The COVID-19 pandemic has introduced a number of added obstacles to safe employment for already-challenged essential workers. Essential workers not employed in the health sector generally include racially diverse, low-wage workers whose jobs require close interaction with the public and/or close proximity to their coworkers, placing them at increased risk of infection. A narrative review facilitated the analyses of health outcome data in these workers and contributing factors to illness related to limited workplace protections and a lack of organizational support. Findings suggest that this already marginalized population may also be at increased risk of “moral injury” due to specific work-related factors, such as limited personal protective equipment (PPE) and the failure of the employer, as the safety and health “duty holder,” to protect workers. Evidence suggests that ethical and, in some cases, legally required safety protections benefit not only the individual worker, but an employer’s enterprise and the larger community which can retain access to resilient, essential services.

ImportanceRacial disparities in treatment benchmarks have been documented among older patients with hip fractures. However, these studies were limited to patient-level evaluations.ObjectiveTo assess whether disparities in meeting fracture care time-to-surgery benchmarks exist at the patient level or at the hospital or institutional level using high-quality multicenter prospectively collected data; the study hypothesis was that disparities at the hospital-level reflecting structural health systems issues would be detected.Design, Setting, and ParticipantsThis cohort study was a secondary analysis of prospectively collected data in the PREP-IT (Program of Randomized trials to Evaluate Preoperative antiseptic skin solutions in orthopaedic Trauma) program from 23 sites throughout North America. The PREP-IT trials enrolled patients from 2018 to 2021, and patients were followed for 1-year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in analysis. Data were analyzed April to September 2022.ExposuresPatient-level and hospital-level race, ethnicity, and insurance status.Main Outcomes and MeasuresPrimary outcome measure was time to surgery based on 24-hour time-to-surgery benchmarks. Multilevel multivariate regression models were used to evaluate the association of race, ethnicity, and insurance status with time to surgery. The reported odds ratios (ORs) were per 10% change in insurance coverage or racial composition at the hospital level.ResultsA total of 2565 patients with a mean (SD) age of 64.5 (20.4) years (1129 [44.0%] men; mean [SD] body mass index, 27.3 [14.9]; 83 [3.2%] Asian, 343 [13.4%] Black, 2112 [82.3%] White, 28 [1.1%] other) were included in analysis. Of these patients, 834 (32.5%) were employed and 2367 (92.2%) had insurance; 1015 (39.6%) had sustained a femur fracture, with a mean (SD) injury severity score of 10.4 (5.8). Five hundred ninety-six patients (23.2%) did not meet the 24-hour time-to-operating-room benchmark. After controlling for patient-level characteristics, there was an independent association between missing the 24-hour benchmark and hospital population insurance coverage (OR, 0.94; 95% CI, 0.89-0.98; P = .005) and the interaction term between hospital population insurance coverage and racial composition (OR, 1.03; 95% CI, 1.01-1.05; P = .03). There was no association between patient race and delay beyond 24-hour benchmarks (OR, 0.96; 95% CI, 0.72-1.29; P = .79).Conclusions and RelevanceIn this cohort study, patients who sought care from an institution with a greater proportion of patients with racial or ethnic minority status or who were uninsured were more likely to experience delays greater than the 24-hour benchmarks regardless of the individual patient race; institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix. While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias.

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Reusable respiratory protective devices called elastomeric respirators have demonstrated their effectiveness and acceptability in well-resourced healthcare settings. Using standard qualitative research methods, we explored the feasibility of elastomeric respirator use in low- and middle-income countries (LMIC). We conducted interviews and focus groups with a convenience sample of health workers at one clinical center in Mali. Participants were users of elastomeric and/or traditional N95 respirators, their supervisors, and program leaders. Interview transcripts of participants were analyzed using a priori constructs from the Health Belief Model (HBM) and a previous study about healthcare respirator use. In addition to HBM constructs, the team identified two additional constructs impacting uptake of respirator use (system-level factors and cultural factors). Together, these framed the perceptions of Malian health workers and highlighted both facilitators of and barriers to respirator use uptake. As needs for respiratory protection from airborne infectious hazards become more commonly recognized, elastomeric respirators may be a sustainable and economic solution for health worker protection in LMIC.

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