Work and health Hynek Pikhart How can society affect our health? Major determinants of health HEALTH genes (disposition and activation) early life adversity health-related behaviours material and psychosocial environment (e.g. home, work) Importance of work for health • Work is an important determinant of health • It can influence health positively or negatively • For most people work is essential for economic, social as well as physical wellbeing Work and health - the extent of the problem • EU – approx. 10 million of the 150 million workers affected by incidents, accidents or diseases at work every year – direct compensation costs are estimated at 20 billion ECU per year • UK – officials statistics: every year about 2,000 lives lost through occupational disease or injury, about 20,000 major industrial injuries (e.g. skull fracture, loss of sight), and about 200,000 injuries resulting in a work disability of 3 days or more. • Calculations based on the UK Labour Force Survey suggest that in a year at least one million people believed they had ill health caused by work and a further million believed they had ill health made worse by work Number of non-fatal and fatal accidents at work, 2012 (source: Eurostat) Number of non-fatal and fatal accidents at work, 2018 (source: Eurostat) Adverse conditions exposing individuals to a range of health hazards - Number of deaths from workplace exposure to dangerous substances in different countries and regions From ILO 2005, and CSDH Final Report 2008 Importance of work for health Traditionally… ▪ Production process may have impact (both physical and environmental) that would affect workers and physical environment surrounding the workplace ▪ Studies on coal miners, asbestos workers, radiation workers – diseases related to chemical and physical exposures ▪ The occupational exposures are important but probably not the main cause of ill health related to work Importance of work for health ▪ CHD, mental health, other causes of ill health may be influenced by other aspects of work ▪ Wider social and economic context important Importance of work for health Work ▪ is a source of regular income and related opportunities ▪ is a source of personal growth and training opportunities ▪ defines social identity, social status and related rewards ▪ gives access to social networks beyond primary groups ▪ influences a person’s self efficacy and self esteem Work has prominent position among social determinants of health Psychosocial work environment Environment providing options / barriers to meet basic psychological needs of working people: → sense of belonging (membership role; social identity) → sense of control (task accomplishment; self-efficacy) → experience of reward (contractual reciprocity; self-esteem) Theoretical models with a focus on these needs: → social support at work → demand-control → effort-reward imbalance Job demand control model (Karasek and Theorell) Job Demands Low High JobDecisionLatitude HighLow PASSIVE HIGH STRAIN LOW STRAIN ACTIVE Strain Activity High work support Low work support Job demands Low High Low High Johnson and Hall, American Journal of Public Health 1988 Passive High Strain Collective Collective Low strain Active Collective Collective Passive High Strain Isolated Isolated Low Strain Active Isolated Isolated How to measure JD-C-S • “internal”/personal/subjective – questionnaire • “external” • Supervisor – personal or ecological • External researcher,… - personal or ecological • National classification of professions - ecological ▪ Focus on employment contract (salary, esteem, status) ▪ Rooted in general principle of cooperative exchange: social reciprocity ▪ Combines aspects of the work environment (‘extrinsic’) and the working person (‘intrinsic’) ▪ Has policy implications for health promotion through contractual fairness ▪ Can be applied to other types of role-related cooperative exchange The model of effort-reward imbalance at work • Imbalance is maintained if – There is no alternative choice available – It is accepted for strategic reasons – Presence of personal style of coping (overcommitment) Effort-reward imbalance at work Siegrist, 1996 Psychosocial factors at work have been found to predict a range of health outcomes – Both mortality and morbidity – CHD, CVD, hypertension, MI – sickness absence – self-rated health – neck pain and low back pain – depression Job strain in health studies • Karasek, 1981 – Swedish workforce – Prevalence of CHD indicator assoc. with higher demand and lower decision latitude – C-C CVD deaths: OR 4.0 (1.1-14.4) when low latitude combined with high demands • Karasek, 1988 – HES and HANES data – PS exposures estimated ecologically – Myocardial infarction – Top decile of strain: 3.80 (p=0.017) in HES and 4.79 (p=0.022) in HANES Job strain and