Labor unions: a public health institution

Beginning with the End in Mind: Creating a Practice that Centers Equity-Part 2

The concept of equity recognizes historical and current barriers and promotes thriving for veterinary teams and people and animals in the community. It is possible to design equitable workplace systems to prevent and respond to harm using learnings from human medicine and the social sciences. These systems are grounded in the principles of health equity and must incorporate both formal policies and intentional cultivation of supportive culture and relationships. This article is part 2 of 2 articles reviewing how the concept of equity applies and could transform well-being in companion animal veterinary practice in North America.

The relationship between union membership and self-rated health among racially diverse U.S. healthcare workers: The role of control over work schedules and locations

BACKGROUND

Labor unions are associated with better wages, improved working conditions, and greater worker empowerment, which may result in better health. However, less is known about the relationship between unionization and health among U.S. healthcare workers, whether the relationship differs among racially diverse workers, and how much control over workplace schedules and location mediates the relationship.

METHODS

We analyzed a cross-sectional survey of a nationally representative sample of 3000 U.S. healthcare workers collected from March 14 through April 5, 2023. Using ordinal logistic regression, we evaluated whether unionized healthcare workers had better self-rated health (SRH) than their nonunionized counterparts and examined potential differences between White and racially minoritized respondents. We quantified the mediation percentage explained by control over one's schedule and workplace location in the total and stratified samples using Karlson, Holm, and Breen decomposition analysis.

RESULTS

Over a third (36.1%) of racially minoritized respondents were unionized, compared to 22.3% of White respondents. Among racially minoritized workers, a greater share of unionized workers reported excellent health (40.6% vs. 21.8%) than their nonunionized counterparts. In confounder-adjusted ordinal logistic regression analyses, labor union membership was associated with better SRH overall, with a stronger association for racially minoritized workers. Among White healthcare workers, control over workplace arrangements explained 68.1% of the union membership and SRH relationship. For racially minoritized workers, control over workplace arrangements partially mediated the relationship, explaining 17.4% of the variation, suggesting that labor unions may impact health through additional pathways for these workers.

CONCLUSIONS

This study provides empirical evidence of the relationship between labor union membership and health among U.S. healthcare workers. We demonstrate that control over schedules and location is an important mechanism by which unionization may protect healthcare workers' health. Among racially diverse healthcare workers, labor unions may play an important role in health through various pathways beyond workplace control.

Revisiting the Occupational Health Impact of Right-to-Work Laws: A Research Note

This research note reevaluates the occupational health impact of right-to-work (RTW) legislation, incorporating recent developments in causal inference techniques. In an era marked by an uptick in the adoption of anti-union legislation and increases in workplace fatalities and injuries, it is particularly urgent to examine the extent to which RTW laws affect workers' health. Using a state-year-level dataset spanning 28 years and collected from multiple data sources, we apply an innovative generalized synthetic control method to overcome several limitations of the traditional two-way fixed-effects approach to examine the effect of RTW laws on occupational fatal injuries as well as various other health outcomes. Robustness checks were conducted using a wide range of alternative methods for two-way fixed-effects adjustments. In contrast with findings from previous studies, we found null effects on occupational fatal injuries, as well as on all other health outcomes. Overall, our results indicate that findings from previous studies are based on very thin empirical evidence, with potentially underestimated standard errors and unobserved confounders. Our results highlight the importance of revisiting research questions using updated methodological tools.

Nonpharmacological pain management approaches among U.S. construction workers: A cross-sectional pilot study

BACKGROUND

U.S. construction workers experience high rates of injury that can lead to chronic pain. This pilot study examined nonpharmacological (without medication prescribed by healthcare provider) and pharmacological (e.g., prescription opioids) pain management approaches used by construction workers.

METHODS

A convenience sample of U.S. construction workers was surveyed, in partnership with the U.S. National Institute for Occupational Safety and Health (NIOSH) Construction Sector Program. Differences in familiarity and use of nonpharmacological and pharmacological pain management approaches, by demographics, were assessed using logistic regression models. A boosted regression tree model examined the most influential factors related to pharmacological pain management use, and potential reductions in use were counterfactually modeled.

