9
Conclusions and Recommendations

KEY CONCLUSIONS AND RECOMMENDATIONS

To permit effective examination of the relationship between health and employment and work-related factors among older workers it is necessary to create new, longitudinal data sets containing detailed information on workers’ employment histories and the specific demands of the job, as well as objective information on the health and safety risks to workers in the job. Such data sets do not currently exist because they are costly to create.

An ideal longitudinal data set would contain baseline information on the health status and previous work histories of a representative sample of older Americans, with overrepresentation of minority and other high-risk groups. The survey that collects these data would periodically gather from respondents and their employers data that provide researchers with consistent, reliable, and continuous information on respondents’ employment and earnings, the risk factors associated with employment, including work organization and job demands on physical and mental capacity, and exposure to risk factors such as harmful chemicals. These data are needed to follow work and retirement patterns in aging cohorts of workers and to assess the effects of work on health. These data are also needed to assess the effects of health, workplace health risks, family obligations, and other causal factors on employment in later life. The old Retirement History Survey and newer Health and Retirement Study, as well as other longitudinal surveys now available, do not contain reliable or continuous information on the risk factors to which workers are exposed in their jobs.



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9 Conclusions and Recommendations KEY CONCLUSIONS AND RECOMMENDATIONS To permit effective examination of the relationship between health and employment and work-related factors among older workers it is necessary to create new, longitudinal data sets containing detailed information on workers’ employment histories and the specific demands of the job, as well as objective information on the health and safety risks to workers in the job. Such data sets do not currently exist because they are costly to create. An ideal longitudinal data set would contain baseline information on the health status and previous work histories of a representative sample of older Americans, with overrepresentation of minority and other high-risk groups. The survey that collects these data would periodically gather from respondents and their employers data that provide researchers with consis- tent, reliable, and continuous information on respondents’ employment and earnings, the risk factors associated with employment, including work organization and job demands on physical and mental capacity, and expo- sure to risk factors such as harmful chemicals. These data are needed to follow work and retirement patterns in aging cohorts of workers and to assess the effects of work on health. These data are also needed to assess the effects of health, workplace health risks, family obligations, and other causal factors on employment in later life. The old Retirement History Survey and newer Health and Retirement Study, as well as other longitudinal surveys now available, do not contain reliable or continuous information on the risk factors to which workers are exposed in their jobs. 219

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220 HEALTH AND SAFETY NEEDS OF OLDER WORKERS Creating an ideal data set would be very costly, but it may represent the only strategy likely to produce sufficient data to elucidate completely the relationship between workplace risk factors and workers’ health and em- ployment patterns in later life. A more limited and less expensive alternative is to modify existing longitudinal and nonlongitudinal surveys so they con- tain crucial information about workplace health risks. Another alternative is to collect information on a convenience sample for which longitudinal record gathering is less costly in contrast to a nationally representative, random sample with periodic in-person or telephone survey updates. One possibility is to conduct thorough baseline interviews in a cohort of workers and recent retirees from a large national employer, such as the U.S. govern- ment. Personnel and other administrative records and less frequent in- person interviews would be used to construct lifetime work histories and measure subsequent employment and retirement patterns in the cohort. The size of the government workforce would also permit targeted sampling for better assessment of demographic subgroups. It would likely, however, exclude the possibility of assessing a full range of occupations. Recommendation 1: New longitudinal data sets should be developed that contain detailed information on workers’ employment histories and the specific demands of their jobs, as well as objective information on the health and safety risks to workers in the job. If cost makes it impossible to create a nationally representative, longitudinal survey focused on workplace health and safety, a less expensive alternative is to create a new longitudinal data set using a convenience sample in which information gathering is less costly, for example, a representa- tive sample of workers at a large national employer, such as the U.S. government. The risk of workplace injury or illness or disorder varies both across and within occupation and industry, and workers’ exposure to such risks varies across the course of their lives. Therefore, analyses that attempt to explain life course health outcomes or that use health characteristics as variables to help explain major life course transitions such as retirement should have good information on these health and safety risks. However, otherwise richly detailed socioeconomic surveys such as the Health and Retirement Study or the Panel Study of Income Dynamics, which contain detailed information on the health characteristics of their respondents, lack information on the health and safety risks that workers face in their current or past jobs. A National Research Council (2001) report has strongly encouraged longitudinal research to disentangle and illuminate the complex interrelationship among work, health, economic status, and family structure. Without capturing the independent effects of

