3
Health and Safety at Work

Work may be an integral part of the lives of many children and adolescents, but how safe is the workplace for children? Despite child labor laws that are intended to protect children from hazardous working conditions, many young workers face health and safety hazards on the job. In fact, if one examines the major industries in which adolescents are employed, one finds that many of these industries—grocery stores, nursing homes, and agriculture—have higher-than-average injury rates for workers of all ages; see Table 3-1. In general, typical ''teen jobs" cannot be assumed to be safe. Such factors as inexperience, developmental characteristics (physical, physiological, cognitive, and psychosocial), and the need to balance school and work may place younger workers at greater risk than adults confronted with similar hazards.

Injuries are the leading cause of death among children (over age 1) and adolescents (Rosenberg et al., 1996). In 1995, 1,612 children aged 5 to 9 died from unintentional injuries, as did 1,932 children aged 10 to 14, and 6,622 adolescents aged 15 to 19 (National Center for Health Statistics, 1995). Injuries also are the leading cause of hospital admissions for young people (National Center for Health Statistics, 1990) and account for numerous visits to emergency departments and physicians (Baker et al., 1992). Between 1992 and 1994, injuries accounted for 43 percent of 31,447,000 annual emer-



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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States 3 Health and Safety at Work Work may be an integral part of the lives of many children and adolescents, but how safe is the workplace for children? Despite child labor laws that are intended to protect children from hazardous working conditions, many young workers face health and safety hazards on the job. In fact, if one examines the major industries in which adolescents are employed, one finds that many of these industries—grocery stores, nursing homes, and agriculture—have higher-than-average injury rates for workers of all ages; see Table 3-1. In general, typical ''teen jobs" cannot be assumed to be safe. Such factors as inexperience, developmental characteristics (physical, physiological, cognitive, and psychosocial), and the need to balance school and work may place younger workers at greater risk than adults confronted with similar hazards. Injuries are the leading cause of death among children (over age 1) and adolescents (Rosenberg et al., 1996). In 1995, 1,612 children aged 5 to 9 died from unintentional injuries, as did 1,932 children aged 10 to 14, and 6,622 adolescents aged 15 to 19 (National Center for Health Statistics, 1995). Injuries also are the leading cause of hospital admissions for young people (National Center for Health Statistics, 1990) and account for numerous visits to emergency departments and physicians (Baker et al., 1992). Between 1992 and 1994, injuries accounted for 43 percent of 31,447,000 annual emer-

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States TABLE 3-1 Incidence Rates of Nonfatal Occupational Injuries and Illnesses for All Workers in the Private Sector, by Industry   1992 1993 Industry Total Injuries (per 100 FTE) Lost Workday Cases (per 100 FTE) Total Injuries (per 100 FTE) Lost Workday Cases (per 100 FTE) All Private Industriesa 8.9 3.9 8.5 3.8 Agriculturea 12.2 5.5 11.5 5.3 Grocery Stores 12.7 5.0 11.3 4.7 Eating Places 9.1 3.1 8.5 3.0 Nursing Homesb 18.6 9.3 17.3 8.9 NOTES: The incidence rates represent the number of injuries and illnesses per 100 full-time equivalent workers and were calculated as follows: (N/EH) × 200,000, where N = number of injuries and illnesses; EH = total hours worked by all employees during the calendar year; and 200,000 = base for 100 full-time equivalent workers (working 40 hours per week, 50 weeks per year). Lost workday cases involve injuries or illnesses that result in days away from work or days of restricted work activity or both. gency department visits by children and adolescents. The highest rate of injury-related visits occurred among 15-to 17-year-olds (H.B. Weiss et al., 1997). Occupational injuries and illnesses among young people have typically been overlooked in pediatric health care and pediatric public health. At the same time, occupational health experts have generally focused on the health and safety of adult workers. Consequently, until quite recently, the scientific literature has been notably silent on the subject of occupational injuries and illnesses among children and adolescents. Although information remains limited, a

