1
Introduction

Mirroring a worldwide phenomenon in industrialized nations, the United States is experiencing a change in its demographic structure known as population aging, brought about by a combination of lengthening life expectancy, decline in fertility, and the progression through life of an unusually large “baby boom” generation (National Research Council, 2001; Redburn, 1998; Moody, 2002). The speed of the demographic transformation is dramatic. In recent decades the U.S. population over age 65 has been growing twice as fast as the rest of the population. By 2030 about one in every five Americans will be over 65, as contrasted with about one in eight at present. By 2030, the median age of the U.S. population is projected to reach 42 years old, as compared to 35 years old in 2000.

The rapid expansion in older adults’ proportion of the U.S. population is expected to bring about a concomitant aging of the nation’s workforce. Many hard-to-predict factors, such as changes in the state of the U.S. economy and relevant social policies, will influence the course of this development over the next few decades. However, even though the older population today is on average healthier, better educated, and wealthier than that older population of previous generations, serious challenges await them, and the rest of the nation, as their numbers grow. In particular, social adjustments may be needed to ensure that employment is safe and healthy for those who continue to work in their older years. This need is especially urgent for subsets of the working population whose resources and conditions of employment have not kept pace with the nation’s general improvements.



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1 Introduction Mirroring a worldwide phenomenon in industrialized nations, the United States is experiencing a change in its demographic structure known as population aging, brought about by a combination of lengthening life expectancy, decline in fertility, and the progression through life of an un- usually large “baby boom” generation (National Research Council, 2001; Redburn, 1998; Moody, 2002). The speed of the demographic transforma- tion is dramatic. In recent decades the U.S. population over age 65 has been growing twice as fast as the rest of the population. By 2030 about one in every five Americans will be over 65, as contrasted with about one in eight at present. By 2030, the median age of the U.S. population is projected to reach 42 years old, as compared to 35 years old in 2000. The rapid expansion in older adults’ proportion of the U.S. population is expected to bring about a concomitant aging of the nation’s workforce. Many hard-to-predict factors, such as changes in the state of the U.S. economy and relevant social policies, will influence the course of this devel- opment over the next few decades. However, even though the older popu- lation today is on average healthier, better educated, and wealthier than that older population of previous generations, serious challenges await them, and the rest of the nation, as their numbers grow. In particular, social adjustments may be needed to ensure that employment is safe and healthy for those who continue to work in their older years. This need is especially urgent for subsets of the working population whose resources and condi- tions of employment have not kept pace with the nation’s general improve- ments. 13

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14 HEALTH AND SAFETY NEEDS OF OLDER WORKERS Policy makers and the public have expressed concern about the ad- equacy of Medicare and Social Security trust funds, mechanisms for retire- ment savings, and the need for long-term care. Far less attention has been paid to the health and safety needs of older Americans. THE CHARGE TO THE COMMITTEE At the request of the Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health, the National Insti- tute for Aging, the Archstone Foundation, and the Environmental Protec- tion Agency, the Division of Behavioral and Social Sciences and Education of the National Research Council organized a study of the health and safety needs of older workers. The study was directed to: (1) define and understand the size, composition, and other dimensions of the older adult workforce over the next 20–30 years, including the changing nature of work and its implications for workers over the age of 50; (2) identify the range of policy and research issues that should be addressed over the coming decade regarding the health and safety of older workers, including the effects, if any, of inappropriate working conditions on working capacities and occupational injuries and the effects of longer working lifetimes on health; and (3) identify relationships between retirement patterns and these char- acteristics of the older adult workforce and of their jobs. THE NEED FOR RESEARCH We need more information about the factors that influence work deci- sions at older ages; interactions between work and the aging process; ethnicity; socioeconomic status; gender-related differences in work and re- tirement patterns, and effective ways to adapt the workplace to meet the needs of an aging workforce. We also need a clearer understanding of what social policies would best support the safe and productive employment of an older workforce, and what research is most needed to guide policy decisions. Too many commonly held beliefs concerning the capabilities of older workers are either incorrect or based on inadequate data. For ex- ample, it is popularly believed that older workers are less productive, more rigid in their thinking, and less worth the investment for training in new skills than their younger counterparts in the workplace. Since inaccurate ideas create major consequences for hiring, retaining, managing, and re- warding older workers, it is important to provide the factual basis for such conclusions and to identify gaps in our knowledge that need to be filled.