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221 CONCLUSIONS AND RECOMMENDATIONS the work environment on these factors, however, it will be difficult to fully achieve this goal. Regular population-based information on the distribution of common workplace exposures that can be assessed by interview is essential to our understanding of their relationship to the detailed health information in the Health and Retirement Study and the Panel Study of Income Dynamics, and also of the ways these exposures affect labor force exits. Recommendation 2: Ongoing longitudinal surveys (for example, the Health and Retirement Study and the Panel Study of Income Dynamics) should either increase the information they gather on health and safety risk factors of the workplace or develop periodic modules to do so. Accurate occupational injury and illness or disorder data are important to the development of public policy concerning older workers. However, there is evidence-based concern that occupational illnesses or disorders and occupational injuries may be underreported; a number of studies have raised concern about how well these data represent the full complement of work- related illness or disorder and injury experiences of older workers. There is insufficient knowledge of trends in under-ascertainment of both work-re- lated injuries and illnesses or disorders, generally and with regard to older workers, and of the contribution of various factors to under-ascertainment (e.g., decline in unionization, increase in immigrant workforce, growth in precarious employment, incentive systems affecting reporting, and the fea- tures of workers’ compensation systems). The primary assessment of trends has been directed at how well indus- tries are reporting those injuries and illnesses or disorders of which they are aware. Inadequate attention, however, has been given to the barriers that may interfere with individual workers’ documenting of work-related inju- ries and the even greater barriers to recognizing that their illness or disorder episodes may be work related. The Bureau of Labor Statistics (BLS) has undertaken and needs to continue efforts to evaluate and improve the Occupational Safety and Health Administration (OSHA) based reporting of occupational injury and illnesses or disorders. In addition, new ap- proaches are necessary to cast a broader net in order to describe the full extent of work-related injury and illness or disorder burden among older workers. Approaches should include new initiatives in several areas. Com- munity-based studies that focus on older workers, with particular attention to immigrant and minority workers, should be undertaken to add impor- tant new information to that provided solely from current workplace au- dits. Surveys of workers should be used to complement audits of employer records, with particular attention to small and medium-sized firms where the audits have suggested problems may exist. Research collaborations should be developed with a variety of nongovernmental groups such as

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222 HEALTH AND SAFETY NEEDS OF OLDER WORKERS workers’ compensation insurance carriers, industry associations, labor/man- agement health and welfare funds, and other private groups with direct or indirect access to sources of work-related injury and illness or disorder data. Recommendation 3: The National Institute for Occupational Safety and Health should collaborate with the Bureau of Labor Statistics in conducting a comprehensive review and evaluation of occupational injury and illness or disorder reporting systems, examining the extent of and trends in underreporting and underascertainment. This effort should include filling in important knowledge gaps through innovative research approaches and should be complemented by research directed at understanding trends and barriers to reporting, especially for older workers. Studies of incentives/disincentives to injury and illness or dis- order reporting should be conducted with the end in mind of surveil- lance system reform. To monitor the importance of the job environment on morbidity and mortality in nationally available data sets such as the National Health Interview Survey and National Health and Nutrition Examination Survey, it is necessary to have consistent, reliable, and continuous information on the risk factors associated with jobs. This information must be available at a sufficiently detailed level of industry and occupation (for example, at least as detailed as the three-digit categories defined by the Standard Industrial Classification and the Standard Occupational Classification systems). Cur- rently, when work risk factors are assessed it is most common to consider them in a very limited fashion using job title or industry group only. Little detail on the nature of work exposures over a broad range of occupations is currently available for linkage to health-based national or representative data sets. Data that characterize the full range of all types of work exposures are needed to permit assessment and tracking of relation- ships between these exposures and the prevalence or incidence of health conditions. These exposure data should be structured in a way that allows easy linkage to data sets (both administrative records and surveys) that provide individual information on health and socioeconomic characteristics. Previ- ously the National Institute of Occupational Safety and Health (NIOSH) has carried out surveys focusing only on chemical and a limited set of physical hazards (National Occupational Hazards Survey, National Occu- pational Exposure Survey). A more comprehensive assessment of work exposures is required associated with regular revisions to accommodate the evolution of existing occupations and the development of new ones. Recent organizational developments related to stressful systems or fea- tures of work organization (e.g., job strain, effort-reward imbalance, and