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States 1994 1995 1996 Total Injuries (per 100 FTE) Lost Workday Cases (per 100 FTE) Total Injuries (per 100) Lost Workday Cases (per 100 FTE) Total Injuries (per 100 FTE) Lost Workday Cases (per 100 FTE) 8.4 3.8 8.1 3.6 7.4 3.4 10.3 4.8 10.4 4.7 9.4 4.3 11.2 4.7 9.9 4.1 10.1 4.1 7.7 2.6 7.6 2.4 6.2 1.9 16.8 8.4 18.2 8.8 16.5 8.3 aExcludes farms with fewer than 11 employees. b These figures are for nursing and personal care facilities, the category that includes nursing homes, for which separate rates were not available. SOURCE: Data from Bureau of Labor Statistics. Available at: http://stats.bls.gov/sahome.html#OSH [1998, February 2]. growing body of research now suggests that occupational injuries contribute to the overall burden of injuries among youth. This chapter first examines the data on work-related injuries and illnesses among children and adolescents. It then examines the factors that may increase their risk of injuries and illnesses in the work-place. Finally, it includes a review of the available sources of surveillance data and their strengths and weaknesses. Although the information presented here is relevant to both agricultural and nonagricultural settings, the special concerns of agriculture are addressed in Chapter 5.

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States NONFATAL WORK-RELATED INJURIES Since the mid-1980s, a number of descriptive epidemiological studies have characterized the extent and nature of occupational injuries to children and adolescents. Because there is no national system for monitoring occupational illness and injuries, researchers have largely relied on administrative data, such as workers' compensation records, for documentation. No single data source captures all injuries; thus, findings based on any single data source should be considered conservative estimates. Because these data sources are not complete, exhaustive, or mutually exclusive, it is difficult to compare the data or to determine an accurate number of work-related injuries to young people. In addition, most of these data sources are not based on representative samples of working children and adolescents. As is discussed in more detail below (see "Sources of Surveillance Data"), official Bureau of Labor Statistics figures from the Annual Survey of Occupational Injuries and Illnesses are estimated to miss at least 11 percent of workers under the age of 18; hospital emergency rooms are estimated to see only one-third of all work-related injuries (and it is not known what percentage of injuries to young workers are seen in hospitals). Data from administrative sources, such as workers' compensation, differs from state to state. Taken together, however, studies provide an important picture, albeit incomplete, of work-related injuries suffered by young people in the United States. Even less information is available on the severity of injuries suffered by young workers. None of the data sources specifically rates injury severity, but the sources include only injuries that require multiple days away from work or require medical attention—both commonly used indicators of serious injuries. Extent of the Problem One approach to estimating the magnitude of the problem is to examine workers' compensation claims filed for children and adolescents. A review of data from 26 states in 1987 to 1988 identified 59,000 injuries to minors (U.S. General Accounting Office, 1990).1 1   The twenty-six states that reported injury data were Arkansas, Colorado, Florida, Hawaii, Idaho, Iowa, Kentucky, Louisiana, Maine, Maryland, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, New Mexico, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Washington, Wisconsin, and Wyoming.

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States New York state alone reported that more than 1,200 youths received compensation for occupational injuries that resulted in 8 or more days lost from work each year from 1980 to 1987; more than 40 percent of the injuries resulted in permanent disability (Belville et al., 1993). In Washington state, which collects data on all injuries re-gardless of lost work time, more than 4,400 young workers were awarded workers' compensation benefits annually from 1988 to 1991 (Miller, 1995). Brooks et al. (1993) report that in Massachusetts from 1988 through 1990 approximately 700 workers under the age of 18 filed claims annually for injuries resulting in 5 or more days away from work. These findings vary widely because eligibility requirements for worker's compensation vary by state. Table 3-2 summarizes the findings from the major studies of work-related injuries. Injury logs maintained by employers in accordance with the re-quirements of the Occupational Health and Safety Act also shed light on the extent of injuries to young workers. Each year the Bureau of Labor Statistics (BLS) conducts the Survey of Occupational Injuries and Illnesses (SOII), based on the injury logs required of a sample of private employers throughout the United States. According to these official statistics, in 1993 youngsters in private-sector industries suffered an estimated 21,620 injuries and illnesses that necessitated days away from work. The median number of lost work days was 3. The survey excludes the self-employed, farms with fewer than 11 employees, private households, and government, which means that the survey does not cover at least 11 percent of working youth, according to one estimate (Centers for Disease Control and Prevention, 1996). Emergency-department records are another key source of information about work-related injuries suffered by adolescents. These records document not only serious injuries, but also injuries that do not necessarily require time away from work. In the National Hospital Ambulatory Medical Care Survey, the National Center for Health Statistics of the U.S. Department of Health and Human Services annually collects information on a nationally representative sample of emergency department visits. Between 1992 and 1994, there was an annual average of 2,111,000 emergency department visits by 15-to 17-year-olds for injuries. For 1993 and 1994, the years for which data on place of injury were collected, 5 percent

