8
Interventions for Older Workers

Earlier chapters have examined the evidence indicating that more older workers are expected to be on the job over the next 20 or more years and that the workplaces and working relationships they face are changing. These discussions have also reviewed how the physical and cognitive resources of older workers are likely to match these workplace demands. We now turn attention to the range of interventions that might best enhance this matching of older workers and the working environment.

It was suggested in Chapter 1 that intervention and research needs might be approached from either of two perspectives. The first is that insofar as older workers, especially those with high skill levels, may be necessary to meet basic needs of the national economy, our society has a strong interest in retaining older workers. From this perspective our policy and research agenda should focus on the characteristics that predict which older workers are most likely to work most productively and on the best incentives and methods to encourage and enable the most productive workers to stay.

The second perspective focuses on the needs of aging workers and their families. The goal would be to maximize opportunities for workers to make informed decisions about work and retirement that are not unreasonably constrained by economic conditions. The accompanying policy and research agenda should develop information and resources that would assist older workers in making successful choices and also support initiatives to ensure equal protection for older workers on the job.

Both perspectives anticipate significant numbers of older workers and



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8 Interventions for Older Workers Earlier chapters have examined the evidence indicating that more older workers are expected to be on the job over the next 20 or more years and that the workplaces and working relationships they face are changing. These discussions have also reviewed how the physical and cognitive re- sources of older workers are likely to match these workplace demands. We now turn attention to the range of interventions that might best enhance this matching of older workers and the working environment. It was suggested in Chapter 1 that intervention and research needs might be approached from either of two perspectives. The first is that insofar as older workers, especially those with high skill levels, may be necessary to meet basic needs of the national economy, our society has a strong interest in retaining older workers. From this perspective our policy and research agenda should focus on the characteristics that predict which older workers are most likely to work most productively and on the best incentives and methods to encourage and enable the most productive work- ers to stay. The second perspective focuses on the needs of aging workers and their families. The goal would be to maximize opportunities for workers to make informed decisions about work and retirement that are not unreasonably constrained by economic conditions. The accompanying policy and re- search agenda should develop information and resources that would assist older workers in making successful choices and also support initiatives to ensure equal protection for older workers on the job. Both perspectives anticipate significant numbers of older workers and 174

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175 INTERVENTIONS FOR OLDER WORKERS the need for research and policies that will help accommodate their needs and enhance their safety and productivity. The American Association of Retired Persons states: “If employers are to reap the benefits of the work ethic and experience of older workers, they must design the workplace of the future to meet their needs.” We consider interventions from the premise that it is generally preferable to accommodate the working environment to anticipate and meet the needs of older workers than to attempt only chang- ing the aging workers themselves to adapt to their environments. There are two sources for such a premise. The first is pragmatic and finds expression in the science and practice of human factors engineering. It is recognition that human beings are imperfect. Everyone, and that includes you and me, is at some time careless, compla- cent, overconfident, and stubborn. At times each of us becomes distract- ed, inattentive, bored and fatigued. We occasionally take chances. We misunderstand, we misinterpret and we misread. As a result of these and still other completely human characteristics, we sometimes do not do things or use things in ways that are expected of us. Because we are human and because all these traits are fundamental and built into each of us, the equipment, machines and systems that we construct for our use have to be made to accommodate us the way we are, and not vice versa. (Chapanis, 1985) The second source is ethical and legal and finds expression in the Occupational Safety and Health Act (OSHA) of 1971: “The Congress de- clares it to be its purpose and policy . . . to assure so far as possible every working man and woman in the Nation safe and healthful working condi- tions . . .” (P.L. 91-596). These workplace protections apply equally to every worker. But all workers are not the same. There are notable differ- ences in size, strength, age, sex, health status, genetic makeup, and other factors that affect people’s risk from hazards on the job. Since Congress intends to protect workers equally across this varied spectrum of character- istics, including age, it follows that workplaces must adapt and change to accommodate a reasonable range. OSHA’s approach to workplace accommodation and worker protec- tion has been based on the hierarchy of controls concept. This concept in its simplest form holds that workers should be protected by controlling hazards as close to the source as possible. For example, designing a job so that a dangerous chemical is not necessary is preferable to providing a worker with a respirator, which in turn is preferable to training the worker to be as careful around the chemical as possible. Some version of a control hierarchy has been observed by virtually all safety and health professional associa- tions and organizations for more than 50 years. Many OSHA standards require efforts to utilize feasible engineering or administrative controls

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176 HEALTH AND SAFETY NEEDS OF OLDER WORKERS before personal protective equipment or worker training may be consid- ered. A more fully elaborated version of the hierarchy of controls places protective measures in the following order of preference: (1) engineering controls (e.g., elimination, ventilation, mechanical guarding); (2) administrative controls (e.g., safe job procedures, job rotation); (3) personal protective equipment (e.g., respirators, ear plugs); (4) individual behavior (e.g., safe lifting techniques); and (5) warnings (e.g., labels, bells). While these hierarchies vary in their detail, they tend to share at their core the notion that methods of protection that do not rely primarily on individual employee behavior alone are preferred to those that do. Extending the legal and ethical perspective and the goals of maintaining a safe and healthful work environment, however, leads inevitably to vary- ing interpretation of the extent to which health promotion, treatment, and rehabilitative services—crucial to the general health status of older workers—should be provided at or through the workplace. This is in addi- tion to worker education and training, retraining for changing job tasks, and the many other activities that are offered at or through the workplace. A wide variety of employee interventions to maintain and improve health and safety have been established over many decades, albeit usually not universal in coverage, and new delivery and experimental programs are continually appearing. The Americans with Disabilities Act (ADA) is one law that anticipates and addresses the hierarchical approach by requiring job interventions and accommodations. The ADA protects workers if they have a disability that substantially limits one or more major life activities but they are able to perform the essential functions of the job with reasonable accommodations. Accommodations under the ADA require that employers make existing facilities readily accessible and usable, and that they restructure jobs or modify work. While older workers are more likely than younger ones to have disabili- ties covered by the ADA, the need to accommodate older workers goes well beyond these covered limitations. This chapter considers accommodations in the broadest fashion. For example, Burkhauser, Butler, and Kim (1995), using a proportional hazards analysis with data from the 1978 Survey of Disability and Work, found that provision of an accommodation, defined broadly, slowed worker withdrawal from the workforce and delayed the beginning of SSDI payments. Potential recall bias in these studies might be addressed in a longitudinal study, using data now available from the Health and Retirement Study. No studies have examined whether workplace ac-

