Examining Employment Status,Paid Sick Leave,and Access to Care in Relation to Colorectal Cancer Screening Among U.S. Workers: A Structural Equation Modeling Approach

Abstract

Introduction

This cross-sectional study examined the relationship between paid sick leave and colorectal cancer (CRC) endoscopy screening among employed adults, including the examination of potential pathways.

Methods

We analyzed data from 15,352 employed adults aged 45-75 from the 2021 and 2023 National Health Interview Survey. A generalized structural equation model (GSEM) assessed the direct and indirect pathways between employment status (full-time vs part-time), paid sick leave, health insurance, usual source of care, and CRC endoscopy screening. Survey weights were applied to ensure nationally representative estimates.

Results

Full-time employment was positively associated with paid sick leave (OR = 6.57, 95% CI: 5.85, 7.38) and health insurance (OR = 1.30, 95% CI: 1.07, 1.59). Paid sick leave increased the likelihood of having a usual source of care (OR = 1.57, 95% CI: 1.31, 1.87) and was directly associated with CRC screening (OR = 1.15, 95% CI: 1.03, 1.28). Health insurance increased the likelihood of having a usual source of care (OR = 5.32, 95% CI: 4.30, 6.58) and CRC screening (OR = 3.22, 95% CI: 2.58, 4.02). Usual source of care was also associated with CRC screening (OR = 3.53, 95% CI: 2.89, 4.32).

Conclusions

Paid sick leave was associated with CRC endoscopy utilization both directly and indirectly through improved healthcare access. Workplace policies that expand paid sick leave, alongside efforts to strengthen insurance coverage and primary care access, may reduce barriers to CRC endoscopy screening and improve population health.

Keywords

colorectal cancer screening endoscopy health insurance sick leave employment status health services accessibility structural equation modeling

Introduction

Colorectal cancer (CRC) remains a significant public health challenge, being the second leading cause of cancer-related deaths in the United States.¹ Early detection through screening, which can occur through endoscopic methods like colonoscopy and sigmoidoscopy, is key to reducing both the incidence and mortality rates associated with CRC, but utilization rates among adults remain suboptimal.^1,2 Employment-related factors, such as paid sick leave, and healthcare access factors, such as health insurance coverage and having a usual source of care, are important determinants of preventive healthcare utilization, including CRC screening.^3,4,5,6,7 However, these factors are not independent; paid sick leave may directly facilitate screening by enabling time away from work, while also indirectly promoting screening by improving access to health insurance or enabling individuals to establish a usual source of care.^8,9 Understanding these interrelated pathways is necessary to design more effective workplace policies and health interventions that reduce barriers to preventive care.

Paid sick leave plays a critical role in enabling workers to access preventive services without the financial and logistical burdens of lost wages.^8,9 The U.S. remains the only industrialized country without a national paid sick leave mandate, which has led to disparities in healthcare access among workers, particularly those in low-wage jobs or without employer-provided benefits.^10,11 Individuals with paid sick leave are significantly more likely to engage in various forms of preventive care, including CRC screening, mammograms, and influenza vaccinations, compared to those without such benefits.¹² The lack of paid sick leave can lead to delayed medical care, increased use of emergency services, and lower utilization of preventive healthcare services.^13–15 Several studies have highlighted the positive association between paid sick leave and healthcare utilization. For example, a recent study found that workers with paid sick leave were 3.83 percentage points more likely to have office-based healthcare visits, a proxy for routine care, compared to those without paid leave.¹⁶ Moreover, research focusing on cancer survivors has shown that paid sick leave improved preventive services use by 6-19%.¹⁷ A study of metropolitan statistical areas using claims data found that state or local government mandates for employers to provide paid sick leave were associated with 1.56 percentage points higher CRC cancer screening, which is encouraging as more states are adopting state paid sick leave mandates.¹⁸

In addition to paid sick leave, health insurance coverage is a critical determinant of access to colorectal cancer (CRC) screening, particularly endoscopy.^19,20 Extensive research has demonstrated that uninsured individuals are at least 24% less likely to utilize preventive healthcare services, including CRC screening, due to the high out-of-pocket costs associated with these procedures.^21,22,23 Health insurance not only lowers the financial barriers to accessing endoscopy services but also facilitates the continuity of care necessary for follow-up procedures and treatments.^24,25 However, insurance alone is often insufficient to ensure screening; having a usual source of care—a regular healthcare provider or facility—plays a complementary and critical role in facilitating preventive care uptake.^26,27,28,29 Individuals with a usual source of care are more likely to receive provider recommendations for screening, have routine interactions with healthcare professionals, and access preventive services such as CRC screening; for example, women with both a usual place and provider had 4.8 times greater odds of receiving a mammogram compared to those without either, and men ages 50-64 had nearly 10 times higher odds of receiving a PSA test.⁷ The Affordable Care Act, which expanded access to preventive services without cost-sharing, has been associated with a 6-7 percentage point increase in CRC screening rates, particularly among previously uninsured and low-income populations.^{30,31,32,33,34} However, gaps in coverage remain, especially among part-time workers who are at least 6 percentage points less likely to have employer-sponsored health insurance, further exacerbating disparities in CRC screening.³⁵ Moreover, the lack of paid sick leave may indirectly hinder individuals from establishing a usual source of care by making it difficult to attend initial or follow-up visits, reducing opportunities for provider screening recommendations.¹⁴ For example, adults without paid sick leave were 4.2 percentage points more likely to report not seeing or talking to a general doctor in the past year compared to those with paid sick leave.¹⁴

