Out of an estimated U.S. working population of 127 million in 2008, more than 48 million (38%) lack paid sick leave. Approximately 60% of private-sector workers and more than 80% of state and local government workers had paid sick leave. Our analysis shows that it was workers in service or production occupations, those in the private sector, and those in smaller firms with fewer years on the job who were less likely to report having sick leave. Furthermore, our results from this nationally representative sample demonstrate that sick leave could be a significant barrier to cancer testing and medical care seeking.
Both unadjusted and adjusted proportion of workers undergoing mammography, Pap test, endoscopy and medical care-seeking were significantly higher for those with paid sick leave than those who lacked paid sick leave. It was only for home FOBT that we did not see an association with paid sick leave. Compared with endoscopy which requires contact with a physician and time away from work, testing for blood in the stool with an FOBT test kit is performed at home. In addition, the proportion reporting home FOBT was much smaller than the proportion reporting endoscopy.
Screening behavior is affected by a myriad of factors that vary within different populations. We adjusted for sociodemographic factors that have been shown to be barriers or facilitators of cancer testing or medical care-seeking in the United States. Race/ethnicity, education, age, household income, marital status, usual source of care and health-care coverage have been associated with colorectal cancer screening [10, 12, 13], mammography [9, 13], and Pap testing  in population-based surveys, including the NHIS and a random sample of Medicare beneficiaries . Our study population, which included only U.S. working men and women, is likely to differ in important ways from the U.S. population as a whole or the Medicare population. Consistent with previous research, we also reported a significant contribution of age and marital status to models of cancer screening or medical care-seeking as outcomes, but saw no significant differences in cancer screening by health insurance status or poverty. This could be due to a population of working men and women having less variability in insurance status and poverty level than a general population. Among working adults, lack of paid sick leave may pose a more significant barrier to cancer testing and medical care-seeking than lack of insurance or poverty.
This analysis has some limitations. For example, data are based on self-report and respondents may have incorrectly reported their screening use and the timing of that screening. A recent meta-analysis of the accuracy of self-reports of cancer screening concluded that national survey data overestimate the prevalence of screening and mask disparities by race and ethnicity because of differences in reporting accuracy . In addition, the survey seeks information only on paid sick leave and no other leave such as paid personal or annual leave, and the survey does not capture any restrictions on the use of sick leave for preventive health care. Workers may have personal leave or vacation leave but may not consider or report these categories as paid sick leave. Thus, we may have underestimated the proportion of workers with leave that could be counted for cancer screening. However, our estimates of worker’s access to paid sick leave were similar to the Bureau of Labor Statistics (BLS) estimates of 61% for private-industry workers and 89% of state and local workers during 2008 . Differences are primarily due to differences in survey design. Whereas the NHIS is a survey of randomly chosen individuals from households who are representative of the noninstitutionalized U.S. population, the BLS estimates are obtained from the National Compensation Survey, an employer-based survey representing a random selection of establishments chosen from state unemployment insurance records .
Barriers to cancer screening and routine medical care-seeking involve a complex web of individual, community, health care system and societal characteristics. In the working population, a person’s occupation is the source of his or her income and medical insurance coverage, and of other benefits such as paid sick leave, worker’s compensation, paid vacation, and retirement benefits . In short, a person’s occupation is the source of some of the most critical elements determining their health and well-being. And in the United States, access to these benefits is largely determined by the type of occupation. The percentage of workers with access to paid sick leave is lowest among service workers, workers in construction and maintenance, transportation workers, and part-time workers, and highest among managers and professional workers. This occupational structure disproportionately affects women who are more likely to be low-wage and part-time workers .
Lack of paid sick leave can be considered within the category of out-of-pocket costs for medical care. Those without sick leave who take work time off for preventive services may lose pay. High deductibles and other forms of cost sharing have been associated with underuse of preventive services [28, 29], specifically colorectal cancer screening  and mammography [31, 32]. Lack of paid sick leave appears to be a potential barrier to obtaining needed medical care and a societal benefit that is potentially amenable to change.