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15 INTRODUCTION Other common beliefs about aging workers are better grounded in evidence. For example, in many occupations, older workers as a category are in fact more likely than their younger coworkers to have chronic ill- nesses or disorders that involve medical costs and health insurance claims; to command higher pay because of their longer work experience; and to need some level of accommodation in their working conditions in order to work safely. These characteristics pose substantial challenges for the older workers themselves, their employers, and the nation. At present, they create economic incentives for employers to prefer younger workers, particularly during periods when labor is not in short supply. There may be ways of changing these incentives by distributing the costs of health care and illness or disorder differently through reform of social policies. This report presents a picture of what is currently known about the health and safety needs of older workers and what areas still require research. The purpose is to encourage information-based thinking on how best to craft social policies that guarantee older workers a meaningful share of the nation’s work opportunities and implement the government’s legal obligation under the Occupational Safety and Health Act of 1970 to “assure safe and healthful working conditions for working men and women.” THE AGING WORKFORCE: A MOVING TARGET Interpreting the individual and social implications of an aging work- force unavoidably requires that we look at our starting assumptions about aging, health, work, and retirement—no simple matter since the meaning of these concepts depends on their context. Various U.S. laws and public policies offer specific ages after which a worker is considered “older.” For example, workers are legally protected against age discrimination after age 40, and the category “age 55 and older” is used in many analyses carried out by the U.S. Bureau of Labor Statistics. But chronological-age thresholds are arbitrary, and they can cre- ate artificial boundaries that lead to categorical discrimination (Regan, 1981). Policy makers should be aware that older workers’ individual ca- pacities can differ greatly from the average characteristics of their age cat- egory. In a sense, all workers are aging workers. As Chapter 5 discusses, both positive and negative age-related physical and cognitive changes occur throughout the life span. Workers’ earlier training and adaptations to age- related changes follow them into their older years, influencing later capaci- ties for better or worse. Moreover, some hazardous exposures experienced on the job early in life can cast a long shadow, manifesting as long-latency diseases many decades later as the exposed workers grow older. The ad- verse health effects of cumulative exposures over many years may become apparent only later in life, perhaps interacting with age-related physical

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16 HEALTH AND SAFETY NEEDS OF OLDER WORKERS changes or chronic illnesses or disorders. Thus, the health of older workers is closely connected to their occupational experiences as younger workers. In addition, the definition of health among older workers shifts as improvements are made in available medical strategies for managing and adapting to the chronic illnesses or disorders that become more frequent with age. Depending on the older worker’s access to health care, the same set of health conditions—e.g., diabetes or heart disease—can represent ei- ther a major barrier to employment or a manageable health situation. Similarly, the concept of disability has been changing over the last decades. Here, we follow the model put forth in the National Academies’ Institute of Medicine report, Enabling America (Brandt and Pope, 1997): that dis- ability is not just a result of the functional impairments that workers bring to the workplace, but is also a reflection of the supports available in their physical and social environment, both on and off the job. Workers of any age can remain productively employed despite health problems if the work- place offers compensating accommodations such as elevators, lifting aids, increased lighting, more frequent work breaks, and an accepting manage- ment climate. The ability to work safely and productively can also be influenced by community support, such as access to mass transportation that eliminates the need for driving to work, or affordable services and amenities that lessen nonwork time demands, allowing more opportunity for health-promoting activities such as exercise, rest, and medical monitor- ing. Chapter 8 examines some of these accommodations, on and off the job, as a strategy for meeting the health and safety needs of older workers. The concept of work is also growing more complex. The “work” often connotes a well-defined, full-time job in a setting where the workers enjoy a variety of employer-provided benefits and are effectively protected by existing fair labor standards and occupational health and safety regula- tions. While many workplaces do fit this description, a quite different and much more precarious kind of employment also exists, particularly in some small firms and in industries where existing regulations are poorly enforced or for which there are important gaps in legal coverage. Moreover, it is becoming increasingly common for workers to be employed on a contin- gent basis in short-term contracts and other temporary, nonstandard work commitments less likely to provide supports and legal protections (Barker and Christensen, 1998; Capelli et al., 1997; Houseman and Nakamura, 2001; Wong and Picot, 2001). Certain subgroups are particularly likely to lack occupational health and safety protections, such as undocumented workers employed in sweat- shops, restaurants, and as domestic servants (GAO, 1988; Hondagneu- Sotelo, 2001). Reliable information about such workers is scarce and hard to obtain. However, they age along with their counterparts who are better positioned in the workforce, and their health and safety needs as older

