Poor Work is Poor Health
Job characteristics are more detrimental to the health of females and older workers than to men or younger workers.
There is a cumulative negative effect of performing a physically demanding or environmentally hazardous job on worker health, but the effects vary substantially across age, race, and education groups. Individuals who work in jobs with the worst conditions experience declines in their health. Job characteristics are more detrimental to the health of females and older workers than to men or younger workers, and the adverse health effects increase with the length of exposure to job conditions, according to co-authors Jason Fletcher, Jody Sindelar, and Shintaro Yamaguchi in Cumulative Effects of Job Characteristics on Health (NBER Working Paper No. 15121).
Among both men and women, non-white workers have worse job conditions, lower incomes, and work fewer hours than white workers. Men with more than a high school diploma work in jobs with substantially better working conditions, while women without high school diplomas experience fewer physical demands but harsher environmental conditions than their better-educated counterparts. Older workers in general encounter less strenuous physical demands and less harsh environmental conditions than younger workers.
This research suggests that white working males generally report better health than other groups of workers, although their self-reported health status decreases with age. For non-white and older males, physical demands on the job are associated with poorer health. For non-white men, a single standard deviation increase in a jobs cumulative physical demands over a five year period will have an impact similar to two fewer years of schooling or four more years of aging. For women, a single standard deviation increase in a jobs physical demands over a five year period is similar in impact to a reduction in schooling of one half year, or aging by three years.
When the researchers disaggregate their sample by race, they find that that the adverse effect of environmental conditions is particularly evident for non-white women. For white women, in contrast, physical demands have a more negative effect on health than changes in environmental conditions. For women, unlike men, cumulative weekly work hours are negatively associated with health.
The sample used here takes job characteristics from the Dictionary of Occupational Titles and merges them with data from the Panel Study of Income Dynamics. The authors control for childhood and lagged health measures and a set of pre-determined characteristics in order to address concerns that the jobs individuals choose may in part reflect their underlying health characteristics.
Too much work has adverse health effects.
Conversely, flexible working hours and schedules that employees have more control over have been shown to have positive effects on health and well-being.
Despite this, many of us still have a poor work-life balance, and we tend to sleep less. In 1910, a "normal" sleeping schedule was considered an average of 9 hours per night, while today, this has fallen to around 7 hours.
Damaging effects include a higher risk of stroke, coronary heart disease, and mental disorders, such as anxiety and depression.
Some studies have shown that individuals who work 55 hours or more per week have a 1.3 times higher risk of stroke than those working standard hours.
Sleep deprivation has also been linked to cardiovascular disease and an increased risk of death, causing myocardial infarction and stroke.
Long working hours have also been associated with a higher risk of anxiety and depression. A 5-year study found the risk of developing depression in healthy individuals is 1.66 times higher in employees working more than 55 hours a week. The risk of anxiety was 1.74 times higher.
Despite the known adverse effects of sleep deprivation and prolonged working schedules, no study has examined the combined effect of these two factors on health-related quality of life (HRQoL).
How work-life balance in midlife affects health in later life
Researchers at The University of Jyväskylä in Finland wanted to determine the effects of midlife sleep deprivation and long working hours on physical functioning and overall HRQoL in later life.The study looked specifically at the relationship between working hours and sleep duration.
Researchers monitored the HRQoL of 1,527 businessmen born between 1919-1934. They gathered data in 1974 and then again 26 years later.
The results of the study were published in Age and Ageing, the scientific journal of The British Geriatrics Society.
The study used the RAND-36 score to assess the HRQoL of white businessmen who worked more than 50 hours per week and slept less than 47 hours per week in midlife.
The RAND score is a simple, general survey tool comprising of 36 questions that medical care professionals and researchers use to evaluate care outcomes in adult patients. It relies on the respondents' self-reporting.
The study surveyed working hours, sleep duration, and self-reported health issues.
Considering normal work hours as 50 hours a week and normal sleep hours as 47 hours a week, researchers combined work and sleep patterns to come up with four categories: normal work and normal sleep, long work and normal sleep, normal work and short sleep, and long work and short sleep.
In older age, participants scored lower on the RAND scale for physical functioning, vitality, and general health, compared with those who had normal work and sleep patterns.
Businessmen with long work hours but normal sleep patterns still had lower scores for physical functioning in older age. Even taking into account midlife smoking, and other unrelated health issues, the negative effect on physical functioning remained significant.
Findings likely to apply to wider populations
The study was motivated by the fact that modern-day businessmen are under a particular amount of pressure, with over 6 million people in Britain alone currently working more than 45 hours a week. However, the results of the study are likely to apply to other segments of the population.A 2014 Gallup report notes that Americans work an average of 47 hours per week, which is almost a full workday more than the standard 9-5 schedule.
In fact, almost 4 in 10 Americans said they work at least 50 hours on a weekly basis.
The results of the study indicate that although the effects of a poor work-life balance may not be felt immediately, the consequences extend into older age.
Cutting down on work hours and getting plenty of rest as early in life as possible would mitigate adverse health effects in older age.
Read how working long hours and heavy lifting may impact women's fertility.
