between legal debt and duration of homelessness in Seattle, Washington, USA.

BACKGROUND: Legal system involvement is a policy-driven risk factor for homelessness. Legal financial obligations (LFOs), such as court fees, fines and restitution, can endanger the financial security of those ensnared in the criminal justice system. In this study we measured the effect of incarceration and LFOs on duration of homelessness in Seattle, WA, USA. METHODS: To analyze the relationship between incarceration, debt and duration of homelessness, we interviewed 101 adults experiencing homelessness and living in city-sanctioned encampments and tiny house villages in Seattle, WA in 2017-18. We collected personal housing history, presence and amount of debt, and measures of legal system involvement. RESULTS: Our respondents experienced homelessness an average of 41 months during the current episode. Nearly two-thirds reported being convicted of a crime, and 78% had been incarcerated. More than 25% reported owing current legal fines. Individuals with legal fine debt experienced 22.9 months of additional homelessness after considering the effects of race, age, and gender. CONCLUSION: We confirmed a strong association between homelessness and legal trouble. Among high-income countries, the USA has the highest rates of legal system involvement and the highest rates of homelessness; the relationship between the two may be connected.

Connecting mothers to care: Effectiveness and scale-up of an mHealth program in Timor-Leste.

BACKGROUND: Health Alliance International (HAI) with the Ministry of Health (MoH) of Timor-Leste and Catalpa International implemented a mobile phone-based mHealth program in 2013 known as Liga Inan ("Connecting Mothers"). Liga Inan was designed as a sustainable and scalable effort that would support MoH efforts to improve maternal and newborn health care-seeking and home practices. Key aims were to use mobile phone technology to improve communication between pregnant women and their MoH health providers and to increase optimal maternal health behaviors. MoH health staff registered pregnant women into Liga Inan at their first antenatal care (ANC) visit and followed them through pregnancy, delivery and six months postpartum. A web-based platform sent text messages twice weekly to promote safe pregnancy/delivery and facilitated phone communication between pregnant women and their MoH care providers. METHODS: For the program's final evaluation, baseline (2012) and final (2015) surveys interviewed women in one intervention district and one adjacent control district who had given birth in the preceding two years. Primary outcomes were receiving four or more ANC visits, using skilled birth attendants, delivery in health facilities, and timely postnatal care. RESULTS: Multivariate analysis compared endline maternal health behaviors for women in the intervention district compared to baseline and to women in the control district. Controlling for other factors, women in the intervention district had nearly twice the odds of having a skilled birth attendant and a facility delivery, nearly five times the odds of receiving a postpartum care visit within two days of delivery, and over five times the odds of having their newborn's health checked within two days of birth. There was no significant association between Liga Inan exposure and receipt of four or more ANC visits. CONCLUSIONS: Liga Inan was associated with substantial increases in MoH health provider-assisted and facility-based births and timely postnatal care in Timor-Leste. These positive results led the MoH to incorporate Liga Inan into the national maternal and child health program. To date the program has expanded to cover all 13 districts in the country, with gradual assumption of management and financial responsibility by the MoH under way.

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.

Conducting a Large Public Health Data Collection Project in Uganda: Methods, Tools, and Lessons Learned.

We report on the implementation experience of carrying out data collection and other activities for a public health evaluation study on whether U.S. President's Emergency Plan for AIDS Relief (PEPFAR) investment improved utilization of health services and health system strengthening in Uganda. The retrospective study period focused on the PEPFAR scale-up, from mid-2005 through mid-2011, a period of expansion of PEPFAR programing and health services. We visited 315 health care facilities in Uganda in 2011 and 2012 to collect routine health management information system data forms, as well as to conduct interviews with health system leaders. An earlier phase of this research project collected data from all 112 health district headquarters, reported elsewhere. This article describes the lessons learned from collecting data from health care facilities, project management, useful technologies, and mistakes. We used several new technologies to facilitate data collection, including portable document scanners, smartphones, and web-based data collection, along with older but reliable technologies such as car batteries for power, folding tables to create space, and letters of introduction from appropriate authorities to create entrée. Research in limited-resource settings requires an approach that values the skills and talents of local people, institutions and government agencies, and a tolerance for the unexpected. The development of personal relationships was key to the success of the project. We observed that capacity building activities were repaid many fold, especially in data management and technology.