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States TABLE 3-2 Studies on Work-Related Injuries of Adolescents Study Population/Source Sample Banco et al., 1992 14-to 17-year-olds/Connecticut workers' compensation reports for 1989 796 workers' compensation reports for 14-to 17-year-olds (.05% 14-year-olds; 10.2% 15-year-olds; 34.7% 16-year-olds; 54.6% 17-year-olds) Belville et al., 1993 14-to 17-year-olds/Workers' compensation records for 1980–1987; New York state 9,656 work-related injury awards

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States Injury Job Type Event 35% cuts 25% contusions 22% sprains 7% burns 3% fractures dislocation 8% other 42% food stores 27.5% general merchandise stores 11.3% restaurants 7.4% professional and related services 3.6% manufacturing 2.7% public admin 2.6% business and repair services 1.4% personal services 0.4% construction 0.3% agriculture 0.8% other 30% case cutter, knife, other sharp objects 25% struck by object 17% overexertion 13% falls 7% burns 8% other 35% lacerations 18% fracture 18% sprain, strain 9% contusion, crush 9% other traumatic injuries 7% burns 1% amputations 1% other skin conditions 1% systemic injuries 52.3/1,000 unskilled labor 39.5/1,000 building service 38.9/1,000 food service 26.3/1,000 agriculture 25.0/1,000 construction, mechanics 20.2/1,000 clerical 15.9/1,000 sales 14.0/1,000 amusement and health 10.6/1,000 managerial, professional  

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States Study Population/Source Sample Brooks et al., 1993 14-to 17-year-olds/Emergency room and hospital admission records, 1979–1982; 14 Massachusetts communities 1,176 work-related injuries Brooks and Davis, 1996 14-to 17-year-olds/Workers' compensation records for 1987–1990; Massachusetts 2,551 work-related injury awards Broste et al., 1989 872 high school vocational agriculture students in central Wisconsin/Audiometric assessment Noise-induced hearing loss in at least one ear Cooper and Rothstein, 1995 Under 18 years old in Texas/Workers' compensation reports, 1991 1,097 injuries and illnesses 2% 11–13 year olds; 7% 14–15 year olds; 90% 16–17 year olds

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States Injury Job Type Event 49.1% lacerations 12.2% contusions 9.6% strains, sprains 7.5% eye injuries 6.4% burns 3.0% fractures 2.0% concussion, cranial 0.4% amputation 9.9% other   41.7% cutting, piercing objects 12% struck by object 9.6% falls 6.9% machinery 6.8% burns 6.3% overexertion 4.5% caught in or between objects (s) 4.4% foreign object 7.8% other 33.1% sprain, strain 24.3% laceration 15.6% contusion, crushing 8.5% fracture 4.7% burn 0.7% amputation 13.1% other 55.4% retain trade 20% services 11% manufacturing 4.6% construction 3.5% wholesale trade 2.0% transportation 1.2% agriculture 2.2% other   57.1% of students who live and work on farms 54.5% of student who work on farms, but live elsewhere 24% of students who live, but do not work on farms 33% of students with no farm exposure       35% vehicle drivers, material handlers 30% service laborers 19% sales workers  