In
this review, we touch on a broad array of ways that work is linked to
health and health disparities for individuals and societies. First
focusing on the health of individuals, we discuss the health differences
between those who do and do not work for pay, and review key positive
and negative exposures that can generate health disparities among the
employed. These include both psychosocial factors like the benefits of a
high status job or the burden of perceived job insecurity, as well as
physical exposures to dangerous working conditions like asbestos or
rotating shift work. We also provide a discussion of the ways
differential exposure to these aspects of work contributes to social
disparities in health within and across generations. Analytic
complexities in assessing the link between work and health for
individuals, such as health selection, are also discussed. We then touch
on several contextual level associations between work and the health of
populations, discussing the importance of the occupational structure in
a given society, the policy environment that prevails there, and the
oscillations of the macroeconomy for generating societal disparities in
health. We close with a discussion of four areas and associated
recommendations that draw on this corpus of knowledge but would push the
research on work, health and inequality toward even greater scholarly
and policy relevance.
Introduction
Work
and working conditions are essential contributors to social inequality
in health within and across generations, though they have received less
attention from health disparities researchers than other aspects of
socioeconomic position, such as education or income. In this review, we
touch on a broad array of ways that work is linked to health for
individuals and societies. Beyond the material and status rewards that
come with paid work in a particular occupation, work also shapes
individuals' exposure to a wide array of physical, environmental and
psychosocial factors that can influence health. At the population level,
the availability and arrangements of work and occupations across
societies determine the opportunities for livelihoods and exposure to
risk and contribute to health disparities within and between societies.
We
review evidence mainly from studies of work done in exchange for wages
or salary by adults in post-industrial economies. This means that we
give only minimal attention to the conditions faced by workers across
the world whose labor is informal, inconsistent, or unpaid. Other
reviews that incorporate even broader issues faced across the world and
especially in less wealthy societies, such as bonded or child labor (for
example, Muntaner et al., 2010),
offer important additions to what we cover here. We consider a wide
range of measures of health, reflecting the many physiological and
psychological ways in which work can “get under the skin,” but remind
readers to consider how diverse exposures and aspects of work operate
through a range of mechanisms to influence specific health outcomes. We
close with a discussion of four areas and associated recommendations
that draw on this corpus of knowledge but would push the research on
work, health and inequality toward even greater scholarly and policy
relevance.
Work, Inequality & Health at the Individual Level
Scholars
of stratification and inequality have long recognized the centrality of
employment and working conditions as reflections and determinants of
individuals' life chances. Employment is linked to health in positive
ways, both as a predominant mode of earning income and other material
benefits, and as a source of social integration, prestige and meaning.
However, employment also exposes workers to potentially health-harming
physical and psychosocial stressors. Below we discuss these positive and
negative pathways, illustrating with empirical examples, and then
discussing how they contribute to health disparities at a given point in
time and across the life course.
Health-Enhancing Aspects of Work
Some
of the most obvious evidence for the link between employment and health
comes from studies that compare the health of those who work for pay
and those who do not, or assess consequences of job loss and
unemployment. A large body of research has shown that those who do not
work for pay or are unemployed are less healthy than those in the paid
labor force, based on their risk of mortality, self-rated health, and
mental health (Krueger & Burgard, 2011; Rogers, Hummer, & Nam, 2000; Ross & Mirowsky, 1995).
However, it is important to remember that there is variation among
individuals who are not employed for pay. Those who have another source
of material resources and do not work by choice, whether they are
raising a family, attending school, or pursuing other activities, may
not have worse health than those who work for pay (Pavalko, Gong, & Long, 2007).
Employment
may enhance the health of workers through a series of mechanisms.
First, employment status provides a critical link between educational
attainment and earned income for the majority of adults (Mirowsky & Ross, 2003; Schoeni, House, Kaplan, & Pollack, 2008).
Earnings from employment are the major source of financial resources
necessary to purchase health-enhancing goods and services for most
workers and their families. Evidence for the importance of these
resources has been shown in studies that link unemployment to economic
strain that can impact mental health as well as catalyzing an array of
secondary stressors (Price, Choi, & Vinokur, 2002; Price, Friedland, Choi, & Caplan, 1998).
In the United States, other essential material resources are also
directly tied to employers, including pensions, health insurance
coverage, and even eligibility for unemployment insurance.
While
material benefits are obviously critical when considering its relevance
for health, work is far more than a route to a paycheck. Individuals
working in higher status occupations have substantially better health
even after adjusting for their higher education and better pay, a
finding famously demonstrated in the Whitehall study of British civil
servants, who all have access to health care and decent working
conditions (Marmot et al., 1998). U.S. workers with higher occupational status have a lower risk of mortality (Rogers et al., 2000), and other studies have shown a reduced risk of hypertension (Colhoun, Hemingway, & Poulter, 1998) and heart attacks (Möller, Theorell, de Faire, Ahlbom, & Hallqvist, 2005)
among workers of higher status. While the association seems clear,
mechanisms underlying the protective aspects of occupational status have
generated debate. Marmot (2004)
argues that lower status workers compare themselves unfavorably to
their higher status counterparts, generating harmful stress and
potentially leading to risky health behaviors. However, other
researchers have argued that extant studies focused on occupational
status are actually capturing unmeasured physical and psychosocial job
characteristics, other aspects of socioeconomic status, or health
behaviors that are associated with occupational status and health (Erikson, 2006; Kaplan & Keil, 1993; Warren, Hoonakker, Carayon, & Brand, 2004).
Beyond
the potential benefits of high status, other aspects of good jobs could
enhance health. For example, access to creative work, generally more
available to highly educated, higher status workers, has been linked to
better health among U.S. adults even net of these other characteristics (Mirowsky & Ross, 2007).