RESULTS

Of 166 (85%) of 195 participants reporting pain/discomfort in the last year, 72% reported using pharmacological pain management approaches, including 19% using opioids. There were significant differences in familiarity with nonpharmacological approaches by gender, education, work experience, and job title. Among 37 factors that predicted using pharmacological and non-pharmacological pain management approaches, training on the risks of opioids, job benefits for unpaid leave and paid disability, and familiarity with music therapy, meditation or mindful breathing, and body scans were among the most important predictors of potentially reducing use of pharmacological approaches. Providing these nonpharmacological approaches to workers could result in an estimated 23% (95% CI: 16%-30%) reduction in pharmacological pain management approaches.

CONCLUSION

This pilot study suggests specific factors related to training, job benefits, and worker familiarity with nonpharmacological pain management approaches influence use of these approaches.

Cumulative Unionization and Physical Health Disparities among Older Adults

Whereas previous research shows that union membership is associated with improved health, static measurements have been used to test dynamic theories linking the two. We construct a novel measure of cumulative unionization, tracking individuals across their entire careers, to examine health consequences in older adulthood. We use data from the Panel Study of Income Dynamics (1970-2019) and predict self-rated health, functional limitations, and chronic health conditions in ages 60 to 79 using cumulative unionization measured during respondents' careers. Results from growth models show that unionized careers are associated with .25 SD to .30 SD improvements in health among older adults across all measures. Analyses of life course mechanisms reveal heterogeneous effects across unionization timing, age in older adulthood, and birth cohort. Moreover, subgroup analyses reveal unionization to partially, but not fully, ameliorate disparities based on privileged social positions. Our findings reveal a substantial and novel mechanism driving older adulthood health disparities.

Stress, Mental Health, and Coping Among Workers in the Northern California Cannabis Industry: A Qualitative Descriptive Analysis

California is home to a multibillion-dollar cannabis (marijuana) industry, but little is known about the occupational health and safety hazards faced by cannabis workers and even less of the stress, mental health, and coping mechanisms among these workers. Previous research has been based on long-term workers at legal businesses, but most California cannabis is produced and sold unlawfully. There are many seasonal workers whose experiences have not been studied. A qualitative study based on focus group discussions and key informant interviews was performed to understand cannabis workers' experiences, knowledge, and perceptions of occupational hazards. Participants reported sources of stress including production pressure and isolation, and mental health outcomes such as depression and mental fatigue. They described primarily maladaptive coping mechanisms. Unique characteristics of the cannabis industry, including criminalization and isolated, remote farms, make interventions challenging. However, policy approaches that involve community organizations could promote worker health.

Does unionization and working under collective agreements promote health?

Health promoters recognize the social determinants of health (SDOH) shape health outcomes yet generally neglect how unionization and collective agreements (CAs) shape these SDOH. This is surprising since extensive evidence indicates unions and CAs influence wages and benefits, job security, working conditions and income inequality, which go on to affect additional SDOH of food and housing security, child development and social exclusion. We argue unions and CAs should be a health promotion focus by examining how they influence the SDOH and health outcomes in wealthy developed nations in four ways. First, we consider how union density (UD) and CA coverage (CAC) are associated with differences between wealthy western nations in percentage of low-waged workers, extent of income inequality, and low birthweight and infant mortality rates. Second, we bring together literature that shows greater UD and CAC within national sub-jurisdictions are associated over time with more equitable distribution of the SDOH and better health outcomes. Third, we document-also using available literature-how within nations, union membership and working under a CA shape the SDOH one experiences. Fourth, we carry out a Canadian case study-applying a political economy lens-to examine how power relations, working through economic and political systems, determine extent of unionization and CAC and the inclination of health promoters to consider these issues. Implications for health promoters are considered.