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States Study Population/Source Sample Hayes-Lundy et al., 1991 15-to 19-year-olds/ Utah State Insurance fund data, 1982–1985 73 cases Heinzman et al., 1993 (Minnesota Adolescent Occupational Injury Study) 13-to 17-year-olds/Workers' compensation records for 8/90–8/91 742 injured adolescents 534 usable records Heyer et al., 1992 17-year-olds and younger/Washington state Workers' compensation claims,1986–1989 16,481 claims Knight et al., 1995 14-to 16-year-olds/ Follow-up survey of all work-related injury cases seen in emergency rooms participating in NEISS, July 1 to Sept. 30, 1992 174 cases 146 interviews completed Layne et al., 1994 14-to 17-year-olds/Representative sample of emergency departments (NEISS), July 1 to Dec. 30, 1992 37,405 estimated injuries nationwide based on 679 injuries in sample

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States Injury Job Type Event 100% burns from hot grease 100% fast-food restaurants 25% adding, filtering, changing hot grease 16% splashed grease 14% cleaning grill 11% slipped on floor into grease 34% other 13% burns (44% had permanent scars) 39% fast food establishments 37% full service restaurants 50% hot grease 25% grills, other cooking equipment 42% hot grease 35% hot water 5.2% serious injuries 12.8% disabling injuries 7% farm 43% food workers     34% eating places 7% schools 6% grocery stores 6% amusement, recreation services 3% hospitals 44% other 17% moving materials or freight 13% cooking, food preparation 12% janatorial work 10% stocking shelves, cutting up boxes 34% lacerations 18% contusion, abrasion 16% sprain, strain 12% burn 4% fracture, dislocation 15% other 38% eating establishments 7.8% food stores 7.6% other retail 6.7% health services 3.3% amusement, recreation 2.9% educational services 6.7% agriculture 4% manufacturing 15% all other  

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States injuries and illnesses; only 4 percent of the reported injuries and illnesses were to youngsters under the age of 16. Males were somewhat more likely than females to be injured, accounting for 59 percent of reported injuries and illnesses. Although the revised survey is an important source of information about young people's work-related injuries, it has a number of limitations. For several reasons, the survey's estimates may under-count incidents involving working children and adolescents. Because of the industries that are excluded from the survey, it has been estimated to miss at least 11 percent of working children and adolescents under the age of 18 (Centers for Disease Control and Prevention, 1996). Because most young people work only part-time, injuries or illnesses that might have prevented them from working on days they were not scheduled to work would not be counted, even though those injuries might have resulted in their missing school. For both children and adults, the survey is believed to undercount illnesses, especially long-latency illnesses, such as those caused by exposure to carcinogens (Bureau of Labor Statistics, 1997a). Another limitation in using data from the SOII to assess the injuries suffered by working children and adolescents is that injury rates based on the survey's data are routinely computed using the information on hours of employment that is provided by the employers participating in the survey. This information is not broken down by age groups, which means that injury rates by age are not available. Also, data on the number of injuries suffered by young workers are aggregated with the data for adult workers in standard SOII reports, which makes them an inadequate source of information about the health and safety of working children and adolescents. National Electronic Injury Surveillance System The National Electronic Injury Surveillance System (NEISS), maintained by the Consumer Product Safety Commission (CPSC), collects information on product-related injuries from a national probability sample of 91 hospital emergency departments. The NEISS covers not only injuries sustained by individuals who are engaging in paid work, but also injuries suffered by those performing volunteer work for organized groups. Beginning in July 1992, NIOSH collaborated with CPSC to have this system collect information on work-related injuries to youngsters aged 14 through 17.