While paid sick leave and health insurance independently improve access to preventive healthcare, these benefits arise within broader employment structures.^9,10 Full-time employment is more likely to confer both paid sick leave and health insurance.^9,35 Access to paid sick leave may, in turn, reduce barriers to establishing a usual source of care, facilitating preventive services such as CRC screening.^7,14 Paid sick leave may also have a direct effect on screening by enabling individuals to take time off work to undergo an endoscopic procedure.^3,6,18 Health insurance, on the other hand, reduces the financial barriers associated with CRC screening, and having a usual source of care can facilitate screening recommendations and referrals.^5,7,26 Capturing both direct and indirect pathways is necessary to fully understand the mechanisms through which workplace policies influence screening behaviors.

While paid sick leave and health insurance independently improve access to preventive healthcare, the pathways through which these benefits influence colorectal cancer screening remain poorly understood. This study addresses that gap by applying a generalized structural equation model (GSEM) to investigate the direct and indirect pathways linking employment status (as an upstream employment condition) and paid sick leave (as a downstream workplace benefit) to colorectal cancer (CRC) endoscopy screening among employed adults, with health insurance and usual source of care as potential mediators. This study is guided by Andersen’s Behavioral Model of Healthcare Utilization, which identifies enabling resources such as health insurance and usual source of care as key determinants of healthcare use.³⁶ Paid sick leave can also be conceptualized as an enabling resource that reduces time and financial barriers to care, thereby facilitating preventive care such as CRC screening.

Methods

Sample

This cross-sectional study analyzed publicly available, deidentified, pooled data from the 2021 and 2023 National Health Interview Survey (NHIS), which is a nationally representative household survey of the civilian noninstitutionalized population of the United States, conducted continuously throughout the year.^37,38 The analysis included participants who were aged 45 to 75 years, in alignment with U.S. Preventive Services Task Force (USPSTF) guidelines for CRC screening.³⁹ Participants were excluded if they were not currently employed (N = 13,247) or had missing data on any of the study variables using listwise deletion (N = 1025). Unemployed individuals were excluded from the analysis because paid sick leave is only relevant to those currently employed. The final analytic sample included 15,352 participants that were age-eligible for CRC screening, employed, and not missing data on any of the study variables.

Although 6% of age-eligible respondents were excluded due to missing data on one or more covariates, we conducted a sensitivity analysis using Firth logistic regression to assess whether exclusion was systematically associated with sociodemographic or healthcare access variables. The results indicated no statistically significant predictors of missingness, reducing concern that listwise deletion introduced bias into the analytic sample (Appendix Table A1).

We conducted post-hoc power calculations to ensure the adequacy of our sample size. Given the effect sizes observed in the analysis, our sample size of 15,352 respondents provided over 80% power to detect significant associations at a two-tailed 0.05 significance level, particularly for key predictors such as paid sick leave and health insurance coverage, with CRC endoscopy screening as the outcome. Reporting guidelines for cross-sectional studies from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) were followed.⁴⁰

Ethical Considerations

The University of Texas Southwestern Medical Center’s institutional review board determined that the study was not defined as human subjects research because it used publicly available data without personal identifiers.

Measures

The primary outcomes were whether participants had ever undergone any form of colorectal cancer (CRC) endoscopy, which includes colonoscopy or sigmoidoscopy.

Employment status (full-time vs part-time) and paid sick leave are treated as primary exposures. Employment status is conceptualized as an upstream employment condition that influences access to workplace benefits. Paid sick leave, as a downstream workplace benefit, may independently affect healthcare access and utilization by reducing time and logistical barriers to preventive care. Employment status was defined as full-time (35+ hours per week) vs part-time (<35 hours per week) and the presence of paid sick leave, (1 = has paid sick leave, 0 = no paid sick leave). Health insurance coverage (1 = insured, 0 = uninsured), and usual source of care (1 = has a usual source of care, 0 = no usual source of care) were conceptualized as mediators in the pathway from employment status and benefits to CRC screening.