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177 INTERVENTIONS FOR OLDER WORKERS commodations lower the risk of occupational injuries found by Zwerling et al. (1998a) among older workers with various impairments. We adopt here the control hierarchy as an approach to beginning a discussion of the current status of intervention strategies to meet the safety and health needs of older workers. While there is some specific evidence to support this approach, it is limited (e.g., older adults are more likely to read warnings but less likely to comprehend warning signals [Rogers and Fisk, 2000]). Therefore, we use the concept as a useful way to structure and present ideas for accommodating the needs of older workers without argu- ing for a rigid order of preference. Interventions relevant to all workers, but particularly for older workers, also include workplace design and redesign; worker training; learning systems and retraining issues; alternative forms of work; the relation of the workplace to community service support; worksite health promotion and illness or disorder prevention programs; and em- ployee assistance programs, including return-to-work programs. JOB DESIGN AND REDESIGN In keeping with the breadth of potential workplace interventions noted in the introduction to this chapter, we now consider job design, including redesign and engineering, to improve the accommodations for older work- ers. There are many well-documented cross-sectional studies and some lon- gitudinal ones outlining normative changes in vision, hearing, physical strength, and flexibility with age, as examples for requisites for many work environments (see Chapter 5). Some data derive from representative na- tional samples. These age-related changes can be expected to affect older workers if they cannot compensate for such changes. Nonetheless, to the extent that work in the future requires maximal performance rather than typical performance, and if older adults retire later or return to part- time work after retirement, design interventions will probably become necessary. Design Interventions to Accommodate Normative Changes in Vision There are a variety of normative changes in vision with increased age (see Fozard and Gordon-Salant, 2001, for a review). Prominent among these are loss of accommodative power for the lens (near-vision focus), yellowing of the lens that weakens color discrimination, scattering of light in the eye due to debris in the vitreous humor, and inability to expand the pupil fully (senile miosis). Most of these changes result in less light being admitted to the eye—about one-third as much light comparing a 65-year- old to a 20-year-old in low light conditions. Due to increased scattering of light, there is also greater susceptibility to glare from light sources. There

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178 HEALTH AND SAFETY NEEDS OF OLDER WORKERS are also changes due to loss of cells in the visual cortex that reduce the likelihood that correction via lenses will restore youthful vision. Disease processes also contribute to the increased risk of loss of visual function with age. These nonnormative changes include glaucoma, macular degeneration, and cataract. Some of these diseases are linked to high blood pressure and diabetes. Cigarette smoking is also a well-established risk factor (Smith et al., 2001). Not well understood is the extent to which these changes are related to work environment factors. Lifetime exposure to ultraviolet light, which is higher for outdoors (blue-collar) than indoors (white-collar) work, has been found to be a risk factor for development of lens opacities (e.g., Hayashi et al., 2003). There is also evidence of higher risk of age-related maculopathy for blue-collar compared to white-collar professions (Klein et al., 2001). Corrective Lenses Eyeglasses are a potentially effective intervention for protecting against UV exposure and for accommodating to age-related changes in near-dis- tance vision. An increase in computer-related work (e.g., Chan, Marshall, and Marshall, 2001, who reported 4–5 hours per day of computer work at a large corporation) means that instead of reading from paper sources people will increasingly be required to access information from computer monitors. Most monitors are placed about 40 to 60 cm from the user. This is a distance that, similar to vehicle instrument panels, falls between typical near-and far-focus distances and therefore leads to difficulty for older work- ers in their early forties and beyond. Potential solutions involve prescribing gradient lenses (progressive bifocals) and specialized lenses just for com- puter work. There are empirically validated ergonomic guidelines for the positioning of monitors, keyboards, and pointing devices (e.g., a computer mouse) that can minimize strain when working with these tools (e.g., Occu- pational Safety and Health Act, 2002). Whether these guidelines need to be modified to better accommodate older workers is not known. Road Signs For those working in the transportation sector, particularly those driv- ing vehicles, age-related changes in vision and visual attention (e.g., shrink- age of the useful field of view, Owsley et al., 1991) can have a direct impact on safety and productivity. There are several studies demonstrating that signs can be redesigned to make them more visible, particularly by changing spatial frequency characteristics to improve contrast (Kline, Ghali, and Kline, 1990; Kline and Fuchs, 1993). There are many suggestions for

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179 INTERVENTIONS FOR OLDER WORKERS redesigning the road environment to improve safety for older drivers (and pedestrians) as evidenced by the new guidelines for older drivers (Federal Highway Administration, 2000). Because automobile crashes are quite in- frequent for the average driver, with a probability of 0.1 per year (Evans, 1991), it is sometimes difficult to show the effects of an intervention, such as changing signage, on crash rates. There is considerable evidence that older drivers (age 55 and older) adapt their driving patterns to compensate for weaknesses, such as reducing night driving and rush hour traffic expo- sure (Ball et al., 1998). Such strategies may not be considered acceptable by those working under time pressure, such as professional drivers. Lighting Aging processes diminish the sensitivity of the visual system. One simple intervention is to increase the amount of light in the environment, particu- larly for work-related tasks. Care must be taken to avoid increasing glare in the process by controlling the light sources and the work surfaces. Field studies show that light levels in many U.S. office environments generally meet recommended levels for reading tasks of about 100 cd/m2 (Charness and Dijkstra, 1999). However, there is a dearth of information about opti- mal light levels for older workers. Some evidence suggests that legibility of print can be boosted differentially for older office workers by increasing light levels beyond existing guidelines (Charness and Dijkstra, 1999). Infor- mation about the effects of print size, contrast level, and luminance levels on print legibility for older adults is beginning to accumulate (Steenbekkers and van Beijsterveldt, 1998). It would be useful to extend this work to applied settings using typical clerical tasks and to assess the impact of contrast for monitor-based reading tasks. Design Interventions to Accommodate Normative Changes in Hearing Hearing capabilities decline normatively with age (Fozard and Gordon- Salant, 2001). Pure tone thresholds decline with age, particularly for higher frequency tones and more so in men than women. Speech comprehension shows noticeable changes (for monosyllabic words) after age 50. Older adults show more masking of signals by noise. Speech compression (e.g., in automated voice mail systems) and rapid speech rate affect older adults more than younger ones (e.g., Stine, Wingfield, and Poon, 1986). Most of these changes can be attributed to loss of hair cells in the cochlea and loss of cells in auditory areas in the brain as well as to general age-related slowing in comprehension processes.

