Exploring Public Health's roles and limitations in advancing food security in British Columbia.

OBJECTIVES: This research analyzes the roles and limitations of Public Health in British Columbia in advancing food security through the integration of food security initiatives into its policies and programs. It asks the question, can Public Health advance food security? If so, how, and what are its limitations? METHODS: This policy analysis merges findings from 38 key informant interviews conducted with government and civil society stakeholders involved in the development of food security initiatives, along with an examination of relevant documents. The Population Health Template is used to delineate and analyze Public Health roles in food security. RESULTS: Public Health was able to advance food security in some ways, such as the adoption of food security as a core public health program. Public Health's leadership role in food security is constrained by a restricted mandate, limited ability to collaborate across a wide range of sectors and levels, as well as internal conflict within Public Health between Food Security and Food Protection programs. CONCLUSIONS: Public Health has a role in advancing food security, but it also faces limitations. As the limitations are primarily systemic and institutional, recommendations to overcome them are not simple but, rather, require movement toward embracing the determinants of health and regulatory pluralism. The results also suggest that the historic role of Public Health in food security remains salient today.

Stakeholder perceptions of job stress in an industrialized country: implications for policy and practice.

We used a secondary, qualitative analysis of stakeholder perceptions of work stress in Australia to characterize the context for policy and practice intervention. Themes included: Individual versus contextual descriptions of stress; perceived 'gender' differences in manifesting and reporting of stress; the work/home interface; and perceived sectoral and occupational differences in compensation claim rates. We found that people often still perceive stress as an individual rather than organizational problem and view work stress as a stereotypically feminine weakness that affects only certain people. Organizations downplay and overlook risks, increasing worker reluctance to report stressors, creating barriers to job stress interventions. Our study may be relevant to other industrial countries where researchers currently study job stress interventions to improve their effectiveness. Comprehensive approaches can increase knowledge and decrease stigma about job stress and mental illness, and target both work- and non-work-related influences on mental health.

Job strain and shift work influences on biomarkers and subclinical heart disease indicators: a pilot study.

This pilot study is one of the first to examine the impact of job strain and shift work on both the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis using two salivary stress biomarkers and two subclinical heart disease indicators. This study also tested the feasibility of a rigorous biological sampling protocol in a busy workplace setting. Paramedics (n = 21) self-collected five salivary samples over 1 rest and 2 workdays. Samples were analyzed for α-amylase and cortisol diurnal slopes and daily production. Heart rate variability (HRV) was logged over 2 workdays with the Polar RS800 Heart Rate monitors. Endothelial functioning was measured using fingertip peripheral arterial tonometry. Job strain was ascertained using a paramedic-specific survey. The effects of job strain and shift work were examined by comparing paramedic types (dispatchers vs. ambulance attendants) and shift types (daytime vs. rotating day/night). Over 90% of all expected samples were collected and fell within expected normal ranges. Workday samples were significantly different from rest day samples. Dispatchers reported higher job strain than ambulance paramedics and exhibited reduced daily alpha-amylase production, elevated daily cortisol production, and reduced endothelial function. In comparison with daytime-only workers, rotating shift workers reported higher job strain, exhibited flatter α-amylase and cortisol diurnal slopes, reduced daily α-amylase production, elevated daily cortisol production, and reduced HRV and endothelial functioning. Despite non-statistically significant differences between group comparisons, the consistency of the overall trend in subjective and objective measures suggests that exposure to work stressors may lead to dysregulation in neuroendocrine activity and, over the long-term, to early signs of heart disease. Results suggest that further study is warranted in this population. Power calculations based on effect sizes in the shift type comparison suggest a study size of n = 250 may result in significant differences at p = 0.05. High compliance among paramedics to complete the intensive protocol suggests this study will be feasible in a larger population.

Psychosocial and other working conditions: variation by employment arrangement in a sample of working Australians.

