The social consequences of occupational injuries and ...

AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 40:403±417 (2001)

The Social Consequences of Occupational Injuries and Illnesses Allard E. Dembe,

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Background Most outcome studies of occupational injuries and illnesses have tended to focus on direct economic costs and duration of work disability. Rarely have the broader social consequences of work-related disorders or their impacts on injured workers' families, coworkers, and community been investigated. This paper examines a wide range of social consequences including workers' psychological and behavioral responses, vocational function, and family and community relationships. Methods Literature review and development of conceptual framework. Results Complex and multifactorial relationships are described whereby occupational injuries and illnesses produce a variety of social consequences involving ®ling and administration of workers' compensation insurance claims, medical care experiences, domestic function and activities of daily living, psychological and behavioral responses, stress, vocational function, rehabilitation and return to work, and equity and social justice. Conclusion A research agenda is proposed for guiding future investigations in this ®eld. Am. J. Ind. Med. 40:403±417, 2001. ß 2001 Wiley-Liss, Inc. KEY WORDS: occupational; illness; injury; social consequencs; stress; disability; workers' compensation; family; community; equity

INTRODUCTION There is an extensive body of research literature documenting the signi®cant social consequences of human illness. For example, numerous studies from the general health ®eld have examined the impact of disease on patients' emotional health, family dynamics, and economic wellbeing [e.g., Williams, 1989; Nocon and Booth, 1991; van der Sluis et al., 1998; Carr, 1999]. However, comparatively little investigation has been conducted so far into the social effects associated with work-related injuries and illnesses. Most outcome studies in occupational health have focused

This paper was first presented at the NIOSH conference, ``Functional, Economic, and Social Outcomes of Occupational Injuries and Illnesses: Integrating Social, Economic, and Health Services Research,'' Denver, CO, June13^15, 1999. Center for Health Policy and Research, Department of Family Medicine and Community Health, University of Massachusetts Medical School, 222 Maple Avenue, Shrewsbury, MA 01545. E-mail: [email protected] Accepted1February 2001

ß 2001Wiley-Liss, Inc.

instead on workers' compensation (WC) insurance payments, the provision of medical services, the time needed for return to work, and other direct insurance and employment-related measures. Rarely have investigators attempted to estimate the various indirect economic consequences of a workplace injury or evaluate its true impact on the lives and daily activities of affected workers and their families. This paper will attempt to advance this ®eld of inquiry by providing a conceptual framework for identifying and analyzing these ``hidden'' social consequences, reviewing studies that have been performed in this area, and proposing a research agenda to guide future efforts to understand the social consequences of occupational injuries and illnesses.

CONCEPTUAL FRAMEWORK The social consequences of an occupational injury or illness are dif®cult to isolate and measure. Although the injured worker is normally the person most directly affected, workplace accidents also potentially impact on family members, coworkers, medical care providers, insurance admin-

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istrators, and a host of other individuals and groups. The repercussions of an occupational injury or illness reach beyond the boundaries of the victim's workplace and home, extending into hospitals, courts, and the local community. Figure 1 illustrates a model depicting how an occupational injury or illness to an individual worker is embedded

in a complicated web of reciprocal relationships with other individuals, groups, and social institutions. The dark lines with arrows are meant to represent potential impacts and causal connections between entities. The double arrows signify that these determinants can potentially operate bidirectionally, with occupational injuries and illnesses both

FIGURE1. The social context of occupational injuries and illnesses.

Social Consequences of Injuries

resulting from the con¯uence of various social in¯uences while also creating a wide assortment of social effects. In practice, the reciprocal relationships are more numerous and complicated than can be portrayed in this simpli®ed sketch, because each entity and group can potentially affect others. For example, the medical profession's response to diagnosing and treating occupational disorders can affect workplace practices, thereby altering the chances for subsequent job-related injuries. Similarly, family members' response to a worker's injury can spark disputes with WC insurers or help promote labor union involvement. In other words, the various social factors and consequences depicted in Figure 1 are not necessarily independent but rather are tightly intertwined. This makes it dif®cult to track these

many components and address them through appropriate policy measures and services. It also poses interesting methodological challenges for researchers. A potential schema for classifying the social consequences of occupational injuries and illnesses is presented in Table I. The schema is based on categorizing social impacts according to who is affected, how they are affected, where the effect takes place, and the type of effect. It recognizes that there may be social consequences for others besides the injured worker, including the worker's family, friends, and coworkers (Column 1). Individuals and groups can be affected in a variety of ways, according to their domestic, vocational, and other societal roles (Column 2). The in¯uences of a job-related injury can extend into diverse settings