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States Based on an analysis of data from the NEISS, Layne et al. (1994) estimated that 64,100 adolescents aged 14 to 17 were treated in emergency rooms for work-related illnesses in 1992. Eating and drinking establishments (38 percent), followed by grocery stores (7.8 percent), accounted for the greatest number of injuries. Lacerations were the type of injury (34 percent) most likely to be seen in the emergency departments, followed by contusions and abrasions (18 percent), and sprains and strains (16 percent) (see Table 3.2, above, for more details). One limitation of NEISS is that it covers only injuries treated in hospital emergency departments, which comprise only an estimated one-third of all work-related injuries (Ries, 1978; Unpublished tabulations, 1988 National Health Interview Survey, Occupational Supplement, NIOSH). Furthermore, for children and adolescents, emergency department personnel may not think to ask about the work-relatedness of an injury or may not note work-relatedness in the medical records. Comparing NEISS data to those from other systems is also difficult because NEISS uses unique coding systems and does not include the standard medical external-cause-of-injury coding (E-codes). Also, although the participating emergency departments are generally representative of emergency departments throughout the country, the youth populations served by the hospitals are not necessarily representative of the national population of young workers. In spite of its limitations, NEISS data showed more than three times as many work-related injuries to adolescents for 1992 than were reported by employers in the 1993 SOII. Some of the injuries found by NEISS may not have met OSHA's reporting requirements, but that seems unlikely to account for all the differences. In fact, follow-up interviews with youngsters identified by the system found that 68 percent of them experienced limitations in their normal activities (including school, work, and play) for at least one day (Knight et al., 1995)—which requires reporting by employers. National Hospital Ambulatory Medical Care Survey Beginning in December 1991, the National Center for Health Statistics began collecting information annually on emergency department and outpatient department visits from a nationally rep-

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States resentative sample of hospitals, through its National Hospital Ambulatory Medical Care Survey (NHAMCS). The survey collects information on patients' symptoms and demographic characteristics, diagnoses, services provided, drugs prescribed, referral status, and expected payment source. Although not limited to visits for injuries, NHAMCS data includes information on work-related injuries. The injuries are coded using the standard E-codes, allowing this data to be compared to those from other sources. Weiss et al. (1997) used NHAMCS data to study the incidence, characteristics, and payments of child and adolescent emergency department visits by narrow age groupings. No work-related injuries were recorded for youngsters under the age of 15 in the 1993–1994 survey. For adolescents aged 15 to 17 years, 103,000 visits were for injuries identified as work-related, more injuries than found by either SOII or NEISS data. Work-related injuries represented 5 percent of the emergency department visits for injuries by this age group. This may be a conservative estimate as place of injury was unspecified for 19 percent of the injuries. State-Based Surveillance Systems State-based surveillance activities provide important opportunities to link data collection efforts with active intervention in the workplace and community and to identify local concerns that may be obscured in national efforts. The Massachusetts Department of Public Health, for example, has been working since 1992, with funding provided by NIOSH, to establish a model state-based surveillance system for work-related injuries to youth. Recognizing that no single data source captures the full extent of the problem, the department uses several data sources to identify cases. New state regulations require physicians and hospitals to report to the department all cases of young people being injured at work. These reports, together with data from the workers' compensation system, the Census of Fatal Occupational Injuries, and the Fatality Assessment and Control Evaluation program, are used to identify cases. Some of the injured youngsters are interviewed to obtain additional information, and their cases may be referred to other agencies for workplace follow-up. Summary data are used to target a variety of broad-based intervention efforts, ranging from a community-based educa-

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States tion program to inform parents, teens, educators, and employers about the health and safety concerns of young workers to initiatives to update the state's child labor laws. State-level data on the extent of work by young people and on work-related injuries could be helpful in targeting inspections and studying injury rates. Many states oversee health and safety inspections of workplaces, but do not have the resources to mount a surveillance system, so they need better information to target those inspections. Other Data Sources Information from workers' compensation reports and claims has been used to analyze injuries among workers under the age of 18 in several states, including California (Bush and Baker, 1994), Connecticut (Banco et al., 1992), Massachusetts (Brooks and Davis, 1996), Minnesota (Heinzman et al., 1993; Parker et al., 1994a), New York (Belville et al., 1993), Texas (Cooper and Rothstein, 1995), and Washington (Heyer et al., 1992; Miller, 1995). A study in Utah looked at work-related burns, using both data from a hospital burn center and the State Insurance Fund's industrial records (Hayes-Lundy et al., 1991). Emergency-department data in Massachusetts (Brooks et al., 1993), other medical records in Wisconsin (Stueland et al., 1996), and survey methodology in Minnesota (Parker et al., 1994b) have also been utilized in studying injuries of young workers (see Table 3-2, above). The drawbacks to emergency department data have already been noted. Workers' compensation records also have some drawbacks. In no state are all employees covered; small-business employees, farm laborers, domestic servants, and casual employees are frequently excluded from workers' compensation. The self-employed are also excluded, and children working informally for family businesses are unlikely to be covered. The number of lost workdays required to qualify for workers' compensation payments differs by state, so comparisons of injuries across states are difficult. In addition, in many states, claims for medical treatment alone are not included in the computerized datasets, leaving only claims for lost worktime (indemnity claims) available for analysis. This exclusion may eliminate a large proportion of the cases. Between 1988 and 1991, for example, 76 percent of the claims for injuries to children

