Moral injury is extensively studied among trauma-exposed veterans. Two measurement scales are available to screen for symptoms of moral injury among trauma-exposed veterans; however, no measurement scale exists screening for symptoms of moral injury among trauma-exposed firefighters. The objective of this study aims to address the gap in available instruments by developing a moral injury assessment scale for firefighters. Through this project, a psychometrically accepted moral injury scale will be available to researchers, clinicians, and fire organizations to assess moral injury in trauma-exposed firefighters. Military studies found that moral injury and posttraumatic stress disorder (PTSD) are distinct constructs and can co-exist. PTSD is prevalent in firefighters and despite subject experts expressing the need to expand research efforts to first responders (e.g., firefighters), no moral injury scale is available assessing these symptoms. Exploratory themes are recently emerging in these occupations. The EMIS-F yielded almost perfect interrater reliability across raters (.97). Psychometric properties of the EMIS-F were comparable to the military version, yielding excellent internal consistency (ω = 0.94), in addition to the self-directed (ω = 0.92) and others-directed (ω = 0.89) moral injury subscales. Inter-item and item-total correlations are within acceptable ranges (ρ = 0.30–0.73) to empirically conclude the EMIS-F measures a unidimensional construct. Item-total correlations did not detract from the consistency of the overall scale and independently demonstrated positive correlations with the EMIS-F (ρ = .62–79). The EMIS-F demonstrated strong convergent validity with validated measures of PTSD (ρ = .61), depression (ρ = .50), and suicide ideation (ρ = .38), and evidence of divergent validity with strong support systems (ρ =  − .14).

Despite extensive evidence of work as a key social determinant of hypertension, risk prediction equations incorporating this information are lacking. Such limitations hinder clinicians’ ability to tailor patient care and comprehensively address hypertension risk factors. This study examined whether including work characteristics in hypertension risk equations improves their predictive accuracy. Using occupation ratings from the Occupational Information Network database, we measured job demand, job control, and supportiveness of supervisors and coworkers for occupations in the United States economy. We linked these occupation-based measures with the employment status and health data of participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study. We fit logistic regression equations to estimate the probability of hypertension onset in five years among CARDIA participants with and without variables reflecting work characteristics. Based on the Harrell’s c- and Hosmer–Lemeshow’s goodness-of-fit statistics, we found that our logistic regression models that include work characteristics predict hypertension onset more accurately than those that do not incorporate these variables. We also found that the models that rely on occupation-based measures predict hypertension onset more accurately for White than Black participants, even after accounting for a sample size difference. Including other aspects of work, such as workers’ experience in the workplace, and other social determinants of health in risk equations may eliminate this discrepancy. Overall, our study showed that clinicians should examine workers’ work-related characteristics to tailor hypertension care plans appropriately.

In the United States (US), Black—particularly Black female—healthcare workers are more likely to hold occupations with high job demand, low job control with limited support from supervisors or coworkers and are more vulnerable to job loss than their white counterparts. These work-related factors increase the risk of hypertension. This study examines the extent to which occupational segregation explains the persistent racial inequity in hypertension in the healthcare workforce and the potential health impact of workforce desegregation policies. We simulated a US healthcare workforce with four occupational classes: health diagnosing professionals (i.e., highest status), health treating professionals, healthcare technicians, and healthcare aides (i.e., lowest status). We simulated occupational segregation by allocating 25-year-old workers to occupational classes with the race- and gender-specific probabilities estimated from the American Community Survey data. Our model used occupational class attributes and workers’ health behaviors to predict hypertension over a 40-year career. We tracked the hypertension prevalence and the Black–white prevalence gap among the simulated workers under the staus quo condition (occupational segregation) and the experimental conditions in which occupational segregation was eliminated. We found that the Black–white hypertension prevalence gap became approximately one percentage point smaller in the experimental than in the status quo conditions. These findings suggest that policies designed to desegregate the healthcare workforce may reduce racial health inequities in this population. Our microsimulation may be used in future research to compare various desegregation policies as they may affect workers’ health differently.