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223 CONCLUSIONS AND RECOMMENDATIONS extended work hours) have been associated with increased risk of cardio- vascular disease, already a major cause of disability among older workers. Although tools exist to assess organizational factors in etiologic research, they are not necessarily easily adapted to population surveys. In order to characterize exposures associated with work organization for use in such surveys, research will be needed to identify components or factors related to work organization that provide adequate sensitivity, specificity, and ease of use. Recommendation 4: NIOSH should be provided sufficient funds to develop a database that characterizes types and levels of exposures associated with work. Exposures considered should include chemical, physical, biomechanical, and psychosocial factors. The database should be organized in a manner that permits the assignment of a full range of exposures to detailed occupation and industry groups and in a form that permits linkage to population health data sets. The database should be revised and updated periodically, at least every decade. As first cataloged by Shock and others decades ago, populations un- dergo age-related decrements in the functioning of organs and of the human as a whole. While occupational health research has documented many adverse health effects of specific worksite environmental exposures, there is almost no research on the impact of these and other exposures on the trajectory of normal aging throughout the life span. Similarly, there is little research on how later-life workplace exposures affect age-related processes that are already altered by a variety of earlier occupational exposures. Approaches are needed to these issues at the general population level, as well as for cohorts with specific workplace exposures. Additional issues requiring investigation include how these cumulative and age-dependent exposures affect later-life physical, cognitive, and social function, and the occurrence and natural history of the major disabling diseases of older persons, such as heart disease, stroke, cancer, and degenerative arthritis. An emphasis on the effect of workplace exposures on mental health and func- tion is also needed, particularly those related to workplace social stresses and changing work demands and organization. Recommendation 5: Substantial research is needed on the physiologi- cal, pathological, and functional effects of common and potentially harmful worksite exposures—physiochemical, biological, biomechani- cal, and psychosocial—on older workers. This research should include determining how these environmental exposures may affect the trajec- tory of normal age-related human and organ function, including the cumulative effects of various prior workplace exposures, and the net impact on the pathogenesis of age-related chronic illnesses or disorders.

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224 HEALTH AND SAFETY NEEDS OF OLDER WORKERS Many older workers have existing chronic illness or disorder and dis- ease risk factors that are under various levels of personal and clinical man- agement and control, including mental illnesses or disorders. Research is needed on how potentially adverse workplace exposures—physiochemical, biological, biomechanical, and psychosocial—affect the status, control, and outcomes of these chronic conditions. For example, these exposures may have direct, toxic effects on already diseased organs, interact pharmacologi- cally with medications used to treat existing conditions, or distract and impede older workers from timely disease management interventions. Out- comes that might be studied include longevity and mortality, changes in disease and illness or disorder severity, changes in physical functional sta- tus, social effects on the individual and families, interactions with the health care system, and overall quality of life. Chronic conditions that are high priority for consideration in such investigations include cardiovascular dis- ease and musculoskeletal disorders. Recommendation 6: A research program should be conducted to pro- vide systematic and substantial understanding of the effects of poten- tially harmful workplace exposures on individual and population out- comes among older workers with existing chronic conditions, both during periods of employment and after retirement. A variety of public policy interventions have been designed to enable workers to remain in the labor market while minimizing or preventing occupationally caused morbidity. These include polices that operate di- rectly through regulation of workplace hazards (Occupational Safety and Health Act, Mine Safety and Health Act) or indirectly through intervention in more general employment practices that impact older or disabled work- ers (Americans with Disabilities Act, Age Discrimination in Employment Act, Family and Medical Leave Act). Little is known about the effectiveness of these laws in achieving their goals for older workers. For example, there are insufficient data regarding whether the Americans with Disabilities Act has resulted in increased job accommodation, and therefore greater work longevity, for aging workers with qualifying disabilities. There has been no systematic evaluation of the combined and independent effectiveness of the Age Discrimination in Employment Act, the Americans with Disabilities Act, or the Family and Medical Leave Act in assisting aging workers to remain in the workforce and to obtain new employment when they are dislocated. Further study is also needed to assess whether these laws create barriers for continued and safe employment or reemployment of aging workers. Recommendation 7: Evaluation research is needed to determine the degree to which public policies intended to enable workers to remain at

