Social determinants of occupational injuries among US-based commercial fishermen: a systematic review

Abstract

Background

Commercial fishing is a multibillion-dollar industry that supports job growth, small- to large- businesses, and port and city revenue. The commercial fishing industry continues to be one of the most dangerous in the US, with a fatality rate nearly 40 times higher than the national average. Dangers of the fishing industry are multi-faceted and include hazardous working conditions, strenuous labor, long work hours, and harsh weather. Moreover, a vast majority of fishermen suffer from economic insecurity, including safe and affordable housing and food insecurity.

Methods

We followed the recommendations and standards set by the Campbell and Cochrane Equity Methods Group and the Measurement and Evidence Knowledge Network. The review covered 1992–2022 to assess the state of research and to identify new barriers of and facilitators to injury prevention among commercial fishermen using a social determinants of health lens.

Results

Of 292 articles identified, 27 studies met our inclusion criteria. Out of 27 articles reviewed, social determinants of health factors included the built environment, social & community factors, economic stability, health care access, and educational attainment. A major finding was the inability for fishermen to access primary care services, which was often rooted in being a low-wage, im/migrant, or transient worker, and can further escalate injuries. A secondary finding related to injury was a feedback loop where fishermen’s unsafe environments led to a culture of accepting risk and downplaying injury, which further created unsafe environments.

Conclusion

Our review shows how injury is connected to social factors, such as a lack of health care access, as well as political-economic factors, such as a lack of sick leave benefits.

Introduction

Commercial fishing is a multibillion-dollar industry that supports job growth, small- to large- businesses, and port and city revenue. US commercial fishing, seafood industry, and recreational fishing annually generated approximately $208 billion in sales impacts, contributed $97 billion to the GDP, and supported 1.6 million jobs in 2017 [1]. In 2017, the commercial fishing industry harvested over 9.9 billion pounds of seafood and earned $5.4 billion [2]. The total number of workers in the commercial fishing industry is estimated at approximately 40,000 people, which is undoubtedly an underestimate given the vast number of vulnerable workers in the industry, including those who are low-income, aging, im/migrants, or refugees [3, 4].

The commercial fishing industry continues to be one of the most dangerous in the US, with a fatality rate nearly 40 times higher than the national average [3]. Dangers of the fishing industry are multi-faceted and include hazardous working conditions, strenuous labor, long work hours, and harsh weather [3]. There is an average of 114 deaths per 100,000 workers in the commercial fishing industry compared to an average of 4 deaths per 100,000 workers among all US workers [3]. About 80% of fatal injuries are related to water vehicle transportation incidents, with 53% from vessel disasters and 36% from falls overboard [5]. Despite preparedness requirements, as well as increases in dockside inspections and worker trainings [6], the injury and fatality rate among US fishermen remains alarmingly high.

Moreover, a vast majority of fishermen suffer from economic insecurity, including safe and affordable housing and food insecurity. These social determinants of health (SDOH), which we define as the way political-economic systems directly or indirectly impact physical or mental health, may interact with work-related stress and injuries and influence individual decision-making processes and family dynamics. Despite the importance of this industry and the harmful conditions that fishermen often encounter, research has been limited in this population. The current literature is mixed with respect to individual, community, and structural barriers and facilitators to injury prevention. Therefore, we conducted a systematic review to assess the state of research and to identify new barriers of and facilitators to injury prevention among commercial fishermen using a SDOH lens.

Methodology

We followed the recommendations and standards set by the Campbell and Cochrane Equity Methods Group and the Measurement and Evidence Knowledge Network [7]. We conducted an electronic search in CINAHL, Ovid, and Scopus between 1992–2022, developing and testing a range of terms on commercial fishermen, injury, social determinants of health (SDOH), and health. The dates were chosen based on numerous fishery policies that were implemented in the mid-1990’s, including the American Fisheries Act (1998) and Sustainable Fisheries Act (1996), as well as to give a broad range of articles over the past two decades that represent the commercial fishing industry. The search for “injury and SDOH” revealed a limited number of relevant results and did not capture research on broader health outcomes that are indirectly related to injury. Subsequently, we expanded our search strategy to “commercial fishermen AND health”. No language or publication restriction was applied. In addition, we hand-searched relevant journals and websites, and checked references of all articles meeting study inclusion for additional studies. To be included, studies had to be: 1) primary empirical research (any study design), secondary data analysis, or reviews categorizing, describing, or explaining health among commercial fishermen in the US and 2) provide data on the health status or outcomes of US-based commercial fishermen. Specific coastal regions in the US were not excluded because most maritime policy is federal-, not state-based. These criteria were broad to include all study designs and prevention strategies, though we did limit to the US given the differences in international policy.