Predisposing, enabling, and need factors from the Andersen Model were chosen to account for their influence on utilizing health services like CRC endoscopy.³⁶ These factors functioned as control variables in the statistical model and include age (categorized), sex (as a binary variable), metropolitan residence, region of residence, marital status, race and ethnicity, education level, household income relative to the federal poverty level, general health status, and disability status.

Statistical Analysis

The theoretical model presented in Figure 1 illustrates the hypothesized pathways linking paid sick leave to colorectal cancer screening via healthcare access mechanisms. The model is grounded in the premise that employment conditions, specifically the availability of paid sick leave, play a crucial role in facilitating or hindering healthcare utilization. Employment status (full-time vs part-time) and paid sick leave are treated as primary exposures, reflecting upstream and downstream workplace benefits, respectively. Health insurance coverage and having a usual source of care are conceptualized as mediators that may explain the relationship between these employment-related factors and colorectal cancer screening. At the core of the model, employment status is posited to directly influence the likelihood of having paid sick leave and health insurance. Full-time employees are more likely to have access to paid sick leave benefits and health insurance compared to part-time employees. Paid sick leave is hypothesized to affect colorectal cancer screening through both direct and indirect pathways. The direct pathway reflects the notion that individuals with paid sick leave may face fewer work-related barriers to attending screening appointments, including the preparation time required for an endoscopy, allowing them to seek preventive care without fear of income loss. Indirectly, paid sick leave is expected to increase the likelihood of having a usual source of care because individuals with paid leave may be more able to establish and maintain an ongoing healthcare relationship. Health insurance is expected to facilitate having a usual source of care, and both health insurance coverage and having a usual source of care are well-established predictors of preventive health behaviors, including colorectal cancer screening. These interconnections highlight the multifaceted role of workplace benefits in shaping health behaviors. Demographic, socioeconomic, and health status are included as control variables to account for potential confounders that might affect the relationships among the primary variables of interest. Additionally, employment status is treated as a control variable in the portions of the model predicting usual source of care and endoscopy utilization, as it may confound these relationships through work-related time constraints or other employment characteristics.

Figure 1.

Theoretical Model of Pathways Linking Paid Sick Leave, Healthcare Access, and Colorectal Cancer Screening.

Data were analyzed using Stata 18.5 MP/Parallel edition software. Cross-tabulations and chi-square tests were conducted to examine the distribution of the outcome and main predictors. We employed a generalized structural equation model (GSEM) in Stata to estimate the pathways linking employment status, paid sick leave, health insurance, usual source of care, and colorectal endoscopy. GSEM is particularly suitable for our conceptual framework because it allows for the simultaneous estimation of multiple equations with binary outcomes, reflecting the complex and interdependent nature of employment status and healthcare access. The analysis was conducted with survey weights to account for the complex survey design, ensuring representative estimates. The GSEM model specified the following primary pathways: (1) the association between employment status and paid sick leave; (2) the association between employment status and health insurance coverage; (3) the associations between paid sick leave and insurance coverage with having a usual source of care; and (4) the associations between paid sick leave, health insurance coverage, and usual source of care with CRC endoscopy. These pathways allowed us to assess both the direct and indirect effects of paid sick leave and health insurance coverage on CRC endoscopy screening through usual source of care. The exogenous variables consisted of full-time vs part-time employment status and various control variables, such as age category, gender, metropolitan status, region, marital status, race/ethnicity, education, income level, general health status, and disability status. All paths were estimated using logit regression to model the binary outcomes. We obtained exponentiated coefficients (odds ratios) for each pathway to facilitate the understanding of the magnitude and direction of associations. Additionally, marginal effects were calculated to estimate the predicted probabilities of receiving a colorectal endoscopy based on the presence or absence of paid sick leave, health insurance coverage, and a usual source of care. While the GSEM approach provided flexibility in modeling complex relationships and allowed for the estimation of both direct and indirect pathways, a limitation of GSEM is the absence of traditional goodness-of-fit statistics, such as AIC and BIC, when using survey-weighted models with binary outcomes, which prevents evaluation of overall model fit.⁴¹ Despite this limitation, the model offers a comprehensive understanding of how paid sick leave influences healthcare access and colorectal cancer screening through multiple mediating factors. Recognizing that work patterns change after age 65, we conducted a sensitivity analysis of the GSEM limited to adults aged 45-64 to examine whether the pathways were consistent among individuals not yet eligible for Medicare.