Gendered Safety and Health Risks in the Construction Trades.

Objectives: Despite women's increased representation in the overall workforce, construction remains a male-dominated industry. Prior studies have noted that the hazardous workplace environment combined with a culture that can be discriminatory and openly hostile can threaten women workers' health and safety. However, little information exists about the current physical and psychosocial hazards at work affecting tradeswomen. Methods: We examined differences in workplace exposure between women and men, and the association of these exposures with self-reported stress and work injury, in order to highlight how gendered conditions of work negatively affect tradeswomen's health. A holistic view of health that included the influence of both home and work spheres as well as hazards related to women's social experience was considered. Almost 300 workers (198 tradeswomen and 93 tradesmen) throughout Washington State completed surveys. We used descriptive statistics to compare exposures between genders, and logistic regression to model the association between psychosocial exposures and injury and stress outcomes. Results: We found that women were significantly more likely than men to report high perceived stress (31 and 18%, respectively) and being injured at work in the past year (31 and 12%, respectively). Ten of the 12 work-related psychosocial exposures were found to be associated with either stress (job strain, gender and age discrimination, bullying, work/life balance, isolation, sexual harassment, safety climate, and social support) or injury (gender discrimination, bullying, overcompensation, and sexual harassment) for women. Conclusions: The industry continues to lag in supporting tradeswomen's health and safety needs. This study suggests that multiple exposures (including discrimination, overcompensation, and work/life balance) have an important impact on worker well-being. The findings underscore the complex interaction of gender, psychosocial exposures, and occupational risks, and indicate areas for intervention.

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.

Using exposure windows to explore an elusive biomarker: blood manganese.

PURPOSE: We sought to understand the time course between exposure to manganese (Mn) and uptake into the blood, to allow a more meaningful interpretation of exposure biomarker data, and to determine the utility of blood as a biomarker of Mn exposure. METHODS: Welder trainees were monitored over the course of a five-quarter training program. Each quarter, trainees gave eight blood samples and had personal air monitoring four times. A mixed model was fit to obtain estimates of airborne exposure by welding type (fixed effect), adjusted for subject (random effect). Considering weekends and days absent as zero exposure, estimated exposures were summed over various exposure windows and related to measured blood manganese (MnB) using a mixed model. RESULTS: A relationship consistent with zero was found between MnB and modeled 1 or 7 days of exposure. After 30 days of preceding exposure, a 1 mg-days/m(3) increase in air Mn is associated with a 0.57 ng/mL increase in MnB (95% CI -0.04, 1.19). Considering a 90-day exposure window and a cumulative exposure window, a 1 mg-days/m(3) increase in air Mn is associated with a 0.26 (95% CI 0.005, 0.51) and 0.09 (95% CI 0.006, 0.17) ng/mL increase in MnB, respectively. CONCLUSIONS: From this analysis, MnB may begin to act as a biomarker of Mn exposure over longer time periods, or at higher levels of exposure. This novel study design allowed investigation of how MnB relates to different time windows of exposure, representing the most robust Mn exposure assessment in the biomarker literature.

Hair Manganese as an Exposure Biomarker among Welders.

Quantifying exposure and dose to manganese (Mn) containing airborne particles in welding fume presents many challenges. Common biological markers such as Mn in blood or Mn in urine have not proven to be practical biomarkers even in studies where positive associations were observed. However, hair Mn (MnH) as a biomarker has the advantage over blood and urine that it is less influenced by short-term variability of Mn exposure levels because of its slow growth rate. The objective of this study was to determine whether hair can be used as a biomarker for welders exposed to manganese. Hair samples (1cm) were collected from 47 welding school students and individual air Mn (MnA) exposures were measured for each subject. MnA levels for all days were estimated with a linear mixed model using welding type as a predictor. A 30-day time-weighted average MnA (MnA30d) exposure level was calculated for each hair sample. The association between MnH and MnA30d levels was then assessed. A linear relationship was observed between log-transformed MnA30d and log-transformed MnH. Doubling MnA30d exposure levels yields a 20% (95% confidence interval: 11-29%) increase in MnH. The association was similar for hair washed following two different wash procedures designed to remove external contamination. Hair shows promise as a biomarker for inhaled Mn exposure given the presence of a significant linear association between MnH and MnA30d levels.