Background: The Minnesota Safe Patient Handling (MN SPH) Act requires health care facilities to implement comprehensive programs to protect their workers from musculoskeletal injuries caused by lifting and transferring patients. Nursing homes, hospitals, and outpatient facilities each face unique challenges implementing and maintaining SPH programs. The objective of the study was to compare patient handling injuries in these three health care settings and determine whether change in injury rate over time differed by setting following enactment of the law. Methods: Workers’ compensation data from a Minnesota-based insurer were used to describe worker and claim characteristics in nursing homes, hospitals, and outpatient facilities. Negative binomial models were used to compare claims and estimate mean annual patient handling claim rates by health care setting and time period following enactment of the law. Results: Consistent with national data, the patient handling claim rate was highest in Minnesota nursing homes (168 claims/$100 million payroll [95% confidence interval: 163–174]) followed by hospitals (35/$100 million payroll [34–37]) and outpatient facilities (2/$100 million payroll [1.8–2.2]). Patient handling claims declined by 38% over 10 years following enactment of the law (vs. 27% for all other claims). The change in claims over time did not differ by health care setting. Conclusions: In this single-insurer sample, declines in workers’ compensation claims for patient handling injuries were consistent across health care settings following enactment of a state SPH law. Though nursing homes experienced elevated claim rates overall, results suggest they are not lagging hospitals and outpatient facilities in reducing patient handling injuries.

Background: The Kidney Allocation System (KAS) includes a scoring system to match transplant candidate life expectancy with expected longevity of the donor kidney, and a backdating policy that gives waitlist time credit to patients waitlisted after starting dialysis treatment (post-dialysis). We estimated the effect of the KAS on employment among patient subgroups targeted by the policy. Methods: We used a sample selection model to compare employment after transplant before and after KAS implementation among patients on the kidney-only transplant waitlist between December 4, 2011 and December 31, 2017. Results: Post-dialysis transplant recipients aged 18–49 were significantly more likely to be employed 1-year post transplant in the post-KAS era compared to the pre-KAS era. Transplant recipients aged 35–64 with no dialysis treatment were significantly less likely to be employed 1 year after transplant in the post-KAS era compared to the pre-KAS era. Conclusions: This study provides the first assessment of employment after DDKT under the KAS and provides important information about both the methods used to measure employment after transplant and the outcome under the KAS. Changes in employment after DDKT among various patient subgroups have important implications for assessing long-term patient and societal effects of the KAS and organ allocation policy.

Introduction While there is a body of literature that identifies relations between injury occurrence and resulting depression, literature relevant to a relation between work factors and depression and injury occurrence is limited. Objectives To identify the potential relations between: 1) work-related factors and depression diagnosis and 2) depression diagnosis and injury outcome and consequences in a high-risk, understudied population. Methods Specially designed questionnaires were disseminated to 1,200 full-time janitors in the SEIU Local 26 union to collect information on their injury occurrences, personal characteristics, health history, and work-related exposures, for two sequential six-month periods. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using multivariable Poisson regression with robust error variances, and included bias adjustment for non-response and adjustment for within-person correlation using general estimating equations (GEEs). Results A total of 527 observations among 390 janitors identified associations between work environment factors (range = 1, terrible/unhappy/mostly dissatisfied; 2, mixed feelings; 3, mostly satisfied/pleased delighted) and diagnosed depression (n=48): how they felt about people they worked with (1 versus [vs] 3 - RR 3.86; CI 1.31, 11.36); how they felt about the work itself (2 vs 3 - RR 2.54; CI 1.36, 4.77); resources available for their job (1 vs 3 - RR 2.93; CI 1.27, 6.75). Associations were also identified between high (4,5 very much, often) vs low (1–3 sometimes, very little, not at all) frequency of stress and depression (RR 4.79; CI 2.22, 10.36) and between depression diagnosis and risk of injury-related persistent problems (RR 5.19; CI 1.40, 19.24). Conclusions This analysis enabled identification of work-related factors associated with diagnosed depression, the relation between stress and depression, and the risk of injury and consequences among those with depression. These findings serve as a basis for future research and relevant interventions to facilitate optimal working environments.