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17 INTRODUCTION workers should not be ignored simply because they are underrepresented in currently available data sources. We find another ambiguity in the question of how to regard productive activities that share characteristics with paid employment but fall outside the traditional definition of work. For example, individuals who are self- employed in small businesses or on farms are not covered by a number of worker protections, such as unemployment insurance and workers’ com- pensation benefits. Yet, as these self-employed workers age they will have some of the same health and safety needs as older workers who are hired as paid employees. Similarly, the unpaid caregiving and labor provided at home within families (typically by women) have not historically been recog- nized as work, even though the same activities are regarded as work when performed by employees of commercial services (Robinson, 1999). As dis- cussed in Chapter 4, the fact that many women workers have added an unrecognized second shift to their paid employment throughout their lives has important implications for their income security, health, and ability to engage in paid employment in their older years. Conceptions of retirement are changing. Traditional portrayals of work- ing life have emphasized a standardized, normative pattern of three distinct life stages, through which members of an age cohort progress sequentially at roughly the same time: (1) a childhood education period that can be seen as preparation for work; (2) adulthood, involving a working career that may include some job changes but centers around one primary long-term job; and (3) retirement, a period of leisure without paid employment (Cain, 1964; Kohli, 1986; Best, 1980). While more a product of conventional wisdom than careful research, this simplistic three-stage model of working life has shaped many aspects of public policy (Myles, 1989; Myles and Street, 1995). For example, it is the foundation for age-related eligibility criteria for receiving pension benefits. This model also influences public perceptions as well, reinforcing the sense that a particular chronological age such as 65 is the appropriate point at which all workers should expect to retire (Marshall, 1995). Research on transitions in and out of the paid workforce suggests that this normative model of retirement fits workers’ actual experience rather poorly. Instead of crisp exits from the workforce at a particular typical age, many workers make blurred exits that can occur at any chronological age (Mutchler et al., 1997). Marshall and Clarke (1998) suggest that the familiar three-stage life course model needs to be expanded to include some addi- tional transitional periods such as a precareer series of preliminary work experiences; a preretirement period in which the worker prepares to leave the main career job; and a period following exit from the main career job involving bridge jobs in the contingent labor force and possible additional education and training, prior to full retirement from paid employment.

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18 HEALTH AND SAFETY NEEDS OF OLDER WORKERS THE LIFE COURSE PERSPECTIVE To deal with such conceptual complexities, research regarding aging and working life has increasingly made use of a theoretical orientation commonly termed the life course perspective (Riley and Riley, 1994; Mar- shall and Mueller, 2002; Markson and Hollis-Sawyer, 2000). According to this flexible model, while social institutions and public policy structure the life course into stages that most individuals move through, the connection is a loose coupling (Elder and O’Rand, 1995). Individual workers—based on their particular circumstances—can have a much more varied and disor- derly life course than that assumed by the traditional three-stage model (Rindfuss, Swicegood, and Rosenfeld, 1987). Instead of marching predict- ably through uniform life stages, individual members of an age cohort will move in and out of the workforce in a variety of ways at a variety of age points. Their transitions are still socially patterned, but some patterns depart considerably from the normative model. Assessing the available research literature, Marshall and Mueller (2002) note that departures from the normative working life trajectory are particularly common among seg- ments of the population that are not white, middle class, or male. Rather than concentrating on “the aged” as a chronologically defined category, the life course perspective treats aging as a process that unfolds throughout life, reflecting each individual’s social context and cumulative experiences. The orienting principles emphasize the importance of indi- vidual biography, specific historical events and social conditions experi- enced by the individual, the network of relationships an individual has, the timing of specific events in a person’s life, and the choices that people make within the opportunities and constraints of history and social circumstances (Riley, 1979; Elder, 1994, 1997; Elder and Johnson, in press). Figure 1-1 shows a simplified, schematic representation of how a life course perspective informs the understanding of how environmental expo- sures relate to age-related health changes and clinical outcomes. The abscissa represents increasing age; the ordinate represents the functional status of the body’s organs. The three lines sloping downward represent alternative pathways in the function (e.g., physiology and metabolism) of an organ or organ system. This model assumes that there are a variety of environmental and occupational exposures of varying intensity and pathogenicity both early and late in life. The dashed horizontal line represents a threshold below which clinical organ dysfunction (e.g., disease) is apparent. The upper curve represents the optimal scenario for age-related change, in which environmental exposures are minimized and health promotion and disease prevention are maximized. The middle curve represents usual aging, popu- lation averages summarizing varied environmental and occupational expo- sures and preventive applications in the workplace and elsewhere. The