Data Availability

The NHIS data are publicly available from the National Center for Health Statistics at https://www.cdc.gov/nchs/nhis/, which includes detailed information about the survey. We downloaded a publicly available version of the NHIS from IPUMS at https://nhis.ipums.org/nhis/.³⁸

Results

Sample Characteristics

Table 1 presents the weighted percentages and unweighted sample sizes for the study population (N = 15,352). The sample consisted of employed adults aged 45-75 years, with 55% reporting ever having undergone a colorectal cancer (CRC) endoscopy. The majority (81%) were employed full-time, 68% had paid sick leave, 93% had health insurance, and 93% reported having a usual source of care. Demographically, 53% were male, 87% lived in metropolitan areas, and 71% were married or cohabiting. The sample was predominantly non-Latino White (67%), with 11% non-Latino Black, 15% Latino, and smaller proportions of other racial/ethnic groups. Most participants (68%) had more than a high school education, and 58% had household incomes at or above 400% of the federal poverty level. The full covariance matrix is available in Appendix Table A2.

Table 1.

Survey Weighted Percentages and Unweighted Sample Size: National Health Interview Survey 2021 & 2023

	Raw N	Weighted %
N	15,352
Had endoscopy
No	6527	45
Yes	8825	55
Employed status
Part time	3177	19
Full time	12,175	81
Has paid sick leave
No	5031	32
Yes	10,321	68
Health insurance status
Uninsured	1008	7
Insured	14,318	93
Has a usual source of care
No	1070	7
Yes	14,277	93
Survey year
2021	7664	49
2023	7688	51
Age categories
45-49	3114	23
50-59	6627	45
60-69	4640	27
70-75	971	5
Sex
Male	7647	53
Female	7705	47
Metropolitan status
Non-metro	2190	13
Metro	13,162	87
Region
Northeast	2572	19
North central/Midwest	3418	21
South	5578	38
West	3784	22
Marital status
Not married	6486	29
Married/cohabiting	8866	71
Race and ethnicity
Non-Latino white	10,657	67
Non-Latino black	1624	11
Latino	1903	15
Non-Latino Asian	874	6
Non-Latino other	294	2
Highest level of education
Less than high school	945	8
High school	3403	24
More than high school	11,004	68
Federal poverty level categories
400%+	8983	58
<400%	6369	42
Health status
Good/fair/poor	6203	42
Excellent/very good	9149	59
Disability status
No	14,628	95
Yes	724	5

Bivariable Associations

Table 2 displays the bivariable associations between CRC endoscopy utilization and key predictors. Paid sick leave, health insurance, usual source of care, and full-time employment were all significantly associated with CRC endoscopy utilization (P < .001). Among those who had an endoscopy, 69% had paid sick leave, 98% had health insurance, 97% had a usual source of care, and 78% were employed full-time. Conversely, among those who had not undergone an endoscopy, 66% had paid sick leave, 87% had health insurance, 88% had a usual source of care, and 84% were employed full-time.

Table 2.

Bivariable Associations Between Endoscopy Utilization and Key Predictors: National Health Interview Survey 2021 & 2023.

Variable	Category	No endoscopy % (N)	Had endoscopy % (N)	Total % (N)	P-value
Paid sick leave	No	34 (2206)	31 (2825)	32 (5031)	<.001
Paid sick leave	Yes	66 (4321)	69 (6000)	68 (10321)	<.001
Health insurance	No	13 (804)	2 (204)	7 (1008)	<.001
Health insurance	Yes	87 (5709)	98 (8609)	93 (14318)	<.001
Usual source of care	No	12 (810)	3 (260)	7 (1070)	<.001
Usual source of care	Yes	88 (5716)	97 (8561)	93 (14277)	<.001
Employment status	Part-time	16 (1085)	22 (2092)	19 (3177)	<.001
Employment status	Full-time	84 (5442)	78 (6733)	81 (12175)	<.001

Generalized Structural Equation Model (GSEM) Pathways

Table 3 presents the results of the generalized structural equation model (GSEM) examining the pathways linking employment status, paid sick leave, health insurance, usual source of care, and CRC endoscopy utilization. Full-time employment was positively associated with having paid sick leave (OR = 6.57, 95% CI: 5.85, 7.38) and health insurance (OR = 1.30, 95% CI: 1.07, 1.59). Paid sick leave increased the odds of having a usual source of care (OR = 1.57, 95% CI: 1.31, 1.87) and was directly associated with CRC endoscopy utilization (OR = 1.15, 95% CI: 1.03, 1.28). Health insurance was positively associated with both having a usual source of care (OR = 5.32, 95% CI: 4.30, 6.58) and CRC endoscopy utilization (OR = 3.22, 95% CI: 2.58, 4.02). Having a usual source of care was strongly associated with CRC endoscopy utilization (OR = 3.53, 95% CI: 2.89, 4.32). The complete model results are available in Appendix Table A3. As shown in Appendix Table A4, the sensitivity analysis restricted to respondents aged 45-64 years replicated the main findings.