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225 CONCLUSIONS AND RECOMMENDATIONS work safely and productively have met these objectives specifically with regard to older workers. Policies that should be the subject of such evaluation research include the Occupational Safety and Health Act and other health and safety laws; the Americans with Disabilities Act; the Age Discrimination in Employment Act; the Family and Medical Leave Act; and related state laws. Many existing intervention programs have demonstrated at least some efficacy for workers generally, and some for older workers, specifically. In principle, effective workplace interventions address hazards as close to the source as possible. Therefore, job design, including redesign and engineer- ing to improve the exposures and accommodations for older workers, de- serves the highest level of attention. There are design approaches to address a variety of age-related changes in vision, hearing, and physical strength and capacity and approaches that address work-related musculoskeletal disorders that are anticipated to be an important problem for aging work- ers. There is evidence for the effectiveness of a limited number of interven- tions to address cardiovascular disease by improving work organization and job design and by reducing job stressors. Many effective interventions also involve changing the social climate in the workplace (e.g., empowering workers), introducing better work practices (e.g., ergonomic interventions to improve body posture for bending and lifting), improving physical fitness with exercise, and substituting machine work for human exertion. Training is an intervention that seems particularly relevant for older workers, who are likely to be the most distant from initial professional training and from initial job training. Access to training, however, is often too limited. Accommodations for workers with impairments and return-to-work programs are important interventions for older workers, who are more likely to bring impairments into the workplace and to be out of work longer than their younger colleagues after an injury at work. Modified work pro- grams have been clearly shown to facilitate the return to work of workers with temporary or permanent impairments. Attention to general health promotion programs is relevant for older workers, in part because chronic illness or disorder rates are higher at older ages. It is important to add, however, that general health promotion pro- grams directed at workers appear to be more effective when tied to environ- mental controls in the workplace. Factors known to result in shortening the duration of disability consistently include medical and vocational rehabili- tation interventions, organizational level employer factors, and employer- and insurer-based disability prevention and disability management inter- ventions. Although most employee assistance programs (EAPs) have not emphasized employee needs related to aging, they have strong potential as a support for older workers in relation to occupational health and safety

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226 HEALTH AND SAFETY NEEDS OF OLDER WORKERS concerns. EAPs can also assist workers challenged by the need to provide eldercare support, plan for retirement or outplacement, and address sub- stance abuse and emotional distress. For each of these interventions there is need for research on the preva- lence of the intervention (which firms and older workers use them), on the effectiveness of the intervention (the degree to which it protects older work- ers’ health and safety), and on the costs of the intervention (how it com- pares with the benefits obtained). For instance, ergonomic job designs have the potential to create work- places that are suitable for the widest range of worker abilities. Workplace accommodations may permit older adults with a variety of impairments to work safely and productively. It is important to assess prevalence in part to determine whether an efficacious practice is not being employed as well as to assess the extent to which interventions not determined to be efficacious or ones known to be ineffective are being employed. Although many intervention programs have at least some demonstrated efficacy, nearly all have been incompletely evaluated. For instance, weak- nesses in existing evaluations of job design and training interventions in- clude the use of small and unrepresentative samples in a small set of occu- pations. In addition, intermediate outcome measures such as changes in posture or self-ratings of work ability need to be complemented by direct measures of illness or disorder, injury, and symptom syndromes. Few of the interventions and even fewer of the evaluations of those programs have tested their effectiveness specifically for older workers. Moreover, studies have not routinely included samples representative of the workforce of the future that will include increasing proportions of women and minority workers. Past research has focused on a limited set of occupa- tions and workplace environments, and little is currently known about those that will in the future be employing increasing proportions of older workers. For instance, computer workstations have been introduced in many job settings, and yet there has been little evaluation of the adequacy of their design for older users. Such research can lead to the creation of guidelines and best practices that will lead to safer, healthier, and more productive workplaces. Recommendation 8: For promising job design, training, and work- place accommodation interventions, research should be conducted to determine the prevalence, effectiveness, and associated costs of inter- vention. The resulting data should be used to perform evaluations and benefit-cost analyses to guide the implementation of future interventions. There are gaps in our knowledge about how socioeconomic and demo- graphic variables (e.g., minority or immigration status, low literacy, low- education level, lack of fluency in English, lack of continuous connection to