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19 INTRODUCTION Optimal aging Usual aging . Late environmental exposure Organ Functional Early environmental exposure Status Disease Threshold Increasing Age FIGURE 1-1 Schematic view of the impact of early and late environmental expo- sure on elder health outcomes. lower curve represents the unfortunate situation where more intensive ex- posures have occurred and organ function is on a steeper trajectory, thus crossing the disease threshold earlier in life. The figure also portrays the situation of workers facing unhealthy envi- ronmental exposures later in life, such as might occur in older workers. As shown by the dotted lines, these later exposures may lead to accelerated decrements in function for any of the existing aging scenarios. Overall, this model is intended to call attention to several fundamental questions related to older workers: How do early exposures affect the paths of age-related change in organs and in the whole organism, particularly with respect to late life disease and dysfunction? How do occupational exposures later in life alter the trajectories of age-related change with and without a prior history of untoward environmental exposures? Most of these questions, for most occupational exposures, are unanswered and justify an intense re- search agenda that is a major subject of this volume. The life course perspective is not without critics. In a review of life course theory, Dannefer and Uhlenberg (1999: 309) identify what they consider three significant intellectual problems in theorizing about the life course: (1) a tendency to equate the significance of social forces with social change, (2) a neglect of intracohort variability, and (3) an unwarranted affirmation of choice as a simple and transparent determinant of the life

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20 HEALTH AND SAFETY NEEDS OF OLDER WORKERS course. Because of its emphasis on individual behavior and choices, the life course perspective is seen by some as a microlevel theoretical framework with limited value for explaining the macrolevel influences of public policy and social institutions on health and aging (Estes, Gerard, and Clarke, 1984; Estes, 2001). In this report, the focus is not on intellectual critique or defense of a conceptual orientation per se. We are simply using the life course perspec- tive as a source of ideas that may help in making a useful bridge between individual behavior and public policy. Three themes emerge as particularly important for assessing the health and safety needs of the current genera- tion of older workers: (1) Cohort effects Characteristic attitudes and behaviors can become established among workers in specific age groupings because of historical events they have experienced as a cohort. At the same time, improvements in health and life expectancy contribute to changes in the ways that cohorts view their future working and nonworking lives. (2) Linked lives The attitudes, choices, and behavior of individual workers can be greatly influenced by their social ties with other people, including family members, friends, and coworkers. (3) Intracohort diversity Extreme variation in circumstances can exist within each age cohort, resulting in subgroups of special concern as they enter their older working years. This theme, implicit in life course theory even if not well developed, is highly relevant to the present report. Cohort Effects While the life course perspective may shed greater light on actual move- ments in and out of the paid workforce, the traditional three-stage model of working life remains influential for the present cohort of older workers, many of whom early in life accepted it as normative. The U.S. baby boom generation grew up during the years immediately following World War II, a period when the traditional model’s portrayal of predictable, clear-cut transitions from education to career to retirement seemed a realistic de- scription of what a working life should look like. Since then, social circum- stances have changed drastically. However, male workers in the baby boom age cohort may still be expecting a permanent exit from paid employment at around age 65. Women workers in the same cohort may consider it normal to add large amounts of unpaid work to their paid employment in the form of caregiving and home labor. Baby boomers represent a swing generation in an occupational world that may deviate in some respects from their expectations. Indeed, many among the present cohort of aging workers may lack familiarity with varied