TABLE I. The Social Impacts of Occupational Injuries and Illnesses Affected individuals and groups

Societal roles

Institutions and structures

Work environment Injured Worker Coworkers Employer Management Office staff Safety/health officials

Vocational

Workplaces

Domestic

Hospitals/clinics

Leisure

Homes

Recreational

Neighborhoods

Civic

Churches

Political

Schools

Religious

Stores/markets

Economic

Businesses

Educational

Courts

Professional

Prisons

Biological

Social care agencies

Family and friends Worker's family Worker's friends Worker's colleagues Worker's neighbors Community WC insurers Other insurers Health care providers Labor unions Other worker groups Employer groups Lawyers Judges Regulators Lawmakers

Sociocultural

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Examples and manifestations Vocational function Reduced wages Diminished productivity Unemployment Retraining Psychological and behavioral responses Stress Depression Anger Stigmatization Isolation Violence Suicide Unhealthy behaviors,e.g., smoking, drugs Social effects Medical care utilization Household tasks Interpersonal communication Family relationships Sleep/sexual disruption Divorce Community involvement Discrimination Physical status and limitations Impairment Disability Pain Effects on activities of daily living

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including homes, workplaces, medical clinics, and community institutions (Column 3). Multifarious impacts are possible including vocational, psychological, behavioral, social, economic, and functional effects (Column 4). In theory, a wide assortment of social consequences is possible through combining items from each of the four columns in Table I. For example, one consequence of a workplace injury could involve the inability of a worker's child (Column 1) to engage in recreational activities (Column 2) at school (Column 3) because of diminished family income resulting from the injured worker's reduced wages (Column 4). Here again, the effects are not necessarily independent. So, for instance, an injured worker's (Column 1) psychological stress (Column 4) can affect the performance of a spouse's (Column 1) domestic (Column 2) tasks (Column 4). Similarly, retaliatory reactions (Column 4) by employer management (Column 1) to a worker's (Column 1) injury might stimulate anger, drug abuse, or other behavioral reactions (Column 4) among the injured person's coworkers (Column 1). These complex interactions create signi®cant dif®culties for researchers attempting to study the social consequences of workplace injuries and illnesses. Any analysis is likely to be fragmentary because of the investigator's inability to isolate social impacts precisely. Comparative information may be lacking, so even if an effect can be measured (e.g., anxiety among injured workers), similar referent data for uninjured workers or the general population may not be available. Existing claims, personnel, or medical databases will rarely contain suf®cient information for studying these social effects. Workers' compensation data may underestimate the extent of problems because claims might not be ®led or accepted into the system, especially for contingent and undocumented workers who are less likely to report job-related illnesses and injuries [Quinlan and Mayhew, 1999]. To better capture the full range of social effects, some authorities have advocated new research paradigms that go beyond what can be evaluated through the use of conventional data systems and quantitative techniques [Needleman, 1997]. Expanded use of qualitative research approaches, including ethnographic interviews, focus groups, population-based surveys and questionnaires, and case studies may be needed. For some areas of interest (e.g., depression, activities of daily living), validated data collection instruments and assessment systems are available. But many other social impacts lack uniform approaches for data collection or measurement. As a result, investigators may need to develop new approaches, and create and ®eld test their own data collection tools [Pransky et al. this issue]. Some economic analyses of occupational injuries and illnesses have attempted to estimate or impute costs to these social impacts. Such ``indirect'' costs can be compared or combined with direct expenditures made by insurers, em-