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227 CONCLUSIONS AND RECOMMENDATIONS the formal labor market) might increase health and safety risks for sub- populations of older workers, and about the degree to which these variables predict employment in hazardous occupations and industries. There are also gaps in our knowledge about variables that may lead some older workers to stay in the workforce despite declining health (e.g., income insecurity, low-income levels, gaps in health insurance coverage, barriers to access to other public and private benefit programs). A separate research effort is needed to collect data about these high-risk older workers, given that this population may be less readily identified through standard sampling procedures. To assure comparability with find- ings from other studies, it is important that standard instruments be used when feasible. Recommendation 9: Targeted research should be undertaken to iden- tify the extent to which, and mechanisms whereby, socioeconomic and demographic variables are related to health and safety risks of older workers; the degree to which these variables predict employment in hazardous occupations and industries; and how they may be associated with retirement decisions and barriers. ADDITIONAL CONCLUSIONS AND RECOMMENDATIONS According to an agreement with OSHA, the BLS annually collects and analyzes workplace injury and illness or disorder statistics. The employer survey instrument required by OSHA, however, does not seek demographic information on employees at risk of injury or illness or disorder. Conse- quently, much of the data on workplace injury and illness or disorder are presented only as counts or proportions. Denominator data can be devel- oped using occupation and injury data available in the Current Population Survey. The necessary compromises needed to apply Current Population Survey data to this purpose are minor compared with the benefits that result from detailed rate-based data reporting. It has already been deter- mined that it is feasible to determine quite accurate death rates by this method. Recommendation 10: The Bureau of Labor Statistics should initiate reporting of workplace injury and illness or disorder rates according to demographic characteristics (for age, gender, and ethnicity at a mini- mum) based on Current Population Survey reports of total number of hours worked by people in subpopulations defined by age, gender, industry, and occupation. Worksite health promotion programs and employee assistance pro- grams have demonstrated benefits for workers’ health, but their effective-

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228 HEALTH AND SAFETY NEEDS OF OLDER WORKERS ness, specifically for older workers, has not been studied. Worksites can promote the health of older workers through health promotion programs that aim to reduce risk-related behaviors (e.g., tobacco use, physical inac- tivity) and promote screening for early detection and treatment of illness or disorder and disease (e.g., ambulatory blood pressure monitoring at work to detect hidden workplace hypertension). While there is evidence that the integration of health promotion programs with work risk reductions is successful in reducing risky behaviors, little research has been conducted to identify effective ways to tailor these programs to older workers’ needs or strategies to maximize worker participation in programs. In addition, there is need for research to assess the efficacy of these interventions, specifically for older workers. Employee assistance programs can also play a useful role in protecting and promoting the health and safety of older workers, and they may offer support services specifically tailored for older workers, such as preretirement planning, substance abuse interventions customized for older workers, or family care programs. Research is needed to develop and assess the effec- tiveness of such services as well. Another domain of prevention and health promotion programs at the worksite is the possibility of disease management programs for older work- ers. These programs help manage disease risk factors or physiological do- mains that can prevent disease progression. Examples include diabetes, hypertension, and asthma management. Evaluation is needed to assess the feasibility, cost, and maintenance of these worker health programs. Simul- taneously, the overarching problem of maintaining confidentiality or worker medical conditions needs to be considered. In addition, particular attention is needed to develop strategies for extending these interventions to small business settings, where they are often lacking. Recommendation 11: Research should be conducted to assess the ef- fectiveness, benefits, and costs of worksite health promotion programs and employee assistance interventions tailored to older workers in both small and large worksites. The Department of Labor has been developing and validating a system called O*NET™ intended to advance information useful in describing the nature and scope of job characteristics that can be collected for use in a number of settings, most particularly in the BLS statistical systems. The O*NET database, when complete, will provide a valuable description of the knowledge, skills, and abilities required for various jobs; that informa- tion will permit detailed comparison of job requirements with the develop- ing knowledge of the capacities of older workers. The O*NET is a large undertaking, and progress on this valuable resource has been slow.