All studies were initially screened on title, and then the abstract of relevant studies that met inclusion criteria were screened. Full text screening was done independently by five study team members and the first author/PI. Articles were screened to identify papers that met the following objectives: 1) population: article evaluates male or female, US-based commercial fishermen; 2) study: article evaluates how to improve health outcomes that target SDOH; 3) control: article may or may not use a control group to evaluate the effectiveness of an intervention; 4) outcome: article evaluates the effectiveness of an intervention or study at improving health outcomes of commercial fishermen; and 5) article is published in English. Then, the PI reviewed the texts using the same criteria, as well as the study team’s annotated bibliographies to make the final determination of which articles would be included in the systematic review.

Data were extracted on study characteristics, sampling and recruitment, theoretical framework, methods, and results. Studies were reviewed, and those meeting criteria were inputted into a spreadsheet to collect information on study characteristics, topic and focus, and theoretical background. Non-medical factors which contributed to health were coded as barriers or facilitators against a pre-defined list based on the Health People 2030 definition of SDOH (i.e., educational attainment, health care access, social & community factors, economic stability, and built environment) [8]. Because the review aimed to describe a body of literature, and not the size of an effect, no risk of bias assessment was needed. All search strategies were saved using systematic review best practices [9]. Studies were stored, screened, and keyworded using Microsoft Excel (Microsoft Corp., Redmond, WA). To ensure that the methods and search strategies were exhaustive and to be consistent with systematic review guidelines [3, 10], the final protocol was reviewed by three relevant experts in systematic reviews and library science.

Results

Of 292 unique titles, 95 relevant articles were downloaded for further abstract screening, 57 studies were included in the full text screen, and 27 studies met inclusion criteria. Out of 27 articles reviewed, 9 were mixed methods, 6 were qualitative, and 6 were quantitative studies, while 5 were reviews and 1 was a secondary data analysis. SDOH factors included the built environment (n = 19), social & community factors (n = 14), economic stability (n = 10), health care access (n = 7), and educational attainment (n = 7). For more detailed information, see Table 1.

Table 1 Systematic review findings

Economic stability

Lack of economic stability (n = 10) was seen as a factor for increased injuries due to how it affected risk-based decision making. Natural disasters, like oil spills, contributed to long-term economic instability as fishermen become limited in their ability to work post disaster [11,12,13]. For instance, fishermen’s settlement claims after the Gulf of Mexico oil spill were often denied or substantially reduced, often forcing them to work multiple jobs, as well as risk oil and chemical dispersant exposure [11].

Health care access

Health care expenses and access to health care (n = 11) manifested through a lack of health insurance, which was directly connected to fishermen’s reduced income. Their work also impacted their access to a clinic and the ability to take time off from fishing [11, 14,15,16,17,18,19]. Cultural and language barriers were linked to health care access and a lack of trust in the healthcare system, as well as a lack of proper navigation knowledge and skills regarding vessel signaling and radio communication in times of emergency [17, 19, 20]. There were also limited health care resources immediately available in commercial fishing settings, which increased the impact that injuries had on the already-limited, remote, and harsh nature of the workplace [21]. Their lack of accessible and cost-effective health care solutions, in addition to the financial disincentive to miss work (i.e., presentism), created recurrent patterns of addiction and opioid misuse among crewmembers, often related to the self-medication of work-related chronic pain [16, 18, 22].

Built environment

The workplace environment (n = 12) was associated with poor job satisfaction, which led to issues with mental health and family violence [23]. Physical activity related to the type of work resulted in overall poor health, such as poor sleep, susceptibility to injury, and musculoskeletal disorders [22]. A fear of liability and potential vessel investigation also led to the underreporting of nonfatal injuries, which reinforced a certain culture of workplace attitudes that minimized the impact of work-related injuries, exhaustion/overexertion, the acceptance that injuries were part of the job, and "risk diffusion" (i.e., coping with risks led fishermen to underestimate the need for safety equipment) [24, 25]. Finally, the conditions found in the work environment, such as extreme fishing regulations [25] oil spills [12, 13, 26, 27] and COVID-19 [25] led to decreased income, isolation, a lack of social support, and disregarding safety protocols.

Social and community factors

Social and community factors (n = 14) play an important role in safety and injury outcome, especially related to a certain identity and social awareness that comes from being a fisherman. Costliness of comfortable, functional safety equipment and social stigma and superstitions around the use of safety equipment were reported [25]. This included aspects such as the perception of “freedom” to wear safety equipment, and pride at independence which comes with little regulation on the job [25]. Additionally, there was an underestimation of risk and desensitization to occupational hazards reported [16] and a difficultly enforcing safety measures [17]. For example, one particular group that found an underestimation of risk in fishing were individuals who came from a family of fishermen [28].

Educational attainment

Educational attainment was also seen as a social determinant of health that affected occupational injuries (n = 7). Less educated fishermen were more likely to underestimate the risk involved in fishing [28]. Stress and depression, both which are associated with decision-making skills, were also found to be higher in those with lower educational attainment [14].