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180 HEALTH AND SAFETY NEEDS OF OLDER WORKERS The extent to which such loss is driven by exposure to noise versus normal aging is a matter of dispute. Losses are linked to noise exposure as well as to factors such as cardiovascular disease, smoking, and dietary factors. There are a number of approaches to remediating hearing loss. In general, hearing aids have not been particularly functional in fully restoring hearing acuity because they boost both signal and noise. Given that some have estimated that normative hearing loss is at least partially attributed to noise exposure in the workplace (e.g., Corso, 1981), prevention is a potentially useful approach. One important source of noise exposure is aging equipment. Farmers using older tractors can be exposed to noise levels in excess of 100 dB (Pessina and Guerretti, 2000). Also, hearing loss is strongly associated with livestock-related injuries for farmers (Sprince et al., 2003). Noise reduction engineering and promotion of safe practices in inherently noisy environments, such as the use of noise reduc- tion devices (e.g., ear protective equipment such as earplugs), may be im- portant components in preventing problems. Given that hearing loss may pose a significant problem (particularly for older male workers), redesign can be an important tool in preventing hear- ing impairments from becoming disabilities. One such design change is to make use of other less-impaired sensory channels, described below, to sig- nal important information (such as warnings). Use of Redundant Channels and Substitution of Channels There are many examples of using redundant channels to compensate for hearing loss. It is possible to provide both visual and auditory warnings (flashing lights with sound). Perhaps the best-known example is the use of a warning sound (beep) to indicate when a vehicle is backing up (moving in the unexpected direction). Other examples can be found in catalogs of assistive devices, such as those that supplement normal sound channels with tactual feedback (e.g., a vibrating cell phone). For those with profound hearing loss, substitution of vision for hearing is sometimes possible (flash- ing lights for a doorbell, closed captioning on television). Vanderheiden (1997) offers specific recommendations on redesigning to accommodate those with disabilities. Minimizing Background Noise Several studies show greater comprehension impairment for older adults than younger ones at the same signal-to-noise ratios, compared to the case of detection of pure tones in quiet surroundings. Minimizing background noise should aid older workers differentially for comprehension tasks. Sim-

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181 INTERVENTIONS FOR OLDER WORKERS ply increasing signal strength, e.g., shouting over noise, results in diminish- ing returns (Crocker, 1997). Design Interventions to Accommodate Physical Changes The Canada Fitness Survey (Kozma, Stones, and Hannah, 1991) showed cross-sectional linear decline on most fitness and flexibility variables with age, though sometimes gender interacted with age; men typically showed faster decline than women. A main effect on fitness and flexibility was shown for activity level as well, an effect that did not interact with age. Because of changes in the cohort structure of the workforce, particularly the shifts in minority composition from large influxes of Hispanic workers, current data on anthropometry (e.g., Kroemer, 1997; Peebles and Norris, 2003; Steenbekkers and van Bijsterveldt, 1998) may not predict character- istics of future cohorts of older workers. Such data are useful for designing functional workplaces. Anthropometric data typically encompass size, strength, and flexibility ranges for people’s bodies. An example would be extent of reach from a seated position. If a given worker has a shorter-than- average reach, he or she may become inadvertently handicapped and possi- bly suffer musculoskeletal disorders (MSDs) in work environments designed for those with a longer reach. Arthritis, which affects flexibility and dexterity, increases in prevalence with age and affects older women more than men (Verbrugge, Lepkowski, and Konkol, 1991). Arthritis can make many manual tasks difficult to perform. Women tend to be differentially employed in clerical positions that require typing (Chan et al., 2001), implying that some accommoda- tions may be particularly critical for them. Also, arthritis has recently been shown to be a risk factor for occupational injury, for instance, in farmers who are injured by livestock (Sprince et al., 2003). Changes in the mechanisms supporting balance may be an important factor to consider, given the data on age-related increases in death from falls in construction and manufacturing industries (Agnew and Suruda, 1993; Bailer et al., 2003). Shephard (1995) reviewed research on physically demanding work and suggested changes to accommodate older workers (women and men). A central concern is the likelihood of fatigue in a physically demanding task that exceeds a threshold for cardiorespiratory capacity of 33 percent maxi- mal oxygen intake. If aerobic capability declines from about 12 to 14 metabolic units (METS) in young adults to 7 METS in the average 65-year- old, many older workers would not be expected to be able to perform other than light physical work. Given that women typically average two-thirds the aerobic power of men at all ages, older women are most at risk for excessive demands from physically demanding jobs.