Introduction While a body of literature identifies relations between injury occurrence and resulting stress, literature relevant to relations between work factors and stress and injury occurrence is limited. Objectives To identify the potential relations between: 1) work-related factors and stress and 2) stress and depression and injury outcomes in a high risk, understudied population. Methods Specially designed questionnaires were disseminated to 1,200 full-time unionized janitors to collect information on their injury occurrences, personal characteristics, health history, and work-related exposures, for two sequential six-month periods. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using multivariable Poisson regression with robust error variances, and included bias adjustment for non-response and adjustment for within-person correlation using general estimating equations (GEEs). Results 527 total observations among 390 janitors identified associations between the following exposures and high/low stress outcome (collapsed 5 point Likert scale – often/very much versus (vs) not at all/very little/sometimes): work environment factors (range = 1, terrible/unhappy/mostly dissatisfied; 2, mixed feelings; 3, mostly satisfied/pleased delighted) how they felt about their job (1 vs 3 - RR 4.50; CI 2.38, 8.52); where they worked (1 vs 3 - RR 3.46; CI 2.03, 5.92); resources available for their job (1 vs 3 - RR 1.77 CI 1.14, 2.76); and job mentally or physically demanding (high/very high vs very low/low/medium demand) RR 2.49; CI 1.26, 4.93 and RR 3.74; CI 1.37, 10.25, respectively. High vs low stress exposure was associated with outcomes: diagnosed depression yes/no (RR 4.79; CI 2.22, 10.36); and risk of injury (RR 1.45; CI 1.00, 2.10). Conclusions This analysis enabled identification of: work-related factors associated with reported stress; the relation between stress and depression; and risk of injury among those reporting stress levels. These findings serve as a basis for future research and relevant interventions to facilitate optimal working environments.

Background:Numerous drugs pose harm to healthcare workers. Medical surveillance (MS) questionnaires often do not capture desired information. Social cognitive theory, plain language, and quality im...

Approximately 2.4 million janitors work in the United States. High physical workload may explain a lost-work days rate 2.7 times that of other occupations. Information is limited about non-physical workload factors for janitors and their relations to injuries. For this retrospective cross-sectional study, specially designed, pre-tested questionnaires were distributed to full-time janitor members of a union for two six-month sequential intervals. Questions addressed mental workload (modified NASA Task Load Index), job satisfaction (Andrews and Withey Job Satisfaction Scale), stress (Perceived Stress Scale-4 [PSS-4], and the Single Item Stress Scale [SISS]), physical fitness, and occupational injury experiences. Descriptive and multivariable analyses, with bias adjustment, were conducted. A decreased risk of injury was associated with increased job satisfaction (expressed as a risk ratio (RR): 0.91 [95% confidence interval (CI): 0.83, 0.97]) and increased physical fitness (0.89, [0.83, 0.96]). A highly suggestive increased risk of injury was associated with increased mental workload (1.07, [1.00, 1.15]).

Objectives The 2007 Minnesota Safe Patient Handling Act aims to protect healthcare workers from injuries caused by lifting and transferring patients. The effectiveness of the law in nursing homes is unknown. This policy evaluation measured changes in patient handling injuries before and after the law was enacted. Additionally, it assessed whether effects of the law were modified by facility levels of staffing and retention. Methods Workers’ compensation indemnity claims for years 2005–2016 were matched to annual direct care productive hours and facility characteristics (eg, profit status, hospital affiliation and region) for all Medicaid-certified nursing homes in Minnesota. Trends in patient handling claims were analysed using negative binomial regression with generalised estimating equations. The primary predictors were time period, staff hours per resident day and staff retention. Results The patient handling indemnity claim rate declined by 25% in years 4–6 and 38% in years 7–9 following enactment of the law. Claims for all other injuries and illnesses declined by 20% in years 7–9 only. Associations between time period and patient handling claims did not vary by levels of staffing or retention. However, independent of time, facilities with annual retention ≥75% (vs <65%) had a 17% lower patient handling claim rate. Conclusions Results suggest the law reduced patient handling claims in nursing homes. However, claim rates were elevated in facilities with low worker retention and those that were non-profit, not hospital-affiliated or in a non-metro area. Facilities with these characteristics may benefit from targeted state grants and consultation efforts.