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States and adolescents in Washington state were claims for medical benefits only (Miller, 1995). There is also evidence that workers' compensation claims are less likely to be filed for injuries to adolescents than for injuries to adults (Brooks and Davis, 1996; Fingar et al., 1992). Fatal Work-Related Injuries There are a number of sources from which information on work-related deaths among children and adolescents can be garnered. State workers' compensation records, death certificates, medical examiner's records, federal and state safety-inspection records, and newspaper clippings are among those commonly examined. A number of federal systems draw on many of these records for their information. These datasets are collected for different purposes and from different sources, so each yields different estimates of the number of work-related fatalities. Each of the datasets also contains slightly different information and has its own advantages and drawbacks for understanding fatal injuries among youngsters under the age of 18. The Census of Fatal Occupational Injuries, an important recent initiative by the Bureau of Labor Statistics, combines data from multiple sources to obtain a comprehensive count of fatal injuries at work. There are four key sources of federal data on work-related fatalities: Census of Fatal Occupational Injuries; National Traumatic Occupational Fatality Surveillance System; Fatality Assessment and Control Evaluation Program; and Integrated Management Information System. Census of Fatal Occupational Injuries The Census of Fatal Occupational Injuries (CFOI), begun in 1992, is a cooperative effort of the Bureau of Labor Statistics (BLS) and the states to develop a complete and accurate count of work-related deaths. Because no single source of data provides an exhaustive count of all workplace fatalities, CFOI uses multiple sources to identify, verify, and profile all work-related fatalities. At least two independent source documents are used to verify the work-relatedness and the circumstances of the incident for each death recorded in CFOI. Source documents come from both the state and federal

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States levels and include workers' compensation records and claims, death certificates, newspaper articles, aircraft and highway transportation data, and other administrative records. Demographic information, the circumstances of each incident, the industry in which it occurred, the involvement of any equipment or machines, and the victim's occupation are recorded in CFOI. Data are available at the national, state, and metropolitan statistical area levels. BLS and the states share the costs and data-collection responsibilities. From 1992 to 1996, CFOI recorded a total of 339 deaths of children and adolescents. There were annual averages of 27 work-related deaths of youngsters under the age of 16, and 41 work-related deaths of 16-and 17-year-olds (Bureau of Labor Statistics, 1997b; Derstine, 1996). The most common causes of death during the period from 1992 to 1995 (latest year available) were motor vehicle or other transportation-related incidents and homicides. Agriculture was the most deadly industry for younger teens: Some 80 percent of the fatalities of youngsters under the age of 14 were in agriculture, as were 46 percent of the fatalities of 14-and 15-year-olds (Derstine, 1996). For 16-and 17-year-olds, about a quarter of the fatalities occurred in agriculture and a quarter in retail. More than 25 percent of all fatalities of youngsters under the age of 18 occurred in family businesses (Derstine, 1996). As is discussed at greater length in Chapter 6, agriculture is exempt from many child labor and health and safety laws. In 1993, homicides accounted for 28 percent of the work-related deaths of 16-and 17-year-olds recorded in CFOI (Toscano and Windau, 1994), compared with 10 percent of the work-related deaths from 1980 to 1989, as recorded in the National Traumatic Occupational Fatality surveillance system (NTOF) (Castillo et al., 1994). The differences between NTOF and CFOI, however, make it impossible to determine whether homicides at work have been increasing for this age group or were underreported in NTOF during the 1980s. A strength of CFOI is its use of multiple data sources to develop a relatively complete count of fatalities. However, the final count still depends on the recognition, in individual cases, that the deceased was working at the time of the fatal incident. Young people are not typically thought of as workers. It is, therefore, reasonable to assume that deaths among children and adolescents who are fatally injured on the job may not be identified as work-related deaths