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182 HEALTH AND SAFETY NEEDS OF OLDER WORKERS There are similar problems with age-related declines in muscular strength in the general population. Guidelines for strength demands typi- cally recommend that median load be less than 10 percent of maximal load and that peak load be less than 50 percent of peak force. Strength bench- marks are usually set for the case where at least 75 percent of women and 99 percent of men can meet job requirements safely. In practice, there are few cases of aerobic and muscular limitations found in the workplace. This may be due to physical stressors on the job that increase fitness, or because job shifts and disability remove those who cannot meet job requirements. Job redesign is a safe way to reduce physical workload to acceptable levels. OECD Job Redesign Studies Marbach (1968) described a set of case studies of redesign of jobs to accommodate older workers. There was little formal evaluation of the effect of redesign, so these cases are more illustrative than scientifically informative. Most of the examples involved substituting machines (cranes, conveyor belts, forklifts) for human effort on lifting and moving tasks, as well as shifting workers to sitting instead of standing positions. Some in- volved changing the nature of the work task by shifting heavy physical tasks to other team members and having an older worker assume lighter tasks. In another case with computer equipment assembly, instructions were provided aurally via audiotape and headphones instead of with writ- ten instructions, eliminating eyestrain and freeing workers’ hands. In many cases the older workers at risk (because of work-related injuries or develop- ment of arthritis) were able to continue work in cases where they may have otherwise been forced to leave. As Marbach comments, there are probably numerous cases of small but important modifications that have been made to accommodate older workers that were not reported in the OECD survey forms. This approach of gathering examples of best practices seems promising. Design for Safety: Providing More Effective Warnings Given high rates of job turnover in modern labor markets, workers are less likely to remain at the same job site over their entire career than they have during prior historical periods. Accidents are most likely to occur in the first year of employment at a new job setting (Root, 1981). Hence, there is a need to prevent injuries through effective warnings, training, and rede- sign of existing tools and settings. A recent review suggests methods to improve the design of warning systems (Rogers, Lamson, and Rousseau, 2000). As that review noted, older adults demonstrated poorer ability to notice warnings and to compre-

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183 INTERVENTIONS FOR OLDER WORKERS hend warning symbols. Hancock, Rogers, and Fisk (2001) showed that older adults were more likely to report that they read warnings but were also less likely to comprehend warning symbols. There did not appear to be much literature pertaining to age differences in compliance with warnings. If one assumes that appropriate warnings are already posted in workplaces, older workers may be heeding them better, given their lower rate of acci- dents. The medication adherence literature also suggests that older adults are more compliant with medication routines than middle-aged adults (Park et al., 1999). Ergonomic Design Interventions and Musculoskeletal Disorders In addition to training approaches discussed below, there have been studies to assess the effectiveness of engineering, administrative, and indi- vidual-focused interventions at the workplace in the prevention of muscu- loskeletal disorders (MSDs). Due to ongoing changes at most workplaces unrelated to planned interventions, it is difficult to use formal epidemiology studies to determine whether ergonomic interventions are effective. A re- view by Westgaard and Winkel (1997) noted this problem in an assessment of the efficacy of different workplace intervention studies for MSDs. The review examines problems in the current intervention literature, ranging from lack of statistical analysis to failure to include control groups to confounders such as inadvertent changes in the psychosocial climate. Inter- ventions they classified as mechanical exposure interventions unaccompa- nied by organizational change were generally unsuccessful. Production sys- tem interventions based on changing the organization of work also failed to show much benefit. Intervention studies that attempted to change the orga- nizational culture of a work environment achieved relatively good results. So too did modifier interventions that attempted to change the capabilities of a worker through physiotherapy or exercise interventions. These latter approaches involve both targeting of risk factors for workers and interven- tion at the level of the individual worker. It is recognized, however, that it is difficult to isolate the modifier intervention from parallel changes, includ- ing psychosocial improvements. More recently published studies support more optimism about the effectiveness of workplace interventions to prevent MSDs. Several studies have reported a positive impact of ergonomic interventions on low back and other MSDs among workers performing lifting and related manual material handling tasks (Evanoff, Bohr, and Wolf, 1999; Brophy, Achimore, and Moore-Dawson, 2001; Marras et al., 2000; Yassi et al., 2001). Others have found positive effects among workers using video display units (Aaras et al., 2001; Brisson, Montreuil and Punnett, 1999; Demure et al., 2000; Ketola et al., 2002). Positive outcomes of comprehensive interventions,

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184 HEALTH AND SAFETY NEEDS OF OLDER WORKERS including job redesign and organizational change, have also been reported for MSDs among hospital workers (Bernacki et al., 1999; Carrivick, Lee, and Yau, 2002), sign language interpreters (Feuerstein et al., 2000), and office workers (Nelson and Silverstein, 1998). Negative results were found among a small group of assembly workers after jobs were redesigned to be more varied, less repetitive, and more autonomous (Christmansson, Friden, and Sollerman, 1999). A review of interventions aimed at reducing expo- sure to mechanical stressors concluded that there were significant benefits (Lötters and Burdof, 2002). A review of studies for carpal tunnel syndrome suggested the need for better-designed intervention investigations (Lincoln et al., 2000). In three recent intervention studies, ergonomically modified jobs have also been associated with more rapid return to work after work related MSDs (Crook, Moldofsky, and Shannon, 1998; Loisel et al., 1997; Arnetz et al., 2003). The most recent comprehensive review of intervention effectiveness was completed by a National Academy of Sciences committee (National Research Council and the Institute of Medicine, 2001), which evaluated 20 years of formal studies along with results from a best-practices symposium sponsored by the National Institute for Occupational Safety and Health (NIOSH) in 1997 (NIOSH Effective Workplace Practices and Programs Conference, Chicago, 1997). In addition to examining reviews published through the mid-1990s, the committee identified 17 recent intervention epidemiology studies along with 40 case studies from the Chicago confer- ence. The committee arrived at a positive conclusion about the benefits of interventions directed at reducing exposure to mechanical and psychosocial stressors. It concluded that [T]he weight of the evidence justifies the introduction of appropriate and selected interventions to reduce the risk of musculoskeletal disorders of the low back and upper extremities. These include, but are not confined to, the application of ergonomic principles to reduce physical as well as psychosocial stressors. To be effective, intervention programs should in- clude employee involvement, employer commitment, and the development of integrated programs that address equipment design, work procedures, and organizational characteristics (pp. 9–10). Psychological Climate A less researched area is the influence on safety-of-job factors such as degree of empowerment and feelings of insecurity. Metanalysis has shown significant negative impacts of job insecurity on mental and physical health in the range of r = –0.1 to –0.2 (Sverke et al., 2002). Probst and Brubaker (2001) indicated that self-reported accidents increased as a function of the