Excessive daytime sleepiness (EDS) is the most common symptom of sleep-disorders. Although high levels of EDS have been reported among firefighters, there is a limited understanding on EDS in firef...

Background: Nursing assistants have one of the highest injury rates in the U.S., but few population-based studies assess differential injury risk by occupation in nursing homes. This statewide study assessed differences in musculoskeletal disorders (MSDs) and patient handling injuries among direct care workers in Minnesota nursing homes. Methods: Indemnity claims from the Minnesota workers' compensation database were matched to time at risk from the Minnesota Nursing Home Report Card to estimate 2005 to 2016 injury and illness claim rates for certified nursing assistants (CNAs), licensed practical nurses (LPNs), and registered nurses (RNs). Associations between occupation and claim characteristics were assessed using multivariable regression modeling. Results: Indemnity claim rates were 3.68, 1.38, and 0.69 per 100 full-time equivalent workers for CNAs, LPNs, and RNs, respectively. Patient handling injuries comprised 62% of claims. Compared to RNs, CNAs had higher odds of an indemnity claim resulting from an MSD (odds ratio [OR] = 1.67; 95% confidence interval [CI], 1.31-2.14) or patient handling injury (OR = 1.89; 95% CI, 1.47-2.45) as opposed to another type of injury or illness. CNAs had lower odds of receiving temporary and permanent partial disability benefits and higher odds of receiving a stipulation settlement. Conclusions: CNAs in Minnesota nursing homes are at heightened risk for lost time MSDs and patient handling injuries. Claims filed by CNAs are more frequently settled outside the regular workers' compensation benefit structure, an indication that the workers' compensation system is not providing adequate and timely benefits to these workers.

INTRODUCTION A Minnesota union identified to researchers at the University of Minnesota a concern relevant to a possible relation between their daily workload and outcome of occupational injuries among a population of janitors. OBJECTIVE To assess if the ergonomic workload is related to injuries among janitors. METHODS Following an initial group discussion among janitors, which identified common and hazardous tasks potentially leading to occupational injuries, a questionnaire was developed, pre-tested, and distributed to the janitors. Questions addressed various exposures, including workload, and comprehensive information regarding injury occurrence over two six-month sequential periods (May 2016–October 2016, November 2016–April 2017). Quantitative ergonomic analyses were performed on a sub-group of janitors (n = 30); these included data collection to identify Borg Perceived Exertion (Borg) and Rapid Entire Body Assessment (REBA) scores. Descriptive, multivariable with bias adjustment analyses were conducted on the resulting data. RESULTS Eight tasks were found to be common for janitors. All average REBA scores for the tasks were identified in the high-risk category. The task of repeatedly emptying small trash cans (<25lb) was significantly related to injuries. Average Borg scores fell between the very light perceived exertion and somewhat difficult perceived exertion categories. Multivariable regression analyses indicated that age-sex-standardized ergonomic workload, measured by task frequencies and REBA or Borg scores, was positively related to injury occurrence. CONCLUSIONS Standardized ergonomic workload was positively related to injury occurrence. This information serves as a basis for further research and potential intervention efforts.