ployers, and/or healthcare providers. This allows investigators to more precisely approximate the total economic burden created by occupational injuries and illnesses, which may be useful for policy making and allocating resources. However, translating social consequences into an economic scale is tricky, at best, especially for subjective responses such as anger, depression, sleep disturbances, and pain which may have no discernible ®nancial correlates. Studying the social consequences of occupational injuries and illnesses is further complicated by the need to consider the magnitude and severity of the disorder. The type, locus, and extent of social effects, presumably, varies according to the extent of injury. Clearly, a serious, disabling back injury can be expected to produce more substantial and varied social effects than will a minor sprain. A prolonged occupational illness with extensive impairment requiring lengthy rehabilitation will probably have a greater social impact than one which is less severe. Disasters, and accidents resulting in multiple injuries and fatalities, may result in widespread psychological reactions within a community or population of workers. Investigators studying the social impact of occupational disorders must devise a way of classifying different types of workplace injuries and illnesses, and differentiating their severity and scope. Also, severe injuries and illnesses may result in prolonged disability and rehabilitation, which are themselves social impacts that can subsequently produce additional social effects. The sociodemographic attributes of affected individuals and groups can also potentially modify the type and extent of an injury's social consequences. Characteristics such as the injured worker's age, gender, race, ethnicity, nationality, education, and socioeconomic status could in¯uence the responses of the worker as well as the employer, insurer, and medical provider. An outbreak of occupational asthma among a group of young, low-wage, immigrant workers, for example, might be expected to produce substantially different social impacts that a comparable outbreak among welleducated and af¯uent professionals. Women and men might respond very differently to the social pressures imposed by an episode of disabling back pain, even if their back injuries were of a similar type and severity. Similarly, an injured worker's occupation and social class might be an important modifying factor. Dermatitis among a group of manual laborers or migrant farm workers could be expected to have signi®cantly different social repercussions than dermatitis among a group of laboratory scientists. To assess the social impacts of an occupational injury or illnesses, it is also necessary to consider the time course of the patient's medical condition and associated disability. Different types of social consequences can occur at various stages of a patient's response to injury and subsequent recovery. For example, interactions with medical care


providers may be prominent during the early phase of medical evaluation and treatment for a workplace injury. At later stages, social issues surrounding the workers' compensation system and job re-entry may predominate. Depression or other signi®cant psychological reactions might not develop until after a prolonged period of chronic disability and pain. The duration of symptoms and work disability can potentially modify the responses of family, coworkers, and others. Figure 2 depicts some of the ways that these kind of ``modifying factors'' can help determine the social cons-

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equences of an occupational injury or illness. It illustrates how work-related injuries and illnesses, and their consequences can be viewed as part of a broader process of interactions between people, their jobs, and their social environment. Contemporary theories of the so-called psychosocial dimensions of workplace injuries [e.g., Feuerstein, 1993; Sauter and Swanson, 1996; Moon, 1996; Ciof®, 1996] have adopted a similar perspective, emphasizing the interplay between personal, organizational, and ergonomic in¯uences that precipitates job injuries, disability, and related social responses.

FIGURE 2. Examples of modifying factors.

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REVIEW OF CONTEMPORARY RESEARCH Empirical research into the social consequences of work-related injuries and illnesses is in its infancy. Few studies have systematically de®ned or measured these effects. Recently, however, several studies of occupational injuries and illnesses have been undertaken that attempt to broaden the assessment of outcomes beyond those considered in traditional economic evaluations. Most of these new studies examine functional and vocational status, satisfaction, and worker experiences with the workers' compensation and medical care systems. Some of them include an assessment of selected social consequences. Below is a synopsis of some of the key ®ndings of the relevant research conducted thus far in this ®eld.

Workers' Compensation Experiences Injured workers generally report negative experiences with a workers' compensation system that is perceived to be uncaring, unfair, and adversarial [Reid et al., 1991; Imershein et al., 1994; Dawson, 1994; Sum, 1996]. In one Florida study, only 10% of claimants reported having a good experience with the WC system [Imershein et al., 1994]. Many workers face obstacles in gaining what they consider to be rightful bene®ts, are treated in demeaning and disrespectful ways, and receive minimal assistance from employers and WC insurers [Sum, 1996]. Those missing time from work because of an occupational injury are frequently labeled as malingerers, feel stigmatized, and have dif®culty in getting their conditions recognized as legitimate [Reid et al., 1991; Imershein et al., 1994; Dawson, 1994; Eakin and MacEachen, 1998]. Several investigations have documented the signi®cant barriers confronting injured workers trying to gain bene®ts through the workers' compensation system. Available data indicates that injured workers may be reluctant to report work-related ailments for a variety of reasons including fear of reprisal, a belief that pain is an ordinary consequence of work activity or aging, lack of management support after prior reports, and a desire not to lose their usual job [Jefferson and McGrath, 1996; Silverstein et al., 1997; Pransky et al., 1999; Rosenman et al., 2000]. Data from the Michigan state surveillance system indicate that only 9± 45% of workers diagnosed with an occupational disease ®le for WC bene®ts [Biddle et al., 1998]. A recent Connecticut study estimates that just 10.6% of workers with workrelated chronic upper extremity pain ®le a workers' compensation claim for their condition [Morse et al., 1998]. Pransky et al. [1999] found that 10% of surveyed workers do not report work-related injuries because of fear of employer reprisal, and that employer-sponsored safety award programs based on decreasing claims frequency rates create an