BACKGROUND: The evidence linking precarious employment with poor health is mixed. Self-reported occupational exposures in a population-based Australian sample were assessed to investigate the potential for differential exposure to psychosocial and other occupational hazards to contribute to such a relationship, hypothesizing that exposures are worse under more precarious employment arrangements (EA). METHODS: Various psychoscial and other working conditions were modeled in relation to eight empirically derived EA categories with Permanent Full-Time (PFT) as the reference category (N = 925), controlling for sex, age, and occupational skill level. RESULTS: More precarious EA were associated with higher odds of adverse exposures. Casual Full-Time workers had the worst exposure profile, showing the lowest job control, as well as the highest odds of multiple job holding, shift work, and exposure to four or more additional occupational hazards. Fixed-Term Contract workers stood out as the most likely to report job insecurity. Self-employed workers showed the highest job control, but also the highest odds of long working hours. CONCLUSIONS: Psychosocial and other working conditions were generally worse under more precarious EA, but patterns of adverse occupational exposures differ between groups of precariously employed workers.

Charitable food programs in Victoria, BC.

PURPOSE: Few authors have investigated the institutional character of charitable food programs and their capacity to address food security in Canada. METHODS: We surveyed food program managers at charitable agencies in Greater Victoria, British Columbia. We discuss the structure of the "system" of charitable food provision, the value of sourced food, types of services provided, clients' demographic profile, and the estimated healthfulness of meals served. We also describe the proportion of major food types purchased and donated to agencies. RESULTS: Thirty-six agencies served approximately 20,000 meals a week to about 17,000 people. Food valued at $3.2 million was purchased or donated; approximately 50% was donated, mainly by corporations. The largest value of food purchased and donated was from meat and alternatives (40.9%) and nonperishable food items (16%). Dairy products made up the smallest share of donated foods. CONCLUSIONS: Charitable food programs in Victoria depend on food donations. The proportion of dairy products and produce is low, which raises questions about the healthfulness of foods currently fed to homeless and poor people in the city.

Unwanted sexual advances at work: variations by employment arrangement in a sample of working Australians.

OBJECTIVE: We tested the hypothesis that the risk of experiencing unwanted sexual advances at work (UWSA) is greater for precariously-employed workers in comparison to those in permanent or continuing employment. METHODS: A cross-sectional population-based telephone survey was conducted in Victoria (66% response rate, N=1,101). Employment arrangements were analysed using eight differentiated categories, as well as a four-category collapsed measure to address small cell sizes. Self-report of unwanted sexual advances at work was modelled using multiple logistic regression in relation to employment arrangement, controlling for gender, age, and occupational skill level. RESULTS: Forty-seven respondents reported UWSA in our sample (4.3%), mainly among women (37 of 47). Risk of UWSA was higher for younger respondents, but did not vary significantly by occupational skill level or education. In comparison to Permanent Full-Time, three employment arrangements were strongly associated with UWSA after adjustment for age, gender, and occupational skill level: Casual Full-Time OR = 7.2 (95% Confidence Interval 1.7-30.2); Fixed-Term Contract OR = 11.4 (95% CI 3.4-38.8); and Own-Account Self-Employed OR = 3.8 (95% CI 1.2-11.7). In analyses of females only, the magnitude of these associations was further increased. CONCLUSIONS: Respondents employed in precarious arrangements were more likely to report being exposed to UWSA, even after adjustment for age and gender. IMPLICATIONS: Greater protections from UWSA are likely needed for precariously employed workers.

Food sales outlets, food availability, and the extent of nutrition policy implementation in schools in British Columbia.

