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Abstract
The research conducted for this dissertation aims to expand evidence of the deep inequities in Indigenous occupational health evidence and provide recommendations for targeted future research that will appropriately inform policy, practice, and community level outcomes that might reduce the gap in life expectancy between Indigenous and non-Indigenous peoples. This was done through a series of three analyses that used existing data sets to assess their utility for elucidating unique experiences of Indigenous peoples’ occupational health in the United States (U.S.). Our literature review (Shannon et. al, 2022) demonstrated several gaps in the literature on Indigenous occupational injuries and illnesses. Specifically, the current body of research demonstrated inadequate targeting sampling of Indigenous workers, inadequate use of occupational health data sources (primary care, emergency department (ED), community-based research and occupational surveillance systems), lack of uniform definitions of race/ethnicity and limited examination of illnesses, chronic disease and psychological outcomes related to work. The three projects that form this dissertation address these gaps identified in our scoping review. Our first project examined the utility of incorporating outpatient and emergency department hospital data into current occupational health surveillance systems and specifically assessed how ED and outpatient data improves our understanding of Indigenous occupational health issues. We found that hospital data holds value in occupational surveillance, in particular the importance of integrating and utilizing ED visit and outpatient data in addition to widely used trauma registry and admissions data for occupational health research. Inclusive of Indigenous and non-Indigenous hospital presentations, there were 17-times more hospital visits relating to illnesses and musculoskeletal conditions treated in the ED (n=232,999) compared to admissions (n=13,467). The majority were specifically for subacute or chronic musculoskeletal conditions, but there were a large number of visits relating to disorders of the circulatory system, nervous system, and digestive system. Rate ratios by ethnicity using White non-Hispanic as the reference group showed that African American workers had higher rates of ED emergent presentations but were less likely to be admitted for emergent presentations. Rate ratios were not possible for AIAN groups due to unreported employment numbers at the state level. Work related injury and illness (WRII) presentations by AIAN only and AIAN Hispanic race/ethnicity demonstrated significant differences in presentations by age, gender, primary diagnosis, and location of residence in Illinois. American Indian or Alaskan Native and Hispanic (AIAN Hispanic) WRII presentations were younger, more predominantly male and based in urban areas than AIAN only. Presentations were predominantly injury diagnoses in American Indian or Alaskan Native and Hispanics and required a higher proportion of inpatient emergent admissions than AIAN only presentations. The separation of Indigenous groups based on race/ethnicity identifiers in hospital data shows obvious differences in WRII presentations that likely reflect different workforce characteristics and occupational health outcomes. American Indian and Alaskan Native presentations were compared to non-Hispanic Whites (NHW) in multivariable models to evaluate differences in risk factors or predictors of both emergent and elective ED visits compared to admitted cases. Multivariable models demonstrate AIAN-alone had significantly higher odds of being treated as an outpatient compared to NHW. American Indian or Alaskan Native and Hispanic (AIAN Hispanic) workers were more likely to be admitted for emergent events, suggesting a higher occurrence of severe emergent presentations. Those presenting with musculoskeletal conditions compared to illness as the reference group had higher odds of treatment in the ED for emergent cases, but lower odds for elective cases. Traditional occupational surveillance systems fail to capture WRII data relating to these chronic health conditions. In particular, ED data provides an opportunity to further examine the distribution of work-related musculoskeletal conditions and evaluate the relationship between elective procedures and interventions for early return-to-work. National data using the survey of Occupational Injuries and Illnesses in the U.S. has a high proportion participant with missing race/ethnicity. Emergency data is an important source for examining distribution of WRII in minority groups, particularly for Indigenous people due to limited use of Indigenous race/ethnicity identifiers in other data sources.
The second and third study of this dissertation used a national cross-sectional survey, the National Health Interview Survey (NHIS), to gain a better understanding of the role of structural and intermediary determinants on occupational and mental health outcomes for Indigenous people. The historical and ongoing context of colonization has had ongoing impacts on physical and mental morbidity, location and mobility within the US, exclusion from health and social services, separation from cultural and personal identity, ownership of land and present disadvantage that all have contributed to differences in health outcomes, labor force participation and quality of employment outcomes in Indigenous people. The use of NHIS provided a nationally representative survey to address two of the identified gaps in Indigenous WRII research; (1) use of uniform definitions of Indigenous race/ethnicity for specific Indigenous groups in the U.S. and (2) examination of illness, chronic disease and psychological outcomes related to work. The initial NHIS study used three Indigenous groups; (1) Non-Hispanic American Indian Alaskan Native (referred to as AIAN only) (2) Hispanic American Indian and Alaskan Native (referred to as AIAN Hispanic) and (3) American Indian Alaskan Native and other Race group (referred to as AIAN other). Outcomes examined were labor force participation (based on employment status in past week), employment status, paid sick leave benefits at job last week, health insurance offered at workplace for those who reported working last week and income below 200% federal poverty level (FPL) during past year.