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21 INTRODUCTION and complex work-retirement combinations that will become increasingly common, even though these opportunities will seem normal and reasonable to future generations of workers as they age. A number of studies document that workers in the baby boom age cohort are alarmingly uninformed about their actual retirement options and resources (Gustman and Stein- meier, 2001). Confounding these evolving work and retirement options is the fact that older adults are undergoing cohort changes in health, such as living longer and having less disability. As a consequence, older adults in this cohort may have different expectations regarding both work and retirement options than earlier cohorts. Social policies regarding retirement lag as well (Riley, Foner, and Riley, 1999). As discussed in Chapter 7, some policies and programs that were crafted decades ago are slow in adapting to altered social conditions and still implicitly incorporate the lockstep stages and crisp exit assumptions of the traditional three-stage model of working life. An exception is the Social Security system (the main public retirement program), which now allows people to begin claiming benefits after the age of 62 and allows workers to combine reduced work with receipt of pension. However, some pension systems and tax laws can work against new ways of thinking about paid employment in a worker’s later years, such as phased retirement programs (Wiatrowski, 2001). Similarly, the idea that public education should focus primarily on the preemployment years of adoles- cence and early adulthood fosters a neglect of lifelong education strategies (Harootyan and Feldman, 1990) and tends to encourage business, govern- ment, and unions to favor early retirement over retraining of older workers (Schulz, 2000). Linked Lives An important theme in the life course perspective is that most aging workers are not isolated individuals making autonomous decisions, but rather persons embedded in a system of social relationships that influences their thinking and actions. Therefore, work-retirement transitions should be treated as products of social interaction and shared decision making within families and personal networks, summed up in the concept of linked lives. For example, retirement decisions in dual-worker families tend to be made jointly, with total family income being a factor in the decision and workers (most commonly women) sometimes deciding to leave the work- force early so as to synchronize their own retirement with that of their spouses (Blau, 1998; Hurd, 1998; Johnson and Favreault, 2001; Weaver, 1994; Henretta, O’Rand, and Chan, 1993). Caregiving roles are inter- twined with labor force participation in complex ways, again most com- monly for women workers (Moen, Robison, and Dempster-McClain, 1995).

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22 HEALTH AND SAFETY NEEDS OF OLDER WORKERS These family choices and their interconnections with social policy are dis- cussed further in Chapter 4. Decisions about work and retirement in later years may be related to friendship networks inside and outside the workplace; the worker’s level of civic engagement with his or her community; and the kinds of amenities and supports available in the older worker’s living environment. Older workers with weak community linkages and strong friendship ties at work may find that their psychological well-being and life satisfaction are maxi- mized by staying on the job even with declining health. Others whose community linkages are richer may feel they can increase their psychologi- cal well-being and life satisfaction by leaving paid employment and freeing up their time for community-based volunteer work or social activities. More flexible work options would allow older workers to perform these tradeoffs more effectively. Intracohort Diversity and Disadvantaged Subgroups The life course perspective implicitly supports increased attention to the extreme diversity among older workers. In addition to identifying modal patterns for the age cohort as a whole, it is important to understand how the experience of particular subgroups of older workers reflects historical events they have experienced, the timing of key events in their personal lives, and the specific contexts in which their lives are lived. It matters a great deal whether their lives have been lived in an economically advantaged situation or a disadvantaged one; whether or not they have faced discrimi- nation; whether they have had good luck or bad luck at key points in life; whether or not they had support from family and friends; and whether or not they were able to avoid conflicts between potentially competing priori- ties such as caregiving versus paid employment. Different kinds of social disadvantage can intersect, deepening the ef- fects of factors such as race, class, gender, and age (Dressel, 1988). More- over, since positive or negative experiences over the life course have a cumulative effect, intracohort variability increases with age. That is, re- source and income variations within an age cohort will intensify over time. For example, early completion of college and entry into a favorable occupa- tional role produce ongoing advantages, which can open subsequent oppor- tunities for home ownership and a vested pension (Henretta and Campbell, 1976). This pattern has been termed the “Matthew Effect,” reflecting the idea expressed in the Gospel of Saint Matthew that “the rich get richer and the poor get poorer” (Marshall and Mueller, 2002: 23). Warr (1998: 289) points out that intracohort variations in working conditions can also be expected to increase with age, so that “general statements about average exposure to, say, opportunity for control at work . . . may become increas-

