HEALTH ECONOMICS

Health Econ. (2012)

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/hec.2829

ON THE RECURRENCE OF OCCUPATIONAL INJURIES AND

WORKERS’ COMPENSATION CLAIMS

MONICA GALIZZI*
Department of Economics, University of Massachusetts Lowell, Lowell, MA, USA

ABSTRACT
This paper represents the first study to estimate counts of individual occupational injuries and claims over long spells of
working life (up to 13 years) in the USA. It explores data from the National Longitudinal Survey of Youth 1979.
I found that 37% of all surveyed workers who had experienced one on-the-job accident reported at least one additional
injury, but only 56% of all occupational injuries and illnesses resulted in workers’ compensation claims. I estimated different
count models to assess the effect of different individual worker and job characteristics on individual injury counts and workers’
compensation claims counts.
Lower educational levels, less tenure, work in dangerous industries and unskilled occupations, and job demands are found to
be important determinants of multiple on-the-job injuries. The most interesting results, however, refer to the role played by
individuals’ pre-injury characteristics: early exposure to dangerous jobs is among the main determinants of higher counts of
occupational injuries later in life. Early health limitations are also significant predictors of recurrent workers’ compensation
claims. These results provide new evidence about the important role played by both the health and the socioeconomic status
of young people as determinants of their future occupational injuries. Copyright © 2012 John Wiley & Sons, Ltd.

Received 30 August 2010; Revised 15 February 2012; Accepted 2 April 2012

KEY WORDS: occupational injuries; workers’ compensation; determinants of health; count data

1. INTRODUCTION
Since 2003, the Bureau of Labor Statistics (BLS) has reported a continuous and significant decline in the work-
place injury and illness incidence rate among private industry employees. In 2008, firms in the USA reported
3.7 million non-fatal injuries and illnesses, corresponding to a rate of 3.9 cases per 100 equivalent full-time
workers (BLS, 2009).
However, despite the apparent decline in occupational injuries, the National Safety Council’s estimates
of the costs of these injuries have continued to increase since 2001, reaching $175 billion dollars in 20071
(U.S. Census Bureau, 2008). The magnitude of such numbers justifies the continuing interest in understanding
which sectors and professions are more likely to experience these occupational incidents. Administrative data
collected by the BLS indeed allow us to identify which sectors (trade, transportation and utilities, education and
health services, manufacturing, construction), which firm sizes (more than 50 employees), which occupations
(laborers, truck drivers, nursing aides, construction laborers), which event (overexertion), and which part of the
body (back) are associated with higher incidence rates (BLS, 2009). This general picture misses a very
important aspect of the phenomenon of occupational injuries, however. In fact, despite some existing evidence

*Correspondence to: Department of Economics, University of Massachusetts Lowell, Falmouth 302 J, One University Avenue, Lowell,
MA 01854, USA. E-mail: Monica_Galizzi@uml.edu
1
The National Safety Council cost estimates have been found to be lower than those presented in other studies (Leigh et al., 1997). Also,
they do not include on-the-job assaults and homicides.

Copyright © 2012 John Wiley & Sons, Ltd.

 M. GALIZZI

(Gotz et al., 2000; Campolieti, 2002; Ruseckaite and Collie, 2011) suggesting that at least one-third of injured
workers experience new occupational injuries after their return to work, we know very little about the recurrent
nature of occupational injuries and, therefore, the extent to which the costs of occupational injuries fall dispro-
portionately on some workers. These workers experience more physical pain, a decline in life satisfaction, and
more frequent earning losses leading to a reduction in household assets (Strunin and Boden, 2000; Galizzi and
Zagorsky, 2009).
When stakeholders discuss this topic, they often debate who may be at fault for these outcomes: the workers’
compensation and occupational safety regulation systems that fail to prevent work-related injuries and guaran-
tee injured workers successful return to work, or the workers themselves who may learn to “abuse” the com-
pensation system or who may be prone to injuries. The debate is informed by very little research, however,
and the predictive power of the few existing studies on the topic is limited by the fact that they were conducted
only among workers who experienced at least one occupational injury. Such a group may not be representative
of the overall working population. The following analysis tries to overcome this limitation by exploring data
from the National Longitudinal Survey of Youth 1979 (NLSY79). The survey data have several advantages
over administrative data often used to study this topic: these data also cover workers who never experienced
an injury, who can be compared with workers who were injured, and to those injured workers who filed or
did not file a workers’ compensation claim; data are available for workers who had no compensable injury-
related work absence (such as a medical only claims) as well as those who had indemnity claims; data are avail-
able in the same format for all 50 states; workers are followed over a long time period; and for those workers
who got injured on the job, the data allow identification of a sequence of recalled episodes starting as early as in
1987 when respondents’ age ranged between 22 and 31 years. To the best of my knowledge, this study repre-
sents the first analysis that investigates the role played by pre-injury individual worker and job characteristics in
determining both recurrent occupational injuries and recurrent workers’ compensation claims over a long spell
(up to 13 years) of individual early working histories.

2. BACKGROUND

Since the important research by Butler et al. (1995), researchers have become aware of the need to go beyond
the study of initial work absences of injured workers. In their study, these authors found that for 61% of
surveyed workers with permanent impairments, an initial spell off work was followed by additional episodes
of absences from work that were related to the original injury. Since then, a few studies have tried to assess
to what extent such “unsuccessful first returns to work” could be caused by additional episodes of occupational
injuries. Most of this research has made use of workers’ compensation administrative data or claimants’ survey
data. Campolieti (2001) followed Canadian workers with only temporary total disability over 12 months and
found that 14% of individuals had two or more claims. In a further study focusing only on permanently disabled
workers, the same author reported that about 50% of the surveyed injured workers had at least one additional
absence related to the first injury (Campolieti, 2002). Similarly, across all types of lost-time workers’ compen-
sation claims, Gotz et al. (2000) found that workers who returned to work after a lost-time injury were more
likely to have subsequent lost-time claims than others in their firms. In that study, 32% of the workers had at
least one more compensable lost-time claim during the following 3 years. Cherry et al. (2010) followed
Canadian claimants over 10 years and found that 49% of them had at least one further claim. In Ruseckaite
and Collie (2011), 37% of Australian workers with a claim filed a second one over a 5-year period, and 78%
of repeat claims were for a second injury. In both these recent studies, a second claim was more likely among
men, younger workers, and for those in manual occupations. Using only back injury data, Abenhaim et al.
(1988) found that the rate of recurrence of occupational back pain was 36% at 3 years of follow-up and that
the chance of recurrence was, again, higher for men and younger workers. In Krause et al. (1999), 20% of
low back pain claimants experienced multiple episodes of temporary disability during the 1 to 3.5 years of