Introduction: The goal of this study was to evaluate and improve janitors' knowledge of workers' rights and responsibilities for assessing and reporting work-related injuries, and to determine the barriers for reporting occupational injuries. Methods: Questionnaires, designed to collect data retrospectively for two, sequential six-month periods, were disseminated to 1200 full-time unionized janitors in the Twin Cities. Immediately following the baseline questionnaire administration, a randomly selected sub-group of janitors (~600) received information on workers' rights and responsibilities for reporting injuries; six-months later a questionnaire comparable to the baseline questionnaire was disseminated to the 1200 janitors. Analyses included basic descriptive analyses and identification of potential differences in proportions of job-specific reporting barriers pre-post-intervention. Results: Among the participating janitors (n = 390), approximately half (53%) were initially unsure of what an OSHA 300 Log was; 56% reported not knowing what workers' compensation was. At baseline, in both intervention and non-intervention groups, approximately 25% reported having a perceived barrier to reporting an injury to their employer. Reported barriers included “fear,” “reporting takes too long,” “being unsure of the reporting process,” and an “understanding that injuries are a part of the job.” At follow-up, among the intervention group, there was an important reduction (24%–12%) in having a perceived barrier for reporting a work-related injury. Conclusions: A majority of janitors lacked knowledge and awareness of OSHA injury reporting and Workers' Compensation. In order to improve reporting, it is essential to educate employees on OSHA and Workers' Compensation and inform janitors of the injury reporting process through training. Practical applications: Future intervention efforts must focus on the specific barriers for reporting occupational injuries and be tailored specifically to the janitor population. To reduce underreporting of injuries, they must be encouraged to report their occupational injuries. Barriers to reporting these injuries must be eliminated.

Maternal pregnancy nutrition influences fetal growth. Evidence is limited, however, on the relationship of maternal diet during pregnancy and lactation on infant postnatal growth and adiposity. Our purpose was to examine associations between maternal diet quality during pregnancy and lactation with offspring growth and body composition from birth to six months. Maternal diet quality was serially assessed in pregnancy and at one and three months postpartum, using the Healthy Eating Index-2015 in a cohort of 354 fully breastfeeding mother-infant dyads. Infant length-forage (LAZ), weight-forage (WAZ), and weight-for-length (WLZ) Z-scores were assessed at birth, one, three, and six months. Infant body fat percent (BF%), fat mass (FM), and fat-free mass (FFM) were measured at six months using dual-energy X-ray absorptiometry. Higher maternal diet quality from pregnancy through three months postpartum was associated with lower infant WLZ from birth to six months (p = 0.02) and BF% at six months (p ≤ 0.05). Higher maternal diet quality at one and three months postpartum was also associated with lower infant FM at six months (p < 0.01). In summary, maternal diet quality during pregnancy and lactation was inversely associated with infant relative weight and adiposity in early postnatal life. Additional research is needed to explore whether associations persist across the life course.

Full breastfeeding (FBF) is promoted as effective for losing pregnancy weight during the postpartum period. This study evaluated whether longer FBF is associated with lower maternal postpartum weight retention (PPWR) as compared to a shorter FBF duration. The MILK (Mothers and Infants Linked for Healthy Growth) study is an ongoing prospective cohort of 370 mother-infant dyads, all of whom fully breastfed their infants for at least 1 month. Breastfeeding status was subsequently self-reported by mothers at 3 and 6 months postpartum. Maternal PPWR was calculated as maternal weight measured at 1, 3, and 6 months postpartum minus maternal prepregnancy weight. Using linear mixed effects models, by 6 months postpartum, adjusted means ± standard errors for weight retention among mothers who fully breastfed for 1-3 (3.40 ± 1.16 kg), 3-6 (1.41 ± 0.69 kg), and ≥6 months (0.97 ± 0.32 kg) were estimated. Compared to mothers who reported FBF for 1-3 months, those who reported FBF for 3-6 months and ≥6 months both had lower PPWR over the period from 1 to 6 months postpartum (p = 0.04 and p < 0.01, respectively). However, PPWR from 3 to 6 months was not significantly different among those who reported FBF for 3-6 versus ≥6 months (p > 0.05). Interventions to promote FBF past 3 months may increase the likelihood of postpartum return to prepregnancy weight.