Dead Labor: Mortality Inequities by Class, Gender, and Race/Ethnicity in the United States, 1986-2019

Objectives. To estimate social class inequities in US mortality using a relational measure based on power over productive property and workers' labor. Methods. We used nationally representative 1986-2018 National Health Interview Survey data with mortality follow-up through December 31, 2019 (n = 911 850). First, using business-ownership, occupational, and employment-status data, we classified respondents as incorporated business owners (IBOs), unincorporated business owners (UBOs), managers, workers, or not in the labor force (NLFs). Next, using inverse-probability-weighted survival curves, we estimated class mortality inequities overall, after subdividing workers by employment status and occupation, and by period, gender, race/ethnicity, and education. Results. UBOs, workers, and NLFs had, respectively, 6.3 (95% confidence interval [CI] = -8.1, -4.6), 6.6 (95% CI = -8.1, -5.0), and 19.4 (95% CI = -21.0, -17.7) per 100 lower 34-year survival rates than IBOs. Mortality risk was especially high for unemployed, blue-collar, and service workers. Inequities increased over time and were greater among male, racially minoritized, and less-educated respondents. Conclusions. We estimated considerable mortality inequities by class, gender, and race/ethnicity. We also estimated that class mortality inequities are increasing, threatening population health. Public Health Implications. Addressing class inequities likely requires structural, worker-empowering interventions. (Am J Public Health. 2023;113(6):637-646. https://doi.org/10.2105/AJPH.2023.307227).

Gender, Race/Ethnicity, and Unionization in Direct Care Occupations

Objectives. The goal of this study was to measure unionization in the direct care workforce and the relationship between unionization and earnings, looking closely at differences across race/ethnicity and gender. Methods. Using data from the Current Population Survey from 2010 to 2020, we first used logit analyses to predict the probability of unionization among direct care workers across race/ethnicity and gender. We then measured the relationship between unionization and weekly earnings. Results. We found that male (12%) and Black (14%) direct care workers were most likely to be unionized, followed by Hispanic and other direct care workers of color. Unionized direct care workers earn wages that are about 7.8% higher than nonunionized workers, but unionized workers of color earn lower rewards for unionization compared with White direct care workers. Conclusions. Unions are a mechanism for improving job quality in direct care work, and protecting workers' rights to unionize and participate in collective bargaining equitably may be a way to stabilize and grow the direct care workforce. (Am J Public Health. 2022;112(11):1676-1684. https://doi.org/10.2105/AJPH.2022.307022).

Unionisation and injury risk in construction: a replication study

Objective

To replicate, in a more recent time period, a previous cross-sectional study to estimate the association between unionisation and the risk of workers’ compensation injury claims.

Methods

The sampling frame was workers’ compensation company account records in the industrial, commercial and institutional construction sector in the province of Ontario, Canada, 2012–2018. Company unionisation status was determined through linkage with records of unionised contractors. Outcomes were cumulative counts of workers’ compensation injury claims, aggregated to company business. Risk ratios were estimated with multivariable negative binomial regression models. Models were also fit separately to lost-time claims stratified by company size.

Results

Business unionisation was associated with a lower lost-time claim incidence (crude risk ratio, CRR=0.69, 95% CI 0.65 to 0.74); adjusted risk ratio, ARR=0.75, 95% CI 0.71 to 0.80). In subgroup analyses, the magnitude of the ARR declined as company size decreased and was not statistically significant for the smallest-sized companies of ≤4 full-time equivalent employees. Unionisation was associated (positively) with the incidence of no-lost-time claims in a crude model, but not in an adjusted one (CRR=1.80, 95% CI 1.71 to 1.89; ARR=1.04, 95% CI 0.98 to 1.09).

Conclusions

Company unionisation was associated with a lower risk of lost-time workers’ compensation injury claims, corroborating a similar study from an earlier time period. The protective effect of unionisation declined as company size decreased. In contrast to the previous study, a positive relationship between company unionisation and no-lost-time claim incidence was not found, due in part to a methodological refinement.

Recommendations for the Development of Socioeconomically-Situated and Clinically-Relevant Neuroimaging Models of Pain

Pain is a complex, multidimensional experience that emerges from interactions among sensory, affective, and cognitive processes in the brain. Neuroimaging allows us to identify these component processes and model how they combine to instantiate the pain experience. However, the clinical impact of pain neuroimaging models has been limited by inadequate population sampling - young healthy college students are not representative of chronic pain patients. The biopsychosocial approach to pain management situates a person's pain within the diverse socioeconomic environments they live in. To increase the clinical relevance of pain neuroimaging models, a three-fold biopsychosocial approach to neuroimaging biomarker development is recommended. The first level calls for the development of diagnostic biomarkers via the standard population-based (nomothetic) approach with an emphasis on diverse sampling. The second level calls for the development of treatment-relevant models via a constrained person-based (idiographic) approach tailored to unique individuals. The third level calls for the development of prevention-relevant models via a novel society-based (social epidemiologic) approach that combines survey and neuroimaging data to predict chronic pain risk based on one's socioeconomic conditions. The recommendations in this article address how we can leverage pain's complexity in service of the patient and society by modeling not just individuals and populations, but also the socioeconomic structures that shape any individual's expectations of threat, safety, and resource availability.