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
DOI: 10.1002/hec
 ON THE RECURRENCE OF OCCUPATIONAL INJURIES AND WC CLAIMS

follow-up. In a study of a single health care facility, Boyer et al. (2009) reported that 26% of workers who had
filed a workers’ compensation claim (or 5% of all workers) had ended up filing claims for additional injuries.
All these studies indicate that the recurrence of occupational injuries and of claims is a common phenome-
non in different countries. The study of recurrent injuries becomes relevant if such recurrence has specific
economic implications for workers’ well-being and for health care and workers’ compensation systems’ costs.
Most job-related injuries and illnesses require only medical care without time off work and would result in
medical-only workers’ compensation claims. However, almost one-third of occupational accidents lead to days
away from work, job transfer, or restrictions (BLS, 2009). When we study a single lost-time occupational injury
in the context of the neoclassical model of individuals’ time allocation and workers’ labor-leisure trade-off
(Grossman, 1972), we can predict an effect similar to one of any other time-consuming illness: a reduction
in the total amount of time the worker can allocate both to work and to leisure. This will lead to a reduction
in utility and in labor income, although the income loss could be partially compensated by workers’ compen-
sation indemnity benefits. A sequence of occupational injuries will have the same repeated effect but is also
likely to produce a series of additional negative consequences for the worker. First, a history of recurrent inju-
ries is likely to be perceived by employers as a clear signal suggesting a risky hire. This will limit the jobs avail-
able to the injured workers, decrease their reservation wages, and lead to lower wages. Second, time losses
caused by injuries will lead not only to a decline in working time but also in the amount of leisure time indi-
viduals can dedicate to health-improving activities. Overall, both the cumulative income, wage and leisure
losses will lead to a decline in the amount of health capital individuals build over their working lives with
severe implications in terms of their financial and overall well-being. Repeated occupational injuries will also
have financial consequences for other stakeholders, however. Ruseckaite and Collie (2011) found that the cost
associated with a second claim is significantly much higher than the cost of the initial claim. Such a finding may
indicate that both employers and insurance agencies are quite negatively affected by recurrent injuries. Further-
more, increasing concerns about potential under-claiming in workers’ compensation systems (Galizzi et al.,
2009) suggest that recurrent injuries should also be a concern for health care providers and administrators:
the costs of these injuries may be absorbed by the more general health insurance system and they may represent
a non-negligible component of health care costs. Indeed, we know already that, in the more general population,
repetitive injury patients make a disproportionately greater use of medical services (Jansson et al., 2004).
Given this background, this paper casts some light on the determinants of recurrent occupational injuries and
workers’ compensation claims. An initial set of hypothetical factors relates to workers’ attributes. First is the
highly controversial hypothesis suggesting that some individuals may be more “prone” to injury, that is, more
likely to experience more accidents than individuals who are otherwise identical (Visser et al., 2007). Specific
health conditions (including impaired hearing or sight, and strokes) can increase the risk of repetitive injuries
(Jansson et al., 2004) or worsen the chances of a full recovery after a first injury. Or individuals may differ
in terms of their risky behaviors, and some may be more willing to accept more dangerous jobs (Eeckhoudt
and Gollier, 2005; Liu et al., 2009) or to work less carefully. This is likely to apply to young workers who have
not yet fully reached their physical, physiological, and neurological development. As such, workers 25 years
old and younger may be prone to greater frustration and increased reactivity and may be more willing to take risks
because they still lack the ability to take into account the full range of options and consequences associated with
their decisions (Sudhinaraset and Blum, 2010). Finally, some individuals may have more “maladaptive” illness
perception (Hoving et al., 2010) leading them to report more injuries. In the case of workers’ compensation
claimants, some employees may have learned “how to use the system” and possibly to abuse it (Butler, 1994).
The incentive to do so will be affected by state differences in terms of the generosity of wage loss benefits, denial
rates, and restrictions that make it difficult to file claims.
The concept of accident proneness has been the object of great debate, however, because it may be invoked
to put the blame on individuals at the expense of injury prevention policies (Cherry et al., 2010). Indeed, the
fact that a group of individuals is characterized by more repetitive injuries does not rule out the explanation that
this may happen because of higher exposure to risk independent of personal factors (Visser et al., 2007). In fact,
we know that certain industries such as construction, mining, and health care are characterized by more dangerous

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
DOI: 10.1002/hec
 M. GALIZZI

jobs. We know that working conditions characterized by long working hours and shift work are associated
with much more fatigue and a substantial decline in safety (Wagstaff and Sigstad Lie, 2011), and that employ-
ers differ in the amount of safety training they provide (Smith and Mustard, 2007). Also, the recurrence of
occupational injuries could be driven by the lack of proper accommodation or by employees returning to work
before full recovery owing to fear of losing their job or fear of stigmatization (Galizzi et al., 2009). In these
cases, the lack of full recovery could increase their propensity to experience another episode of a work-related
health problem. Finally, not only current employment conditions but also the individual pre-injury labor
history may play a role. Recent economic research has highlighted the effects of early occupations and early
working conditions on adult health status (Case and Deaton, 2005; Fletcher and Sindelar, 2009; Fletcher et al.,
2011), as well as the effects of childhood health on adult health (Case et al., 2005; Cambois and Jusot, 2010)
and on future employment (Smith, 2009).
It is not easy to distinguish among these alternative hypotheses because most of the research available has
used workers’ compensation data or surveys conducted only among injured workers who had filed a workers’
compensation claim. The use of such data limits the generalizability of the results. The survey data used in this
study instead exploit information that long periods of working histories provide regardless of individual injury
or claiming status. They also permit studying occupational injuries as health events that may possibly be related
to individuals’ early employment and health histories.

3. THE DATA
This study makes use of data contained in the NLSY79, a nationally representative panel survey of US work-
ers sponsored by the BLS, U.S. Department of Labor. A total of 12,686 men and women were first inter-
viewed in 1979 when they were between the ages of 14 and 22. Until 1994, the survey was conducted on
an annual basis, and since 1994, it has been administered every other year for a total of 23 rounds. Between
1988 and 2000, the survey also collected information about job-related injuries and illnesses. To better frame
the study of such incidents, I merged the NLSY79 industry codes with the industry non-fatal occupational
injury and illness incidence rates reported by the BLS for 1994. I also made use of information regarding
the worker’s state of residence included in the NLSY79 Geocode data in order to merge each worker’s record
with information about his/her state’s workers’ compensation laws (the US workers’ compensation system is
regulated at the state level and not at the federal level). This information compares each state’s implemented
rules as of 1988 and 1999 with the “19 Essential Recommendations” of the 1972 National Commission on
State Workmen’s Compensation Laws (Whittington, 1988 and 1999).2 Such recommendations relate to coverage,
income benefits, and medical benefits. For each state and for each year, I also included information regarding
the duration of the waiting period prior to benefit payments (US Chamber of Commerce, 1988–2000). I explored
the contribution of this set of data to add some evidence to the debate regarding the effect of different workers’
compensation programs’ generosity on workers’ compensation outcomes (Fishback et al., 2010; McInerney and
Simon, 2010.)
I found that from 1988 to 2000, a total of 3280 NLSY79 individuals reported that they suffered at least one
occupational injury or illness for a total of 5185 incidents.3 This represents 26% of the entire initial popula-
tion surveyed by the NLSY79 (n = 12,686). Incidence rates at each survey ranged from a low of 5% (in 1994)
to a high of 8% (in 1988) (Table I). Similar results were previously reported by Pergamit and Krishnamurty
(2006). Because the NLSY79 started being administered every other year after 1994, the incidence rates

2
I could only obtain this information for 1988 and 1999. However, there were very few improvements in state laws, and the national average
of State Compliance with the 19 Essential Recommendations remained the same during the 1990s (Burton, 2009). The average number of
implemented recommendation was 12.17 in 1988 and 12.77 in 1999.
3
In 1988, individuals were asked whether they had had an incident at any job that resulted in an injury or illness during the “past 12 months”.
In the following survey rounds, the same question referred to the time “since the last interview”. In my analysis, I did not distinguish
between injuries and illnesses because only 8% of all the recalled incidents resulted in illnesses.