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229 CONCLUSIONS AND RECOMMENDATIONS Recommendation 12: This committee endorses the recommendation, defined in the 1999 National Research Council report The Changing Nature of Work, that the O*NET system be developed as a fully opera- tional system. A sense of urgency should be applied: efforts should be devoted to achieving a comprehensive, interactive O*NET database as quickly as possible. Development of information on the individual, family, and societal costs of occupational injuries and illnesses or disorders is necessary to allow policy makers to place a proper priority on the problem and determine the necessary level of effort for prevention efforts focused on this older worker population. Much of the necessary data to carry out such studies is avail- able from the Health Care Financing Administration, the National Hospital Discharge Survey, the Healthcare Cost and Utilization Project, the Health and Retirement Study, and the Ambulatory Care Visits Study, along with data from the BLS that provides age-specific rates on all categories of occupational injuries and illnesses or disorders, including days away from work, restricted workdays, and events with no lost or restricted time. Recommendation 13: Research should be undertaken to assess the full (direct and indirect) costs of older workers’ occupational injuries and illnesses or disorders to individuals, families, and society. The National Health Interview Survey (NHIS) is the principal source of information on the health of the civilian noninstitutionalized population of the United States. The main objective of the NHIS is to monitor the health of the U.S. population through the collection and analysis of data on a broad range of health topics. A major strength of this survey lies in its ability to display these health characteristics by many demographic and socioeconomic characteristics. To date, only the 1988 survey included sub- stantial information about population exposure to work-related risk factors and detailed assessment of the occupational nature of selected conditions. Regular population-based information on the distribution of common workplace exposures that can be assessed by interview is essential to under- standing the relationship of these risk factors to health data contained within NHIS. Recommendation 14: The National Center for Health Statistics and the National Institute for Occupational Safety and Health should de- velop a survey supplement on work risk factors and occupational disor- ders for periodic inclusion in the National Health Interview Surveys. Additional funds should be devoted to support this effort. The National Health and Nutrition Examination Survey (NHANES) is a continuous annual survey designed to examine public health issues that

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230 HEALTH AND SAFETY NEEDS OF OLDER WORKERS can best be addressed through physical and laboratory examinations of the U.S. population. Currently over 100 environmental chemicals are measured in either blood or urine specimens for various subpopulations. Recommendation 15: The National Center for Health Statistics and the National Institute for Occupational Safety and Health should col- laborate in an effort to identify, using the National Health and Nutri- tion Examination Survey, subpopulations of older workers where chemical exposure is likely to be an important work risk factor and to develop a list of chemicals to be included in surveys of such populations in the future. Additional funds should be devoted to support this effort. In the 1970s, the BLS carried out national Quality of Employment Surveys to describe the prevalence of and trends in job characteristics and other workplace risk factors. These nationally representative databases proved a valuable resource for assessing prevalence and trends for work risk factors. For example, the surveys were central to the development of the Job Content Questionnaire. Recommendation 16: The National Institute for Occupational Safety and Health and the Department of Labor should collaborate and be funded to develop a survey instrument and periodically conduct sur- veys to describe the prevalence of and trends in job characteristics and other workplace risk factors in a manner similar to the Quality of Employment Surveys.