Obesity (Silver Spring) 2017; 25:2092-2099. doi:10.1002/oby.22025 The authors of this article recently discovered that the C-reactive protein values used in the analysis were approximately threefold higher than the true concentration. The manufacturers of the ELISA kit recently informed the authors that the kit instruction manual gave the wrong volume of buffer needed to reconstitute the standard. This laboratory error affected the data presented in Tables and and Figure of the manuscript. After rerunning all of the statistical analyses with the corrected C-reactive protein values, there are no changes in either the statistical significance of the associations or the conclusions and interpretation of the findings. The authors apologize for this error. Summary statistics for breast milk inflammatory markers at 1 and 3 months post partum (Table presented.) Data presented as median (interquartile range) or mean ± SD. aP value testing for differences between 1- and 3-month summary statistics using Wilcoxon signed rank sum test for nontransformed data and paired t tests for log-transformed data. Bolded values are statistically significant (P<0.05). bThe value of 1 was added to the raw interleukin-6 values before log transformations were performed to avoid negative values on the log scale. Associations of maternal anthropometrics with log-transformed breast milk C-reactive protein at 1 and 3 months post partuma (Table presented.) aAll continuous independent variables (pre-pregnancy BMI, gestational weight gain, and postpartum weight loss) were standardized to a mean of 0 and a standard deviation of 1. Bolded values are statistically significant (P<0.05). bModel 1 is the crude model. cModel 2 adjusts for maternal education and gestational age at delivery. dModel 3 adjusts for covariates in Model 2, as well as pre-pregnancy BMI. eCalculated using the 2009 Institute of Medicine gestational weight gain guidelines, based on pre-pregnancy BMI. fPostpartum weight loss was calculated as maternal weight at delivery minus maternal weight at 1 and 3 months post partum and was entered into the mixed effects models as a time-varying independent variable. (Figure presented.) Adjusted means of back-transformed C-reactive protein (CRP) at 1 and 3 months post partum by pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) category. Differences between the mean values for each pre-pregnancy BMI and GWG category are denoted by different superscript letters (a, b, c, or d). In the top panel, at 1 month post partum, women with normal weight who gained weight below/within the guidelines (a) had significantly lower breast milk CRP than all other groups (b), except overweight women who gained weight below/within the guidelines. Women with obesity who gained below/within GWG guidelines (c) had significantly higher CRP than women with overweight, regardless of GWG category, and women with normal weight who gained below/within GWG guidelines (d). In the bottom panel, at 3 months post partum, women with normal weight who gained weight below/within guidelines (a) had significantly lower CRP than women with normal weight who exceeded GWG guidelines and women with obesity, regardless of GWG category (b). Women with obesity who experienced excessive weight gain (c) had significantly higher CRP than all normal weight and overweight groups (d; P<0.05 for all).

Elevated in utero and early childhood exposure to manganese may have adverse effects on neurodevelopment. We conducted preliminary analyses to evaluate toenails as a matrix for investigating manganese exposure in infants. Infant and maternal toenail and hair samples were collected from 25 infants (7 months old) and their mothers. A subset of mothers was recruited in the third trimester of pregnancy and some also provided pre-natal toenail, hair, and blood samples, cord blood, and additional post-natal samples. Collected samples were analyzed by inductively coupled plasma mass-spectrometry. Toenail manganese levels in infants ranged from below the limit of detection (LOD) to 2.80 µg/g. Only 1 toenail sample and 4 hair samples contained levels of manganese below LOD. Associations between infant and maternal biomarkers were not statistically significant. Analysis of multiple post-natal toenail samples from a single infant-mother pair showed an increase in the infant’s toenail manganese and a decrease in maternal toenail manganese over the first year of the infant’s life. Overall, our findings suggest that toenails may serve as a valuable biological matrix for measuring manganese exposure in newborns and infants; however, additional studies are needed to determine the impact of the timing of toenail sample collection on its utility in assessing early life exposure and health outcomes.