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
DOI: 10.1002/hec
 ON THE RECURRENCE OF OCCUPATIONAL INJURIES AND WC CLAIMS

Table I. NLSY79: Percent of occupational incidents and workers’ compensation claims reported in different survey years
Occupational injury or illness causing missed
NLSY79 Any occupational injury or illness scheduled days of work

Survey Total Injuries incidence WC claims as % of Injuries incidence rates WC claims as % of

year interviewed rates (%) injuries (%) injuries
1988 10,465 8* 47 4 61
1989 10,605 6 55 3 64
1990 10,436 6 57 3 65
1992** 9016 6 61 4 72
1993 9011 5 55 3 68
1994 8891 5 61 3 67
1996 8636 7 59 4 66
1998 8399 7 59 4 69
2000 8033 6 59 4 68
*Injuries reported at each survey round usually occurred in the same calendar year but could refer to previous years as well (especially after
1994). In particular, of the 849 injuries/illnesses recalled in 1988, 70% had happened in 1988, 29% in 1987, and 1% had happened in pre-
vious years starting in 1977.
**The survey did not ask questions about injuries in 1991.

reported in Table I actually indicate a decline in such rates over the years. Indeed, as was shown in an earlier
study by Galizzi and Zagorsky (2009), such incidence first increased by age, peaking at the time when
workers were 30 years old, and then declined as individual aged, and possibly, gained more on-the-job
seniority and experience.
In terms of file-claiming behavior, the NLSY79 shows that only 56% of the reported work-related injuries
were filed (either by the worker or by the employer) as workers’ compensation claims, however, for a total of
2043 individuals and 2927 workers’ compensation claims.
Because the focus of this study is the recurrence of occupational injuries, Table II, column 1, ranks all
surveyed workers according to the number of occupational injuries and illness they reported between 1988
and 2000: 2055 individuals reported only one injury but 1255 individuals, or 37% of all 3280 workers who
had experienced one on-the-job incident reported from one to seven additional on the job injuries; 617 respon-
dents, or 30% of all 2043 individuals who had filed for at least one workers’ compensation claim, filed more
than one (Table II, column 2). These percentages are consistent with what was found in the previous studies
reviewed earlier.
My regression analysis, however, is based on a smaller group of workers. In fact, despite the exceptionally
high retention rate of the NLSY79 survey population (out of the 12,686 individuals who were interviewed in

Table II. Percent of individuals with single and multiple occupational injuries and workers’ compensation claims
NLSY79 NLSY79 Subsample*

(n = 12,686) (n = 6855)

Number of injuries Individuals with injuries Individuals with claims Individuals with injuries Individuals with claims
or claims (1) (2) (3) (4)
0 9406 (74.1%) 10,643 (84.0%) 4600 (67.1%) 5417 (79.0%)
1 2055 (16.2%) 1426 (11.2%) 1342 (19.6%) 962 (14.0%)
2 782 (6.2%) 433 (3.4%) 551 (8.0%) 326 (4.8%)
3 284 (2.2%) 123 (1.0%) 221 (3.2%) 97 (1.4%)
4 107 (0.8%) 45 (0.3%) 91 (1.3%) 38 (0.6%)
5 32 (0.3%) 11 (0.1%) 30 (0.5%) 10 (0.2%)
6+ 20 (0.2%) 5 (0.0%) 20 (0.3%) 5 (0.1%)
*Individuals who participated to all survey rounds from 1988 to 2000.

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
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 M. GALIZZI

the original sample in 1979, 8033 participated in interviews in 2000), some respondents were lost to attrition or
did not participate in all survey rounds. For these “lost’” respondents, it is possible to calculate the hazard of
getting injured. However, such censored observations do not provide the full information about individual
working histories and, therefore, about the total time (weeks of employment) during which surveyed indivi-
duals may have been “exposed” to the risk of recurrent injuries over all the years I am studying. Then, to be
able to compare only the histories of individuals for whom I have all the available information about potential
occupational injuries, I limited my analysis to the subset of 6855 individuals who participated in all survey
rounds from 1988 to 2000 when workplace injury information was collected. Among this subgroup, 33% of
individuals (n = 2255) had experienced at least one occupational injury or illness for a total of 3747 incidents.
Among those who reported one injury, 40% (n = 913) reported two or more occupational incidents during the
surveyed years (Table II, column 3). Additional calculations also showed that out of the total 3747 incidents
studied in the subsample, 7% occurred in the same individuals and with the same part of the body (mainly eyes,
back, and hands); 3% occurred to the same individual and were caused by the same type of injury (sprains and
strains, open wounds, and disease of the peripheral nervous system); and 2% occurred to the same individual
both with the same part of the body and because of the same type of injury or illness.4
The percentages of individuals with at least one injury or with recurrent injuries are higher in my selected
subsamples than for the full NLSY79 (26 vs 33% and 37 vs 40%, respectively). These differences may raise
questions about the representativeness of the subsample I used in my analysis. From a previous study
(MaCurdy et al., 1998), we know that among NLSY79 respondents after age 20, attrition occurred randomly
across the wage and earnings distribution. The same study also showed that prospective “attriters” were more
likely to be non-employed (rather than being employed or in school) before leaving the sample. We also know
that after 1990, the NLSY79 dropped 13% of the original sample (1643 individuals who belonged to a supple-
mental economically disadvantaged, non-black and non-Hispanic subsample). Therefore, I tested whether after
1990 at each survey round the number of attriters differed across individuals who had reported an occupational
injury in the previous round. I found no statistical difference. I also estimated with a logit fixed effect model the
likelihood of being an attriter as a function of having previously reported an injury and found no significant
relation between the two variables. Finally, I found that, as of 1988, the individuals in my subsample of
continuously interviewed had significantly higher family income, more education, more stable previous
employment, and larger families than the individuals who were also interviewed in 1988 but dropped out from
at least one of the following survey rounds (this set of calculations is available upon request). Therefore, I
concluded that the choice of my subsample is unlikely to exclude individuals who dropped from the NLSY79
because of the specific outcome I am studying, that is, occupational injuries. However, my subsample may not
be fully representative of young individuals with less education and experience and employed in low-paying
jobs. But if anything, these attributes usually describe those workers who should be more likely to get injured
on the job, which leaves my subsample possibly underestimating the total number of injuries and recurrent
injuries.
Tables III and IV describe some individual characteristics for my chosen subsample as of 1988, the first year
that respondents were asked about occupational injuries. Because the NLSY79 is a multi-stage random sample
that over-sampled blacks and Hispanics, descriptive results are reported after being adjusted by survey weights
that account for the representativeness of individuals continuously surveyed between 1988 and 2000. Such
weights remove the over-sampling effects and allow the answers to be considered as national totals: 79% of
workers were white, 15% were black, and 6% were Hispanic.
Table III has three columns of data. The first column tracks those individuals who never reported an occupa-
tional injury during the survey rounds between 1988 and 2000, whereas the second and third columns track those
who reported one or more on-the-job incidents, respectively. In 1988, the typical respondent was 27 years old,
and those who got injured were typically male and had less education and less tenure on the job. Individuals who