Creative self-expression at work could improve psychological well-being
and cognitive function, and could reduce stress that can lead to
deregulation of the hypothalamus-pituitary-adrenal (HPA) axis (Mirowsky & Ross, 2007),
and all of these positive benefits could also improve chances for a
positive career trajectory if they enhance work performance, creating a
sustaining positive loop.
Health-Harming Exposures at Work
Despite its potential to enhance the quality of life via earnings and other rewards, a long line of social scientists from Marx (1992)
forward have recognized that many aspects of modern labor are
alienating, exploitive, and even dangerous. Considerable research in the
social and health sciences since then has focused on negative exposures
in the workplace that can harm health. Researchers have examined
physical and environmental risk factors, such as those associated with a
specific occupation, and increasingly have also addressed more
commonly-experienced psychosocial stressors associated with work or with
balancing paid work with other adult responsibilities. These types of
exposures at work “get under the skin” to affect health in a variety of
ways, ranging from inhalation of dust or physical contact with toxins to
changes in levels of hormones in the body in response to stress, and
subsequent HPA axis dysregulation and somatic disease and
psychopathology.
Chemical and biological hazards and
other physical dangers to workers have been the focus of a large body of
research. For example, exposure to crystalline silica for workers in
mining and those who do stone work or sandblasting increases the risk of
silicosis-related mortality (Bang, Attfield, Wood, & Syamlal, 2008) and exposure to asbestos increases the risk of lung cancer (Yano, Wang, Wang, Wang, & Lan, 2001).
Other exposures including noise, heat, vibration, and other chemical
and physical hazards have also been the subject of occupational health
research (Donoghue, 2004). Workplace and task arrangements associated with repetitive work have been linked to repetitive strain-related injuries (Silverstein, Viikari-Juntura, & Kalat, 2002),
and are even more broadly relevant because they can affect workers in
production as well as in service and professional occupations. Another
aspect of work that has received attention is the timing and regularity
of working hours and schedules. The rise in nonstandard work hours and
the shift to a 24/7 economy have been linked to shift work sleep
disorder and other physical health problems including coronary heart
disease and peptic ulcer (Kawachi et al., 1995; Knutsson, 2003; Presser, 2005).
Because
of changes in the occupational structure of post-industrial economies
and the implementation of occupational health and safety regulations,
many workers in wealthy societies escape the burden of most physical
hazards at work, though repetitive strain and nonstandard work hours are
broadly and increasingly relevant. However, contemporary workers in
post-industrial and other economies face a variety of psychosocial
stressors on the job. Examples of commonly-studied psychosocial
stressors include job strain, job insecurity, and negative spillovers
from work to other domains. Job strain is the combined experience of too
little task control and high levels of demand with little workplace
social support (Karasek & Theorell, 1990), and has been associated with a range of health problems including psychiatric morbidity (Marmot, Bosma, Hemingway, Brunner, & Stansfeld, 1997; Stansfeld & Candy, 2006), musculoskeletal symptoms (Bongers, Ijmker, van den Heuvel, & Blatter, 2006), insomnia (Nomura, Nakao, Takeuchi, & Yano, In Press), and coronary heart disease (Bosma, Peter, Siegrist, & Marmot, 1998; Kivimaki et al., 2002).
Some, but not all, of these associations have been validated using
longitudinal data and objective measures of demands or control (DeSanto Iennaco et al., 2010).
Other studies have used more objective measures of physiological
change; job strain has been linked to certain neuroendocrine and
cardiovascular reactions that over a prolonged period of time may lead
to cardiovascular complications (Taylor, Repetti, & Seeman, 1997).
Other research shows that women in jobs with high job stress or low
support from supervisors exhibit higher levels of fibrinogen, which is
also linked to increased risk for cardiovascular disease (Davis, Matthews, Meilahn, & Kiss, 1995).
In
addition to these psychosocial stressors, insecure or precarious
employment is an important component of risk in many economies as firms
pursue leaner workforces and engage in outsourcing to less expensive
labor sources. Workers who believe that they may lose their job in the
near future have been shown to have worse mental and physical health (Sverke, Hellgren, & Näswall, 2002), even when adjustment is made for actual job losses or unemployment (Burgard, Brand, & House, 2009; Burgard, Kalousova, & Seefeldt, in press).
Moreover, those undergoing firm restructuring or layoffs, and thus
exposed to objective employment uncertainty, have also shown poorer
biomedical indicators such as increases in blood pressure (Ferrie, Shipley, Stansfeld, & Marmot, 2002) and worse general health attributable at least partly to perceived job insecurity (Geuskens, Koppes, van den Bossche, & Joling, 2012).
Finally,
research on the links between work and health has begun to extend
beyond the workplace and the individual worker. As work and family
conditions have changed and diversified in the latter half of the 20th
century, there has been increasing interest in understanding how the
intersection of responsibilities in both of these domains influences the
health of workers and their families (Bianchi & Milkie, 2010).“Work-family
conflict” or “negative work-family spillover” is a type of inter-role
conflict that arises when responsibilities in one domain interfere with
the ability to fulfill responsibilities in the other domain (Greenhaus & Beutell, 1985).
Most extant research has focused on negative spillover's association
with mental health; cross-sectional studies have shown a positive
association between negative work-family spillover and depressive
symptoms (Allen, Herst, Bruck, & Sutton, 2000; Frone, Russell, & Barnes, 1996; Grzywacz & Bass, 2003), psychological stress and distress (Kelloway, Gottlieb, & Barham, 1999) and anxiety disorders (Frone, 2000).
