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In the late 19th century, workers' health was among the central concerns of the social reform movement to improve public health. Today, few state health agencies have comprehensive occupational health programs. Yet, state public health agencies have critical roles to play in occupational health and may be particularly instrumental in addressing the occupational health needs of underserved worker populations.
Since the mid-1980s, with support from the National Institute for Occupational Safety and Health, the Massachusetts Department of Public Health has been working to build an occupational health program and promote the integration of occupational health concerns with ongoing public health activities in the state. This article provides a framework for considering the range of integration activities and presents examples of successful occupational health integration efforts in Massachusetts.
In the late 19th century, factory conditions and worker's health were among the central concerns of the social reform movement that led to the development of the public health system in the United States.1 In the first half of the 20th century, the lead role in occupational health and safety alternated between the U.S. Public Health Service and the U.S. Department of Labor.2 With the passage of the Occupational Safety and Health Act in 1970 and the new regulatory roles subsequently entrusted to federal Occupational Safety and Health Administration and state labor departments, responsibility for occupational safety and health appears to have been largely relinquished by state health departments. Today, relatively few state health departments have well-developed occupational health programs.3
Regulatory agencies clearly have central and essential functions in protecting workers' health. However, enforcement of workplace health and safety regulations and compliance assistance are only one component of a comprehensive public health approach to workplace health and safety. State public health agencies have critical, complementary roles to play in conducting surveillance of work-related diseases and injuries, investigating occupational health problems in the community, and implementing prevention activities to protect workers' health.4–6 Public health departments, which have always emphasized addressing health concerns of those most in need, may play a particularly important role in addressing the occupational health needs of underserved worker populations, such as immigrant and minority workers, who comprise a significant proportion of an increasingly diverse workforce.
In 1986, with funding from the National Institute for Occupational Safety and Health (NIOSH), the Massachusetts Department of Public Health (MDPH) established the Occupational Health Surveillance Program (OHSP) with two professional staff members. Early on, OHSP spearheaded an interagency task force that developed recommendations to improve surveillance of work-related injuries and illnesses, leading to new state public health regulations requiring health-care providers to report select occupational health conditions to MDPH.7 Today, OHSP has a professional staff of nine and is supported by a combination of state (25%) and federal (75%) resources. OHSP has succeeded in using a wide variety of state data sources, many not traditionally used for occupational health surveillance, to track work-related injuries and illnesses (Figure 1).
Case-based surveillance systems that include case follow-up activities are in place for a number of targeted health conditions including, among others, fatal occupational injuries, work-related injuries to teens younger than 18 years of age, and work-related asthma. Population-based data sources are also used to characterize occupational health risks faced by Massachusetts workers and to generate state occupational health indicators annually.8 OHSP actively links surveillance findings with intervention efforts at the state and local levels, and works with numerous government and community partners to address identified health and safety problems.
Over time, our experience has revealed many untapped opportunities for integrating occupational health with the ongoing activities of other public health programs in the state. In 2001, we set out to systematically identify these opportunities, conducting key informant interviews with the staff of 32 programs throughout MDPH. In this article, we describe a simple conceptual framework for considering the range of potential integration activities that emerged from this effort and provide several examples of successful efforts to integrate occupational health with mainstream public health practice in Massachusetts.
Two major themes emerged from interviews with staffs of other public health programs and our experience: convergence and access. Convergence in public health practice occurs when the health concerns of workers and the public at large clearly intersect. Many health hazards, such as poor indoor air quality in schools and latex exposures in hospitals, directly threaten the health of workers and the general public. These shared hazards demand solutions that protect all those at risk. Convergence also occurs when the public health focus is on health outcomes, such as asthma, cardiovascular disease, and violence-related injuries, for which occupational risk factors are among multiple contributing factors. Comprehensive approaches to these shared health outcomes require collaborations between occupational health practitioners and colleagues in other public health fields.
Likewise, contemporary public health concerns regarding emerging infectious diseases, such as severe acute respiratory syndrome, and biological and chemical terrorism preparedness, are also worker health issues, not only because exposures and attacks have occurred in workplaces, but also because those responsible for first response and recovery are workers. Policy makers dealing with these concerns require the expertise of a public health team that includes occupational health experts, as well as worker representatives.4
The theme of access emerged as we identified a range of opportunities for using the existing public health infrastructure to reach workers, workplaces, and health-care providers. As noted, public health often focuses on those most in need. Many public health programs target specific underserved populations, such as minorities, immigrants, migrants, adolescents, and those with disabilities. These are the very same populations that have been identified as priority worker populations, defined as groups of workers who have social, economic, or biologic characteristics that place them at increased risk of developing work-related health problems.9,10 Occupational health disparities arise both from overrepresentation of priority populations in the most hazardous occupations, as well as lack of access to occupational health and general health-care resources due to social, cultural, or economic barriers (e.g., language, literacy, and marginal economic status).11,12
Existing public health programs and networks can serve as important points of access for reaching priority worker populations with information about health and safety risks, prevention strategies, occupational health services, and legal rights. These avenues can be two-way streets through which health departments can not only provide occupational health and safety information and services, but also collect information from community members about their health and safety needs and experiences. Occupational health practitioners can also learn from public health colleagues who are (1) experienced in working with underserved populations, (2) familiar with issues of linguistic and cultural competency, and (3) passionate about serving their constituencies.