4
These calculations are available upon request and were based on the original ICD-9 codes that are used in the NLSY79.

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
DOI: 10.1002/hec
 ON THE RECURRENCE OF OCCUPATIONAL INJURIES AND WC CLAIMS

Table III. NLSY 1988–2000 subsample* of all workers as of 1988 (weighted summary statistics)
Never hurt at Only one occupational Recurrent occupational p-value**
work between injury between injuries between
1988–2000 1988–2000 1988–2000

(n = 4600) (n = 1342) (n = 913)

Mean (SE) Mean (SE) Mean (SE)
Age 27 (0.04) 27 (0.08) 27 (0.08) 0.38
White 0.79 (0.01) 0.79 (0.01) 0.83 (0.01) 0.17
Black 0.15 (0.01 ) 0.14 (0.01) 0.11 (0.01) 0.00
Hispanic 0.06 (0.01) 0.07 (0.01) 0.06 (0.01) 0.00
Female 0.54 (0.01 ) 0.42 ( 0.02) 0.38 (0.02 ) 0.00
Education:
< High school 0.10 (0.01 ) 0.15 (0.01) 0.16 (0.01) 0.00
High school 0.41 (0.01 ) 0.48 (0.02) 0.59 (0.02) 0.00
> High school 0.49 (0.01 ) 0.38 (0.02) 0.25 (0.02) 0.00
Before 1988:
In poverty before age 23 0.38 (0.01) 0.38 (0.02) 0.41 (0.02) 0.42
Health limitation before age 23 0.16 (0.01) 0.19 (0.01) 0.23 (0.02) 0.00
Dangerous/unhealthy jobs before 1983 0.39 (0.01) 0.49 (0.02) 0.60 (0.02) 0.00
As of 1988:
Family income 31,273 (405.2) 27,529 (649.0) 25,704 (805.5) 0.00
Family in poverty 0.11 (0.01) 0.12 (0.01) 0.16 (0.01) 0.03
Wage 2,167 (1,144.9) 886 (27.4) 981 (102) 0.35
Employed 0.77 (0.01) 0.82 (0.01) 0.84 (0.01) 0.00
With health insurance 0.77 (0.01) 0.73 (0.01) 0.75 (0.01) 0.07
Tenure (weeks) 151 (2.9) 145 (5.3) 134 (5.8) 0.03
Weekly worked hours 41 (0.3) 43 (0.5) 44 (0.6) 0.00
Fixed shifts 0.86 (0.01) 0.84 (0.01) 0.81 (0.01) 0.00
Industry incident rate (1994) 7.60 (0.09) 8.92 (0.16) 9.37 (0.18) 0.00
Note:
*Individuals who participated to all survey rounds from 1988 to 2000 regardless of their employment status in 1988.
**F-test for the null hypothesis that the three means are equal.

had experienced work limiting health conditions and dangerous occupations in their early years got injured more
frequently. Workers who reported more injuries were more likely to be already employed as of 1988 (when other
individuals were more frequently still in school or “keeping house”). They were also the ones who, as of 1988,
had lower family incomes, were employed in more dangerous sectors, and were working longer hours, and on
less regular shifts. Table IV describes injured workers by their claim filing behavior and shows very few
significant differences among the three studied groups of workers: recurrent claims were more frequent among
workers with only a high school degree and individuals who had been exposed to dangerous occupations in their
early years. Surprisingly, they were also more common among workers who were covered by health insurance
and among those who took longer time off work after a first injury. Even among workers who did not file for
workers’ compensation, at least 23% reported that they had lost wages because of the accident.

4. REGRESSION ANALYSIS

Compared with other data sources that were limited to workers who had experienced at least one work-related
problem, the NLSY79 also covers workers who never experienced an injury; and for those who did, it allows iden-
tification of a very early episode, although not necessarily the first (theoretically, occupational injuries could have
happened to the NLSY79 respondents before 1987). Therefore, the data allow us to study the factors that may ex-
plain recurrent episodes of work-related injury and illness through a regression model where the dependent variable
is the expected number of occupational injuries or illnesses for each individual. This is, however, a situation where

Copyright © 2012 John Wiley & Sons, Ltd. Health Econ. (2012)
DOI: 10.1002/hec
 M. GALIZZI

Table IV. NLSY 1988–2000 subsample* of on the job injured workers as of 1988 (weighted summary statistics)
No WC claims Only one WC claim More than one WC claim p-value**
between 1988–2000 between 1988–2000 between 1988–2000
(n = 819) (n = 960) (n = 476)

Mean (SE) Mean (SE) Mean (SE)

Age 27 (0.10) 27 (0.08) 27 (0.12) 0.82
White 0.80 (0.01) 0.81 (0.01) 0.82 (0.01) 0.53
Black 0.13 (0.01 ) 0.12 (0.01) 0.11 (0.01) 0.52
Hispanic 0.07 (0.01) 0.06 (0.01) 0.07 (0.01) 0.91
Female 0.43 (0.02 ) 0.40 ( 0.02) 0.36 (0.02 ) 0.11
Education:
< High school 0.14 (0.01 ) 0.17 (0.01) 0.14 (0.02) 0.28
High school 0.45 (0.02 ) 0.54 (0.02) 0.61 (0.02) 0.00
> High school 0.40 (0.02 ) 0.29 (0.02) 0.25 (0.02) 0.00
Before 1988:
In poverty before age 23 0.39 (0.02) 0.38 (0.02) 0.40 (0.02) 0.73
Health limitation before age 23 0.19 (0.01) 0.20 (0.01) 0.22 (0.02) 0.54
Dangerous/unhealthy jobs before 1983 0.52 (0.02) 0.51 (0.02) 0.60 (0.02) 0.00
As of 1988:
Family income 27,329 (884) 26,455 (747) 26,376(1098) 0.70
Family in poverty 0.14 (0.02) 0.14 (0.01) 0.12 (0.02) 0.60
Employed 0.82 (0.03) 0.84 (0.03) 0.85 (0.03) 0.29
Wage 1,007 (112) 858 (32) 934 (100) 0.36
With health insurance 0.59 (0.02) 0.60 (0.02) 0.67 (0.02) 0.01
Tenure (weeks) 139 (6) 144 (6) 136 (8) 0.74
Weekly worked hours 44 (0.6) 43 (0.6) 44 (0.8) 0.70
Fixed shifts 0.81 (0.02) 0.84 (0.01) 0.83 (0.02) 0.40
Industry incident rate (1994) 9.03 (0.20) 8.99 (0.18) 9.49 (0.26) 0.28
After first injury:
Average no. of work days missed 3 (0.8) 14 (3.9) 11 (2.1) 0.00
Lost wages 0.23 (0.04) 0.28 (0.04) 0.31 (0.04) 0.36
WC benefits collected 0.46 (0.05) 0.40 (0.05) 0.40