Labor unions and health: A literature review of pathways and outcomes in the workplace

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Unique literature review links economic and epidemiologic studies on unions.

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Unions raise wages, decrease inequality, and thereby likely improve health.

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Unions decrease discrimination and affect other determinants of health.

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Unions improve workplace safety and health and decrease job-related fatalities.

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Unions are an underappreciated social determinant of health.

Extensive economic research demonstrates correlations between unions with wages, income inequality, health insurance, discrimination, and other factors. Corresponding epidemiologic literature demonstrates correlations between income, income inequality, insurance, discrimination, and other factors with health. The first purpose of this narrative review is to link these literatures and identify 28 possible pathways whereby labor unions might affect the health of workers. This review is restricted to effects within workplaces; we do not consider unions' political activities. This review covers studies from the US, Europe, and Canada from 1980 through April 1, 2021. Pathways are grouped within five domains informed by the CDC 5-domain model of social determinants of health and the traditional 3-domain model of occupational medicine. Linked pathways include wages, inequality, excessive overtime, job satisfaction, employer-provided health insurance (EPHI), and discrimination. Second, we identify studies analyzing correlations between unions directly with health outcomes that do not require links. Outcomes include occupational injuries, sickness absence, and drug overdose deaths. Third, we offer judgments on the strength of pathways and outcomes --- labeled “consensus,” “likely,” “disputed” or “unknown” --- based on literature summaries. In our view, whereas there are four “consensus” pathways and outcomes and 16 “likely” pathways and outcomes for unions improving health, there are no “consensus” or “likely” pathways for harming health. The strongest “consensus” pathways and outcomes with salubrious associations include EPHI, OSHA inspections, dangerous working conditions, and injury deaths. Fourth, we identify research gaps and suggest methods for future studies. Unions are an underappreciated social determinant of health.

Union Burying Ground: Mortality, Mortality Inequities, and Sinking Labor Union Membership in the United States

BACKGROUND

Over the last several decades in the United States, socioeconomic life-expectancy inequities have increased 1-2 years. Declining labor-union density has fueled growing income inequities across classes and exacerbated racial income inequities. Using Panel Study of Income Dynamics (PSID) data, we examined the longitudinal union-mortality relationship and estimated whether declining union density has also exacerbated mortality inequities.

METHODS

Our sample included respondents ages 25-66 to the 1979-2015 PSID with mortality follow-up through age 68 and year 2017. To address healthy-worker bias, we used the parametric g-formula. First, we estimated how a scenario setting all (versus none) of respondents' employed-person-years to union-member employed-person-years would have affected mortality incidence. Next, we examined gender, racial, and educational effect modification. Finally, we estimated how racial and educational mortality inequities would have changed if union-membership prevalence had remained at 1979 (vs. 2015) levels throughout follow-up.

RESULTS

In the full sample (respondents = 23,022, observations = 146,681), the union scenario was associated with lower mortality incidence than the nonunion scenario (RR = 0.90, 95% CI = 0.80, 0.99; RD per 1,000 = -19, 95% CI = -37, -1). This protective association generally held across subgroups, although it was stronger among the more-educated. However, we found little evidence mortality inequities would have lessened if union membership had remained at 1979 levels.

CONCLUSIONS

To our knowledge, this was the first individual-level US-based study with repeated union-membership measurements to analyze the union-mortality relationship. We estimated a protective union-mortality association, but found little evidence declining union density has exacerbated mortality inequities; importantly, we did not incorporate contextual-level effects. See video abstract at, http://links.lww.com/EDE/B839.

The role of nonstandard and precarious jobs in the well-being of disabled workers during workforce reintegration

BACKGROUND

Nonstandard employment arrangements are becoming increasingly common and could provide needed flexibility for workers living with disabilities. However, these arrangements may indicate precarious employment, that is, employment characterized by instability, powerlessness, and limited worker rights and benefits. Little is known about the role of nonstandard and precarious jobs in the well-being of disabled persons during workforce reintegration after permanent impairment from work-related injuries or illnesses.