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208 HEALTH AND SAFETY NEEDS OF OLDER WORKERS 1994; Decker, Starrett, and Redhouse, 1986). Some EAP-based interven- tions have the potential to raise issues of discrimination and employer liability (Starkman, 2000; Capron and Creighton, 1998), but such prob- lems do not appear to be widespread. In 1989, a national Employee Benefits Survey conducted by the U.S. Bureau of Labor Statistics found that among full-time workers in private- sector establishments with 100 or more employees, 49 percent had access to EAPs, and 23 percent were served by wellness programs (Cooley, 1990). A Canadian study at about the same time underscored the rapid growth of EAPs. During the period from 1988 to 1993, among 647 companies in Ontario with over 50 employees, the percentage with EAPs doubled from 16.1 to 32 percent (Macdonald and Wells, 1994). However, the coverage was very uneven. The same Canadian study also confirmed the existence of wide variations among major work sectors, ranging from highs of 51 per- cent with EAPs in government and 46 percent in health and education, to lows of 13 percent in retail trade and 3 percent in construction. Small to medium-sized workplaces are much less likely to have such supports, an important fact because the majority of the U.S. workforce is employed in work sites with fewer than 50 employees. Donaldson and Klien (1997: 17) reported that “one of the main findings of the 1992 National Survey of Workplace Health Activities [in the United States] was the identification of a pressing need to understand how to formulate effective strategies for providing comprehensive health promotion [and EAP] services to . . . tradi- tionally underserved employee populations; particularly ethnically diverse operating-level employees working in small, medium-sized, and women and/or minority-owned businesses.” In contrast to the early EAPs, in which at least some direct treatment was usually offered onsite in the workplace, the actual services of EAPs and MAPs are now often delivered by offsite service providers with the program’s in-house aspects being limited to assessment and referral; both models have advantages (Brummett, 2000; Csiernik, 1999; Straussner, 1988). Along with these organizational changes, the orientation of EAPs and MAPs has gradually been shifting from rehabilitation to prevention. Instead of a quasidisciplinary intervention aimed at workers whose perfor- mance has already suffered because of personal problems, these programs are increasingly seen as a way to keep workers productive and healthy by helping them avoid problems in the first place. Current EAPs tend to en- courage self-referrals and promote their services as a positive employee benefit. In addition, there is growing awareness that the work climate itself can contribute to the personal troubles and unhealthy behavior of indi- vidual employees. For example, management policies and enabling behav- ior by peers and supervisors can create a prodrinking, prosmoking, work- aholic, or reckless work environment that endangers employee health and

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209 INTERVENTIONS FOR OLDER WORKERS safety (Bennet and Lehman, 1997). Some EAP specialists have urged that in such situations the EAP client should be defined as the organization itself (Googins and Davidson, 1993). To understand the kinds of support that EAPs might offer for older workers, two different sets of concerns are involved: 1. What kinds of EAP support will assist aging employees to continue working safely and productively in their career jobs? Some aging workers find it difficult to balance their work with medical management of emerg- ing health problems, the time demands of caregiving at home, increased difficulty with activities such as driving to work, a changing sense of what matters in life, and stressful work relationships related to age discrimina- tion and stigma. Age-related physical changes such as hearing loss and arthritis may call for job redesign, and they may need retraining for new kinds of work assignment. If the choice to remain working is driven by income insecurity, workers may find themselves between a rock and a hard place as their work ability declines but their need for earning continues. 2. What kinds of EAP support will help aging workers prepare ad- equately for retirement? Most aging workers expect eventually to be leav- ing their career jobs, either exiting the workforce entirely or moving into a phased retirement period involving some combination of reduced work hours, periodic leaves of absence while still employed, and alternative paid or unpaid work. At least some may be making unrealistic choices due to lack of information and feeling great distress if their retirement plans are being undermined by economic downturns. If they plan to phase out of the workforce gradually through alternative work, they may be uninformed about their options and legal rights, and unprepared to find the bridge jobs they will need. Even those eager to leave the workforce may be experiencing uncertainty and anxiety about what their financial and social circumstances will be in retirement. Those facing the prospect of being unwillingly forced out through layoffs or pressure to retire at a certain age may be very angry with supervisors and coworkers. Particularly as workers approach the traditional retirement age, these concerns can overlap. Separately or together, by creating unmanageable levels of stress, they put the older worker at increased risk for workplace accidents, depression, physical illness or disorder, health-damaging per- sonal behavior, and even workplace violence. There are already at least three ways in which EAPs have begun to offer supports of special relevance to aging workers: eldercare support, preretire- ment planning, and customized versions of traditional services such as drug and alcohol treatment and outplacement.

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210 HEALTH AND SAFETY NEEDS OF OLDER WORKERS Eldercare Support Also known as support to working caregivers, eldercare support is meant to help employees who are struggling to balance their jobs with their commitments to care for elderly parents, care for an older spouse who is ill, or deal with the responsibilities of caring for elderly parents on top of having dependent children still at home (Eubanks, 1991). These workers, typically women in their 40s and 50s, are in effect working a permanent double shift without relief, at a point in life when they are aging themselves and their career demands may be peaking after delays for childrearing (Winfield, 1987). The result can be extreme stress, fatigue, and isolation for the individual worker, potentially leading to physical illness or disorder, depression, accidents on and off the job, breakdown of work relationships, and alcohol or drug addiction. Having workers experience this high level of strain is costly to employ- ers as well. Employers’ measurable costs associated with eldercare giving have been estimated at $2,500 to $3,100 per year per caregiver from losses in employee productivity, management/administration, and health/mental health care (Marosy, 1998). A substantial proportion of eldercare givers hold jobs. In 1987, of the approximately 2.2 million persons providing unpaid informal assistance for older adults in the United States, 31 percent were at the same time em- ployed outside the home (Seccombe, 1992). By 1997 that had risen to 55 percent, according to a national survey conducted by the National Alliance for Caregiving and the American Association of Retired Persons (AARP) (Wagner, 1997). Looking at it from the other side, eldercare givers make up a substantial proportion of the workforce. In a survey of 3,658 employees of a major company in southern California, Scharlach and Boyd (1989) found that 23 percent of respondents reported that they were assisting an older person. Of these working caregivers, 80 percent reported emotional strain and 73.7 percent (as compared to 49.1 of other employees) reported interference between work and family responsibilities. About 20 percent said it was likely they would eventually have to quit their jobs to provide care. The sheer amount of time demanded by caregiving activities is quite considerable. Wagner (1990) notes that the employed caregivers in one study reported spending an average of 12.8 hours weekly on caregiving and had been doing so for an average of 6.5 years. During the 1990s EAPs began to respond to this increasing need by exploring ways to help working caregivers get information, negotiate flex- time and leaves, manage financial pressures, and find appropriate counsel- ing. Eldercare support is, in fact, one of the fastest growing new EAP services (Earhart, Middlemist, and Hopkins, 1993). A 1996 survey of 1,050 major U.S. employers found that eldercare programs were offered by nearly