Variance components of short-term biomarkers of manganese exposure in an inception cohort of welding trainees.

Various biomarkers of exposure have been explored as a way to quantitatively estimate an internal dose of manganese (Mn) exposure, but given the tight regulation of Mn in the body, inter-individual variability in baseline Mn levels, and variability in timing between exposure and uptake into various biological tissues, identification of a valuable and useful biomarker for Mn exposure has been elusive. Thus, a mixed model estimating variance components using restricted maximum likelihood was used to assess the within- and between-subject variance components in whole blood, plasma, and urine (MnB, MnP, and MnU, respectively) in a group of nine newly-exposed apprentice welders, on whom baseline and subsequent longitudinal samples were taken over a three month period. In MnB, the majority of variance was found to be between subjects (94%), while in MnP and MnU the majority of variance was found to be within subjects (79% and 99%, respectively), even when controlling for timing of sample. While blood seemed to exhibit a homeostatic control of Mn, plasma and urine, with the majority of the variance within subjects, did not. Results presented here demonstrate the importance of repeat measure or longitudinal study designs when assessing biomarkers of Mn, and the spurious associations that could result from cross-sectional analyses.

Sources of variability in wideband energy reflectance measurements in adults.

BACKGROUND: Wideband acoustic immittance measurements of the middle ear, such as wideband energy reflectance (ER), can provide information about how the middle ear functions across the traditional audiometric frequency range. These measurements are being investigated as a new means of evaluating conductive hearing disorders, and studies have been reported on a number of middle-ear disorders. However, the normative database for wideband ER is still being developed, and more information is needed about sources of test variability. PURPOSE: The purpose of the present study was to evaluate sources of variability in wideband ER measurements at baseline and across annual tests for up to 5 yr in subjects with normal hearing. STUDY SAMPLE: The main group consisted of 112 subjects (187 ears), 24 females and 88 males, with normal hearing and normal 0.226-kHz admittance tympanometry. An additional 24 adults with abnormal 0.226-kHz tympanometry provided baseline comparison data. RESEARCH DESIGN: A longitudinal design was used in obtaining annual measurements of audiometry, tympanometry, and wideband ER at ambient pressure in adults. DATA COLLECTION AND ANALYSIS: Clinical audiometry and tympanometry data and 1/3-octave wideband ER measurements were obtained at baseline and annually for up to four additional tests. Descriptive statistics and t-tests were used to explore differences in 1/3-octave baseline ER measures in terms of subject age, test ear, sex, and clinical tympanometry. Longitudinal mixed-effects linear regression models at 1.0, 2.0, and 4.0 kHz were used to examine the different sources of variance affecting ER over time. RESULTS: There were small but statistically significant mean differences in ER for baseline measurements as a function of ear, sex, and age. Compared with these results, data for 29 ears with abnormal 0.226-kHz tympanometry differed from mean normal data across a broad frequency range by as much as 20%. ER varied as a function of peak compensated static acoustic admittance (Ytm) for measures at 1.0 kHz but was unrelated to Ytm at 2.0 and 4.0 kHz. ER also varied as a function of the test ear, with significantly higher ER on the left at 1.0 and 2.0 kHz, but was not significantly related to the test ear at 4.0 kHz. The standard deviation for test-retest variability was about 0.1 at each frequency, which is consistent with previous studies. CONCLUSIONS: Mean wideband ER at baseline showed small but significant differences related to sex, ear, and age. ER was significantly related to Ytm at 1.0 kHz in the longitudinal data but not at 2.0 or 4.0 kHz and to the test ear at 1.0 and 2.0 kHz but not at 4.0 kHz. When evaluated at ambient pressure, ER for ears with negative middle-ear pressure was similar to that of ears with abnormally low Ytm. Therefore it might be necessary to evaluate wideband acoustic immittance compensated for middle-ear pressure by using tympanometry to obtain an effective differential diagnosis of middle-ear disorders in adults.