METHODS

We used linked survey and administrative data for a sample of 442 Washington State workers who recently returned to work and received a workers' compensation permanent partial disability award after permanent impairment from a work-related injury. Multivariable logistic regression models were used to examine associations between nonstandard employment and outcomes related to worker well-being and sustained employment. We also examined associations between a multidimensional measure of precarious employment and these outcomes. Secondarily, qualitative content analysis methods were used to code worker suggestions on how workplaces could support sustained return to work (RTW).

RESULTS

Workers in: (1) nonstandard jobs (compared with full-time, permanent jobs), and (2) precarious jobs (compared with less precarious jobs) had higher adjusted odds of low expectations for sustained RTW. Additionally, workers in precarious jobs had higher odds of reporting fair or poor health and unmet need for disability accommodation. Workers in nonstandard and precarious jobs frequently reported wanting safer and adequately staffed workplaces to ensure safety and maintain sustained employment.

CONCLUSIONS

Ensuring safe, secure employment for disabled workers could play an important role in their well-being and sustained RTW.

Does the Union Make Us Strong? Labor-Union Membership, Self-Rated Health, and Mental Illness: A Parametric G-Formula Approach

Union members enjoy better wages and benefits and greater power than nonmembers, which can improve health. However, the longitudinal union-health relationship remains uncertain, partially because of healthy-worker bias, which cannot be addressed without high-quality data and methods that account for exposure-confounder feedback and structural nonpositivity. Applying one such method, the parametric g-formula, to US-based Panel Study of Income Dynamics data, we analyzed the longitudinal relationships between union membership, poor/fair self-rated health (SRH), and moderate mental illness (Kessler 6-item score of ≥5). The SRH analyses included 16,719 respondents followed from 1985-2017, while the mental-illness analyses included 5,813 respondents followed from 2001-2017. Using the parametric g-formula, we contrasted cumulative incidence of the outcomes under 2 scenarios, one in which we set all employed-person-years to union-member employed-person-years (union scenario), and one in which we set no employed-person-years to union-member employed-person-years (nonunion scenario). We also examined whether the contrast varied by sex, sex and race, and sex and education. Overall, the union scenario was not associated with reduced incidence of poor/fair SRH (relative risk = 1.01, 95% confidence interval (CI): 0.95, 1.09; risk difference = 0.01, 95% CI: -0.03, 0.04) or moderate mental illness (relative risk = 1.02, 95% CI: 0.92, 1.12; risk difference = 0.01, 95% CI: -0.04, 0.06) relative to the nonunion scenario. These associations largely did not vary by subgroup.

The association between union membership and perceptions of safety climate among US adult workers

OBJECTIVES

An individual's perceptions of their workplace safety climate can influence their health and safety outcomes in the workplace. Even though union membership has been declining in the US, union members still comprise 10% of the working population and have higher-than-industry average non-fatal illness and injury rates. Due to limited research focused in this area, this study examined whether union membership was associated with worker perceptions of safety climate.

METHODS

This was a secondary data analysis study utilizing data from the Quality Work Life module from the General Social Survey centered on US workers aged 18 and above. Propensity-score matching was implemented to reduce potential selection bias between unionized and non-unionized workers. Linear regression explored the association between union membership and perceptions of safety climate, controlling for age, sex, education, industry, resource adequacy, supervisor support, co-worker support, and workload.

RESULTS

For perceived safety climate (on a 0-16 scale, the higher the more positive), those in union had a lower mean of perceived safety climate (12.44) compared to those not in a union (13.20). Based on the regression results, those who were in a union reported more negative perceptions of their workplace safety climate in a 12-month period (β = -0.61, p < .001).

CONCLUSIONS

By demonstrating a commitment to proactive injury prevention and bolstering the business's overall safety performance indicators, businesses who are open to collaborations with unions may see some long-term benefits (e.g. return on investment, increased job satisfaction) and enhance union workers' perceptions of safety climate.