Table 3.

Multivariable Adjusted Odds Ratios for Pathways in the Generalized Structural Equation Model: National Health Interview Survey 2021 & 2023, N = 15,352.

Pathway	OR	95% CI	P-value
Employment status → sick leave	6.57	5.85, 7.38	<.001
Employment status → health insurance	1.30	1.07, 1.59	.01
Sick leave → usual source of care	1.57	1.31, 1.87	<.001
Health insurance → usual source of care	5.32	4.30, 6.58	<.001
Sick leave → endoscopy	1.15	1.03, 1.28	.01
Health insurance → endoscopy	3.22	2.58, 4.02	<.001
Usual source of care → endoscopy	3.53	2.89, 4.32	<.001

Note: GSEM logit model adjusted for age, sex, metropolitan residence, region of residence, marital status, race/ethnicity, education, household poverty, general health, and disability status.

Predicted Marginal Probabilities

Table 4 presents the predicted probabilities of CRC endoscopy by key access-to-care factors, based on marginal effects from the GSEM. The predicted probability of CRC endoscopy was 55.7% (95% CI: 54.7%, 56.8%) among those with paid sick leave compared to 53.0% (95% CI: 51.4%, 54.7%) among those without, reflecting an absolute percentage point difference of 2.7 (95% CI: 0.6, 4.8). The probability of CRC endoscopy was substantially higher among insured individuals (56.2%, 95% CI: 55.4%, 57.1%) compared to uninsured individuals (32.9%, 95% CI: 29.7%, 36.9%), with a difference of 23.3 percentage points (95% CI: 19.1, 27.5). Similarly, the probability of CRC endoscopy was 56.4% (95% CI: 55.6%, 57.2%) among those with a usual source of care, compared to 31.4% (95% CI: 27.8%, 35.0%) among those without, representing a 25.0 percentage point difference (95% CI: 21.3, 28.7).

Table 4.

Predicted Probabilities (With 95% Confidence Intervals) of Colorectal Endoscopy for Sick Leave, Health Insurance, and Usual Source of Care, Based on Marginal Effects From the Generalized Structural Equation Model.

		Sick leave	Health insurance	Usual source of care
Colorectal Endoscopy	No	53.0 (51.4, 54.7)	32.9 (29.7, 36.9)	31.4 (27.8, 35.0)
	Yes	55.7 (54.7, 56.8)	56.2 (55.4, 57.1)	56.4 (55.6, 57.2)
	Difference	2.7 (0.6, 4.8)	23.3 (19.1, 27.5)	25.0 (21.3, 28.7)

Note: Difference represents the absolute percentage point difference in the predicted probability between those with and without the characteristic (Yes – No).

Discussion

This study examined the relationship between paid sick leave and colorectal cancer (CRC) endoscopy screening among employed adults, with particular attention to the mechanisms through which workplace benefits like paid sick leave facilitate CRC screening. Using GSEM, we simultaneously assessed the direct and indirect pathways linking employment status, paid sick leave, healthcare access, and CRC endoscopy screening. Our findings demonstrate that paid sick leave was positively associated with CRC endoscopy screening, both directly and indirectly through increased likelihood of having a usual source of care. Both paid sick leave and health insurance were important, yet distinct, pathways to CRC screening, with usual source of care serving as a critical link connection each to a greater probability of CRC endoscopy.

The results from our GSEM analysis expand upon previous research that has documented associations between paid sick leave and preventive health services utilization.^{12,13,14,15,16} By explicitly modeling the pathways from employment status to paid sick leave, health insurance coverage, usual source of care, and ultimately CRC screening, this study provides new evidence supporting the hypothesis that workplace benefits can influence preventive screening behaviors through multiple mechanisms. One key finding is that paid sick leave was positively associated with having a usual source of care and CRC screening. This is consistent with previous research suggesting that individuals with paid sick leave are more likely to seek routine healthcare and establish ongoing relationships with providers.^12,14,16 This finding is also consistent with prior work that found paid sick leave not only facilitates time off work for medical appointments but also supports the establishment of continuity for one’s health care needs, which facilitates preventive care.^{24,25,26,27,28} Importantly, our results demonstrate that paid sick leave influences CRC screening directly, as well as indirectly through its association with a usual source of care.¹⁸ These findings underscore the value of paid sick leave beyond its immediate benefit of providing time off; it may also contribute to broader healthcare engagement and preventive health-seeking behaviors.