Blood manganese as an exposure biomarker: state of the evidence.

Despite evidence of adverse health effects resulting from exposure to manganese (Mn), biomarkers of exposure are poorly understood. To enhance understanding, mean blood Mn (MnB) and mean air Mn (MnA) were extracted from 63 exposure groups in 24 published papers, and the relationship was modeled using segmented regression. On a log/log scale, a positive association between MnA and MnB was observed among studies reporting MnA concentrations above about 10 µg/m(3), although interpretation is limited by largely cross-sectional data, study design variability, and differences in exposure monitoring methods. Based on the results of the segmented regression, we hypothesize that below the concentration of about 10 µg/m(3), Mn in the body is dominated by dietary Mn, and additional inhaled Mn only causes negligible changes in Mn levels unless the inhaled amount is substantial. However, stronger study designs are required to account for temporal characteristics of the MnA to MnB relationships that reflect the underlying physiology and toxicokinetics of Mn uptake and distribution. Thus, we present an inception cohort study design we have conducted among apprentice welders, and the analytical strengths this study design offers. To determine if blood could be a useful biomarker for Mn to be utilized by industrial hygienists in general industry requires additional time-specific analyses, which our inception cohort study design will allow.

10-Year prospective study of noise exposure and hearing damage among construction workers.

OBJECTIVES: To characterise the effects of noise exposure, including intermittent and peaky exposure, on hearing damage as assessed by standard pure-tone thresholds and otoacoustic emissions, a longitudinal study was conducted on newly hired construction apprentices and controls over a 10-year period. METHODS: Among the 456 subjects recruited at baseline, 316 had at least two (mean 4.6) examinations and were included in this analysis. Annual examinations included hearing threshold levels (HTLs) for air conducted pure tones and distortion product otoacoustic emission (DPOAE) amplitudes. Task-based occupational noise exposure levels and recreational exposures were estimated. Linear mixed models were fit for HTLs and DPOAEs at 3, 4 and 6 kHz in relation to time since baseline and average noise level since baseline, while controlling for hearing level at baseline and other risk factors. RESULTS: Estimated L(EQ) noise exposures were 87±3.6 dBA among the construction workers. Linear mixed modelling demonstrated significant exposure-related elevations in HTL of about 2-3 dB over a projected 10-year period at 3, 4 or 6 kHz for a 10 dB increase in exposure. The DPOAE models (using L1=40) predicted about 1 dB decrease in emission amplitude over 10 years for a 10 dB increase in exposure. CONCLUSIONS: The study provides evidence of noise-induced damage at an average exposure level around the 85 dBA level. The predicted change in HTLs was somewhat higher than would be predicted by standard hearing loss models, after accounting for hearing loss at baseline. Limited evidence for an enhanced effect of high peak component noise was observed, and DPOAEs, although similarly affected, showed no advantage over standard hearing threshold evaluation in detecting effects of noise on the ear and hearing.

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.

A multi-component intervention to promote hearing protector use among construction workers.

Hearing protection devices (HPD) remain a primary method of prevention of noise-induced hearing loss despite their well-known limitations. A three-pronged intervention to increase HPD use was conducted among construction workers and included a baseline hearing loss prevention training, follow-up 'toolbox' (TB) reinforcement trainings, and use of a personal noise level indicator (NLI). A total of 176 subjects on eight sites completed three assessments. Prior to intervention, HPDs were used an average of 34.5% of the time and increased significantly, up about 12.1% after intervention and 7.5% two months after interventions were completed. The increase in HPD use was greatest among the group receiving both TB and NLI interventions; up about 25% from baseline, and this group was about two times more likely to use HPDs than the BL (baseline) training only group. This study demonstrates the mild impact of a well-constructed HPD use training and provides support for the additional use of a personal NLI to increase use of HPDs among construction workers. The most effective procedures for using such instruments require further exploration.