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States and may be undercounted in the CFOI system. This undercounting may be particularly true of young workers on family farms and in family businesses, where the boundaries between work and family life are blurred. Information about whether safety or child labor laws were being violated during the fatal incidents is not systematically recorded. Another problem in using data from CFOI to assess the fatal injuries among young workers is that the rates presented by BLS in its standard reports are misleading. These rates are routinely computed using estimates of the number of employed persons in the denominator (e.g., deaths per 100,000 workers). For populations of workers who are employed part-time or temporarily, such as teens, calculating the rate using the number of workers overestimates the true period of exposure to job risks. In computing rates, the use of employment figures rather than numbers of full-time-equivalent workers results in underestimates of the risk-per-hour-worked for part-time workers. Exposure would be more closely approximated by hours of work. Ruser (1998) reports that the fatality rate for 15-to 19-year-olds is 4.0 per 100,000 full-time-equivalent workers, compared with a rate of 2.5 per 100,000 employed persons. (The rates for workers aged 20 to 64, who are more likely than youngsters to work full-time, remain substantially the same regardless of the denominator.) National Traumatic Occupational Fatality Surveillance System The National Traumatic Occupational Fatality Surveillance System (NTOF) is a census of all U.S. death certificates that have an external cause of death noted (i.e., are E-coded) and for which the certifier checked ''injured at work" on the death certificate. The National Institute for Occupational Safety and Health collects and automates death certificates from the 52 vital statistics reporting units (the 50 states, New York City, and Washington, D.C.) for workers 16 years of age and older. This system includes information on the victim's industry, occupation, cause of death, and a description of the injury, taken from the death certificate. Between 1980 and 1989, NTOF listed 673 deaths of 16-and 17-year-olds (Castillo et al., 1994). The leading causes of death were incidents involving motor vehicles (24 percent), machines (17 percent), electrocution (12 percent), and homicide (10 percent). The

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States industries with the most deaths were agriculture (110), construction (59), and services (56). Nearly half of the death certificates for 16-and 17-year-olds did not contain information on industry or occupation, however, so these numbers should be interpreted with caution. This surveillance system has a number of other limitations. Studies have found that, on average, death certificates capture only 81 percent of work-related deaths (Stout and Bell, 1991). Certain types of deaths are more likely to be undercounted by NTOF, including work-related homicides and motor-vehicle-related deaths—important causes of occupational fatalities among children and adolescents. Furthermore, only a 60–76 percent agreement exists between the "usual occupation" and "usual industry" entries on death certificates and the victim's actual employment at the time of death (Bell et al., 1990). For adolescents, the agreement may be even worse. Castillo et al. (1994) found the "usual occupation" of a high percentage of young people was listed as "student,'' even though other information on the death certificate indicated that the fatality was work-related. The NTOF surveillance system predates the CFOI by 10 years. The National Institute for Occupational Safety and Health and the Bureau of Labor Statistics are working to merge the two systems. Fatality Assessment and Control Evaluation Program The Fatality Assessment and Control Evaluation (FACE) program was developed by NIOSH to obtain more detailed information about the interactions of the worker, work environment, and work processes in work-related fatalities, details that are necessary to devise prevention strategies. This program provides an important follow-up component to the occupational fatality surveillance system. It involves in-depth, research-oriented investigations of targeted occupational fatalities, including fatal falls and machinery-related deaths. Confined-space deaths and electrocutions have been targeted in the past. NIOSH staff investigate deaths due to targeted causes in West Virginia and five surrounding states. With the assistance of NIOSH, 14 states enumerate all work-related fatalities occurring within their borders and conduct investigations of targeted deaths. For each investigation, a FACE report is prepared; it includes recommended measures to prevent similar deaths in the fu-