Public health agencies also serve as a critical point of access to the health-care community, including health-care facilities and individual providers. Public health agencies are responsible for licensing health-care facilities and assuring the quality of patient care. While quality assurance activities are focused on the patient, they can also have important implications for health-care workers. State health departments routinely interface with health-care providers directly and through state professional organizations, and can play an active role in educating them about the diagnosis and treatment of occupational diseases. They may also readily call on the clinical expertise of the medical community through department advisory boards and councils. Because public health agencies have responsibilities for food and school safety, they can also serve as avenues to employers and workers in restaurants and schools.
Following are several examples of how OHSP has partnered with other public health programs in efforts to improve the health and safety of working people in Massachusetts.
OHSP participates in the NIOSH-funded Sentinel Event Notification System for Occupational Risks (SENSOR) asthma program, which tracks work-related asthma (WRA) in the state. SENSOR is a sentinel case surveillance system intended to identify asthma-causing agents and workplaces where people are at risk. In the mid-1990s, multiple cases of latex-related asthma among health-care workers were reported, highlighting the problem that latex in gloves poses for both workers and patients. The Massachusetts cases helped prompt NIOSH to develop an alert on latex in the workplace.13
Locally, OHSP spearheaded an intra-agency latex team that included representatives of multiple MDPH programs: communicable disease control, immunization, human immunodeficiency virus (HIV), dental health, food safety, and child care safety, as well as the MDPH division that licenses hospitals and clinics in Massachusetts. In collaboration with other programs, OHSP surveyed acute care hospitals statewide about latex-glove use. The MDPH team also joined with the state medical society, the hospital association, and several nurses' organizations to sponsor a statewide conference on the risks of latex and proposed solutions. Existing networks were used to disseminate the NIOSH alert on latex to health-care facilities statewide.13
In 2000, revised MDPH food safety regulations cautioned against using latex gloves in food service, and, in 2002, emergency medical service regulations were issued requiring the availability of latex-free kits in ambulances. OHSP's occupational health experts brought important technical expertise and leadership to the MDPH team, contributing to the development of public health policies and practices to protect the public at large, with secondary gains for worker safety and health.
From 1994 through 2003, 45 cases of WRA associated with latex were reported to Massachusetts SENSOR; since 2004, no cases associated with latex have been reported. The findings from this sentinel case surveillance system do not necessarily reflect the underlying incidence of latex-associated asthma in Massachusetts workers. However, the decline in reported latex cases parallels a decline in the use of powdered latex gloves, as well as changes in latex-glove manufacturing processes. Collaborating with other public health programs, OHSP was able to maximize limited prevention resources to protect both patients and workers.
In 2001, the Council of State and Territorial Epidemiologists identified 13 priority occupational health conditions for surveillance in a comprehensive nationwide occupational health surveillance system (Figure 2).6 Only one of the priority health conditions identified, pneumoconiosis, is uniquely occupational. The remaining health conditions are also the focus of other public health domains, and all are addressed in Healthy People 2010 objectives outside of those established for occupational safety and health.14 Comprehensive approaches to preventing these conditions required (1) breaking down the traditional silos reinforced by categorical funding to bring together experts from various public health domains and (2) including stakeholders in the process.
In 2001, MPDH became one of 14 state health agencies funded by the Centers for Disease Control and Prevention (CDC) to launch a statewide, coordinated effort to prevent and control heart disease and stroke. The focus was on improving policies and systems to effect change, and the workplace was specifically designated by CDC as one of several venues in which to consider taking action. The MDPH Heart Disease and Stroke Prevention and Control Program enlisted a wide range of community partners in strategic planning to identify short- and long-term priorities, as well as lead partners to be responsible for implementing specific objectives. As an early step in this process, the MDPH Heart Disease and Stroke Prevention and Control Program conducted a survey of workplaces about worksite wellness policies and practices. This survey, while informative, did not address occupational risk factors for heart disease. Recognizing this initiative as an opportunity to raise awareness about these risk factors, OHSP staff joined the strategic planning group, recruiting local academic colleagues with expertise in workplace stress to play an active role.