additional disincentive for appropriate reporting of work injuries. Even though the employer's WC insurance is supposed to pay for all medical care for work-related conditions, many persons suffering work-related injuries and illnesses utilize their own health insurance or other private or public assistance programs to pay for medical care and other expenses related to their injury [Dawson, 1994; Texas Workers' Compensation Research Center, 1995; Morse et al., 1998; Keogh et al., 2000]. In some cases, injured workers incur substantial out-of-pocket expenses for treatment of job-related disorders [Morse et al., 1998; Galizzi et al., 1998]. Workers' compensation insurance is also intended to provide wage replacement bene®ts for employees who are unable to earn their regular income as the result of a job injury. In reality, because most states cap the amount of available income replacement bene®ts and/or limit their duration, injured workers commonly suffer a net loss of real earnings and can, as a result, experience signi®cant economic hardship [Boden and Galizzi, 1999; Reville, 1999]. A sizable proportion of injured workers report that they needed to dip into savings, had problems paying bills, or were forced to borrow money as a consequence of their work injury [Texas Workers' Compensation Research Center, 1995; Morse et al., 1998; Keogh et al., 2000; Pransky et al., 2000]. Workers interviewed in Pennsylvania reported that they had to wait an average of 20 months after a workplace injury to get income replacement bene®ts because of delays in approving and processing their WC claims [Dawson, 1994].

Medical Care Experiences Several recent studies have examined workers' satisfaction with medical care for job-related injuries and illnesses [Appel and Borba, 1994; Borba et al., 1994; Imershein et al., 1994; Keyes et al, 1999; Oregon Workers' Compensation Division, 1999]. In general, these studies have found that patient satisfaction is lowered when care is provided within managed care plans, in part because of the diminished ability of injured workers to choose a treating provider and inconvenience in accessing appropriate care [Dembe, 1998; Keyes et al., 1999]. Satisfaction with medical care provided through workers' compensation is generally lower than for general health care provided for nonoccupational conditions [Dembe, 1998]. Patients with work-related conditions report that physicians often do not take their problem seriously and fail to understand the nature of their jobs [Reid et al., 1991; Imershein et al., 1994; Pransky et al., 2000]. Most injured workers report that the primary treating physician did not give them any advice about the prevention of further injury [Pransky et al., 2000] Not surprisingly, a large proportion


(about 38%) of injured workers experience a reinjury after returning to work [Pransky et al., 2000]. In addition, many of those who return to their jobs after a work injury continue to experience residual pain [Keogh et al., 2000; Pransky et al., 2000]. Many workers have trouble accessing appropriate medical care because of delays and insurance company denials [Dawson, 1994; Galleagher and Myers, 1996; Herbert et al., 1999; Kelley and Amparo, 2000]. Available evidence suggests that the likelihood of claim denial and subsequent delays in medical care is related to the patients' ethnicity (nonwhites more likely to be affected) and socioeconomic status (low-wage earners) [Dembe, 1999; Herbert et al., 1999].

Domestic Function and Activities of Daily Living Preliminary results from a study of Maryland workers indicate that upper-extremity cumulative trauma disorders interfere with sleep and the performance of household activities [Keogh et al., 2000]. In another study, domestic disability among workers with hand/wrist repetitive strain disorders was found to be minimal, though they frequently needed to use assistive devices such as jar openers [Helliwell et al., 1992]. Because of the ®nancial burdens created by job injuries, workers suffering from upperextremity musculoskeletal disorders reported that they were more likely to have moved their primary residence, lost their home, lost their car, and lost their health insurance compared to a non-injured control group [Morse et al., 1998; see also Keogh et al., 2000]. These workers also reported considerably more dif®culty performing activities of daily living, such as writing, gripping, household chores, opening jars, child care, carrying bags, brushing, bathing, and driving a car [Morse et al., 1998]. Similar results were obtained by Keogh et al. [2000] who examined workers with upper-extremity cumulative disorders at an average of 28 months after their initial WC claim ®ling, and found that over 40% of them were still experiencing dif®culty pushing a window open, pouring from a container, writing with a pen, lifting a child, mopping ¯oors, and placing items on a high shelf. Ethnographic interviews of Wisconsin workers with disabling back pain have shown that owing to their occupational injuries, most men and about 20% of women have problems doing outdoor chores like mowing the lawn, shoveling snow, and yard work [Strunin and Boden, 1997]. A third of these workers reported some dif®culty performing other household tasks including cleaning, shopping, taking out the garbage, vacuuming, and carrying laundry. Over one-third of the males and 13% of females could not ski, bike, bowl, play volleyball, or engage in other vigorous recreational activities. Fewer people were limited in their

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ability to ®sh, hunt, or camp. Twenty-eight percent of both the men and women reported dif®culty in having sex, and a smaller proportion had problems sleeping, getting out of bed in the morning, and attending children's events [Strunin and Boden, 1997].