Studies have also found that increased exposure to work-family
spillover is associated with poorer self-rated health, hypertension,
obesity, and musculoskeletal problems (Frone et al., 1996; Grzywacz, 2000; Hammig, Knecht, Laubli, & Bauer, 2011; Winter, Roos, Rahkonen, Martikainen, & Lahelma, 2006).
Aside
from, or as a result of the stress associated with these exposures,
psychosocial stressors may influence health via increases in risky
behaviors. For example, work-family negative spillover has been linked
to greater use of tobacco (Frone, Barnes, & Farrell, 1994) and alcohol (Allen et al., 2000; Frone et al., 1996; Frone, Russell, & Cooper, 1997; Grzywacz & Bass, 2003), and lower levels of physical activity (Allen & Armstrong, 2005; Bellavia & Frone, 2005; Grzywacz & Marks, 2001).
High levels of spillover may also decrease consumption of healthy foods
or increase the intake of fatty foods, because struggles to balance
work and family spheres may reduce time available to prepare healthy
meals (Allen & Armstrong, 2005; Devine, Connors, Sobal, & Bisogni, 2003).
Evidence from intervention studies shows that flexible work policies
that give employees control of their schedules can lessen work-family
conflict and aid in promoting better health behaviors, such as getting
more sleep and exercising regularly (Moen, Kelly, Tranby, & Huang, 2011).
While
the evidence for links with poorer health continues to accumulate,
measurement is a challenge in research on psychosocial stressors because
at issue is the worker's appraisal of the situation, rather than the
presence of an objectively measureable risk factor like low occupational
status or asbestos exposure. In the case of psychosocial exposure,
appraisal is what links a worker's environment to their physiological
response, making researchers dependent on worker's own reports. However,
many studies have relied on self-reported measures of these working
conditions and of health, raising concerns about unmeasured
characteristics that could account for an apparent link between exposure
and outcome. Researchers have addressed this challenge with objective
measurement of health, or by assigning individuals an average value of
the psychosocial exposure for workers in their occupation/industry
category (e.g., Amick et al., 2002).
One recent study found some evidence that current job strain was
associated with measures of cortisol, a biomarker of HPA axis activity
marking stress, even though recent negative life events and childhood
abuse were not associated (Holleman, Vreeburg, Dekker, & Penninx, 2012).
A study that compared objective measures of job demands and control
obtained from expert raters with respondents' own ratings of these
measures found that both objective and self-reported demands were
associated with worker depression, while only self-reported control
showed an association (Rau, Morling, & Rosler, 2010).
However, there is room for considerably more research to help us
understand the strengths and limitations of varying measurement
strategies. Moreover, it is important to develop reliable ways to
measure emerging hazards at work, such as the exposures relevant for
those who are telecommuting, or for those who are engaged even outside
of work hours with social media or electronic communications for work
reasons. Measures of demands in the job strain model, for example, were
developed to apply to industrial settings, but may not be the most
salient factors in service sector jobs, and should be accompanied by a
broader array of measures of working conditions (Netterstrøm et al., 2008).
Causal, Reciprocal and Spurious Relationships between Work and Health
To
this point we have implied that exposures and experiences associated
with work impact subsequent health, the perspective often labeled
“health causation.” However, another major perspective in the social
sciences focuses on the reverse relationship: health as a personal
resource that determines paid work engagement and quality, or “health
selection.” Individuals with existing health problems may be more likely
to be hired for a job with poor working conditions (Korpi, 2001; Schur, 2003),
and their health outcomes could subsequently be worse because of
earlier health deficits, not due to exposure to any particular working
conditions. Moreover, employment status and working conditions can
change multiple times over the career, and establishing temporal order
between these exposures and changes in health as workers age is often
difficult given the available data. A related concern for researchers is
that unmeasured individual characteristics, such as difficulty delaying
gratification, could lead to both poor employment histories as well as
poor health, such that working conditions are not a direct cause of
health (J. P. Smith, 1999).
Another frequently unmeasured characteristic, health in early life,
could also predict both earnings from paid employment and health,
creating a spurious relationship between these adult characteristics (Haas, 2006; Hayward & Gorman, 2004).
To
address these important concerns, some researchers have adjusted for
early life health or other typically unmeasured characteristics, or have
used longitudinal data and change models to eliminate the effect of
stable individual characteristics that are difficult to measure. Others
have examined the health consequences of relatively exogenous shocks to
employment. For example, studies have linked job displacement to
heightened mortality risk even among those who lost jobs in mass layoffs
and not because of health problems or other individual characteristics (Strully, 2009; Sullivan & von Wachter, 2009).
Many researchers have begun to accept a model of reciprocal causation
between work and other aspects of socioeconomic position like earnings
on the one hand, and health on the other (Mulatu & Schooler, 2002).
The causal directionality of the association might vary over the life
course and across different health conditions, so it remains important
to consider the contributions of health causation, health selection, and
potentially spurious associations when assessing the links between work
and health.
Unequal Work, Unequal Health? Inequality within Careers and Across Generations
The
likelihood of being employed on the terms one prefers, of holding a
high status job, of avoiding a host of negative exposures at work, and
of having the opportunity for a positive career trajectory are
differentially distributed across social groups, making work an
important domain that can amplify health disparities through midlife (Lipscomb, Loomis, McDonald, Argue, & Wing, 2006).