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211 INTERVENTIONS FOR OLDER WORKERS one-third of these employers, an increase of 17 percent from 1991 (Hewitt Associates, 1997). As one example, in the mid-1990s, Control Data Corpo- ration expanded its longstanding EAP to include comprehensive eldercare services to more than 1,100 employers with 1.2 million employees (Ensign, 1996). Unfortunately, however, eldercare is not yet offered in the majority of workplaces with EAPs. The need for it is sometimes not recognized by employers and EAP practitioners (Kola and Dunkle, 1988). Even when recognized, awareness of the need does not necessarily translate into an actual program. In a survey of 371 chief executive officers of U.S. corpora- tions, 60 percent of respondents were aware of work-related problems experienced by employees who give care, but less than 20 percent were actively considering offering a specific caregiving program at the worksite. The 1996 Hewitt survey and other similar ones (Lefkovich, 1992) found the most common approach in EAP-based eldercare support to be a re- source information and referral service, sometimes accompanied by related policy changes within the company such as work scheduling that included flex-time, flex-place, compressed work weeks, temporary part-time status, and personal leaves. Other related policy changes include dependent-care spending accounts that set aside up to $5,000 in pretax dollars to pay for eldercare expenses, and management training policies that sensitize manag- ers to employees’ caregiving responsibilities. In addition, some EAPs are partnering actively with community-based service resources such as home care agencies, which are already equipped to provide eldercare supports such as emergency backup for in-home adult companion care and child care on short notice; financial planning with a nurse geriatric care manager to develop an affordable care plan; senior day care; respite services; and emo- tional support for caregivers through support groups, hospice, and certified eldercare counselors (Marosy, 1998; Tober, 1987). A wealth of information on resources for developing workplace elder- care assistance programs, including case examples and guidance materials such as the AARPs’ Caregivers in the Workplace kit, can be found in Dellman-Jenkins, Bennett, and Brahcae (1994). The Washington Business Group on Health has prepared a guidebook intended to help human resources professionals, benefits managers, and other corporate decision makers become more knowledgeable about eldercare issues in the work- place (Coberly, 1991). Additional resources and a good example of union involvement in eldercare support appear in symposium proceedings from a conference sponsored by the Federal Council on the Aging (1984), which includes a description of a New York City service delivery program of the United Auto Workers.

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212 HEALTH AND SAFETY NEEDS OF OLDER WORKERS Preretirement Planning Preretirement planning (PRP) is recognized as a need in the field of employment assistance, but relatively few U.S. firms offer these services to date, and where they do exist, older workers reportedly tend not to use them (Perkins, 1994). However, they could be of enormous benefit to both employees and employers as workers move toward exiting the workforce. By making the transition from work to retirement smoother and less stress- ful, such planning may increase the chances that retiring workers’ final few years in the workforce will be safe and productive ones. There is a clear need for planning, particularly financial advice to help the worker make realistic choices about retirement timing and budgeting. Numerous studies document that the current generation of aging workers are woefully uninformed about the options and decisions that they will confront on retirement and very unprepared for the realities that await them (Marshall and Mueller, 2002). The economic downturn that started in 2000 has greatly worsened the situation by eroding the value of many workers’ retirement savings and pensions. Workers now have diminished resources for their anticipated golden years, but they may not yet fully recognize the need to adapt their previous plans. LaRock (1998) describes some of the varied approaches that are cur- rently being offered by large employers, often channeled through EAPs. Boeing conducts focus groups to identify life-planning topics of greatest interest to its employees and then offers individualized classes. Weyerhauser holds one-day seminars on retirement planning with separate sessions for those over 30 and those under 30, as well as an enhanced version for employees over 60, consisting of a two-and-a-half day seminar led by out- side financial planners and estate attorneys. Dow Agro holds retirement planning sessions during lunch at the company’s cafeteria and fitness cen- ter. The Washington State Department of Retirement Systems offers one- day seminars at various locations throughout the state, with 300 to 400 people attending each seminar. Good resources for employers interested in developing such planning sessions are readily available (Sherman, 1997). Preretirement planning involves more than financial information. Exit- ing the workforce requires developing new ways to use time and find mean- ing in life, tasks for which many workers are unprepared—particularly men (Moen, 1996, 1998) and those who have left the labor force involuntarily or reluctantly (Sijuwade, 1996). Retirement can also provide enhanced opportunity for enjoying family and other relationships. Perkins (2000) presents a case example of a pre-retirement planning program in which an EAP facilitated a series of lunchtime workshops for older workers to ad- dress such issues. The workshops were led by former employees who were leading meaningful and zestful lives after leaving the company—some as