Psychological and Behavioral Responses Studies suggest that work injuries have a variety of effects on people's psychological well-being and behavior. The overall mental health status of individuals suffering work injuries has been found to be worse than in the general population, and it is particularly poor for those who have been out of work for at least 1 year following an injury [Pransky et al., 2000]. Self-reported feelings of anxiety and depression have been found to be higher among individuals with work-related repetitive strain injuries [Helliwell et al., 1992; Keogh et al., 2000]. Workers suffering from occupational cumulative trauma disorders have elevated levels of stress at home and are more likely to divorce [Morse et al., 1998], and those with chronic low back pain have greater levels of family con¯ict [Feuerstein et al., 1985]. Patients with more serious work-related disability have higher rates of psychological problems, drug abuse, and marital dif®culties [Texas Workers' Compensation Research Center, 1995]. Occupational hearing loss reportedly weakens the quality of the affected worker's family relationships [HeÂtu et al., 1987]. Qualitative studies of individuals with work-related conditions have found that many workers perceive their injuries as a potentially lifelong problem which heightens their sense of vulnerability to reinjury and chronic disability [Tarasuk and Eakin, 1994; Dawson, 1994]. For some workers, the perceived threat of future reinjury is itself disabling and appears to discourage a return to normal social roles [Tarasuk and Eakin, 1994]. Injured workers in Pennsylvania report sleep disturbances, sexual problems, depression, lowered self-esteem, and, occasionally, suicidal tendencies [Dawson, 1994]. Focus groups with injured workers in California have uncovered widespread feelings of sadness, anger, humiliation, and despair in response to the handling of their claims within the workers' compensation system [Sum, 1996]. Canadian workers with work-related low back pain have reported feeling stigmatized as the result of suspicions about the legitimacy of their injuries expressed by supervisors and coworkers [Tarasuk and Eakin, 1995]. Psychological and behavioral responses to a work injury are not limited to the injured individual. Care givers, administrators, managers, family members, and others can respond to an occupational injury with a range of emotions and attitudes. For example, nurses and other health professionals treating patients with chronic work-related low

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back complaints tend to respond with skepticism and minimize the patients' self-reported pain [Wiener, 1975; Skelton 1996]. Skelton [1996] suggests that health professionals and others are prone to denigrate and distrust any occupational condition, including cumulative trauma disorders, that are purportedly linked to psychosocial factors like job pressure and stress.

Stress Stress is a particularly complex factor to analyze and study because of its putative role as a potential cause, effect, and modi®er of occupational injuries and illnesses Johnston, 1995]. Smith and Carayon's [1996] model of job stress and disease emphasizes the complicated feedback loops that exist between disease states, stress reactions, and stressors (Figure 3). According to this model, stress could for example potentially lead to the occurrence of workplace injuries and illnesses, develop out of unemployment, anger and other consequences of job injuries, and mediate the ensuing social consequences following an occupational mishap (Figure 4). Empirical studies have documented stress reactions in direct response to various occupational disorders, including

low back pain [Feuerstein et al., 1985], and HIV exposure among healthcare workers [Armstrong et al., 1995]. Numerous investigations have examined acute stress reactions and post-traumatic stress disorder (PTSD) among police of®cers and ®re®ghters [Fullerton et al., 1992; Gist and Woodall, 1995; Carlier et al., 1997], military aviators [Alkov et al., 1982], professional drivers involved in vehicle accidents [Guastello, 1991], miners [Pfeiffer et al., 1976], workers exposed to toxic chemicals [Schottenfeld and Cullen, 1985], and victims of workplace violence [Hashemi and Webster, 1998]. Asmundson et al. [1998] found that the majority of injured workers report symptoms consistent with PTSD or partial PTSD. Researchers have also studied stress reactions among survivors of major occupational disasters and catastrophes including nuclear reactor accidents [Chisholm et al., 1986; Koscheyev et al., 1993], explosions and ®res [Weisaeth, 1989], railway collisions [Karlehagen et al., 1993], and oil rig disasters [Ersland et al., 1989].

Vocational Function Studies indicate that workers injured on the job face signi®cant disruption in their working lives and subsequent

FIGURE 3. Smith and Carayon's [1996] model of job stress.