Key social identities in many wealthy economies that influence access
to these aspects of healthy work include educational attainment,
racial/ethnic group of membership, immigrant status, and gender. For
example, because of the critical material benefits tied to employment,
differences in the likelihood of experiencing job loss or unemployment
across social groups plays an important role in explaining social
disparities in health that are tied to income. Less-educated and
minority employees are often at greater risk of job losses and trouble
finding reemployment (Kletzer, 1998; Moore, 2010), though job losses and job insecurity are increasingly affecting higher status workers in places like the United States (Fullerton & Wallace, 2007).
Even
among those who can obtain stable employment, there is unequal access
to high quality work offering adequate wages and fringe benefits, hours,
and other rewards (Kalleberg, 2011; Kalleberg, Reskin, & Hudson, 2000).
In response to major macroeconomic and policy changes, since the
mid-1970s many firms in wealthy economies have pursued more flexibility
in their employment relationships, increasing the divide between core
workers and a more peripheral group of workers who involuntarily or by
choice take nonstandard contracts. Standard workers have full-time
contracts with a fixed schedule and expectation of continued employment,
while nonstandard work encompasses an array of alternatives from
on-call workers to temporary help agency employment to independent
contracting. Some scholars also include part-time work in otherwise
“conventional” jobs and self-employment as nonstandard work (Kalleberg et al., 2000).
Some nonstandard workers, particularly those working part-time or for
temporary help agencies, earn lower wages, receive fewer fringe
benefits, and face worse working conditions, including more job
insecurity (Kalleberg, 2011).
While there has been relatively little assessment of its association
with health, and associations seem to vary depending on the
voluntariness and specific conditions of the arrangements, nonstandard
working arrangements have been linked to greater psychological distress
and in some studies, poorer physical health (Dooley & Prause, 2004; Virtanen et al., 2005). Women are heavily overrepresented in nonstandard work, as are minorities and less-educated individuals (Nollen, 1996), suggesting its potential relevance for understanding the contribution of paid work to health disparities.
Beyond
contractual differences, considerable evidence shows that less
advantaged workers are more likely to be exposed to physically dangerous
work (Lipscomb et al., 2006).
Some studies also suggest that workers from lower status groups have
more exposure to psychosocial stressors, as they are more likely to
report low control or high strain at work (Brand, Warren, Carayon, & Hoonakker, 2007; Stradzins, D'Souza, Lim, Broom, & Rodgers, 2004).
By contrast, highly-educated individuals can achieve both autonomy and
high levels of creativity on the job, both of which are associated with
better health (Mirowsky & Ross, 2007).
Nonetheless, more highly-educated workers could be at relatively
greater risk of other kinds of psychosocial strain. One recently
emerging argument, the “stress of higher status” hypothesis, suggests
that some working conditions previously seen as resources for workers,
such as autonomy or authority, may exacerbate the permeability between
work and family domains. Increased permeability may lead to higher
levels of spillover or interference between work and family domains,
leading to higher levels of strain and negative spillover, and
potentially worse health outcomes (Glavin, Schieman, & Reid, 2011; Schieman, Milkie, & Glavin, 2009).
Gender
determines access to healthy work in ways that sometimes differ from or
modify the influences of other social identities. Despite the rapid
increase in the proportion of U.S. women involved in paid labor over the
last half a decade, and in particular the participation of mothers in
the paid labor force (Bianchi & Milkie, 2010), women still spend fewer of their adult years in full-time employment in many wealthy economies (DiNatale & Boraas, 2002; S. Jacobs, 1999).
This holds even net of their socioeconomic, racial, immigrant and other
identities because of the differential socialization of men and women
and the traditional division of labor around paid market and unpaid
household work. Furthermore, women are also differentially sorted into
jobs within the occupational structure (Wooten, 1997),
leading to differential exposures at work and varying total exposure
over the career. On the one hand, women are disadvantaged at work in
many ways, earning less than men and occupying fewer of the highest
level positions in many organizations and occupations (Blau & Kahn, 1994; J. Jacobs & Gerson, 2005), and more commonly holding nonstandard employment contracts (Kalleberg et al., 2000).
Moreover, women also often remain the primary caregivers in families,
and thus take on a “second shift” of labor that may influence health (Hochschild & Machung, 2012).
On the other hand, women are less likely than men to hold many of the
most physically dangerous jobs, and spend less total time at work, which
may lend a health advantage for women (Leeth & Ruser, 2006; Oh & Shin, 2003).
As the gendered composition of the occupational structure and the
gendered norms about balancing work and parenting continue to change,
gender inequalities generated by differential exposure to working
conditions will also evolve.
Beyond differential exposure
to harmful working conditions, some scholars have found that women
appear to be less affected by problems at work than men (MacIntyre & Hunt, 1997),
and have speculated that their identities are not as strongly tied to
their employment roles as men's. For example, studies have shown that
the relationship between labor force participation and mortality is
stronger for men than for women (Krueger & Burgard, 2011).
However, others have found that women were more likely than men to
encounter negative mental health consequences as the result of the guilt
they feel when encountering work spilling over into family (Glavin et al., 2011), so the modifying effect of gender could depend on the work exposure and health outcome in question.
While
they are important in the short run, all of these differences in access
to healthy work can compound over adulthood, with implications for
persistence or change in health disparities over the career.