Health insurance coverage was also a critical mediator in the pathway to CRC screening. Individuals with health insurance were significantly more likely to have a usual source of care and to undergo CRC screening, aligning with the well-established literature on the protective role of insurance coverage in accessing preventive services.^3,4,26 The magnitude of the effect of insurance on CRC screening highlights the ongoing importance of coverage expansions under the Affordable Care Act and other policies aimed at reducing financial barriers to care.^31,32,33,34 Similarly, having a usual source of care was strongly associated with CRC screening, consistent with research highlighting its importance in facilitating preventive health behaviors and promoting adherence to screening guidelines.⁷ Importantly, our findings demonstrate that usual source of care served as a key mechanism through which both paid sick leave and health insurance were linked to CRC screening. This suggests that policies aimed at expanding health insurance coverage and strengthening primary care access could work in tandem with paid sick leave policies to promote preventive care utilization. The magnitude of the effects observed underscores the need for comprehensive interventions that address multiple barriers to care, as improving healthcare access at multiple levels may have synergistic effects on screening rates.

Policy Implications

These findings have important policy implications. First, expanding paid sick leave policies could serve as a lever to improve preventive care utilization, particularly for workers who may face time and financial barriers to accessing healthcare. While federal legislation on paid sick leave remains limited, state-level and municipal policies have demonstrated positive effects on preventive health behaviors.¹¹ Future efforts to standardize paid sick leave coverage across the United States could enhance not only workforce protections but also public health outcomes. Second, our results reinforce the need for policies that ensure robust health insurance coverage and promote primary care access. Interventions that integrate paid sick leave benefits with insurance coverage expansions and initiatives to strengthen primary care relationships may be particularly effective in addressing disparities in CRC screening and other preventive services. Finally, the use of GSEM in this study illustrates the utility of pathway-based approaches in health services research. Traditional regression models may overlook the indirect effects through which workplace policies influence health behaviors. Future research should continue to apply structural modeling techniques to better capture the complex interplay between employment, healthcare access, and preventive care.

Limitations and Future Directions

Several limitations should be acknowledged. While our model examines direct and indirect pathways, it is not a formal mediation analysis in the causal inference framework; the estimates reflect associations along the specified pathways, but do not establish causal mediation effects. While GSEM allows for the estimation of pathways, the relationships observed in this study are associative, and reverse causation cannot be ruled out. Although the GSEM approach offers a more comprehensive view of the relationships between workplace benefits and health behaviors, the lack of formal model fit statistics is a known limitation of this method in survey-weighted data.⁴¹ Additionally, unobserved confounding—such as individual differences in health-seeking behavior or risk aversion—may influence both access to employment-related benefits and preventive care utilization. While the GSEM approach allows estimation of direct and indirect associations, these unmeasured factors may bias the observed relationships. The self-reported measures of paid sick leave and CRC screening may be subject to recall or social desirability bias. The study focused on employed adults that meet the current USPSTF screening guidelines, and therefore the study is not generalizable to unemployed populations or younger age groups. Our models do not account for variation in work schedules or workplace flexibility, such as nontraditional hours or remote work, which became more common during the COVID-19 pandemic. These factors may influence the extent to which paid sick leave is needed to access preventive care, particularly if workers can schedule appointments outside of standard working hours. Unfortunately, the NHIS does not include consistent or detailed measures of occupation type or work flexibility to allow for adjustment. We were also unable to distinguish between screening and diagnostic endoscopy procedures. Given that CRC endoscopy use was impacted by the COVID-19 pandemic, some procedures may have been prioritized for diagnostic rather than routine screening purposes.² The NHIS data do not include detailed clinical indicators, which limits our ability to determine the clinical context of each procedure. Finally, we were unable to account for state or local paid sick leave mandates due to the lack of geographic identifiers in the public-use NHIS data. Although most mandates were already in place by 2021, future research using restricted-use data could explore whether variation in local policy environments modifies these associations.

While this study advances understanding of the pathways linking workplace benefits to preventive screening, additional research is needed. Longitudinal studies could better clarify the temporal sequence and causal relationships between paid sick leave, healthcare access, and screening behaviors. Future work should also explore subgroup differences, particularly examining how individuals with paid sick leave but lacking health insurance navigate preventive care. Understanding these nuanced intersections could inform policy interventions aimed at reducing screening disparities. Future research using clinical data sources or more granular employment information could further clarify how job characteristics and care prioritization influence access to preventive services.

Conclusion

Paid sick leave was associated with increased CRC screening, both directly and indirectly through improved access to health care. This study highlights the critical role of workplace benefits in facilitating preventive healthcare utilization. Policies that expand paid sick leave, alongside efforts to strengthen insurance coverage and primary care access, may collectively reduce barriers to CRC screening and improve population health outcomes.