Indigenous groups were less likely to participate in the U.S. labor force, with inequities present in employment quality comparative to other racial-ethnic groups. In the adjusted model controlling for age, sex, and education, all three Indigenous groups had substantially higher odds of earning below 200% of the FPL compared to all other race/ethnicities. Among participants who reported working during the past year, the most common industry for AIAN only subgroup was accommodation and food services (15.9%; 95% CI:7.6, 24.2). Health care and social assistance industry is the most common industry in both AIAN Hispanic (12.3%, 95% CI:5.4-19.3) and AIAN other subgroups (12.7%, 95% CI:7.3, 18.2). Indigenous subgroups were less likely to work in professional, scientific, and technical services than all other race/ethnicity groups combined. Indigenous subgroups ranging between 3.9%-5.6% of the workforce in their respective groups compared to 9.3% (95% CI: 8.7, 9.8) in non-Hispanic whites or 8.2% (95% CI: 7.8, 8.7) in all non-Indigenous groups. They were also less likely to work in the education services industries with Indigenous subgroups ranging between 7.0-7.2% of workers compared to 9.7% (95% CI: 9.3, 10.2) in non-Hispanic Whites. This research demonstrated that the three Indigenous groups reported in the NHIS survey (AIAN only, AIAN Hispanic and AIAN other) are very different worker populations that need to be addressed separately in future Indigenous occupational health research and strategic planning. The results also demonstrate that a review is required of the standards for maintaining, collecting, and presenting federal data on race and ethnicity that are now dated and treat all Indigenous peoples of the Americas as a homogenous group.
A review of NHIS occupational health indicators showed standard measures of health and wellbeing reflective of those in the World Health Organization (WHO) social and structural determinants(WHO, 2010). Factors within Indigenous health and wellbeing represent a broader understanding of physical, mental, social, spiritual and cultural components that are couched in local personal and community context (Milroy, 2006, Thunderbird Partnership Foundation, 2018) with distinct determinants of health including self-determination, cultural attachment, relationship with land, social capital, racism and justice systems (Gracey & King, 2009). The implication within the current frameworks is that in the absence of a given determinant, health and wellbeing is poor; however, there is no explicit consideration of mediators or moderators in the pathway from SDoH to adverse outcome, specifically those distinct determinants of health for Indigenous people. Land dispossession, cultural attachments, social supports and racism and discrimination may all be mediators in relationships between occupational and non-occupational SDoH.
Occupational health and wellbeing depend on interactions between Indigenous workers, interactions with individuals at work, environmental characteristics and group values, beliefs and norms. For Indigenous people, an individual’s occupational health and wellbeing is also going to be intertwined with their core self and the spiritual, cultural, and social aspects of Indigenous health and wellbeing that are not represented in the WHO social and structural determinants. We developed a framework for future Indigenous occupational health indicators that is focused on Indigenous led capacity building and adoption of strengths-based models in this area.
Our third aim, using the NHIS, provided a detailed description of the characteristics of AIAN adults with depressed symptoms and examined their sociodemographic, health, functional and disability characteristics by working status. Mental health outcomes have worsened nationally for Indigenous adults in the U.S. in recent years, with no examination of outcomes by employment status or occupational group. Our research demonstrated differences in mental health outcomes including depressive symptoms, mental health diagnoses and treatments between employed and unemployed Indigenous adults and by specific occupational group of those employed. Among Indigenous workers, adults with service jobs had significantly higher odds for depressive symptoms and previous diagnosis of depression and white-collar jobs had significantly higher odds of previous diagnosis of depression and mental health therapy in the past 12 months when compared to blue collar Indigenous workers. Appropriate tools to assess psychosocial risk in the workplace through a cultural lens and the collection of race/ethnicity data against a range of occupational health measures is required. Such evidence will be critical to addressing barriers and successful enablers of cultural safety and reducing the risk of work- related depression.
The lack of appropriate data to fully understand these issues, including a lack of culturally appropriate measures of occupational health and wellbeing impedes our full understanding of the health disparities experienced by Indigenous people in the workforce. These include (1) WRII rates, (2) the health benefits of good work in specific occupational groups including aspects of self-determination and positive spiritual and cultural components and (3) the negative consequences of poor-quality work that includes experiences of discrimination, acculturative stressors and poor benefits that may worsen health outcomes. This impedes our ability to make policy that promotes healthy work in this population group.