Opportunities for occupational trajectories offering stable job
histories, improving wage and benefit profiles, and increases in status,
safe and pleasant working conditions are determined in early adulthood
on the basis of credentials, abilities, early workplace performance, and
employer discrimination, and trajectories diverge throughout adulthood.
Theories of cumulative advantage and disadvantage elaborate how initial
disadvantages can render individuals ineligible for opportunities for
advancement (Ferraro & Kelley-Moore, 2003),
and how negative turning points, such as an involuntary job loss, can
block further progress by “scarring” workers in terms of their wage
trajectories and opportunities for reemployment in similar jobs (Gangl, 2006).
For example, job losses and unemployment spells are turning points that
may create differences in material resources in the short and longer
term that are important for health. Immediate consequences include the
need to spend down any assets, which already tend to be lower for less
advantaged workers. Interruptions in one's work history can also lead to
foregone seniority and advantages within a given firm, the loss of
pension and health care benefits coverage, and flatter wage trajectories
that compound social disadvantage over the career (Brand, 2006; Jacobson, LaLonde, & Sullivan, 1993).
Unfavorable
career trajectories have been shown to predict health change; one study
showed a higher mortality risk for men who moved through a series of
unrelated jobs and those who were successful in promotions early but not
later in their careers, compared to those with more consistently
successful career trajectories (Pavalko, Elder Jr., & Clipp, 1993).
Other studies have shown that downward mobility in occupational social
class between age 25 and age 50 was associated with poorer self-reported
mental health in English men (Tiffin, Pearce, & Parker, 2005),
and that among university-educated Canadians, those working in
occupations for which they were overqualified had a significant risk of
decline in their self-rated health over a four year period (P. Smith & Frank, 2005).
Total exposure to negative conditions by those who are unable to
advance into jobs with better working conditions over their careers
could also have substantial effects on health; studies have shown links
between persistent psychosocial stressor exposure at work and mental
health (Godin, Kittel, Coppieters, & Siegrist, 2005) and mortality (Amick et al., 2002).
Finally, trajectories of workplace exposures can condition the terms of
retirement; less-advantaged workers who have borne the accumulation of
unhealthy exposures are more likely to retire because they become
disabled and unable to work (Hayward, Grady, Hardy, & Sommers, 1989), even though they may be most in need of the earnings late in life because they have not had access to ample pension benefits.
The
influence of working conditions on health may extend beyond the
individual worker to his or her children. Intergenerational transmission
of health could occur if the physical or psychosocial experiences of
parents at work are transmitted to their children, or if parent's jobs
do not offer sufficient pay or benefits to support their children's
health. There is considerable evidence that mothers' physical, chemical
and psychosocial exposures at work can influence child development in
utero, increasing the risk of problems that could influence childhood
and later life health (Wigle, 2008).
For example, working physically demanding jobs while pregnant,
including standing for long hours during the day and lifting heavy
objects, or working nights or on shift work schedules have all been
linked to preterm births and low birth weight infants (Bonzini, Coggon, & Palmer, 2007; Cerón-Mireles, Harlow, & Sánchez-Carrillo, 1996; Mozurkewich, Luke, Avni, & Wolf, 2000; Saurel-Cubizolles et al., 2004).
Additionally, women who are underemployed or involuntarily work
part-time may also be at greater risk of delivering low birth weight
infants (Dooley & Prause, 2005).
Perhaps an even more obvious mechanism linking work to health in
subsequent generations is material resources. Parents whose jobs offer
low income and do not offer access to high quality health insurance
coverage may be unable to provide an array of health-relevant resources
their children need for optimal health.
Contextual Influences on Work, Health & Inequality
While
much of the research on work and health is conducted at the individual
level, other research examines the contextual influences that affect the
health of individuals and differentiate the health of populations.
Here, we discuss several key macro-level factors, including the
occupational structure prevailing in a given society, which determines
the availability and mix of good and bad jobs, and which has been
changing recently in response to globalization in ways that changes the
risks and rewards available to workers across societies. We also touch
on the ways that policy environments differentiate the consequences of
particular working conditions across societies and over time, and also
explore how the unemployment rate is associated with the health of the
population in ways that may differ from the association between an
individual's unemployment and his or her health.
Occupational Structures & Health
A
society's occupational structure determines which jobs are available to
workers, and thus determines the distribution of positive and negative
exposures for the workforce. Some societies are characterized by
post-industrial economies and are dominated by professional/managerial
and service occupations that put workers at risk for psychosocial
stressors but avoid most physical or environmental dangers. However, the
majority of workers across the world live in less-wealthy societies
where agricultural occupations prevail and production occupations are
increasing. These workers face some of the same hazards at work as those
in wealthier economies, such as job strain or job insecurity, but also
bear additional risks associated with their different occupational mix,
home production, weaker regulatory environments, and other factors (Rosenstock, Cullen, & Fingerhut, 2005).
Many households in less-wealthy societies combine subsistence
agriculture with various forms of home-based production or informal work
on the street, none of which is subject to occupational health and
safety (OHS) regulation. For example, work-related exposures to
agricultural pesticides or to lead used to make batteries in home
workshops occur at home and can affect the entire family's health (Rosenstock et al., 2005).
Moreover, more of the household members in less wealthy societies may
be engaged in work for pay, including children, who are often exposed to
dangerous work like charcoal production in Brazil, fireworks
manufacturing in Guatemala and Columbia, or gold mining in Indonesia and
Zimbabwe (Bose-O'Reilly et al., 2008; Giuffrida, Iunes, & Savedoff, 2002; Salazar, 1998).