Supplemental Material

Supplemental Material - Examining Employment Status, Paid Sick Leave, and Access to Care in Relation to Colorectal Cancer Screening Among U.S. Workers: A Structural Equation Modeling Approach

Supplemental Material for Examining Employment Status, Paid Sick Leave, and Access to Care in Relation to Colorectal Cancer Screening Among U.S. Workers: A Structural Equation Modeling Approach by Jim P. Stimpson, Sungchul Park, Anna M. Morenz, Tami Gurley, and Fernando A. Wilson in Cancer Control

Footnotes

ORCID iD

Jim P. Stimpson

Ethical Statement

Author Contributions

JPS (Conceptualization, Formal Analysis, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing). SP (Conceptualization, Methodology, Writing – Review & Editing). AMM (Conceptualization, Writing – Review & Editing). TG (Writing – Original Draft + Review & Editing). FAW (Conceptualization, Methodology, Writing – Review & Editing)

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: For this study, JPS and FAW were supported by the American Cancer Society (DBG-23-1155771-01-HOPS).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Supplemental Material

Supplemental material for this article is available online.

Appendix

References

National Cancer Institute . Cancer Trends Progress Report. Bethesda, MD: National Cancer Institute, NIH, DHHS; 2024. https://progressreport.cancer.gov

Star

Bandi

Siegel

, et al. Cancer screening in the United States during the second year of the COVID-19 pandemic. J Clin Oncol. 2023;23:JCO2202170. doi:10.1200/JCO.22.02170

Wilson

Wang

Stimpson

. The role of sick leave in increasing breast cancer screening among female employees in the US. J Cancer Policy. 2014;2(3):89-92. doi:10.1016/j.jcpo.2014.07.003

Wilson

Wang

Stimpson

. Universal paid leave increases influenza vaccinations among employees in the US. Vaccine. 2014;32(21):2441-2445. doi:10.1016/j.vaccine.2014.02.084

Ward

Halpern

Schrag

, et al. Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin. 2008;58:9-31. doi:10.3322/CA.2007.0011

Hammig

Bouza

. Paid sick leave benefits and adherence to recommended screening tests among male labor workers in the United States. J Occup Environ Med. 2019;61(2):102-106. doi:10.1097/JOM.0000000000001481

Blewett

Johnson

Lee

Scal

. When a usual source of care and usual provider matter: adult prevention and screening services. J Gen Intern Med. 2008;23(9):1354-1360. doi:10.1007/s11606-008-0659-0

DeRigne

Stoddard-Dare

Quinn

Collins

. How many paid sick days are enough? J Occup Environ Med. 2018;60(6):481-489. doi:10.1097/JOM.0000000000001300

Slopen

. The impact of paid sick leave mandates on women’s employment and economic security. J Pol Anal Manag. 2024;43(4):1129-1151. doi:10.1002/pam.22582

10.

Heymann

Rho

Schmitt

Earle

. Ensuring a healthy and productive workforce: comparing the generosity of paid sick day and sick leave policies in 22 countries. Int J Health Serv. 2010;40(1):1-22. doi:10.2190/HS.40.1.a

11.

Pomeranz

Silver

Lieff

Pagán

. State paid sick leave and paid sick-leave preemption laws across 50 U.S. States, 2009-2020. Am J Prev Med. 2022;62(5):688-695. doi:10.1016/j.amepre.2021.11.018

12.

Lamsal

Napit

Rosen

Wilson

. Paid sick leave and healthcare utilization in adults: a systematic review and meta-analysis. Am J Prev Med. 2021;60(6):856-865. doi:10.1016/j.amepre.2021.01.009

13.

Glied

. Associations between a New York City paid sick leave mandate and health care utilization among Medicaid beneficiaries in New York City and New York State. JAMA Health Forum. 2021;2(5):e210342. doi:10.1001/jamahealthforum.2021.0342

14.

DeRigne

Stoddard-Dare

Collins

Quinn

. Paid sick leave and preventive health care service use among U.S. working adults. Prev Med. 2017;99:58-62. doi:10.1016/j.ypmed.2017.01.020

15.

Peipins

Soman

Berkowitz

White

. The lack of paid sick leave as a barrier to cancer screening and medical care-seeking: results from the national health interview survey. BMC Public Health. 2012;12:520. doi:10.1186/1471-2458-12-520

16.

Hegland

Berdahl

. High job flexibility and paid sick leave increase health care access and use among US workers. Health Aff. 2022;41(6):873-882. doi:10.1377/hlthaff.2021.01876

17.

Zheng

Fedewa

Islami

, et al. Paid sick leave among working cancer survivors and its associations with use of preventive services in the United States. J Natl Compr Cancer Netw. 2022;20(11):1244.e3-1254.e3. doi:10.6004/jnccn.2022.7058

18.