BACKGROUND: The purpose of this study was to determine the number and types of different food sales outlets, the types of foods offered for sale in all school food outlets, and the extent of nutrition policy implementation in schools in British Columbia. We also directly measured the number and types of snack foods available for sale in each vending machine at each school. METHODS: Based on a thorough literature review and guided by an expert panel of nutritionists, we developed an instrument to measure the quantity and types of foods offered for sale in vending machines, the types of food for sale in all school food outlets, and the extent of nutrition policy development. RESULTS: The survey response rate was approximately 70%. Approximately 60% of surveyed schools had a permanent food sales outlet. Snack and beverage vending machines were most common in secondary schools, while tuck shops and food-based fundraisers were more common in elementary schools. While few snack vending machines were present in elementary schools, tuck shops stocked items commonly found in snack machines. Approximately 25% of schools had a formal group responsible for nutrition. These schools were more likely to have nutrition policies in place. CONCLUSION: "Junk" foods were widely available in elementary, middle, and secondary schools through a variety of outlets. Although snack machines are virtually absent in elementary schools, tuck shops and school fundraisers sell foods usually found in snack machines, largely cancelling the positive effect of the absence of snack machines in these schools. Schools with a group responsible for nutrition appear to have a positive impact on nutrition policy implementation.

Impact of the specificity of the exposure metric on exposure-response relationships.

BACKGROUND: Exposure misclassification may occur when nonspecific exposure indicators are used. Developing estimates of more specific measures may be difficult due to sampling limitations or a paucity of historical measurements and, thus, often requires substantial effort. We examine the impact on exposure-response relationships of moving from 2 measures of exposure mixtures (dust, chlorophenols) to more specific exposure indicators (wood dust, pentachlorophenol, tetrachlorophenol) in a retrospective cohort. METHODS: The study population consisted of 26,847 male sawmill workers (> or =1 year employment between 1950 and 1995) with linkage to national cancer registries. A subcohort (n = 11,273 employed more than 1 day between 1985 and 1995) was linked to hospital discharge records. We evaluated the shape (log-linear vs log-log models), goodness of fit, precision, and expected versus observed attenuation of the exposure-response relationships. RESULTS: The correlation between the cumulative exposure indices was moderately high (dust/wood dust, r = 0.68; total chlorophenol/pentachlorophenol, r = 0.88; total chlorophenol/tetrachlorophenol, r = 0.78). An increase in chronic obstructive pulmonary disease hospitalizations was found with wood dust but not with total dust. Stronger associations for non-Hodgkin lymphoma and kidney cancer incidence were observed with pentachlorophenol than with total chlorophenol; no association was observed with tetrachlorophenol. We observed greater attenuation than expected using total dust, but less than expected using total chlorophenol. CONCLUSIONS: The relationships between health outcomes were substantially attenuated when nonspecific exposure indicators were used. This study demonstrates the importance of developing exposure metrics as specific to the disease-causing agent as possible, particularly when the composition of mixed exposures varies by work areas.

Psychosocial and other working conditions in relation to body mass index in a representative sample of Australian workers.

BACKGROUND: The aim of the study was to examine the relationship between psychosocial and other working conditions and body-mass index (BMI) in a working population. This study contributes to the approximately dozen investigations of job stress, which have demonstrated mixed positive and negative results in relation to obesity, overweight and BMI. METHODS: A cross-sectional population-based survey was conducted among working Australians in the state of Victoria. Participants were contacted by telephone from a random sample of phone book listings. Information on body mass index was self-reported as were psychosocial work conditions assessed using the demand/control and effort/reward imbalance models. Other working conditions measured included working hours, shift work, and physical demand. Separate linear regression analyses were undertaken for males and females, with adjustment for potential confounders. RESULTS: A total of 1101 interviews (526 men and 575 women) were completed. Multivariate models (adjusted for socio-demographics) demonstrated no associations between job strain, as measured using the demand/control model, or ERI using the effort/reward imbalance model (after further adjustment for over commitment) and BMI among men and women. Multivariate models demonstrated a negative association between low reward and BMI among women. Among men, multivariate models demonstrated positive associations between high effort, high psychological demand, long working hours and BMI and a negative association between high physical demand and BMI. After controlling for the effort/reward imbalance or the demand/control model, the association between physical demand and working longer hours and BMI remained. CONCLUSION: Among men and women the were differing patterns of both exposures to psychosocial working conditions and associations with BMI. Among men, working long hours was positively associated with higher BMI and this association was partly independent of job stress. Among men physical demand was negatively associated with BMI and this association was independent of job stress.