Note:
*Individuals who participated to all survey rounds from 1988 to 2000 regardless of their employment status in 1988.
**F-test for the null hypothesis that the three means are equal.

the dependent variable – the count of work-related injuries – assumes values bounded from below by zero. Under
these conditions, a common estimation technique is the Poisson regression model. Poisson regression models,
however, are based on the implicit assumption of the independence of events, that is, that the variance of dependent
variable is equal to its mean. If this condition does not hold because the events are correlated (which seems
plausible in the case of recurrent occupational injuries), we run into a phenomenon called “overdispersion”. The
expected number of injuries is then better described by a negative binomial model, which permits us to estimate
a, the overdispersion parameter (a would be equal to zero in a Poisson model).
In my data, however, overdispersion could also be caused by a different characteristic of the specific data I am study-
ing: the preponderance of zero counts. Indeed, the majority of the surveyed individuals did not report any occupational
incidents and, among the ones who filed workers’ compensation claims, the majority only filed one time. Under this
condition, a solution is to estimate a zero-inflated count model (Karazsia and van Dulmen, 2008). Such a model esti-
mates simultaneously a binary probability model to determine whether a zero or a non-zero outcome occurs and a count
model (either a Poisson or a negative binomial model) to estimate what predicts the frequency of positive outcomes.
In my analysis, I first estimated simple Poisson and negative binomial regression models. Then, when pos-
sible, I compared them with their corresponding zero-inflated models where the binary outcome was estimated
with a logit model and the positive count outcomes were estimated by assuming first a Poisson and then a neg-
ative binomial count process. I conducted a Voung test to test whether the zero-inflated models were better
choices for my data given the preponderance of zero outcomes. The statistics showed that zero-inflated models
were indeed more appropriate estimation techniques. Finally, to acknowledge the possibility that

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 ON THE RECURRENCE OF OCCUPATIONAL INJURIES AND WC CLAIMS

overdispersion in my data could be caused not only by an excess of zeros but also by correlation among events,
I compared the zero-inflated Poisson and the zero-inflated negative binomial models with a Likelihood ratio test
to assess whether the overdispersion parameter was equal to zero. This last statistic was statistically significant
indicating that the zero inflated negative binomial model, and not the Poisson model, was the good choice to
describe the count events I was studying. Therefore, for the counts of injuries, I am only reporting here the
regression results based on the zero-inflated negative binomial model.
For the count of workers’ compensation claims, however, the zero-inflated models failed to converge, a
result that is not unusual with this type of estimation (Deb et al., 2010). Then, I estimated a two-part model: a logit
model to determine whether a zero outcome (no claim filing) or a non-zero outcome (workers’ compensation claim
filed) had occurred after the first injury, and a zero-truncated negative binomial regression describing the count of
workers’ compensation claims.

4.1. The recurrence of occupational injuries or illnesses: empirical results

The National Longitudinal Survey of Youth 1979 respondents were first asked about their experience with on-
the-job injuries and illnesses in 1988, although the occupational incidents they reported could have happened
before that year. Only 5% of all the reported on-the- job injuries and illness had happened in 1987, however.
Therefore, in examining the determinants of the total count of work-related injuries recalled by individuals
between 1988 and 2000, I use as explanatory variables information about individual and occupational charac-
teristics as of 1988. Also, because occupational injuries can only occur when workers are employed, in my
model, I accounted for different “exposure” in terms of the number of weeks during which each person was
working between the survey years 1987 and 2000.
I first studied the role played by demographic characteristics as of 1988.5 The zero-inflated model described
in columns 1 and 2 of Table V estimates simultaneously a logit model for the likelihood of having experienced
zero occupational incidents up to the year 2000 (so that an estimated negative coefficient indicates a higher like-
lihood of being injured at least once) and a negative binomial model for the determinants of higher counts of
occupational injuries or illnesses. This first set of results shows that female workers are less likely to have
recurrent injuries. Compared with black and Hispanic workers, white employees are less likely to be injured,
although they face a higher likelihood of injury recurrence. It also becomes immediately clear that human
capital accumulation, in terms of formal schooling, is one of the main individual attributes that can shelter
workers from repetitive injuries, probably either because it produces better skills or because it increases their
ability to qualify for safer jobs. However, the most interesting results come from information regarding the
socioeconomic status of respondents during their early years. The NLSY79 enables us to calculate whether
each respondent’s total family income was above or below the poverty level; whether individuals suffered
any work-limiting health conditions; and whether they had been exposed to unsafe jobs at an early age. For
each respondent, I calculated whether any of the preceding conditions had happened before respondents turned
23 years old.6 These variables are found to be importantly related to individuals’ likelihood of getting injured
and re-injured: those who had experienced economic hardship or had health-limiting conditions at young age
were found to be at significantly higher risk of experiencing recurrent occupational inquiries during their
subsequent 20 years of employment. Young workers (between the age of 14 and 25) who were employed or
self-employed during the first few rounds of the survey (from 1979 to 1982) were also asked whether they were
employed in dangerous or unhealthy jobs. Given the young age of individuals during these first interview
rounds, their answers apply to some of their very first jobs. Such early experience in unsafe jobs is also found

5
Following chapter 2 of the NLSY79 User Guide (Zagorsky, 1997), I did not weight my regressions, but instead used dummy variables for
the black and Hispanic oversamples.
6
In calculating the variables capturing early socioeconomic and health status, I chose to study records until age 22 because this was the
highest age reported by the oldest surveyed individuals in 1979, the first round of the NLSY79. Also in my models, I do not include
age as a regressor because of its very limited variation in the NLSY79: in 1988 respondents’ age ranged between 23 and 32 years.

