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)
Occurrence of one or more work-related health problems
in the past 12 months in different sectors
Source: Eurostat; Health and safety at work 1999-2007
Occurrence of work-related health problems in different
age groups
Source: Eurostat; Health and safety at work 1999-2007
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
Good Work
Employment and working conditions have powerful effects on
health and health equity
When these are good they can provide:
financial security
 paid holiday
 social protection benefits such as sick pay, maternity leave,
pensions
 social status
 personal development
 social relations
 self-esteem
 protection from physical and psychosocial hazards
(CSDH Final Report, WHO 2008)
10
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
Reviews of evidence
• Hemingway and Marmot, BMJ 1999
– Evidence based cardiology: Psychosocial factors in the
aetiology and prognosis of coronary heart disease:
systematic review of prospective cohort studies
• In healthy populations, prospective cohort studies show a
possible aetiological role for psychosocial work characteristics
in 6/10 studies
• In populations of patients with coronary heart disease,
prospective studies show a prognostic role for psychosocial
work characteristics in 1/2 studies
– Most of reported studies use JD/C but also hectic work,
job satisfaction, job variety,…
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
PLOS One, 2013
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)
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
Unemployment and mortality—a longitudinal
prospective study on selection and causation in
49321 Swedish middle-aged men
Lundin et al; J Epidemiol Community Health 2010
“The results suggest that a substantial part of the increased relative risk of mortality
associated with unemployment may be attributable to confounding by
individual risk factors.”
Virtanen et al: Perceived job insecurity as a risk
factor for incident CHD: systematic review and
meta-analysis
BMJ 2013; 347: f4746
17 studies
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:
Increase in temporary employment
Policies and regulations to combat precarious employment ILO 2011
For example, the proportion of
temporary jobs in European and
OECD countries steadily increased
over the 20 years to 2007 and has
continued to increase since.
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.
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