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States ture. These reports are widely disseminated to relevant trade associations, workers' organizations, and health and safety professionals. Because only certain causes of death are targeted, not all deaths of young people are investigated in participating states. Massachusetts is an exception, in that it targets all deaths of young people. Even though not all work-related deaths are included in the FACE program, it provides important contextual information that is unavailable in the other systems and can be vital to prevention efforts. Integrated Management Information System The Integrated Management Information System (IMIS) is maintained by OSHA. It is an inspection-based system, containing only information obtained as a result of visits by agency inspectors. Employers are required to report work-related fatalities to OSHA within 48 hours of their occurrence, but only the information on fatalities that are investigated is entered into IMIS. This information is the basis for annual reports by the agency on the number of inspections it has undertaken, the number of violations cited, the penalties imposed, and so forth. From 1984 through 1987, the database included 104 deaths of individuals under the age of 18; of these, 14 (13 percent) involved youngsters under the age of 15 (Suruda and Halperin, 1991). Incidents involving industrial vehicles or machines accounted for 30 percent of the deaths of children and youth under the age of 18. The other most frequent causes of death were electrocution (16 percent), falls (11 percent), and asphyxiation (11 percent). It should be noted that OSHA investigates less than 30 percent of all work-related deaths (Stout and Bell, 1991; Suruda, 1992). It does not investigate work-related homicides or most transportation accidents—neither of which is under OSHA jurisdiction—deaths in industries regulated by other federal agencies, deaths among federal workers, or deaths among the self-employed. In many states, all state and local public-sector workers are also excluded. Although a large number of young workers' deaths occur in agriculture, the industry is little investigated by OSHA. Although IMIS does not include all work-related deaths of children, it offers the ability to match violations of safety and child labor laws with deaths. Of 104 children whose deaths were identified through this system for the period from 1984 to 1987, Suruda and Halperin (1991) found that

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States 41 percent were doing work prohibited by federal child labor laws. Citations for safety violations were issued in 70 percent of these deaths. CONCLUSIONS Based on currently available data, injuries that are identified and specified as related to work appear to represent only a small percentage of all the injuries suffered by children and adolescents. Nevertheless, work-related injuries are widely recognized to be under-reported. As a national policy, the United States treats workplaces differently than other places. The Occupational Safety and Health Act was passed "to assure so far as possible every working man and woman in the Nation safe and healthful working conditions" (29 U.S.C. §651 (b)). Current child labor laws demand a higher degree of safety for those under the age of 18 by prohibiting them from engaging in jobs determined to be hazardous by the Secretary of Labor. Furthermore, people generally are more averse to risks that are not under their control (i.e., risks imposed on them) than they are to those over which they believe they have control or which they voluntarily assume (National Research Council, 1989; Slovik, 1987). The committee believes that most young people (and their parents) expect their workplaces to be safe and, therefore, do not voluntarily assume the risk of injury at work. The laws, in combination with the different values placed on voluntary versus involuntary risks, argue for attention to work-related injuries, particularly in cases when changes in the workplace could prevent injury. Children and adolescents routinely face hazardous working conditions. In spite of being legally prohibited from the most hazardous jobs, significant numbers of teens are still injured on the job each year. Factors that contribute to these injuries are largely determined by where the youngsters work, but the specific characteristics of workplace risks need to be better understood. Attention also should be paid to the roles played by inexperience, age, and developmentally inappropriate work assignments, as well as to factors related to physical and emotional development. Virtually no research has been done on illnesses resulting from occupational exposure during adolescence. Existing injury surveillance systems contain significant gaps. No single data source captures all occupational injuries. Although CFOI

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Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States combines data on fatal occupational injuries from multiple sources, no comparable system is available at the federal level for nonfatal work-related injuries. Surveillance of young people's work-related injuries is contingent on reliable identification of work-relatedness. It is reasonable to assume that occupational injuries suffered by youngsters are less likely to be recognized as work-related than are those suffered by adults. The potential for systematic omission of injured youths from existing occupational injury surveillance systems has not been rigorously evaluated. Ambulatory care data may provide an important complement to conventional occupational injury surveillance data-sets, such as workers' compensation and the Survey of Occupational Injuries and Illnesses, and to the ability to examine occupational injuries in relation to other injuries suffered by children and adolescents.