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Table V. Count models of recurrent occupational injuries (dependent variable: count of occupational injuries or illnesses
reported between survey rounds 1988 and 2000)
Zero-inflated negative binomial models

(1) (2) (3)

Demographic and pre-injury Job attributes Job demands

Zero outcome Count outcome Zero outcome Count outcome Zero outcome Count outcome
(logit) (neg. binomial) (logit) (neg. binomial) (logit) (neg. binomial)
Female 0.34 0.20*** 0.04 0.10 0.15 0.11
Hispanic Reference group
Black 0.26 0.06 0.93** 0.03 1.08* 0.11
White 0.82** 0.19*** 1.93*** 0.17*** 1.15** 0.15*
Education < high school Reference group
High school degree 12.15 0.01 0.91 0.01 0.36 0.07
> High school 13.09 0.33*** 1.08 0.29*** 0.91 0.33***
Early health problem 1.07** 0.18*** 0.59* 0.20*** 1.38 0.12
Early life in poverty 0.25 0.09* 0.63*** 0.05 0.93* 0.07
Early exposure to 0.52*** 0.21*** 0.32 0.17*** 0.32 0.19***
unsafe job
Occupation dummies Yes** Yes** Yes Yes**
Industry dummies Yes Yes** Yes Yes**
Tenure 0.01 0.01*** 0.01 0.01***
Union 0.16 0.19*** 0.68 0.13*
Sector injury rate 0.12*** 0.01 0.12* 0.01
Weekly worked hours 0.02** 0.01*
Fixed shifts 0.86 0.13*
Constant 14.15 6.80*** 13.31 6.95*** 0.76 7.12***
Vuong test 3.36 (p = 0.000) 5.25 (p = 0.000) 4.95 (p = 0.000)
Likelihood–ratio test 87.16(p = 0.000) 83.77 (p = 0.000) 70.07 (p = 0.000)
of a = 0
Observations 6718 5814 4765

NOTE: Exposure is calculated in terms of the total number of weeks during which each individual was employed between the 1987 and the
2000 survey rounds. Job-related variables refer to the main jobs individuals held as of 1988 or, for workers injured in 1988 or before, the
job where the first injury happened. An additional dummy variable captured whether the information about safety in early jobs was missing.
Occupation dummies: professional, managers, sales workers, clerical and unskilled, craftsmen, operatives, laborers, service workers. Industry
dummies: agriculture, mining and construction, durable manufacturing, nondurable manufacturing, transportation, communication and public
utilities, wholesale retail, finance, insurance, and real estate, business and personal services, professional services, public administration.
Stars track significance with
*p < 0.10,
**p < 0.05, and
***p < 0.01.

to be a strong predictor of multiple injuries over individuals’ working lives. This result could suggest either
long-lasting health consequences of exposure to unsafe working conditions or that certain individuals are more
prone to engage in riskier occupations either because they have less risk aversion or are forced to do so by
economic need. The result may also suggest the difficulty workers could encounter in leaving the “bad” side
of a dual labor market after they have first entered it at young age.
As a second step, the analysis includes information on the main job individuals were performing in 19887
(columns 3 and 4 of Table V). Most of the previous results are confirmed, although controlling for job

7
The NLSY79 does not permit us to easily identify the first job individuals took after finishing school. Therefore, I chose to extract job
information corresponding to the main job respondents reported in 1988, the year when questions about occupational injuries were first
introduced and a substantial number of injuries were reported. 1988 was also the year when the employment rate of individuals surveyed
by the NLSY79 reached 90%. For those injured workers who were injured in 1988 or in a previous year, the job information refers to the
specific job (out of five described jobs) where the incidents happened.

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 ON THE RECURRENCE OF OCCUPATIONAL INJURIES AND WC CLAIMS

attributes removes any statistically significant gender difference, suggesting that males and females faced the
same risk of recurrent on-the-job injuries when employed in the same job and in the same industry. In addition,
we learn that workers employed in industrial sectors with higher rates of incidents, or working as craftsmen and
operatives, were indeed at higher risk of getting injured at least once. Workers who were employed as
operatives and service workers, or who were employed in mining, construction, durable manufacturing,
transportation, or public administration, were at higher risk of recurrent work-related injuries in subsequent
years. Workers who had less tenure (and were possibly less experienced) also faced higher occupational risk.
Contrary to the expectation that unions would positively affect job safety, workers covered by collective bargain-
ing were more at risk of recurrent injuries.
The last model specification (columns 5 and 6 of Table V) permits to control also for job demands
that are often associated with fatigue: longer weekly worked hours and whether the job required irregular
shifts. It is very interesting to notice that not only these two variables affect significantly the recurrence
of occupational injuries but also that their inclusion makes insignificant the role played by early health
conditions.
Finally, the interpretation of the relationship between socioeconomic variables and health outcome vari-
ables is always challenged by the potential simultaneity between health, occupation, and economic status.
To better understand the role played by early disabling health conditions and the exposure to early unsafe
jobs, I estimated the same model for two different groups of respondents: those who had lived, when they
were young, in households that qualified as poor and those who did not. Table VI suggests that, indeed,
early health limitations and early exposure to unsafe jobs still play a role in determining the likelihood
of recurrent occupational injuries, although their effect is significantly different depending on individuals’
early financial means: early health limitations remain a significant regressor only for people without financial
need, whereas exposure to early unsafe jobs still plays a role only for people whose families had been
in poverty.

4.2. The recurrence of workers’ compensation claims: empirical results

In my NLSY79 “continuous 1988–2000” subsample, only 57% of all occupational injuries and illnesses that
were recalled resulted in workers’ compensation claims. Among the on-the-job injuries that caused the workers
to miss at least 1 day of scheduled work (not counting the day of the incident), only 67% resulted in workers or
employers “filling out a worker’s compensation form.” This number increased only to 73% among injuries
requiring at least 3 days off work. This last percentage suggests then that a potentially remarkable number of
cases of occupational injury or illness were underreported to workers’ compensation agencies. However,
among those 1438 workers whose injuries resulted in workers’ compensation claims, 33% filed more than
once, although the majority only filed a total number of two workers’ compensation claims over the survey
years I was studying (1988–2000) (Table II, column 4).
To study what may affect the likelihood of filing multiple claims, I used a model specification that includes
four different sets of explanatory variables calculated in correspondence with the first injury or claim: personal
characteristics, job attributes, injury characteristics (length of time off work, whether it was a back injury, i.e.,
the type of injury more likely to reoccur, receipt of workers’ compensation benefits, accommodation after an
injury8), and some measures of the degree of generosity of the workers’ compensation system of the state where
the worker got injured (the number of essential recommendations concerning coverage, income benefits, and
medical benefits met by each state law – out of the 19 essential recommendations included in the 1972 Report
of the National Commission on Workmen’s Compensation – and the waiting period that must elapse before
income benefits become payable). Given the inclusion of this state level information, I checked the robustness
of my estimators by clustering the observations by state.

8
Being assigned temporarily to another job, to reduced duties, or to part-time jobs.

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 M. GALIZZI

Table VI. By early poverty status: count models of recurrent occupational injuries (dependent variable: count of occupa-
tional injuries or illnesses reported between survey rounds 1988 and 2000)
Zero-inflated negative binomial model

If household is in poverty before age 23 If household is not in poverty before age 23

Count outcome Count outcome

Zero outcome (logit) (neg. binomial) Zero outcome (logit) (neg. binomial)
Female 0.23 0.03 0.03 0.20*
Hispanic Reference group
Black 0.75* 0.02 1.47** 0.04
White 0.45 0.07 1.18* 0.23**
Education < high school Reference group
High school degree 0.53 0.01 0.95 0.01
> High school 0.76 0.21* 1.22 0.32**
Early health problem 0.07 0.15 0.18 0.37***
Early life in poverty
Early exposure to unsafe job 0.58 0.26*** 0.46 0.01
Occupation dummies Yes** Yes** Yes Yes
Industry dummies Yes Yes Yes Yes**
Tenure 0.01** 0.01** 0.01 0.01***
Union 0.76* 0.33*** 0.23 0.15
Sector injury rate 0.24*** 0.03 0.13*** 0.01
Fixed shifts † 12.74 0.52 0.10
Constant 11.72 6.72*** 13.92 6.82***
Vuong test statistics 3.80 (p = 0.00) 4.51 (p = 0.00)
Likelihood–ratio test of a = 0 32.53(p = 0.000) 45.52 (p = 0.000)
Observations 2619 3107
NOTE: See Note to Table V.
†
All the main results of the last two columns did not change when the model was controlled also for weekly worked hours. However, the
regression for individuals in household in poverty before age 23 did not converge, and therefore those results are not presented.