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213 INTERVENTIONS FOR OLDER WORKERS retirees, some having reentered the labor market. Subsequent evaluation of the program through focus groups showed that “one of the more promi- nent issues to emerge from the workshop was the need for older adults to move beyond the ‘work ethic’ values of the middle years. It was determined that new ‘yardsticks’ were needed for measuring what makes life worth living” (p. 69). To date, employer-supported retirement planning support appears to be available mainly to employees of large companies. Encouraging the spread of similar services in smaller firms, perhaps through consortium arrangements, would be desirable since an even greater need for retirement planning exists for many workers employed in small firms and/or intermit- tent jobs, particularly women and minorities (Angel and Angel, 1998; Mitchell, Levine, and Phillips, 1999; O’Rand and Henretta, 1999; Dancy and Ralston, 2002). Traditional EAP Services Customized for Older Workers While substance abuse interventions have long been the backbone of EAP services, these interventions may require modification to meet the needs of older employees with drug or alcohol problems. As Goldmeier (1994: 624) points out, “Substance abuse among the elderly may be masked by physical problems and therefore escape detection; in addition, the elderly tend to underreport physical illnesses or disorders because they fear dis- crimination, and they may be more vulnerable to the effects of alcohol or illicit drugs because of age-related physical changes.” The picture may be further complicated by interactions of alcohol or illicit drugs with prescrip- tion drugs that the older worker may be taking. The potential for unrecog- nized alcoholism is of particular concern, because heavy alcohol consump- tion is related to occupational injury among older workers. In a nationally representative sample of 6,857 nonfarm workers aged 51–61, alcoholism was positively associated with occupational injury, even after controlling for age, sex, education, occupation, and strenuous job activity (Zwerling et al., 1996). In this study, the injury rate among the older workers who consumed five or more drinks a day was five times greater than for the category showing the lowest injury rate (who consumed one to two drinks per day). Potentially, EAPs can play a useful roles on several levels: (1) pri- mary and secondary prevention of substance abuse among older workers through worksite wellness programs of medical screening, drug screening, education, review of work attendance and accident records, and mainte- nance of a positive work environment; and (2) tertiary prevention—after a substance abuse problem has been identified—through referral to commu- nity resources, counseling, mediation, advocacy, and case management (Goldmeier, 1994; Brummett, 1999).

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214 HEALTH AND SAFETY NEEDS OF OLDER WORKERS Another traditional service offered by some EAPs is outplacement, in which employees who are leaving the company but remaining in the labor force are assisted with job-search counseling and skills assessment, help with resume writing, use of company telephones and copiers during the job search, and use of the company mailing address for a period following termination. This kind of service has generally been aimed at younger workers who are leaving the company because of layoffs. However, it could be adapted to serve older workers who expect to seek other work (bridge employment) after leaving their career jobs. Outplacement could also assist the older worker with customized searches for alternative jobs and/or vol- unteer positions, opportunities for retraining, and information on using legal protections against age discrimination. A 1989 telephone survey of 3,509 adults aged 50–64 found that longest-held positions typically ended long before normal retirement ages, creating a large pool of older individu- als seeking bridge jobs in an employment climate rife with age discrimina- tion (Ruhm, 1994). The bridge employment choices facing older workers are quite com- plex, and outcomes differ considerably depending on how voluntary the career job exit is (Weckerle and Schultz, 1999). Ruhm (1994: 73) notes: “Of particular concern is the limited ability of some groups of workers (nonwhites, females, the less educated, and those in poorly compensated occupations) to either retain longest jobs or to obtain acceptable bridge employment.” These older workers are less likely to be employed in large companies that have EAPs. Reaching them with outplacement support (and other EAP services) would require new strategies for encouraging small firms to make such services available to their workers—for example, tax incentives, technical assistance, and consortium arrangements (Donaldson and Klein, 1997). ACCOMMODATIONS FOR WORKERS WITH IMPAIRMENTS AND RETURN-TO-WORK PROGRAMS Accommodations for workers with impairments and return-to-work programs are both important interventions that may play an important role in maintaining older workers productively in the workforce because these workers are more likely to bring impairments into the workplace and be- cause they are likely to be out of work longer than their younger colleagues after an injury. Workplace Accommodations Over the last 25 years, there have been changes both in the prevalent conceptual model of disability and in the public policy approach to people

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215 INTERVENTIONS FOR OLDER WORKERS with disabilities. Two reports from the National Academies Institute of Medicine (IOM, 1991, 1997) played a major role in the refinement of the conceptual model. This emerging model distinguished between impairment, a loss of function at the organ system level; functional limitation, the inabil- ity to perform a specific task, such as lifting a 20-pound package; and disability, a limitation in performing socially expected roles. Impairment and functional limitation are characteristics of an individual; disability de- notes a mismatch between an individual’s functional capacity and the individual’s environment. In the workplace, this translates into a mismatch between an individual’s functional capacity and the essential requirements of his or her job. For example, a worker who could not lift a 20-pound package might be totally disabled as a construction laborer, but that same person might be able to carry out all of the job requirements of a secretary. This concept of disability as a mismatch between the worker’s functional capacity and the demands of their job leads easily to the concept of work- place accommodations—modifications of the job or workplace that allow the worker to carry out the essential functions of his or her job in spite of functional limitations. Parallel to this change in the conceptual model of disability, there has emerged a new public policy approach as well (Miller, 2000). As discussed earlier in this report, the Americans with Disabilities Act of 1990 marked the ascendance of a new approach to persons with disabilities, a civil rights approach that aimed to help them overcome the barriers to full participa- tion in American society. Specifically, Title 1 of the ADA was aimed at integrating workers with disabilities more fully into the workforce. It pro- hibited discrimination against qualified employees (or job applicants) with disabilities. A qualified person with a disability is an individual who, with or without reasonable accommodation, can perform the essential functions of the job. Reasonable accommodation may include, but is not limited to: (1) making existing facilities readily accessible to persons with dis- abilities; (2) restructuring jobs, modifying work schedules, and reassigning em- ployees to vacant positions; (3) modifying equipment, examinations, training materials, or poli- cies; and (4) providing qualified readers and interpreters. As noted above, older workers are more likely to have a wide variety of impairments and may require accommodations to remain in or reenter the workplace. Although a dozen years have passed since ADA became law, we still know relatively little about key aspects of these workplace accommodations.