More than 100 organizations and agencies met during a four-year period to develop the state plan. Participating occupational health experts underscored the importance of addressing workplace stress, which is recognized as a risk factor for heart disease in a number of countries, but not widely acknowledged as such in the United States.15 The planning group, known as the Partnership for a Heart Healthy Stroke Free Massachusetts (hereafter called the Partnership) decided that building awareness would be an essential first step. The final plan, released in 2005, included a specific objective to increase awareness among health professionals of the causal relationship between workplace stress and the development of heart disease and stroke.16
Implementation of the strategic plan for a heart-healthy, stroke-free Massachusetts is underway. The University of Massachusetts at Lowell (UML), with support from NIOSH, is the lead partner in implementing the workplace stress objective.17 UML investigators conduct key informant interviews with employee assistance professionals, health-care practitioners, and workplace health professionals to ascertain current knowledge and attitudes about workplace stress, with the goal of developing user-friendly educational materials and programs for target audiences.
OHSP's participation in this effort has resulted in an ongoing working relationship between OHSP and the expanding MPDH Worksite Wellness Program. The two programs have recently collaborated to develop a Worksite Health Survey tool that includes questions about health protection (e.g., occupational health) as well as health-promotion programs and policies. This survey was administered by mail in spring 2008 to a stratified (by size, region, and industry) random sample of 3,000 Massachusetts workplaces with 11 or more employees. Findings based on responses from a representative group of 890 establishments have provided important new information about worksite health and safety and wellness programs in the state that can serve as a baseline for monitoring progress in promoting healthy worksites (Figure 3).18
Eliminating racial/ethnic health disparities is an overarching public health goal for Massachusetts, as well as the nation.14,19 OHSP has, in turn, established the need to address gaps in the surveillance of underserved worker populations and to work with community partners to address disparities in occupational health as a program priority. Community health centers (CHCs) have been identified as partners in this effort. CHCs are nonprofit, community-based providers of primary and preventive health care that serve one out of every nine patients in the state. These centers, licensed and partly funded by MDPH, serve as points of access to low-income families, minorities, and immigrants. They aim to provide culturally appropriate health care to the diverse patient populations they serve. In Massachusetts, 52 CHCs provide community-based care across 184 sites, caring for an estimated 47% of the state's medically underserved residents.20
During 2000 and 2003, funded by a NIOSH surveillance research grant, OHSP conducted a project to assess the feasibility of collecting data on the occupational health experience of low-income minority and immigrant workers through CHCs. As a component of that project, OHSP surveyed more than 1,400 working patients in five CHCs (66% of whom were immigrants) about their occupational health experiences. The occupational distribution of survey respondents closely resembled the employment profile of immigrant workers in Massachusetts (highly overrepresented in service occupations and as operators and laborers). Survey findings based on this convenience sample provided previously unavailable local data on the occupational health experience of low-income minority and immigrant workers and underscored the need to address the occupational health concerns of these underserved workers (Figure 4).21
The project also allowed OHSP to learn about CHC practices, data systems, and community programs and to meet with providers and other staff to discuss possible future collaborations for improving occupational health surveillance. OHSP is currently engaged in a follow-up project to pilot-test implementation and institutionalization of occupational health surveillance at CHCs. Electronic health records systems, rapidly being adopted at CHCs statewide, represent an opportunity to improve case identification and management of work-related conditions and reporting to state surveillance systems. The ongoing project involves implementing occupational health surveillance at four CHCs through modifications to clinical records systems and provider education. The long-range goal is to institutionalize capacity to collect data that will allow OHSP and others, including community-based health-care providers, to target intervention activities effectively and reduce occupational illnesses and injuries among minority and immigrant workers in Massachusetts.
Health care is the largest single industry in Massachusetts, employing 470,000 people, approximately 40% of whom work in hospitals.22 In 2000, Massachusetts joined a growing number of states enacting laws to prevent sharps injuries to hospital workers. The Massachusetts law requires all hospitals licensed by MDPH to use sharps with engineered injury prevention features to the extent feasible, develop written exposure control plans, maintain logs of sharps injuries, and use this information for quality improvement.23 This law mirrors federal needlestick legislation, adding the requirement that Massachusetts hospitals submit data from their sharps injury logs to MDPH and calling for the establishment of a committee comprising representatives of industry, labor, and health-care professional organizations to advise MDPH on sharps injury prevention.