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23 INTRODUCTION ingly inappropriate as the variance in exposure becomes progressively greater.” Therefore, in assessing and addressing the health and safety needs of older workers, it is important to remember that they are not all alike. Those who have been employed intermittently or at low wages for all of their working lives, without medical insurance or pension benefits, are in a dif- ferent position from those who were more fortunate and who will have different needs. For some, voluntary retirement may not be an option at any age because they need paid employment as a matter of economic necessity. In the absence of other means of economic support, financially insecure workers are likely to work as long as they can, even if the jobs available to them put their health and safety at risk. Reasons for Attending to the Health and Safety Needs of Older Workers Why should attention be paid to the health and safety needs of older workers? One reason is that understanding the capabilities, limitations, and needs of older workers can help to address issues of productivity and labor supply. The U.S. Bureau of Labor Statistics projects a serious slowing in the growth of the labor supply in coming years, falling from an average annual rate of 1.1 percent between 1990 and 2000 to an annual rate of 0.7 percent between 2000 and 2025 (GAO, 2001). While some labor needs may be met through immigration, older workers already in the U.S. labor force (espe- cially those with high skill levels) represent an important resource. To maximize benefits to the economy and investment capital, a societal interest exists in retaining older workers in the labor force. From this viewpoint, the highest priority concern is to learn which older workers can be expected to work productively, what kinds of tasks they are best suited for, and how their productivity might be increased through cost-effective accommoda- tions and support programs in the workplace and community. Another reason for attending to the health and safety needs of older workers is that addressing their capabilities, limitations, and needs can help maximize their opportunities for making work-related choices that pro- mote health, safety, and life satisfaction in their later years. This perspective also encourages attention to workplace and community accommodations and support programs specifically aimed at older workers. It includes broader considerations such as the following: • adequate and effectively enforced occupational health and safety regulations for workers of all ages, to help them enter their older working years with less pre-existing exposure to occupational hazards;

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24 HEALTH AND SAFETY NEEDS OF OLDER WORKERS • policies aimed at providing adequate health insurance coverage for the U.S. population generally, and aging workers specifically; • dissemination of effective information to workers throughout their working lives to prepare them for the work and retirement decisions they will be making; • recognition that work/retirement transitions, which occur at many points in working life, could be facilitated by policies that see blurred rather than crisp exits from work, and that these transitions are generally family decisions rather than individual decisions; and • recognition that the U.S. working population includes some sub- groups that may be poorly protected by existing public policy, are difficult to study, and appear to be underrepresented in available databases. THE STUDY AND THE REPORT To fulfill its charge, described above, the study committee gathered information from the relevant scientific literature and community. The committee also heard from the sponsors and invited guests about various data and issues pertinent to older working adults and about relevant re- search findings. Under the sponsorship of the U.S. Environmental Protec- tion Agency, the committee also conducted a workshop on differential susceptibility of older persons to environmental hazards. The committee discussed data availability and research findings; identified critical issues; analyzed data (including Current Population Survey Data for March 2001) and issues; and formulated the findings, conclusions, and recommendations expressed in this report as follows. Chapter 2 discusses what is known about the characteristics and retire- ment patterns of the older population and workforce, including an over- view of their health status. Chapter 3 reviews the changing structure of the American labor market and the changing nature of work experiences. Chap- ter 4 reviews sources of disparities in older workers’ work experiences and related health outcomes, presenting what is known about social and eco- nomic differences between older and younger workers. Chapter 5 reviews what is known about the physical, cognitive, and social differences between older and younger workers and the psychologi- cal characteristics of older workers. Chapter 6 reviews overall health effects of workplace exposures, including consideration of biological, sociological, psychological, and economic effects, and examines their specific implica- tions for older workers. Chapter 7 reviews labor laws, antidiscrimination laws, and wage and benefit protections that directly and indirectly affect an older worker’s likelihood and choice of staying in or leaving the workforce. Chapter 8 presents intervention strategies to meet the safety and health needs of older workers. Approaches considered include accommodation

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25 INTRODUCTION through job design; alternative forms of work; vocational rehabilitation and return-to-work programs; access to preventive and restorative health care; community-based support services; physical aids; health promotion; employee assistance programs; physical fitness programs; and learning sys- tems and retraining. Chapter 9 presents the committee’s recommendations. NOTE ON DATA TABLES IN APPENDIXES In addition to the data tables contained in this report, two appendixes containing additional data tables (several of which are expansions of tables presented in the report) are provided on the National Academies Press internet site (website address www.nap.edu). References to the tables in the appendixes are included as appropriate in the report.