Callison

Pesko

Phillips

Sosa

. Cancer screening after the adoption of paid-sick-leave mandates. N Engl J Med. 2023;388(9):824-832. doi:10.1056/NEJMsa2209197

19.

Holden

Jonas

Porterfield

Reuland

Harris

. Systematic review: enhancing the use and quality of colorectal cancer screening. Ann Intern Med. 2010;152(10):668-676. doi:10.7326/0003-4819-152-10-201005180-00239

20.

Abdelsattar

Hendren

Wong

. The impact of health insurance on cancer care in disadvantaged communities. Cancer. 2017;123(7):1219-1227. doi:10.1002/cncr.30431

21.

Rahman

Rosenberg

Flores

, et al. A systematic review and meta-analysis of unmet needs for healthcare and long-term care among older people. Health Econ Rev. 2022;12(1):60. doi:10.1186/s13561-022-00398-4

22.

Ginde

Lowe

Wiler

. Health insurance status change and emergency department use among US adults. Arch Intern Med. 2012;172(8):642-647. doi:10.1001/archinternmed.2012.34

23.

Kazibwe

Tran

Kaiser

, et al. The impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries: a systematic review of the evidence. BMC Health Serv Res. 2024;24(1):432. doi:10.1186/s12913-024-10815-5

24.

Villarroel

Cohen

. Health insurance continuity and health care access and utilization, 2014. NCHS Data Brief. 2016;249:1-8.

25.

Zhang

Song

Feng

. Utilization of public health care by people with private health insurance: a systematic review and meta-analysis. BMC Public Health. 2020;20(1):1153. doi:10.1186/s12889-020-08861-9

26.

Wallace

Sommers

. Health insurance effects on preventive care and health: a methodologic review. Am J Prev Med. 2016;50(5 Suppl 1):S27-S33. doi:10.1016/j.amepre.2016.01.003

27.

Freund

Reisinger

LeClair

, et al. Insurance stability and cancer screening behaviors. Health Equity. 2019;3(1):177-182. doi:10.1089/heq.2018.0093

28.

Yabroff

Reeder-Hayes

Zhao

, et al. Health insurance coverage disruptions and cancer care and outcomes: systematic review of published research. J Natl Cancer Inst. 2020;112(7):671-687. doi:10.1093/jnci/djaa048

29.

Stimpson

Pagán

Chen

. Reducing racial and ethnic disparities in colorectal cancer screening is likely to require more than access to care. Health Aff. 2012;31(12):2747-2754. doi:10.1377/hlthaff.2011.1290

30.

Zhao

Han

Nogueira

, et al. Health insurance status and cancer stage at diagnosis and survival in the United States. CA Cancer J Clin. 2022;72(6):542-560. doi:10.3322/caac.21732

31.

Nguyen

Sommers

. Access and quality of care by insurance type for low-income adults before the affordable care Act. Am J Public Health. 2016;106(8):1409-1415. doi:10.2105/AJPH.2016.303156

32.

Wright

Conlin

Allen

Tsui

Carlson

. What does Medicaid expansion mean for cancer screening and prevention? results from a randomized trial on the impacts of acquiring Medicaid coverage. Cancer. 2016;122(5):791-797. doi:10.1002/cncr.29802

33.

Nathan

Bakhsheshian

Ding

Mack

Attenello

. Evaluating Medicaid expansion benefits for patients with cancer: national cancer database analysis and systematic review. J Cancer Policy. 2021;29:100292. doi:10.1016/j.jcpo.2021.100292

34.

Sabik

Adunlin

. The ACA and cancer screening and diagnosis. Cancer J. 2017;23(3):151-162. doi:10.1097/PPO.0000000000000261

35.

Berdahl

Moriya

. Insurance coverage for non-standard workers: experiences of temporary workers, freelancers, and part-time workers in the USA, 2010–2017. J Gen Intern Med. 2021;36:1997-2003. doi:10.1007/s11606-021-06700-0

36.

Andersen

. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1-10. doi:10.2307/2137284

37.

National Center for Health Statistics . National Health Interview Survey. Public-Use Data File and Documentation. https://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm

38.

Blewett

Rivera Drew

King

, et al. IPUMS Health Surveys: National Health Interview Survey, Version 7.4 [dataset]. Minneapolis, MN: IPUMS; 2024. doi:10.18128/D070.V7.4

39.

Colorectal cancer: screening. Published May 18, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening

40.

von Elm

Altman

Egger

, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147(8):573-577. doi:10.7326/0003-4819-147-8-200710160-00010

41.

StataCorp . Stata 18 Structural Equation Modeling Reference Manual. College Station, TX: Stata Press; 2023. https://www.stata.com/manuals/sem.pdf

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.22 MB