Organized Labor and Depression in Europe: Making Power Explicit in the Political Economy of Health

Despite engagement with the construct of power relations, research on the political economy of health has largely overlooked organized labor as a determinant of well-being. Grounded in the theory of power resources, our study aims to fill this gap by investigating the link between country-level union density and mental health while accounting for the compositional effects of individual-level union membership. We use three waves of the European Social Survey (N = 52,737) and a variation on traditional random-effects models to estimate both the contextual and change effects of labor unions on depressive symptoms. We find that country-level union density is associated with fewer depressive symptoms and that this is true irrespective of union membership. We discuss our findings vis-à-vis the literatures on the political economy of health, power resources, and fundamental causes of disease.

Solidarity and disparity: Declining labor union density and changing racial and educational mortality inequities in the United States

BACKGROUND

Recently, United States life expectancy has stagnated or declined for the poor and working class and risen for the middle and upper classes. Declining labor-union density-the percent of workers who are unionized-has precipitated burgeoning income inequity. We examined whether it has also exacerbated racial and educational mortality inequities.

METHODS

From CDC, we obtained state-level all-cause and overdose/suicide mortality overall and by gender, gender-race, and gender-education from 1986-2016. State-level union density and demographic and economic confounders came from the Current Population Survey. State-level policy confounders included the minimum wage, the generosity of Aid to Families with Dependent Children or Temporary Assistance for Needy Families, and the generosity of unemployment insurance. To model the exposure-outcome relationship, we used marginal structural modeling. Using state-level inverse-probability-of-treatment-weighted Poisson models with state and year fixed effects, we estimated 3-year moving average union density's effects on the following year's mortality rates. Then, we tested for gender, gender-race, and gender-education effect-modification. Finally, we estimated how racial and educational all-cause mortality inequities would change if union density increased to 1985 or 1988 levels, respectively.

RESULTS

Overall, a 10% increase in union density was associated with a 17% relative decrease in overdose/suicide mortality (95% confidence interval [CI]: 0.70, 0.98), or 5.7 lives saved per 100 000 person-years (95% CI: -10.7, -0.7). Union density's absolute (lives-saved) effects on overdose/suicide mortality were stronger for men than women, but its relative effects were similar across genders. Union density had little effect on all-cause mortality overall or across subgroups, and modeling suggested union-density increases would not affect mortality inequities.

CONCLUSIONS

Declining union density (as operationalized in this study) may not explain all-cause mortality inequities, although increases in union density may reduce overdose/suicide mortality.

On-the-ground health and safety experiences of non-union casino hotel workers: A focus-group study stratified by four occupational groups

OBJECTIVES

To understand the health- and safety-related experiences of specific occupations among non-union casino hotel employees to identify processes leading to worker health and safety risks.

METHODS

Using purposive, criterion sampling, 61 workers participated in 13 recorded focus groups (FGs). A semi-structured topic guide addressed work-related health and safety impacts, workplace hazards, and management responses, among others. FG transcripts were analyzed following grounded theory methodology. Demographic and occupational health information was collected via survey.

RESULTS

Codes (97) were collapsed into seven themes: activities/exposures negatively affecting health/safety; barriers to health/safety; injury/pain occurrences; coping mechanisms; job vulnerability; management policies/enforcement; lack of management concern for employees. From these themes emerged the Dynamic Theoretical Framework of Employee Health and Safety Risk.

CONCLUSIONS

"Management's lack of concern" creates a negative environment whereby employer-controlled factors jeopardize employees' health and safety. Interventions targeting management's lack of concern for employee health and safety could favorably change work-based risks.

Compensation Appraisals and Labor Union Membership

Given the beneficial effects of labor unions on "bread and butter issues," union members should appraise their economic circumstances more favorably than nonunion members do. Yet, research on the anomaly of the dissatisfied union worker challenges this expectation. Using the General Social Survey's Quality of Work Life module, this article examines whether union members appraise their economic circumstances less favorably than nonunion members. Results suggest that union membership is associated with more favorable appraisal of benefits but not wages. These findings may help to provide at least a partial explanation for the anomaly of the dissatisfied union worker. Because income constitutes a vital component of job satisfaction, this study contributes more broadly to our understanding of employee well-being. It also connects the study of occupational health to that on institutions, contributes to the growing literature on the political economy of health, and highlights latent effects of union security agreements.