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FIGURE 4. Stress as a potential effect, cause, and modifier of injuries and illnesses.

labor market experiences. Evidence suggests that after an occupational injury, workers are more likely to change or lose their jobs [Texas Research and Oversight Council, 1997; Katz et al., 1998; Keogh et al., 2000]. More than onethird of workers returning to a job after an occupational upper-extremity disorder had to cut down on their work pace because of the condition [Morse et al., 1998]. Many could not return to work because their employer would not take them back [Imershein et al., 1994]. Vocational impacts of workplace injuries appear to be related to the length of work disability. For example, workers missing at least 1 week of work due to an occupational musculoskeletal injury report greater subsequent (after return to the job) changes in the quality of work, motivation to work, job satisfaction, and the ability to handle job responsibilities compared to those missing less than 1 week [Pransky et al., 2000]. Economic analyses have shown that the indirect costs associated with lost productivity far exceed the direct healthcare expenditures for injuries and illnesses [Cooper and Rice, 1976; Miller and Galbraith, 1995; Leigh et al., 1997]. Recent studies have veri®ed that employees continue to suffer a real wage loss for several years after experiencing a disabling workplace injury, suggesting to some researchers that career displacement and other social aspects of dis-

ability are responsible for a large part of the ®nancial consequences of a workplace injury [Reville, 1999]. The study of vocational effects of workplace injuries has been hampered by the absence of a standardized assessment tool for measuring the impact of an injury or illness on work activities. A new standardized tool, the Work Limitations Questionnaire, has recently been developed and ®eld tested, and is now being utilized in several locations [Amick et al., 2000].

Social Aspects of Rehabilitation and Return to Work Studies have consistently shown that return to work after injury is a socially predicated event. Factors such as the personal characteristics of the worker and his or her family, the injured person's social and economic environment and job characteristics, and the extent to which compensation is received all in¯uence the duration of disability and successful return to work [Cheadle et al., 1994; Atlas et al., 1996; Baldwin and Johnson, 1998; Greenough and Fraser, 1988; MacKenzie et al., 1998]. The kinds of social support available to the patient are particularly important in mediating the process of job re-entry [Feuerstein and Thebarge, 1991; MacKenzie et al., 1998]. Few injured employees report that

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the employer provided assistance to help them return to work [Imershein et al., 1994; Roberts and Gleason, 1994; Intracorp, 1997]. On the contrary, many workers report being forced back to work prematurely and having to work with pain [Roberts and Gleason, 1994]. Evidence suggests that the duration of work disability is longer for patients who are divorced [Cheadle et al., 1994] and those who experience psychological stress [Feuerstein and Thebarge, 1991]. Injured workers with less formal education take longer to return to work after an injury than do those having more education [Imershein et al., 1994]. Some investigations have suggested that pre-injury job satisfaction and motivation to work are signi®cant predictors of return-towork [Brewin et al., 1983; Yelin et al., 1986; Cats-Baril and Frymoyer, 1991], while other studies have not detected this effect [MacKenzie et al., 1998]. Work disability itself can be thought of as a complex socially predicated consequence of occupational injuries and illnesses. Whether or not a person can resume work after a workplace injury or illness is not determined solely by physical limitations, but also by a variety of social considerations such as the availability of suitable work, ambient economic and labor market conditions, and the injured person's skills and experience [Stone, 1984; Dembe, 2000]. Even the notion of physical impairment, which is generally considered to be an objective medical condition, is subject to social in¯uences. Studies have revealed, for instance, that the vast majority of physicians consider non-medical factors such as a patient's education, motives, intelligence, personality, and social environment in determining an impairment rating [Brand and Lehmann, 1983; Greenwood, 1985].

Equity and Social Justice Longstanding social divisions in the United States have led to the disproportionate concentration of blacks, Hispanics, and other minorities in low-paying and dangerous jobs [Taylor and Murray, 2000]. Historical records show that black workers, in particular, have suffered from being concentrated in jobs with heavy exposures to silica, cotton dust, coke oven emissions, and chromate dust [Cherniak, 1986; Frumkin et al., 1999]. Contemporary studies suggest that signi®cant disparities in the incidence of occupational injuries, illnesses, and deaths still exist among various racial and ethnic groups. For example, the US occupational injury rate for job categories in which more than 25% of the workers are black is three times higher than for job categories having a low proportion (< 1%) of black workers [Frumkin et al., 1999]. The US occupational fatality rate for blacks exceeds the rate for whites by 12%. Moreover, immigrant workers (those born outside of the United States) suffer a disproportionate share (25%) of workplace homicides [Windau, 1997]. Nonwhite construction laborers have a 27% higher occupational fatality rate than whites [Ore and Stout, 1997].