MDPH sharps injury regulations are incorporated within the MPDH hospital licensure regulations enforced by the MDPH Division of Health Care Quality (DHCQ). OHSP collaborates with DHCQ and the MPDH Bureau of Communicable Disease Control in implementing these regulations and has taken the leading role in developing the Massachusetts Sharps Injury Surveillance System.24
Prior to implementing the new requirements, MPDH conducted a survey of hospital employee health staff to identify occupational injury data collection practices and worked closely with members of the Sharps Injury Prevention Advisory Committee to develop effective mechanisms for reporting sharps injury data that could easily be used by hospitals. Since the reporting regulations went into effect in 2001, OHSP has received annual summary reports of sharps injuries from all 99 licensed hospitals. OHSP has prepared annual reports of sharps injury surveillance findings as well as special topic reports, and an analysis of the first six years of sharps injury data is underway.
Surveillance findings have been shared at annual meetings of employee health staff from hospitals throughout Massachusetts. These meetings also provide opportunities for hospitals and health-care workers to learn from each other. OHSP staff has accompanied DHCQ health-care surveyors on visits to hospitals to assess compliance with regulations. OHSP also provides technical assistance to hospitals regarding sharps injury surveillance and prevention on an ongoing basis via site visits, telephone consultations, and periodic statewide educational conference calls.
The Massachusetts Sharps Injury Surveillance System provides the country's most complete and representative statewide data on sharps injuries to hospital workers. Success in building this surveillance system can be attributed to a combination of factors: MDPH's regulatory authority over hospitals, regular communication with hospital employee health staff, and ongoing collaboration of OHSP with other MDPH programs and with both employers and labor. Surveillance findings allow MDPH, hospitals, and hospital workers to track progress in meeting sharps injury prevention goals and have identified needed interventions and outstanding research questions. As shown in Figure 5, a substantial number of injuries continue to occur with devices that lack safety features, underscoring the need for additional efforts to replace these products with safety devices. However, injuries also occur with safety devices, and more research is needed to evaluate the efficacy of different types of safety features and the effect of training people to use these newer devices.
In part as a result of its leading role in sharps injury surveillance, OHSP has become a known resource regarding bloodborne pathogen exposure control for a number of other MDPH health programs, including school health and dental health. Currently, OHSP is participating in an MPDH team including the diabetes control, HIV/acquired immunodeficiency syndrome, environmental health, and communicable disease control programs working to craft legislatively mandated state policy for community disposal of the more than 70,000 needles used by Massachusetts residents each week. Whereas the environmental health program is taking the lead in this effort to protect the public, OHSP's role is to ensure that the health and safety needs of workers at disposal sites are addressed.
The examples in this article are just several of the many activities OHSP has undertaken to integrate its work with that of other public health programs in Massachusetts. Our public health colleagues have been very open to collaboration and, in fact, opportunities for integration have far exceeded OHSP's capacity to respond. In some cases, such as the cardiovascular health initiative described previously, we have been able to enlist local experts to take up the task. While occupational health has been well-received, we have also found that it is often not well-understood, underscoring the need to build core occupational health capacity within state health departments.
The briefest summary of lessons learned echoes lessons from any cross-disciplinary collaboration: (1) build trusting relationships (this takes time), (2) avoid jargon, and (3) listen closely to the priorities of partners. In choosing integration opportunities, we learned to select those that were consistent with our own program objectives. By working with our public health colleagues, we have been able to extend our capacity for occupational health surveillance and intervention, garner additional state resources, and build new occupational health allies. We have been able to offer needed expertise to other programs, and likewise to learn from experts in other public health domains.
The fundamental challenge for public health departments interested in addressing worker health and safety is garnering resources to develop and sustain core occupational health capacity. As noted previously, MDPH continues to rely heavily on federal resources to support OHSP. This reliance on federal support is hardly exceptional: the federal government provides nearly 60% of all public health funds in the U.S. and nearly 75% of funding for U.S. epidemiologic activities.3,25 For example, CDC provides all U.S. states with funding for surveillance of both communicable and chronic diseases. While NIOSH acknowledges the critical role that state surveillance plays in the overall surveillance of work-related conditions nationwide, resources allocated to surveillance are limited, and fewer than 15 states have NIOSH funding to implement occupational health programs. There is clearly a gap in the federal infrastructure with respect to providing core support for occupational public health in the states, which needs to be addressed.
The majority of adults and many adolescents spend much of their waking lives at work. The work environment—both physical and organizational—contributes to the development of adverse health outcomes directly though exposure to workplace hazards. Furthermore, the stresses and rewards of work can either undermine or enhance workers' ability to care for their own health. It is essential to address the impact of work on health in the overall effort to protect the public's health and reduce preventable human suffering and health-care costs. The integration of occupational health with mainstream public health is long overdue and is particularly important today as we seek to address the full range of health needs of an increasingly diverse and mobile workforce.
The work of the Massachusetts Department of Public Health Occupational Health Surveillance Program described in this article has been funded in large part through cooperative agreements with the National Institute for Occupational Safety and Health.