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216 HEALTH AND SAFETY NEEDS OF OLDER WORKERS First, how much do workplace accommodations cost? The President’s Committee on Employment of People with Disabilities (1995) suggested that the cost of accommodating an employee with a disability is low, aver- aging about $200. Blanck (1996) found similar results when examining the costs of accommodations at the Sears Roebuck Company. However, these early estimates may well be significantly lower than the true costs because they were prepared by advocates of the ADA who construed the costs very narrowly. Instead, for example, of just accounting for the cost to buy special equipment, it would be useful to give an accounting of the full opportunity cost of accommodating an average person with a disability. These costs would need to include the time of other employees and manag- ers involved in the accommodation, as well as the time of the disabled person (Chirikos, 2000). It is also likely that the accommodations sampled are not representative of the range of accommodations that may be imple- mented in the future. One could argue that the least expensive accommoda- tions are likely to be implemented first. Subsequent accommodations might be more expensive (Chirikos, 2000). Second, how frequent are workplace accommodations? Which accom- modations are most frequently provided and who gets them? Daly and Bound (1996) used data from the Health and Retirement Study, a longitu- dinal panel study of older Americans, to examine the experience of older workers (51–61 years of age) when they had the onset of a medical condi- tion that limited the work they could do. They found that about half of the workers stayed at their current jobs; just less than a quarter changed jobs; just over a quarter stopped working. Of those who remained with their employer, 29 percent of the men and 37 percent of the women received accommodations. Those who changed employers were less likely to receive accommodations: 14 percent of the men and 29 percent of the women. The most commonly provided accommodations included the alteration of job duties, assistance with the job, a change in schedule or a shorter work day, and more breaks. These results are consistent with previous work that suggested that up to one-third of workers experiencing a disability report some type of employer accommodation (Lando, Cutler, and Gamber, 1982; Schechter, 1981; Chirikos, 1991). Third, how effective are workplace accommodations in allowing work- ers to remain safely and productively in the workforce? The goal of work- place accommodations is to allow workers with a range of impairments to enter or remain in the workplace. There have been very few studies explor- ing the effectiveness of these accommodations. In two studies, Burkhauser and colleagues (Burkhauser, Butler, and Kim, 1995; Burkhauser et al., 1999) has addressed this issue. Applying a proportional hazards analysis to the HIS component of the 1978 Survey of Disability and Work, Burkhauser

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217 INTERVENTIONS FOR OLDER WORKERS et al. (1995) found that the provision of an accommodation significantly slowed a worker’s withdrawal from the workforce after the onset of an impairment. In a subsequent study employing additional data from the Health and Retirement Study and using a proportional hazards model, Burkhauser et al. (1999) found that the time to the beginning of SSDI payments was significantly delayed by the provision of workplace accom- modations. However, both of these studies relied on retrospective data on the provision of accommodations. Thus, they are both vulnerable to poten- tial recall bias—those who withdrew from the workforce may be less likely to remember accommodations their employers made than those who re- mained in the workforce. The longitudinal data now available in the Health and Retirement Study would permit a prospective examination of this issue. Data summarized above (Zwerling et al., 1998a,b) suggest that older workers with impairments have an increased risk of occupational injuries. Appropriate workplace accommodations might be expected to lower this risk, but we know of no empirical studies addressing that issue. Likewise, it might be expected that appropriate workplace accommodations would in- crease the productivity of workers with a variety of impairments, but we were only able to find anecdotal evidence on this issue. Return-to-Work Programs As noted above, national databases show that older workers are less likely to be injured at work than their younger colleagues, but they are likely to require a longer period of recuperation before they are ready to resume their normal duties. This prolonged period of work disability has been extensively documented among older workers with low back pain (Bigos et al., 1986; Dasinger Krause et al., 2000; Infante-Rivard and Lortie, 1996; Krause et al., 2001a; McIntosh et al., 2000), but it has also been documented among cardiac patients (Karoff et al., 2000) and trauma pa- tients (MacKenzie et al., 1998). Given the prolonged period of recuperation among older workers, the design, implementation, and evaluation of return- to-work programs among older workers merits special attention. Leigh and colleagues (1997) estimated that occupational injuries cost Americans about $145 billion in 1992. The overwhelming majority of these costs derived from the disability costs of injured workers. These significant costs have been associated with many efforts to find the risk factors that predict prolonged disability after work-related injuries. In a recent review of the literature, Krause and colleagues (2001b) identified about 100 differ- ent determinants of return-to-work outcomes. Krause categorized the risk factors for disability in seven broad groups ranging from the most indi- vidual level factors to the most societal level factors: the individual level

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218 HEALTH AND SAFETY NEEDS OF OLDER WORKERS worker characteristics associated with return-to-work outcomes (useful in predicting prolonged disabilities, but generally not amenable to change); the individual-level worker factors that describe the injury; medical and vocational rehabilitation programs; the physical and psychosocial job char- acteristics; the organizational level employer factors; the employer- or insurer-based disability prevention programs; and the societal level legisla- tive and policy related factors. The factors that most consistently resulted in a shortening of the duration of disability included medical and vocational rehabilitation interventions, organizational level employer factors, and em- ployer- and insurer-based disability prevention and disability management interventions. Each of these three areas provides many opportunities for implementing and evaluating interventions. However, several challenges must be overcome before researchers can establish which interventions are most effective (Krause et al., 2001b). Researchers need to agree on the best outcome variables to use in return-to- work studies. We need to bring together multidisciplinary teams that can address the social/behavioral, biomedical, and analytic issues in the re- search. These multidisciplinary teams will need to create new, interdiscipli- nary conceptual models for the process of returning to work. We need to prioritize among the diverse group of risk factors related to return-to-work outcomes, focusing on those that are amenable to change and relevant to workers and employers. We also need to raise the methodological level of our research, making use of survival models to account for censoring of data and to maximize the efficiency of our modeling (Collett, 1994). That of hierarchical models to simultaneously assess risk factors from several levels, ranging from the individual to the societal (Diez-Roux, 1998). Of the almost 100 predictors of return-to-work identified in Krause’s (2001a) extensive review of the literature, most were only measured in a handful of studies, but one was repeatedly identified in a variety of different studies. In a detailed review of the literature, Krause and colleagues (1998) found that in 13 high-quality studies, modified work programs facilitated the return-to-work of workers with temporary or permanent impairments. Injured workers who were offered modified work were about twice as likely to return to work as those who were not offered modified work, and they returned to work about twice as quickly. Almost all of these work- modification programs centered on making light duty assignments avail- able to impaired workers. One of these studies presented data suggesting that the light-duty program was cost-effective, but most presented no eco- nomic data.