Occupational Health Disparities (2023)

The concept of social determinants of health (SDOH), which is fundamental to public health practice, can help identify what those disparities might be. As defined by Healthy People 2030, an initiative of the Department of Health and Human Services Office of Disease Prevention and Health Promotion, SDOH are the “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” Healthy People 2030 identifies five categories of SDOH: economic stability, healthcare access and quality, social and community context, education access and quality, and neighborhood and built environment. For example, in the neighborhood and built environment context, certain communities, and especially historically excluded and under-resourced ones, have had hazardous waste sites placed near their neighborhoods, resulting in greater exposure to harmful chemicals and chemical byproducts.

The SDOH of employment is considered to fall under the domain of “economic stability,” but realistically, employment affects all five domains. Type of employment ultimately affects one’s healthcare access (if any) and quality. Interpersonal interactions at work can impact one’s relationships with others (the social and community context). One’s access to education, and the quality of that education, may affect employment opportunities, and where one works can influence the neighborhood and built environment in which one lives (unless the job is fully remote). Thus, work is indeed a determinant of health because it affects every facet of our lives, including our health outcomes. As explained in a post to the NIOSH Science Blog in 2022, OSH research on occupational health disparities aims to examine the broader social, economic, and environmental contexts in which work-related injuries and illnesses occur to identify primary interventions that prevent poor health outcomes.

SURVEILLANCE CHALLENGESHow do occupational health disparities affect differences in injury, illness, and mortality rates? First, it is important to acknowledge that even now, the occupational health status of some underserved worker populations is difficult to capture. A 2010 paper in AJIM attributes this difficulty to limitations in existing surveillance systems and limited interest in or bandwidth for collecting such information. Workers who experience occupational health disparities may be undocumented or work in small businesses (those with 10 or fewer employees) for which OSHA injury and illness recordkeeping requirements are more lenient. A key study of occupational health disparities that also appeared in AJIM utilized national data from the Bureau of Labor Statistics for the period 2005 through 2009 to characterize high-risk occupations and examine relationships between demographic work-related variables and fatalities. The ultimate goal was to find disparities in work-related injuries, illnesses, and fatalities to target prevention efforts. The researchers found that high-injury and high-illness occupations were independently associated with workers who were male, Black, or born outside the U.S.; had a high school education; or worked low-wage jobs. For example, the fatality rate of foreign-born workers in sales and related occupations was 4.1 per 100,000 compared to the national rate of 1.9 per 100,000. This discrepancy may be attributed to precarious work, undocumented work, and higher rates of hate crimes and homicides.

Another finding from this study was that males were five times more likely to die at work than females even when controlling for age, race/ethnicity, place of birth, industry, and occupation. This finding may be attributed to SDOH, including the tendency for males to exhibit more risk-taking behaviors and fewer healthcare-seeking behaviors. Although this study was published nearly a decade ago, it underscores that one-size-fits-all programs or policies for preventing workplace injuries, illnesses, and fatalities may not always succeed because there are factors beyond the workplace to consider. These factors are a major consideration during the COVID-19 pandemic, which is a prime example of occupational health disparities because some worker subpopulations are disproportionately affected by the disease, as explained by research published in the Journal of Allergy and Clinical Immunology.

CASE STUDIESAccording to the American Immigration Council, as of 2019 there were nearly 170 million immigrant and migrant workers in the world and 28.5 million in the U.S., which equates to 17 percent of the U.S. workforce. Often these workers are engaged in precarious work that presents greater health hazards—they work for less pay, longer hours, and in worse conditions than nonmigrant workers. Furthermore, they may be subject to human rights violations, abuse, violence, and human trafficking. Thus, as argued in a 2018 paper that appeared in the Annual Review of Public Health, immigrant and migrant workers worldwide have higher rates of occupational exposures that lead to poorer health outcomes and greater workplace injuries, illnesses, and occupational fatalities.

NIOSH acknowledges that “a central challenge of securing occupational health equity is that the same structures that contribute to higher injury and illness risks also operate within occupational safety and health institutions, organizations, and programs.” The following case studies exhibit how the organization of work may contribute to occupational health disparities.

Janitorial Workers in CaliforniaA 2022 publication by the UCLA Labor Center highlights occupational health disparities among janitorial workers in California. The authors point out that private sector janitors are some of the most exploited workers in the service industry: many earn wages at the poverty line, receive no benefits, are subjected to wage theft and tax fraud, are routinely misclassified, experience sexual harassment and assault, and are regularly exposed to unsafe working conditions that can include exposures to toxic chemicals, bloodborne pathogens, and human excreta. Some key findings were that female janitors in the private sector had lower wages than their male counterparts ($12.21 per hour vs. $14.08 per hour) and experienced higher levels of poverty. Forty percent of private-sector janitors had family incomes that fell below 200 percent of the federal poverty level. Additionally, nearly 2 in 5 private-sector janitors were working as subcontractors, reducing their occupational and wage protections to a greater extent.