Joint health and safety committee education and the value of bipartite cooperation in the healthcare sector in British Columbia, Canada.

In 1999, in British Columbia, Canada, the healthcare workforce, healthcare employers and unions partnered to develop the Occupational Health and Safety Agency for Healthcare (OHSAH), a bipartite (labor-management)-governed organization with a mandate to implement evidence-based programs to reduce injury rates in health care. Within a year of its establishment, OHSAH began delivery of a province-wide joint committee education and development (JCED) program. A telephone survey after six months showed that the training program had modestly increased the establishment of new programs and had significantly increased positive health and safety behaviors and quality of JC functioning. The spirit of bipartite collaboration fostered by this and other OHSAH programs has been hugely successful at reducing injuries, time loss, and cost, and should be promoted.

Choosing a model of care for patients in alternate level care: caregiver perspectives with respect to staff injury.

The population of alternate level care (ALC) patients utilizing acute-care hospital resources inappropriate to their needs is growing. The purpose of this study was to explore how the care of ALC patients was managed at 4 acute-care facilities in the Canadian province of British Columbia and to examine how this care impacts on outcomes of staff injury. Interviews were conducted to identify and characterize the different models of ALC. Injury outcomes for all caregivers were obtained (n = 2,854) and logistic regression conducted to compare staff injuries across ALC models. Injured workers were surveyed regarding their perceptions of injury risk and ALC. Five ALC models were identified: low-mix, high-mix, dedicated ALC units, extended care units, and geriatric assessment units. The risk for caregiver injuries was lowest on dedicated ALC units. These findings suggest that acute-care facilities faced with a growing ALC population should consider creating dedicated ALC units.

Factors associated with staff injuries in intermediate care facilities in British Columbia, Canada.

BACKGROUND: Large variations in staff injury rates across intermediate care facilities suggest that injuries may be driven by facility-specific work environment factors. OBJECTIVES: To identify work organization, psychosocial, and biomechanical factors associated with staff injuries in intermediate care facilities, to pinpoint management practices that may contribute to lower staff injuries, and to generate a provisional conceptual framework of work organization characteristics. METHODS: Four representative intermediate care facilities with high staff injury rates and four facilities with comparable low staff injury rates were selected from Workers' Compensation Board (WCB) databases. Methods included on-site injury data collection and review of associated WCB data, ergonomic study of workloads, a telephone survey of resident care staff, manager-staff interviews, and focus groups. Pearson product-moment correlation coefficients identified associations between variables. Analysis of variance and t tests were used to determine differences between low and high staff injury rate facilities. Content analysis guided the qualitative analysis. RESULTS: There were no significant differences between low and high staff injury rate facilities in terms of workers' characteristics, residents' characteristics, and per capita public funding. The ergonomic study supported the survey data in demonstrating a relation among low staffing levels, greater muscle loading, and greater risk of injury. As compared with facilities that had high staff injury rates, facilities with low staff injury rates had significantly more favorable staffing levels and supportive work environments. Perceived quality of care was strongly correlated with burnout, health, and satisfaction. CONCLUSIONS: Safer work environments are promoted by favorable staffing levels, convenient access to mechanical lifts, workers' perceptions of employer fairness, and management practices that support the caregiving role.

Labor markets and employment insecurity: impacts of globalization on service and healthcare-sector workforces.