I started this analysis by again estimating zero-inflated count models, but I was not able to achieve
reliable regression results (the likelihood function could not be maximized). Therefore, in Table VII, I
present two different estimation techniques to cast light on the phenomenon of multiple workers’ com-
pensation claims. In column 1 (Table VII), a Poisson model estimates the determinants of repetitive
claims for all workers who got injured at least once. A goodness-of-fit w2-test had indicated that, in this
case, a Poisson regression model was indeed more appropriate than a negative binomial one (w2 = 1648
with p = 0.20). The estimated coefficients in column 1 suggest that less formal education and less tenure,
original health limitations, the potential severity of the first injury (captured by the number of scheduled
work days the worker had to take off work), and occupational injuries to the back are factors associated
with higher numbers of recurrent claims. Workers who are more likely to file several claims are
employed as unskilled clerical workers or as service workers, or as craftsmen, operatives, and laborers.
They are less likely to file recurrent claims if they are employed in mining or construction or in repair,
personal, or recreation services. Firm size does not affect the number of individual recurrent claims.
Workers are found to be more likely “users” of the workers’ compensation system when they are working
in jobs covered by collective bargaining, in jobs that offer health insurance, and when they received accom-
modations after the first occupational injury. This could indicate that filing for workers’ compensation is
indeed not a straightforward decision and that workers are more likely to initiate it when they are already
familiar with other types of assistance. However, the reliability of these estimates is compromised by the fact
that our data would have been more suitably studied with inflated models, given the large preponderance of
respondents with zero counts.
To overcome the lack of convergence of the zero-inflated models, but still account for the preponderance of
zeros, I estimated a two-part model for counts: a logit model for the likelihood of not filing a claim after a first injury

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 ON THE RECURRENCE OF OCCUPATIONAL INJURIES AND WC CLAIMS

Table VII. Count models of recurrent workers’ compensation claims (dependent variables: count of workers’ compensation
claims reported between survey rounds 1988 and 2000)
Poisson model Two-part model

Logit model Zero-truncated negative

binomial count model
(1) (2) (3)
Counts of workers’ Probability of not filing Counts of additional workers’
compensation claims a claim after first compensation claims if a
after a first occupational occupational injury claim was filed after a first
injury occupational injury
Female 0.03 0.13 0.05
Hispanic Reference group
Black 0.03 0.01 0.07
White 0.04 0.06 0.02
Education < high school Reference group
High school degree 0.01 0.08 0.07
> High school 0.18** 0.09 0.10
Early health problem 0.13** 0.01 0.26***
Family in poverty 0.05 0.23 0.09
Early exposure to government programs 0.10 0.11 0.11
Tenure 0.01*** 0.01 0.01***
Health insurance 0.25*** 0.79*** 0.06
Occupation dummies Yes*** Yes** Yes**
Industry dummies Yes** Yes Yes**
Firm size 0.01 0.01 0.01
Union 0.18*** 0.02 0.37***
Sector injury rate 0.01 0.01 0.01
Number missed work days 0.01*** 0.01*** 0.01*
Back injury 0.15*** 0.49*** 0.20*
Accommodation 0.10* 0.43*** 0.10
Benefits collected after first claim 0.07
Essential W.C. coverage 0.06 0.07 0.07
recommendations met by state
Essential W.C. benefits recommendations 0.03 0.05 0.04†
met by state
Essential W.C. medical recommendations 0.06 0.15 0.16
met by state
Length of state waiting period 0.01 0.01 0.01
Constant 7.35*** 1.65** 7.63***
Observations 1688 1683 1100

NOTE: See Note to Table V but here job-related variables refer to the job where the first injury happened and standard errors are clustered
by state because of the inclusion of state varying regressors.
†
, the estimated coefficient doubled in size and reached significance of ***p < 0.01 when I used information about state’s workers’
compensation systems in 1999 (instead of 1988).

(Table VII, column 2) and a zero-truncated negative binomial regression9 (Table VII, column 3) where the depen-
dent variable is the total positive number of recurrent workers’ compensation claims associated with each injured
worker. Both models share the same regressors, but the count model also includes a variable capturing whether the
workers had received benefits after the first claim. The results of the logit regression indicate that, again, back
injuries and more severe injuries are found to be more likely to lead to a claim, and that in jobs that offer health
insurance, employees are more likely to file for workers’ compensation as well (an estimated negative coefficient
indicates a higher likelihood of filing a claim) (Table VII, column 2). Unskilled clerical workers, laborers, and ser-
vice workers are again found to be more likely to file for workers’ compensation after their first recalled injury. This

9
In this case, the overdispersion parameter was found to be significantly different from zero, rejecting the hypothesis of a Poisson distribu-
tion. However, this test was conducted on a model that did not cluster observations by state because clustered standard errors do not permit
conducting likelihood ratio tests.

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 M. GALIZZI

is also true for managers, however. The industrial sector of the employer and the size of the firm do not make a
difference. The truncated count model (Table VII, column 3) shows that having original health limitations, having
less tenure, being a laborer or a service worker, and being in a unionized job at the time of first injury are the major
predictors of additional repetitive claims. Workers in finance, insurance or real estate and those employed in repair,
personal, or recreation services are less likely to file additional claims after a first one. Belonging to a household in
poverty or having previously received assistance by government programs such as unemployment or disability
benefits does not make a difference. Neither the generosity of the state’s workers’ compensation system nor having
received workers’ compensation benefits after the first claim affect the count of claims itself. However, when the
same model is estimated by using information about workers’ compensation systems in 1999 (instead of in
1988),10 state’s higher compliance with the recommendations regarding income benefits is found to be a strong
predictor of the prevalence of additional workers’ compensation claims.

5. DISCUSSION AND CONCLUSIONS

This study represents the first analysis of the determinants of individual occupational injury counts among a
representative sample of both injured and uninjured US workers. It is also the first study to address this problem
by examining very long spells of individuals’ working lives (13 years.)
The analysis confirms what had been found in previous studies: recurrent occupational injuries represent no-
ticeable health and labor market outcomes because they occurred to at least one-third of all survey respondents
who had recalled at least one on-the-job injury or illness. Among the reported injuries, only 7% occurred to the
same individuals and to the exact same part of the body suggesting a sequence of relatively different injuries.
Only 56% of all occupational injuries and illnesses resulted in workers’ compensation claims.

