Strategies for Advancing Occupational Safety and Health: Examining Health Inequities

How can we improve occupational safety and health research to better address health inequities?

The United States has a long history of occupational safety and health (OSH) research, policy, and intervention. Despite this, long-standing occupational health inequities continue, with underserved workers experiencing higher rates of injury and illness. Occupational Health Equity Program researchers at the National Institute for Occupational Safety and Health (NIOSH) recently wrote a commentary published in the International Journal of Environmental Research and Public Health. The commentary discusses the evolving framework for understanding worker injury and illness, and it suggests how to “push the needle forward” to make sure work-related benefits and risks are more evenly distributed among all workers.

The OSH field grew out of social medicine, which began in the 1800s and studies the social origin of illnesses and how biological, social, and environmental factors interact with one another to influence health [1]. Over the past 50 years, OSH research and practice evolved to apply a biomedical model based on biology and medicine. The model focuses mainly on isolating and removing a single biological or physical factor that may contribute to an injury or illness [2,3,4]. This approach has improved worker safety and health. However, greater gains might occur by returning to the OSH field’s social medicine roots. Studying the impact of social, economic, and organizational factors could lead to achieving better workplace health [5,6].

Public health research recently began using these considerations, commonly called “social determinants of health,” to better understand individual and population health; worker safety and health research has been slower to again consider the role that social determinants play in health outcomes [7,8].

Avoidable differences in work-related injury and illness happen for many reasons. Some social groups, such as foreign-born workers, and certain racialized or ethnic groups, are more likely than other workers to do dangerous jobs [9,10]. Often, these groups may not have worker protections to lessen their risks because of social factors like immigration status, and this makes them less likely to receive worker rights and benefits granted to them by law. Other factors include industry practices of shifting risk from larger companies to smaller ones; industries exempt from certain labor laws; and workers having temporary, less secure, jobs [11,12]. For example, foreign-born workers and some racialized and ethnic groups are employed in the meat, poultry, and seafood processing industries at higher rates than they are in the general workforce [13]; industries which generally have higher rates of work-related injury and illness [14]. For socially marginalized and economically disadvantaged workers, injury and illness is also impacted by factors like limited ability to advocate for good working conditions and limited access to social programs and resources, like workers’ compensation.

When OSH research examines the broader social, economic, and environmental contexts in which work-related injury and illness occur, this research can better help identify interventions to prevent poor health outcomes. This is often easier said than done because the same social dynamics that can worsen differences in work-related benefits and risks also affect how OSH researchers, practitioners, and policymakers do their work. We discuss this in the “Inclusive Research” section below. Managers, workers, researchers, practitioners, and institutions exist in a social context that can bias OSH efforts to favor the dominant social group [15]. The OSH field  should make targeted efforts to learn and respond to the needs of marginalized workers, rather than trust that the usual way of doing things will benefit all.

The NIOSH Occupational Health Equity Program team advances health equity by exploring how social, economic, and organizational issues overlap and affect worker health and well-being. We are a group of experienced OSH researchers with varied personal and professional backgrounds. Drawing on this base, we propose how research can better address occupational health inequities.

Using an approach based on biological, psychological, and social factors to advance worker health equity

Successfully addressing health inequities needs a biopsychosocial approach, which considers how biological, psychological, and social factors interact to affect worker health [4]. This approach helps researchers think about what affects health equity among workers, and it helps expand health equity research about workers. Individual researchers and organizations can use a biopsychosocial approach through these related practices:

• Expanding research on occupational health inequities: OSH could benefit from more research in the following areas. These data may help us learn more about how on-the-job risk interacts with social determinants of health.
  • How to identify, understand, and lessen the specific social, economic, and environmental disadvantages that lead to worker health inequities;
  • How factors like economic vulnerability and discrimination can affect workplace risk;
  • How policies can control access to social programs like workers compensation, unemployment, and health insurance; and
  • How specific interventions have helped to remove these barriers or reduce their effect on worker safety.
• Integrating inclusive research practices across OSH: While not all OSH research needs to focus exclusively on health equity, it is important for OSH-related institutions to prioritize the diversity of the workforce in their research. We describe below three areas to help OSH research institutions use inclusive research practices.
  • Structural invisibility: When the dominant social and cultural group’s needs are favored over other groups, the challenges for other groups can become structurally invisible to institutions and organizations. This may be unintended because the dominant group may be the largest group and represent more of an “average” experience. Efforts to reduce inequities will fail unless we pay special attention to the needs of groups that do not have enough representation in OSH research. Researchers can acknowledge that the “average” experience may not be what marginalized groups experience. Data from studying historically underrepresented groups can be collected, analyzed, and reported to make visible what typical methods and practices can overlook.
  • Institutionalized exclusion: This happens when researchers “bake into” scientific models and research methods the experience of the dominant group. Because the models and methods are scientific, researchers may consider them as objective, standard approaches. Researchers may then use these results uncritically to inform future research and interventions. One example of institutionalized exclusion was personal protective equipment (PPE) fit. For over three decades, the standard set of measures for PPE design was based on research conducted in the 1960s and 1970s using mostly white male military recruits. Without critical study of how well those measurements represent the current workforce, we didn’t know if PPE fit people outside of the measured group. If PPE does not fit properly, it cannot keep workers safe [16]. Since the U.S. population has changed since 1970, NIOSH conducted a number of studies to update the body measurements of the U.S. workforce [16-20]. These studies have led to improved sizing and a new respirator fit test panel (the NIOSH Bivariate Panel) [19,21]. This NIOSH Bivariate Panel is currently being used to assess the fit of respirators, and is being integrated into the NIOSH Respirator Approval Regulations. Efforts, like these, are essential to ensuring that our research does not inadvertently benefit workers from certain social groups more than others. We can reduce institutionalized exclusion by critically examining the data we use to inform our interventions, how representative the data are to the participating workers, and what different groups of workers might need.
  • Unexamined assumptions: OSH scientists can have implicit and explicit bias, even when it’s unintentional and we are well-meaning. If we ignore that our identities and experiences influence our worldviews (including science), we may allow assumptions to go unexamined and affect our research designs and therefore, results. Critical self-reflection as part of diverse research teams could be integrated into all stages of OSH research to identify and correct unexamined assumptions

One way for researchers to address these three challenges for worker health equity is by forming diverse research teams (as in socioeconomic, cultural, and disciplinary backgrounds). Another way is to look at our own work critically and get input at all stages.

• Examining the relationship between work and overall health: Despite the many ways that work and health affect one another, past research largely treated work as independent from other factors that affect health (such as work-related vs. not-work-related factors). Work does not exist separately from the context of people’s lives; work is fully integrated. More recently, researchers have grown more aware of how work and other social determinants of health interact with one another. In fact, a person’s job affects many aspects of life that impact health; such as income, housing, free time, social status, sleep schedules, stress, and social relationships [22–25]. Better jobs and improved working conditions can reduce workplace health inequities while also helping to reduce population health inequities. These are not separate goals or efforts. To effectively address health inequities, future research can reveal the complex ties between social factors in all aspects of people’s lives—including work—and the influence of “work-related factors” on overall health.

Conclusion

Health equity is an essential part of the future of occupational safety and health research (OSH)[26]. A biopsychosocial approach can inform research to better address OSH inequities. We should do more research that addresses the social context of worker injuries and illnesses. This includes expanding how we collect work-related variables in large-scale surveys and designing research projects that look past surface level analysis of demographic categories. Finally, by taking a critical look at our institutions and ourselves we can identify biases that may prevent OSH from meeting the needs of a workforce that is growing more diverse.

To learn more about this topic please read the original commentary. To learn more about the NIOSH Occupational Health Equity Program, go to the Program webpage.

Jacqueline Sivén, PhD, MA, MPH, is a social scientist in the NIOSH Division of Science Integration and an Occupational Health Equity Program assistant coordinator.

Laura Syron, PhD, MPH, is an epidemiologist in the NIOSH Western States Division and an assistant program coordinator for the Occupational Health Equity Program and the Center for Maritime Safety and Health Studies.

Andrea L Steege, PhD, MPH, is a lead research health scientist and epidemiologist in the NIOSH Division of Field Studies and Engineering and an Occupational Health Equity Program assistant coordinator.

Pietra Check, MPH, is a contractor with Synergy America, Inc., supporting the NIOSH Occupational Health Equity Program and the NIOSH Division of Science Integration.

Michael Flynn, MA, is a social scientist in the NIOSH Division of Science Integration and coordinates the Occupational Health Equity Program.

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