In California, workplace injuries were found to occur 32% more frequently among black workers than among whites, and the rate for Hispanics is 18% higher [Robinson, 1987]. Most studies of occupationally induced cancer have found an elevated incidence among nonwhite workers compared to whites [Kipen et al., 1991]. Based on emergency room records, the relative risk of occupational injury in Washington, DC compared to the general population is 2.07 for Hispanic men and 3.83 for Hispanic women [Weddle et al., 1993]. There is scattered evidence indicating that the social consequences of occupational injuries and illnesses also fall most heavily on women, minorities, immigrants, and other vulnerable populations. For example, some studies have suggested that women are more likely to have their workrelated medical conditions dismissed or trivialized by medical practitioners [Reid et al., 1991; Dembe, 1996; Messing, 1998]. Recent analyses of carpal tunnel syndrome in New York State showed that the likelihood of claim denial by the WC insurer is greater for nonwhites, low-wage earners, and union members [Herbert et al., 1999]. In another study, blacks were found to be twice as likely as whites to have WC claims rejected for treatment of occupational asbestosrelated lung disease, even after adjusting for disease severity, job classi®cation, smoking status, and other potential confounding factors [Nevitt et al., 1994]. Immigrant and migrant workers face especially signi®cant barriers in obtaining appropriate medical care for work-related conditions [Meister, 1991]. A recent study among a population of Central American immigrant workers in the Washington, DC area revealed that only 40% of the immigrant workers suffering occupational injuries or illnesses ®led claims for medical treatment under workers' compensation [Pransky and Thackrey, 1998]. Preliminary data from a study being conducted in Worcester, MA, suggest that about 11% of low-income and immigrant patients coming to community-based free care clinics are receiving treatment for work-related disorders [Dembe et al., 1999]. Non-native language speakers have been found to be more likely to have WC claims denied by employers and insurers [Thomason, 1994; Hyatt and Kralj, 1996]. These patterns of differential exposure and response to occupational injuries and illnesses re¯ect and reinforce prevailing inequalities in our society, and they are experienced by many injured workers as a form of social injustice. Workers in Michigan expressed a profound sense of having been treated unjustly after a job injury, believing that responses to their condition were frequently inconsistent, biased, and unethical [Roberts and Gleason, 1994]. Studies of worker reaction to the WC claims process have reported widespread perceptions that the process is not fair [Ray, 1986; Thomason, 1994; Sum, 1996]. Roberts and Young [1997] found that the quality of the interactions between the claimant and professionals during the course of WC claims


processing has a signi®cant impact on the claimant's return to work. Because of the perceptions of unfairness, claimants are often represented by attorneys and engaged in disputes with employers and insurers. All too often, experiences of discrimination, inequity, and injustice, along with resulting legal disputes, are a major social consequence of occupational injuries and illnesses. 4.

STUDYING SOCIAL CONSEQUENCES: A RESEARCH AGENDA I have attempted to provide a conceptual framework for understanding the social consequences of occupational injuries and illnesses, described some of the distinctive conceptual challenges involved in studying this topic, and provided examples of contemporary research ®ndings. The investigation of social consequences in occupational health is complicated by the intricate reciprocal relationships between the determinants, modi®ers, and effects of workrelated disorders. Research studies of social consequences will need to account for the multifactorial in¯uences of personal, social, organizational, and environmental variables and the complex interplay of the individual worker with a variety of forces from the workplace, community, medical profession, workers' compensation system, and broader society. Although there have been numerous studies examining the impacts of workplace injuries and illnesses, few have really concentrated on social effects or adequately considered their complex interaction. Here are some speci®c suggestions for enhancing research in this ®eld. 1.

2.

3.

Researchers must clearly identify and de®ne the social consequences under study. Operational measures for each social factor will generally need to be developed. Investigators studying the social and psychosocial aspects of work-related conditions must clarify whether they are referring to causal factors, outcomes, intermediary processes, or a combination of all three. Virtually all studies so far have treated social consequences as independent variables. The most interesting and credible studies will be those that look at their interdependencies, and treat them as intertwined, mutually dependent factors. For example, it would be interesting to examine how the injured worker's experiences with the workers' compensation system affect interpersonal relationships at home or vice versa. Most studies in this ®eld have considered social consequences from the injured worker's perspective and have relied on information obtained from

5.

6.