5.1. Recurrent occupational injuries

Recurrent injuries are likely to produce cumulative losses both in terms of income and health capital. They are
also responsible for large proportion of medical costs. For these reasons, it is important to understand which
factors may cause a group of workers to be more at risk of repeated occupational injuries. As expected, workers
employed in more manual jobs and in traditionally more dangerous sectors were found to be more likely to
experience a higher number of injuries. However, the data permit us to cast some light on the relative impor-
tance of additional personal and job characteristics. One consistent result across all model specifications is that
higher education levels protect workers from the recurrence of injuries. Because these models control for
occupation and industry characteristics, this finding does not indicate that higher education simply captures
employment in safer jobs. We know from other studies (Fuchs, 1982; Cutler and Lleras-Muney, 2008) that
education is an important factor in the production of health because it either identifies those individuals who
are more efficient producers of health (and therefore are overall healthier) or it characterizes those people
who are forward-looking and therefore more risk adverse. Education may then capture individuals’ abilities
to handle occupational hazards. Similarly, longer tenure in the job decreases the prevalence of recurrent inju-
ries. This could indeed indicate that as workers gain seniority, they are given not only greater but also safer
responsibilities. However, given the relatively young age of the surveyed workers, the tenure variable probably
also proxies both experience and better ability to asses risk resulting from on-the-job training. But some of the
most interesting results come from the analysis of the role played by events that were determined quite early in
workers’ lives: early health-limiting conditions, early life in poverty, and early exposure to unsafe jobs. These
data allow for calculating whether individuals had suffered any health limitations before age 23. This event
turns out to be one of the strongest predictors of recurrent occupational injuries. This result is consistent with

10
See footnote n. 2. The regression results presented in Table VI make use of the 1988 rules but the main estimates of the coefficients the
other variables did not differ when the 1999 were used instead.

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 ON THE RECURRENCE OF OCCUPATIONAL INJURIES AND WC CLAIMS

recent findings showing that early health may affect labor market outcomes (Smith, 2009) and supports the
controversial hypothesis of injury proneness. However, it is very interesting to note that such a variable loses
its explanatory power when the model also accounts for those current working conditions (long working hours
and working irregular shifts) that are associated with fatigue on the job. This suggests that working conditions
rather than an individual’s pre-injury health are among the main factors behind the prevalence of individual
occupational injuries. Such an interpretation is reinforced by the fact that another strong predictor in the model
is a variable capturing whether individuals reported that they were exposed to unhealthy or risky jobs during
their early working years. This highlights a new potential channel mechanism through which early occupational
choice may determine future health (Fletcher and Sindelar, 2009). Because we are dealing with self-reported
answers, however, we cannot rule out that a worker’s report of early exposure to unsafe jobs also partly captures
differences in perceptions and tolerance of risk.

5.2. Recurrent workers’ compensation claims

When the analysis focuses not on recurrent injures but on recurrent workers’ compensation claims among injured
workers, early health limitations is again a factor that is found to be associated with a higher number of recurrent
claims. This is a potentially important finding because stakeholders in workers’ compensation systems often debate
to what extent employers should compensate for on-the-job injuries that may have been caused by original non-
work-related health conditions. As expected, the potential severity and nature of the first injury (measured by
the number of missed work days and by back injuries) are also found to be significant determinants of the likeli-
hood of filing both a claim after a first injury and recurrent claims. It is also quite interesting to note that workers
are found to be more likely “users” of the workers’ compensation systems when they are working in “good” jobs
covered by collective bargaining (Fenn and Ashby, 2004) and in jobs offering health insurance. Given the difficulty
of navigating the workers’ compensation system and the intimidation that workers sometimes feel (Galizzi et al.,
2009), unions can play a very important role; they provide employees with needed information, and supervisors in
unionized firms play a more active role in assisting workers through the filing process (Hirsch et al., 1997). In
certain instances, unions also provide injured workers with additional financial benefits. And employees may be
less afraid of potential retaliation, including job loss, when they are employed by a unionized firm. The additional
result concerning health insurance reinforces the idea that workers’ compensation is indeed not a straightforward
decision and that workers are more likely to initiate it when they are in a supportive work environment (employers
who provide richer fringe benefits) or when they are already familiar with other types of assistance. Indeed, the
result may also suggest the need to further study whether primary care physicians or the health insurance
companies play a role in informing and directing injured workers toward the workers’ compensation system.
Finally, the results do not seem to support the hypothesis that workers will file more claims in systems that
are more generous with coverage and medical and income benefits.11 Although these results should be further
tested with different measures of the adequacy of states’ workers compensations laws, they are consistent with
the findings of recent research on the effect of workers’ compensation generosity on claiming behaviors
(McInerney and Simon, 2010).

5.3. Future research and policy implications

The findings of this study clearly need to be further explored: we need research to understand the nature of the
original health conditions that make workers more prone to become injured in future jobs; we need to better
understand what leads young workers to accept unsafe jobs; and, finally, we need to further explore how the
phenomenon of multiple occupational injuries is affected by the experience that workers have with their
employers, with the health care system, and with the workers’ compensation system after their first accident

11
However, the generosity of the workers’ compensation systems in terms of income benefits was found to affect the prevalence of recurrent
claims when the generosity was measured by the number of laws in place toward the end of studied period (1999).

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 M. GALIZZI

on the job. Despite such limitations, however, these results highlight the need to acknowledge and address the
phenomenon of recurrent multiple occupational injuries.
This study suggests the need to avoid working conditions that induce fatigue and therefore increase occupa-
tional hazards. It also confirms the importance of increased experience and, therefore, of both on-the-job and spe-
cific safety training to diminish the recurrence of injuries. Also, after an injury takes place, the worker should be
given all the necessary time to properly heal, and firms should have in place appropriate accommodation practices.
However, the results also show that workers come to a job with an individual employment and health history that
may make them more likely candidates for recurrent injuries. This may suggests the need to develop case manage-
ment systems (Høgelund and Holm, 2006) or programs with surveillance of injury claims (Anderson et al., 2010)
that include all available key information regarding the history of injured workers. Such systems should be
designed to target reintegration practices but also carefully minimize invasion of privacy issues as well as the risk
of employment discrimination. As part of such systems, medical care providers should be made more aware of the
phenomenon of recurrent occupational injuries and of its predictors (including the important role played by
previous and current working conditions) in order to better assess, follow up, and advise their patients.
The phenomenon of recurrent occupational injuries is a clear example of the interaction that exists between
health and employment. We need to further understand this link in order to guarantee workers’ long-term health
and financial well-being and to reduce medical care and social insurance costs.

ACKNOWLEDGEMENTS

This research was conducted with restricted access to Bureau of Labor Statistics (BLS) data. The views
expressed here do not necessarily reflect the views of the BLS.
This study was originally supported by Grant Number K01 OH007999-03 (PI: Dr Galizzi) from the National
Institute for Occupational Safety and Health. Its content is solely the responsibility of the authors and does not
necessarily represent the official views of NIOSH.
I thank Keith Bateman, Les Boden, Lisa Dickson, Rebecca Gore, Forrest McCluer, and two anonymous
referees who offered useful insights and comments on this study. I thank John Burton for providing me with
information regarding State Workers’ Compensation Laws.

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