verified CHD 0 1 2 high low DEMANDSCONTROL Whitehall II study, men and women, 11 years follow-up high low Kuper and Marmot, JECH 2003 HR Effect modification of the association between the effort-reward ratio and CHD by SES Whitehall II-Study; 11 year follow-up 0.8 1 1.2 1.4 1.6 1.8 high SES medium SES low SES Source: H. Kuper et al. (2002), Occ Environ Med, 59: 777-784. All CHD Hazardratio highestvs.lowestERIquartile Fatal CHD / non-fatal MI high SES medium SES low SES Kivimaki et al - Association of job strain with incident coronary heart disease – a collaborative meta-analysis of individual participant data The Lancet, 2012; 380: 1491–97 IPD-Work Consortium Summary: Work stress and health High job strain and/or High ERI have adverse effects on all stages of the disease process… • Disease risk factors, such as smoking and obesity • Preclinical disease, such carotid IMT • Disease, such as diabetes and CHD • Premature death • Also measures of ill-health, such as sickness absence, mental health and well-being Other work-related factors • Focus of presentation so far on work-related PS factors • Nothing said about the role of unemployment or job insecurity • Unemployment or job insecurity affected much more by broader economy Unemployment Unemployment figures In 2006 there were about 195 million unemployed in the world (6.3%) In many non-industrialized countries the rate is approx. 30%, in developed countries 4-12% Distribution of unemployment Women more likely to be unemployed than men (6.6 vs. 6.1%) Over 85 million (44%) of the unemployed are youth aged 15 to 24, although they are only 25% of the working age population Unemployment is more concentrated among all underprivileged groups, such as ethnic minorities, immigrants and the least skilled and educated. For example, in 2003, a person in the developed economies with only primary education was 3x as likely to be unemployed as a person with tertiary education (ILO 2006 & 2007) Trends in unemployment 2005-2020 (OECD) Unemployment by education, % of 25-64, 2019 SMRs 1981-1992 by employment status at the 1981 Census, men and women by age at death Bethune A. in Drever and Whitehead (eds) Health Inequality (1997) Mortality of men in England and Wales in 1981–92, by social class and employment status at the 1981 Census Bethune 1997 Mortality 1990-2001 in women: 10-town study, Finland Unemployed women vs women in permanent employment Kivimaki et al 2003;158:663-668 * adjusted for age and salary Unemployment and health • Short- and long-term effects on health • Duration of unemployment affects health • Ways how unemployment may affect health: – Unempl → Financial problems → Worse living standards → Lower self-esteem – Unempl → distress, depression (of unemployed, partners, children) – Unempl → health behaviours Ferrie et al. AJPH 1998 Job insecurity and risk of ischaemia adjusted for age, grade and ischaemia before jobs were threatened Organisational downsizing and mortality 7.5 years follow-up of 22,430 public employees Vahtera et al; BMJ 2004; 328:555-558 Major impact on work and employment ▪ Increased job instability and unemployment (mergers, downsizing, outsourcing) ▪ Segmentation of labour market (disparities in quality of work and income) ▪ Increased competition (reduced social support and solidarity) ▪ De-standardization of work contracts (flexible work, fixed-term contracts, homework etc.) Economy in current period of globalization: Summary • There is large evidence supporting important role of work in health • This presentation has focused mostly on risk associated with some PS factors (and work stress in particular) but there is much larger evidence for the role of work-related factors on health • Psychosocial and social factors and health is a dynamic area of research, with a need for new large studies and possibly new study designs Policy implications – (more) interventions needed Potential actions may be taken in several levels ▪ Personal level: Coping as strengthening of the individual‘s competence of problem solving ▪ Group level: Cooperation and handling of conflicts, collective assertion, leadership training ▪ Organizational level: Changes at the level of work organization (organizational and personnel development) including training/qualification DRIVERS FOR HEALTH EQUITY (FP-7 FUNDED PROJECT • http://health-gradient.eu/home/publications/english/ • Montano D, Hoven H & Siegrist J (2013). A meta-analysis of health effects of randomized controlled worksite interventions: Does social stratification matter? In: Scand J Work Environ Health. DOI: 10.5271/sjweh.3412. • Montano D, Hoven H & Siegrist J (2014). Effects of organisationallevel interventions at work on employees' health: a systematic review. In: BMC Public Health 14, S. 135. DOI: 10.1186/1471-2458-14-135. THANK YOU!