Because of these large variations in occupational structures,
regulatory environments and the way households spread work across family
members, as well as in related differences in average household income
distributions and levels of public health infrastructure, health
profiles are likely to vary substantially across societies, generating
global health disparities.
Occupational structures in
different societies are increasingly connected with the emergence of
multinational corporations, as work that can be outsourced is sent to
wherever the costs of labor and production are most affordable. This has
ramifications for the availability and quality of jobs in both sending
and receiving societies, and thus has implications for health
disparities within and across them as well. As societies transition to
post-industrial modes of production, manufacturing and production jobs
are often “exported” to societies with weaker OHS regulations and less
expensive, less organized labor forces. While these new occupational
opportunities can provide the potential for growth in household incomes
and could have positive health benefits for some workers and their
families, they also bring stressful and unsafe working conditions (Heymann, 2003).
Globalization
of labor also means that average working conditions in wealthier
nations could potentially be worse for workers than before because of
polarization of the labor force and increasingly precarious employment
on the bottom. Job creation in wealthier economies like the U.S. is
occurring mainly in high-wage and low-wage service work (Autor, Katz, & Kearney, 2008; Blank, 1995),
such that more of the workforce have access only to bad jobs.
Importantly, the divide in working conditions is widening, with rising
inequality in wages and non-wage benefits across the labor force in the
United States, and a decline in opportunities for career advancement for
lower wage workers (Blank, 1995; Farber, 1997). These changes are also weakening workers' sense of job security in some wealthy economies (Geishecker, 2008), even among workers in otherwise good and historically more secure jobs.
Policy and Macroeconomic Environments & Health
As
we have already begun to discuss above, societies vary in their level
of economic development and stage of production as well as in their
regulatory environments, influencing the jobs that are available and the
protections for workers who hold those jobs. Additionally, the power of
workers to demand healthy and well-paid work varies across societies
depending on the success of worker organization in labor unions.
Further, the consequences of employment problems depend on the broader
“safety net.” In addition to these context-specific conditions, the
oscillations of the macroeconomic environment influence policies and
other conditions across many societies, and may have their own direct
effects on health. Each of these factors will influence the health of
the population overall and may modify the influence of employment on
health for individual workers.
The globalization of
production and the related weakening of labor unions in some wealthy
economies has increased the insecurity and reduced the rewards of
employment for many workers in these societies (Price & Burgard, 2008).
These changes have decreased workers' ability to obtain good wage and
benefit packages, particularly in manufacturing, because employers can
threaten to move jobs elsewhere if their terms are not met. Decisions to
deregulate markets and make other policy changes favoring business
interests at the expense of worker protections have increased employers'
ability to pursue nonstandard contracts and avoid health and safety
regulations, worsening workers' relative power and potentially their
health (Kalleberg, 2011).
Other
aspects of the policy environment in a given society also contribute to
global variation in worker and population health. These include the
social safety net for individuals who are unsuccessful on the labor
market, which could include unemployment insurance programs, worker
retraining programs, and other public assistance programs to help those
whose earnings have been interrupted or those whose skills have been
rendered obsolete by changes in the occupational structure. For example,
the health consequences of job losses and unemployment spells in a
given society will be modified by the availability of these kinds of
social benefits. Other social programs, such income support for those
with disabilities or those with young children, may also help to
equalize the health of those engaged in paid work and those who are
unable to work because of health problems or other obligations. The
means by which individuals obtain their health care and retirement
benefits, specifically whether these are tied to particular employers,
also could modify the link between work and health.
A
final contextual factor that has increased in salience due to the
late-2000s global recession is the level of macroeconomic growth or
contraction and the subsequent unemployment rate that these conditions
generate. At the individual level, there is considerable evidence for an
association between unemployment and poor health as discussed above,
but economists have shown for a variety of societies that when the
unemployment rate rises, average levels of population health improve on
some dimensions. While historically, economic growth has led to
improvements in population health (Preston, 1976),
adult mortality from causes including traffic accidents, coronary heart
disease, and cirrhosis in many wealthy societies now increases when the
economy improves and decreases during downturns (Granados, 2008; Ruhm, 2007).
Several mechanisms have been proposed, including less overtime work and
commuting when the economy slows, reducing both traffic and air
pollution, the reduction of some unhealthy consumption patterns and the
increase of some health promoting treatments or improvement in health
care (Ruhm, 2007; Stevens, Miller, Page, & Filipski, 2011).
While there may be a silver lining to recessions, not all population
health indicators improve when the unemployment rate goes up. Suicide
mortality and deaths from diabetes and hypertension rise in recessions (Granados, 2008),
and other research has shown that higher state-level unemployment
increases the likelihood of regional and widespread influenza activity (Cornwell, 2012).
Transforming the Study of Work & Health
While
researchers from across the fields of medicine, epidemiology,
psychology and social demography have demonstrated important links
between work and health at the individual and aggregate levels, we can
continue to improve the evidentiary base for researchers and policy and
intervention designers. To close, we detail four suggestions that build
on these extant approaches and findings.