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questionnaire surveys of injured workers. However, given the variety of potential impacts to other individuals and groups (as portrayed in Figure 1), it would also be important to ascertain the social effects and to collect information directly from family members, coworkers, supervisors, workers' compensation personnel, medical care providers, labor unions, and other community groups. Few of the studies to date examine social consequences among a group of injured workers in comparison to an appropriately selected control population or baseline measure, thus limiting the study's ability to draw valid conclusions about those outcomes. For instance, a study may be able to document that a certain proportion of workers suffer from sleep disturbances following a particular type of workplace injury. But unless comparable information is available about sleep disturbances in similar workers without the injury, it is impossible to tell whether the sleep problems are the result of the injury or some other extraneous factors (e.g., normal job demands or supervisory practices). Because of the paucity of research conducted in this area, there are few standardized data collection instruments or uniform methodologies. Some researchers adopt instruments used in the general health ®eld (such as the SF-36 form to assess functional status and quality of life). However, these tools were not originally designed or validated for use in a population of injured workers, and may not contain relevant questions or examples for investigating the vocational and functional repercussions of occupational ailments and work disability. Other researchers may design their own customized tools, which requires extensive pretesting and validation, and makes generalization dif®cult. What is needed is the development of a standardized method for data de®nition and collection, and the ultimate creation of a national research database for the study of workplace injuries that would allow multistate analysis and have suf®cient numbers of cases to detect small effects. The Robert Wood Johnson Foundation has recently launched a grantmaking initiative to support this undertaking. Although the workers' compensation system is the primary mechanism for processing bene®t claims for workplace injuries and illnesses, preliminary research has shown that the economic and social consequences of work injuries extend well beyond WC into Social Security, unemployment insurance, general health care, disability coverage, Medicaid, and other private and public insurance

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systems. Additional study is needed to understand these ``cross-system'' effects and their impacts on injured workers, their families, employers, medical care practitioners, and others. Studies that rely solely on WC data will not be able to analyze the full range of outcomes. 7. Very little has been done so far to systematically study equity and social justice issues in occupational health and health care. To facilitate research on this important social topic, investigators need to collect sociodemographic information from injured workers and other affected individuals regarding race, ethnicity, education, socioeconomic status, and nationality, in addition to their age and gender. Studies are needed to examine whether there are disparities among groups with respect to exposure, health care, claims processing, outcomes, and vocational and domestic functional impacts. 8. Additional research is needed to evaluate the experiences of family members caring for people with serious job-related in®rmities and chronic work disability. In the general healthcare ®eld, considerable evidence has been amassed demonstrating that family care givers of people with cancer and other serious illnesses experience increased symptoms of depression, anxiety, psychosomatic symptoms, restrictions of roles and activities, strain in marital relationships, and diminished physical health [Weitzner et al., 1997]. No such comparable research has yet been undertaken in the area of occupational health. 9. Much of the existing work on social consequences and stress in occupational health has focused on chronic low back pain, upper-extremity cumulative trauma disorders, and other musculoskeletal ailments. This may be due to the connection of those conditions with ergonomics, and the longstanding history of ergonomics research into the evaluation of human factors and psychosocial in¯uences. Less emphasis has been placed on looking at the social consequences of traumatic injuries (e.g., amputations, electric shock injuries, burns, etc) and occupational illnesses (other than cumulative trauma disorders). Expanded study is needed in those areas.

CONCLUSION Occupationally induced injuries and illnesses have many outcomes including the payment of workers' compensation bene®ts, economic costs for the employer, the delivery of medical care services, and work disability. In

addition, there are less obvious implications of job-induced disorders for labor relations, family dynamics, domestic activities, community involvement, and personal mental health. Such social consequences are complex, interrelated, and mutually dependent. Their study is complicated by the methodological dif®culty of clearly de®ning and measuring the pertinent variables and evaluating their intricate connections. Nevertheless, understanding the social consequences of workplace injuries and illnesses is essential in order to appreciate the full impact of workplace accidents, minimize their repercussions, and plan appropriate preventive measures. Because this elusive, neglected aspect of occupational health is so important for public health, researchers in this area should be prepared to be as creative and ¯exible as necessary in their choice of study designs and methodology.

ACKNOWLEDGMENTS An earlier version of this paper was presented on 13 June 1999 in Denver, CO at a conference entitled, ``Functional, Economic, and Social Outcomes of Occupational Injuries and Illnesses: Integrating Social, Economic, and Health Services Research,'' which was co-sponsored by the National Institute for Occupational Safety and Health, and the Robert Wood Johnson Foundation. The author is grateful for the helpful reviews and comments concerning this paper provided by Benjamin Amick, Brian Day, Charles Levenstein, Joan Eakin, Emily Spieler, Leslie Boden, and others at the conference, as well as the detailed and insightful suggestions made by the AJIM editors and reviewers.

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