Right-to-Work-for-Less: How Janus v. AFSCME Threatens Public Health

In February 2018, the Supreme Court heard oral arguments in Janus v. AFSCME, a case poised to make right-to-work (or, as some call it, right-to-work-for-less) the law in the public sector. At issue is the constitutionality of requiring non-union members, who benefit from collective bargaining, to pay fees that support contract negotiations on the terms and conditions of their employment. We argue that a win for Janus would threaten public health by eroding organized labor's power to improve working conditions. Furthermore, we critique the dubious legal theory underpinning Janus's case and describe the moneyed political interests backing his legal representation. Finally, we chart a path forward for labor organizing in a post- Janus world, drawing inspiration from the winter 2018 educators' strike in West Virginia. Regardless of how Janus itself is decided, the issues raised in this article remain crucial because the ongoing weakening of unions by legislative and judicial means undermines workers' health and exacerbates inequities.

Same-level fall injuries in US workplaces by age group, gender, and industry

BACKGROUND

As the workforce ages, occupational injuries from falls on the same level will increase. Some industries may be more affected than others.

METHODS

We conducted a cross-sectional study using data from the Bureau of Labor Statistics to estimate same-level fall injury incidence rates by age group, gender, and industry for four sectors: 1) healthcare and social assistance; 2) manufacturing; 3) retail; and 4) transportation and warehousing. We calculated rate ratios and rate differences by age group and gender.

RESULTS

Same-level fall injury incidence rates increase with age in all four sectors. However, patterns of rate ratios and rate differences vary by age group, gender, and industry. Younger workers, men, and manufacturing workers generally have lower rates.

CONCLUSIONS

Variation in incidence rates suggests there are unrealized opportunities to prevent same-level fall injuries. Interventions should be evaluated for their effectiveness at reducing injuries, avoiding gender- or age-discrimination and improving work ability.

Respectable Gentlemen and Street-Savvy Men: HIV Vulnerability in Sri Lanka

In this article, I investigate how particular discourses surrounding class specific understandings of sexual behavior and female morality shape awareness and views of the disease and personal vulnerability. Although both groups belong to the working class, those employed by the transportation board consider themselves government servants and, therefore, "respectable gentlemen." Construction workers identify easily with their class position, recognizing and sometimes trying to live up to the stereotypes of free sexuality. These different perceptions directly affect their concern and awareness of risk factors for sexually transmissible infections and safe-sex practices. While the "respectable gentlemen" consider themselves invulnerable, the "street-savvy men" learned about risks and took precautions to prevent STIs.

The Role of Labor Unions in Creating Working Conditions That Promote Public Health

We sought to portray how collective bargaining contracts promote public health, beyond their known effect on individual, family, and community well-being. In November 2014, we created an abstraction tool to identify health-related elements in 16 union contracts from industries in the Pacific Northwest. After enumerating the contract-protected benefits and working conditions, we interviewed union organizers and members to learn how these promoted health. Labor union contracts create higher wage and benefit standards, working hours limits, workplace hazards protections, and other factors. Unions also promote well-being by encouraging democratic participation and a sense of community among workers. Labor union contracts are largely underutilized, but a potentially fertile ground for public health innovation. Public health practitioners and labor unions would benefit by partnering to create sophisticated contracts to address social determinants of health.

Two decades of Neo-Marxist class analysis and health inequalities: A critical reconstruction

Most population health researchers conceptualize social class as a set of attributes and material conditions of life of individuals. The empiricist tradition of 'class as an individual attribute' equates class to an 'observation', precluding the investigation of unobservable social mechanisms. Another consequence of this view of social class is that it cannot be conceptualized, measured, or intervened upon at the meso- or macro levels, being reduced to a personal attribute. Thus, population health disciplines marginalize rich traditions in Marxist theory whereby 'class' is understood as a 'hidden' social mechanism such as exploitation. Yet Neo-Marxist social class has been used over the last two decades in population health research as a way of understanding how health inequalities are produced. The Neo-Marxist approach views social class in terms of class relations that give persons control over productive assets and the labour power of others (property and managerial relations). We critically appraise the contribution of the Neo-Marxist approach during the last two decades and suggest realist amendments to understand class effects on the social determinants of health and health outcomes. We argue that when social class is viewed as a social causal mechanism it can inform social change to reduce health inequalities.