Improving Measurement of Working Conditions
Measurement
of negative and positive working conditions could be expanded in
multiple ways. Collection of actual stress responses using biospecimen
collection or ambulatory monitoring of blood pressure at the workplace
and at home, for example, could be combined more often with more typical
questions about particular exposures at work to improve our
understanding of which working conditions are actually “getting under
the skin.” Even when these forms of monitoring are not possible,
researchers should examine more than one working condition at a time to
better understand which cluster, and what their independent and joint
consequences are for health. This would mark a departure from the
traditional approach in occupational epidemiology, which tends to focus
on high quality measurement of a single type of exposure, whether
asbestos, poor ergonomic conditions or perceived job insecurity, but
cannot determine how negative conditions cluster and potentially have
synergistic impacts. Such focus is an important limitation because
research has shown, for example, that negative spillover from work to
home exacerbates the negative effects of other working conditions on
mental health (Glavin et al., 2011; Marshall & Tracy, 2009).
Workers
are subject to an array of potentially harmful conditions at work, and
these change over time. Moreover, health effects of workplace exposures
may take some time to manifest in visible disease, necessitating a long
term view. More longitudinal data collection tracking an array of
indicators over time would improve our understanding of the cumulative
burdens workers face at a point in time and over their careers, and how
these may link to health problems that arise in the short or much longer
run (see, for example Robone, Jones, & Rice, 2011).
While costly, more longitudinal data collection would also offer
several other benefits. First, such data allow assessment of how
individuals respond to the negative aspects of their jobs or shocks to
employment. Do they change jobs, or leave paid work altogether? For
example, high levels of exposure to negative spillover has been shown to
push individuals out of the labor force, which may have mixed effects
on health (Bellavia & Frone, 2005; Bianchi & Milkie, 2010).
While leaving the labor force may ease the burden of spillover on an
individual, and thus mitigate some of the negative consequences of
strain, leaving a job may deprive an individual of health enhancing
social networks and activities (Pavalko & Smith, 1999; Williams, 2010),
as well as influencing earnings and benefits trajectories.
Understanding more about turning points and how workers respond would
improve our understanding of the links between work and health.
Longitudinal data may also improve assessment of the temporal ordering
of changes in work, material resources, and health, strengthening
inferences about their associations.
Broadening the Lens: Multilevel Studies of Work & Health
Improvements
in measurement of working conditions and workers' responses to them
would be most powerfully applied if researchers continue to develop a
multilevel approach to the determinants of health and health
disparities. Pushing the analytic lens to encompass change over time and
multiple levels of aggregation could better integrate the valuable
findings we already have about work, health, and the persistence and
transmission of inequality. This means using conceptual models that
acknowledge intra- and inter-generational trajectories of workplace
exposures and health, but also the embeddedness of workers in
households, organizations, and societies subject to evolving
occupational structures and policy and regulatory environments that are
themselves responding to a changing macroeconomic environment. While it
is unlikely that any one study could incorporate all of these
dimensions, awareness of them could allow researchers to draw on
findings that cover other portions of this broadened conceptual diagram
to design stronger studies and make their results more useful to other
researchers.
Taking Advantage of Comparisons across Societies & Time
Comparative
studies provide exciting opportunities for those who study work and
health. Existing research has shown that the policy environment and the
availability of a social safety net modify the material consequences of
job losses for workers (Gangl, 2006),
but comparisons across different welfare state regimes could be more
broadly applied to the study of health consequences of particular
working conditions or employer-employee relationships. For example, some
have studied cross national differences in the health consequences of
nonstandard employment contracts (Kawachi, 2008) or job insecurity (László et al., 2010),
but there is a need to consider other working conditions and to
integrate a wider array of societies. Comparisons across time can offer
other advantages, sometimes providing natural experiments that can help
to identify the effect of a particular exposure of interest. Some
contemporary examples could include comparing the health of individuals
or populations before and after the onset of a major change in the
employment rate, such as a major recession, or before and after a major
policy change that alters the typical relationships between work and
health, such as the implementation of the Affordable Care Act in the
United States that will weaken the link between particular employers and
having health insurance coverage.
Learning from Good Jobs and Good Workplaces
Finally,
our understanding of the full scope of the association between work and
health could be improved if researchers did not solely focus on
exposures that harm health. Learning more about the positive aspects of
work, whether they are specific working conditions or factors intrinsic
to organizations or occupations, would make the findings even more
useful for interventions. For example, positive spillover from work to
home domains has been linked to better mental and physical health
employees (Grzywacz, 2000), and to less depression for spouses (Hammer, Cullen, Neal, Sinclair, & Shafiro, 2005).
In the realm of workplace conditions, some studies of specific
organizations have explored the benefits of schedule flexibility for
reducing work-family negative spillover (Moen et al., 2011), or have promoted work-family friendly policies for enhancing worker well-being (Williams, 2010).
Others have examined how factors like supervisor support can modify the
influence of stressful conditions at work for worker perceived load and
anxiety (Kirmeyer & Dougherty, 1988).
While quantitative studies of working conditions have been particularly
useful in documenting the relationship between negative aspects of work
and health, qualitative studies may be needed to document how these and
positive, health-enhancing aspects of workers' experiences matter for
health. While survey-based studies have shown the utility of supervisor
support in the workplace, for example, in-depth case studies of
workplaces or in-depth interviews with workers (e.g., MacIntosh, Wuest, Gray, & Cronkhite, 2010)
could serve to highlight the mechanisms through which supervisor
support and work-family friendly policies influence worker attitudes and
stress, and eventually result in better employee health. A better
understanding of aspects of work that can enhance health or buffer the
negative effects of more toxic exposures could add to future research
using more comprehensive data and models to assess the links between
work, working conditions, and health inequalities.
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