Migrant and Seasonal Farm Workers Migrant and seasonal workers make up the vast majority of the U.S. agricultural workforce. Approximately 65 percent of these workers are Latino; in California, as much as 90 percent of agricultural workers are Latino. As explained in the Annual Review of Public Health, workers in this $1.05 trillion industry are essential to the U.S. economy but are disproportionately exposed to occupational hazards such as heat-related illnesses and heat stress, environmental exposures (for example, to extreme weather events and temperature shifts, particulate matter, and smoke from wildfires), and chronic chemical and pesticide exposures. A review of 24 studies published in the International Journal of Occupational and Environmental Health analyzing chronic exposures to organophosphate (OP) pesticides and neuropsychological functioning in farm workers found that occupational exposure to OP resulted in difficulties in executive functions, psychomotor speed, processing, visual-spatial functioning, and coordination. Extant research on pesticides in farming has confirmed that exposures can result in damage to other bodily systems and cancer; for more information, read “Kidney Disease Among Agricultural Workers” in the May 2021 Synergist. Unfortunately, many immigrant and migrant workers have few occupational protections, let alone access to healthcare, to address the adverse outcomes of their work exposures.

Nonmigrant and domestic farmworkers tend not to work in such extreme conditions. A study in the Journal on Migration and Human Security analyzed data from the U.S. Department of Labor National Agricultural Workers Survey and uncovered great occupational health disparities among the American farmworker community. The study found that workers who were foreign born, lacked legal authorization, and were migrants received significantly lower wages than their U.S.-born, authorized, nonmigrant counterparts—$1,700, $4,000, and $2,800 of annual income, respectively, when controlling for other factors. Additionally, female farmworkers earned from $3,500 to $9,000 less than male farmworkers regardless of legal status when taking authorization status into consideration.

RECOMMENDATIONS FOR OEHS PROFESSIONALS While OEHS professionals focus on the workplace, our potential impact can expand beyond the workplace and interface with some SDOH. But first, it is critical to identify any existing workplace health disparities. This may require an analysis of injury, illness, and fatality logs when taking sociodemographic characteristics into consideration. If this information doesn’t exist, it will need to be collected, which may take several years.

As mentioned previously, a lack of surveillance data is a significant hindrance to addressing occupational health disparities. Informed by national datasets of sociodemographic, SDOH, and occupational variables, NIOSH’s current research priorities for occupational health equity focus on improving safety and health among contingent workers and workers in nonstandard work arrangements (for example, gig workers) who are in the services sector; reducing musculoskeletal disorders and hearing loss among construction workers who are at elevated risk compared to other professionals; and preventing neurologic disorders related to pesticide exposure among agricultural workers. If additional surveillance data on occupational health disparities were available, we may see research priorities shift and focus on industries that are less well researched than services, construction, and agriculture.

Additionally, it is important to recognize that workplace interventions have the potential to not only prevent work-related injuries and illnesses but also to reduce health disparities. A paper in the Journal of Occupational and Environmental Medicine argues that work should be considered a venue for population- and community-level health because the workplace has the capability to positively influence the physical and social environments that affect health. It is critical to determine what the potential short-, intermediate-, and long-term outcomes of an intervention will be and if the intervention is inclusive enough to address the work group or population. A 2021 paper in the International Journal of Environmental Research and Public Health suggested an intervention that integrates multiple approaches to target low-wage food service workers, who have some of the highest work-related injury and illness rates among workers in the food service industry and tend to have poor health outcomes due to SDOH. The first component of the intervention would be to address working conditions (for example, safety, ergonomics, work intensity, and job enrichment) through sequential training; the second component would be to develop site-specific solutions based on assessment reports, planning tools, and consultation provided by subject matter experts from the intervention team; and the third component would be to enhance employee engagement by training site managers on transformational leadership approaches. Though this intervention has yet to be tested, it has the potential to not only improve injury and illness outcomes for low-wage food service workers, but also to positively influence psychosocial factors such as job satisfaction, decreased turnover intention, and greater feelings of coworker and supervisor support. As explained on the NIOSH Science Blog, psychosocial factors also affect physical health.

BEYOND THE WORKPLACEWhile addressing occupational health disparities is complex and multifaceted, recognizing their existence and starting the conversation is the first step in the right direction. As our workforce becomes more diverse—in race/ethnicity, gender, age, behavior (that is, neurodiversity), abilities, and so on—it will be more important than ever for OEHS professionals to recognize factors beyond the workplace that help determine differences in health outcomes among workers and realize we have the power to address occupational health disparities.

AURORA B. LE, PhD, MPH, CSP, CPH, is the John G. Searle Assistant Professor of Environmental Health Sciences at the University of Michigan School of Public Health.

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