Global changes in the economies of most developed nations have impacted the way healthcare is organized, even within largely public systems, and the working conditions of healthcare workers. Since the acceleration of globalization in the 1970s, service-sector workers in developed nations have faced high unemployment, increased skill requirements for most jobs, and a rise in non-traditional work arrangements. These secular shifts in service-sector labor markets have occurred against the background of an erosion of the welfare state and growing income inequality. As well, many healthcare systems, including Canada's, were severely downsized and restructured in the 1990s, exacerbating the underlying negative secular trends in the service sector, and worsening the working conditions for many healthcare workers. Globalization has altered the labor market and shifted working conditions in ways that have been unfavorable to many healthcare workers.

Workload as a determinant of staff injury in intermediate care.

Care aides (CAs) and licensed practical nurses (LPNs) in intermediate care (IC) facilities experience high risks of injury. Workload measures were examined in eight IC facilities to ascertain their relationships with musculoskeletal injury rates, pain, burnout, and self-reported health. Workload was measured using (1) focus groups and telephone interviews to obtain CA/LPN perceptions; (2) systematic observation (numbers of tasks performed in shift); and (3) CA-to-resident staffing ratios. Controlling for resident dependency and facility funding, all workload measures were correlated with staff injury rates and burnout. Facilities with low injury rates had better CA/LPN-to-resident staffing ratios and fewer tasks. The differences in staffing reflected differences in how organizations prioritized and allocated resources. Thus, workload is an important determinant of injuries and increased staffing levels correlate with decreased injuries.

Understanding "globalization" as a determinant of health determinants: a critical perspective.

The purpose of this article is to explain how globalization has evolved, in order to provide a context for assessing the health care restructuring that is occurring worldwide. The authors begin by defining globalization and introducing a framework for considering pathways that can affect social organization and health. They then draw attention to current trends, such as the GATS (General Agreement on Trade in Services), that promise to open health services provision to increased pressures of globalization.

Work organization and patient care staff injuries: the impact of different care models for "alternate level of care" patients.

BACKGROUND: The number of elderly patients who do not have acute-care needs has increased in many North American hospitals. These alternate level care (ALC) patients are often cognitively impaired or physically dependent. The physical and psychosocial demands on caregivers may be growing with the increased presence of ALC patients leading to greater risk for injury among staff. METHODS: This prospective cohort study characterized several models for ALC care in four acute-care hospitals in British Columbia, Canada. A cohort of 2,854 patient care staff was identified and followed for 6 months. The association between ALC model of care and type and severity of injury was examined using multinomial and ordinal logistic regression. RESULTS: Regression models demonstrated that the workers on ALC/medical nursing units with "high" ALC patient loads and specialized geriatric assessment units had the greatest risk for injury and the greatest risk for incurring serious injury. Among staff caring for ALC patients, those on dedicated ALC units had the least risk for injury and the least risk for incurring serious injury. CONCLUSIONS: The way in which ALC care is organized in hospitals affects the risk and severity of injuries among patient care staff.

A comparison between the effort-reward imbalance and demand control models.

BACKGROUND: To compare the predictive validity of the demand/control and reward/imbalance models, alone and in combination with each other, for self-reported health status and the self-reported presence of any chronic disease condition. METHODS: Self-reports for psychosocial work conditions were obtained in a sample of sawmill workers using the demand/control and effort/reward imbalance models. The relative predictive validity of task-level control was compared with effort/reward imbalance. As well, the predictive validity of a model developed by combining task-level control with effort/reward imbalance was determined. Logistic regression was utilized for all models. RESULTS: The demand/control and effort/reward imbalance models independently predicted poor self-reported health status. The effort-reward imbalance model predicted the presence of a chronic disease while the demand/control model did not. A model combining effort-reward imbalance and task-level control was a better predictor of self-reported health status and any chronic condition than either model alone. Effort reward imbalance modeled with intrinsic effort had marginally better predictive validity than when modeled with extrinsic effort only. CONCLUSIONS: Future work should explore the combined effects of these two models of psychosocial stress at work on health more thoroughly.