Suggestions to decrease occupational injuries

Two major themes identified in the review that could address the SDOH associated with fishermen’s higher-than-average injuries included 1) better health care access (n = 8) and 2) safety regulations or trainings (n = 13). Other suggestions included clear risk communication (n = 2) [17, 27] and better surveillance (n = 3) [17, 26, 29] of the industry, including oil and gas companies and monitoring restrictive fishing regulations.

For health care access, suggestions were focused on increasing health promotion programs, provider’s knowledge of the fishing industry (including language and cultural barriers of fishermen), health screening opportunities for fishermen, and communication between agencies that provide health information to fishermen [15, 17,18,19,20, 30]. Mental health was also identified, especially the mental health impact of the COVID-19 pandemic [12, 31].

Additionally, safety was a main theme in many of the suggestions to improve the fishing industry, which typically focused on increased trainings [17, 19, 21, 28, 32,33,34]. Within safety trainings, there were specific calls to focus on first aid training, disseminate safety messages, and improve safety training and awareness programs. In addition to safety trainings, researchers focused on improvements to risk management, such as sleep schedules [13, 30], fishing operations/policy and Coast Guard safety regulations [24, 31], and improved technology for navigation and safety, including safety product design (e.g., greater comfort and function of a personal flotation device; decreased safety product cost) [25, 35].

Discussion

A major finding from our systematic review was the inability for many fishermen to access health care services, whether for primary care or to treat occupational injuries, which was often rooted in being a low-wage, im/migrant, or transient worker [11, 12, 14,15,16,17,18, 21]. Through a SDOH lens, our examination of the high rates of fatal and non-fatal injury among commercial fishermen shows how injury is connected to social factors, including lack of health care access, social isolation, language and cultural issues, physical location, and food insecurity [11, 12, 14,15,16,17,18,19, 21, 22, 24, 25, 27, 28]. At the same time, political-economic factors such as decreased income, health care costs, lack of sick leave benefits, and work environment play a significant role in the high rates of fatal and non-fatal injury among commercial fishermen [13, 15, 17, 18, 22, 23, 26, 29,30,31]. To treat occupational injuries and improve intermediary determinants (e.g., access to health care) [36], practitioners may consider bringing clinical services to fishermen via mobile clinics [37], ensuring language services are available [38], or employing community health workers to assist them in applying for government programs or health care coverage [39].

A secondary finding related to occupational injury was a feedback loop where fishermen’s unsafe environments led to a culture of accepting risk and downplaying injuries, which further created unsafe environments and exacerbated occupational injuries. Based on someone’s social status, there are individual differences in exposures and vulnerabilities to illness and injury (i.e., intermediary determinants) [36]. Coping with financial pressures and the dangerous workplace of commercial fishing led to “risk diffusion” where fishermen underestimated the importance of safety decisions [25, 28, 31]. Moreover, illness or injury can create a “feedback loop” by compromising someone’s economic position [24]. For example, employment opportunities could be compromised if someone was sick or injured, which could reduce their income and further stratify them within social hierarchies. This is particularly evident with fishermen who chose to ignore, delay, or self-medicate their illness and injury [16, 21, 24].

In our systematic review, safety trainings were a primary response to dangerous workplace environments, yet the results point towards safety being connected to larger systemic factors that are outside the scope of traditional safety training programs [17, 19, 21, 24, 25, 28, 30]. For example, traditional safety measures (like first aid and personal flotation devices) are inadequate on their own because they fail to address deeper systemic and SDOH issues like financial instability or lack of health care, which exacerbate injury risks. To prevent occupational injuries, we advocate that public health practitioners, academic researchers, and policymakers adopt a SDOH framework to address the self-reinforcing cycle of commercial fishing environments facilitating a culture of risk acceptance and injury downplay.

Implications for practice

Implementing prevention strategies to reduce fatal and non-fatal injury among commercial fishermen in the Gulf of Mexico is often described as a problem [6, 20]. Therefore, we conducted a systematic review to assess the state of research in this area and to identify prevention strategies. Uniquely, our study examined the impact of the SDOH, which we defined as the way political-economic systems directly or indirectly impacted fishermen’s physical or mental health. SDOH factors above contributed to health care barriers for fishermen, which included 1) decreased income secondary to a range of issues (e.g., oil spills, net bans), 2) language and cultural issues, which arose from largely im/migrant shrimping fleets, and 3) physical location, namely fishermen living in rural areas or at sea for extended periods. These barriers increased health care costs and food inaccessibility for fishermen, as well as decreased their ability to properly communicate with health care providers or maintain equipment.

For future interventions to be equitable, we must have a research agenda that looks at occupational health holistically, including economic costs of safety equipment, vulnerabilities of low-wage work, prioritizing of safe work by employers, and regulatory environments. Our systematic review, which took a SDOH lens to examine the fishing industry and the high rates of fatal and non-fatal injury among commercial fishermen, shows how injury is connected to social factors, such as a lack of health care access as well as political-economic factors, such as a lack of sick leave benefits. Therefore, more practical and actionable solutions with a SDOH framework to bridge the gap between fishermen and access to health care need to be implemented.