The Social Determinants of Health:
Working Conditions as a Determinant of Health

This summary is primarily based on papers and presentations by Andrew Jackson, Senior Economist, Canadian Labour Congress, and Michael Polanyi Assistant Professor, Saskatchewan Population Health Research and Evaluation Unit, and Faculty of Kinesiology and Health Studies, University of Regina. The presentations were prepared for The Social Determinants of Health Across the Life-Span Conference, held in Toronto in November 2002.

The opinions expressed in this publication are those of the authors and do not necessarily reflect the views of Health Canada.

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Current Situation

Over the 1980s and 1990s, there has been an ongoing restructuring of the labour market and of employment relationships. The intent of these changes has been to promote productivity and competitiveness, as opposed to promoting a worker-centred agenda of "good jobs" (Lowe, 2000).

In Canada, only two-thirds of the employed workforce are in "standard" salaried jobs with no defined end date (mostly provided by large firms and the public sector). In this shrinking core job market, workers who have survived layoffs, privatization and contracting-out are generally working longer and harder. Employers have tried to increase profitability and competitiveness and to contain budgets by boosting productivity. This has been accomplished largely by increasing workloads. For example, in the health sector, fewer nurses, social workers and other health professionals must now deal with more clients and perform more duties.

Investments in new labour-saving equipment, new information-based technologies, and experimentation with new forms of work organization have also boosted productivity. Some workplaces have become less hierarchical and alienating with the elimination of lower level supervisors and expanded job content. However, the overall incidence of innovative new work practices is very low (Betcherman, McMullen and Davidman,1998; Applebaum, 1997). For example, only 10% of Canadian workplaces have adopted self-directed work groups, and just 32% have adopted flexible job designs (Jackson and Robinson, 2000).

Canadian minimum wages and employment standards are minimal to modest compared to countries in northern Europe. In these countries, the great majority of workers are covered by collective agreements that create a relatively high standard of pay, benefits and working conditions.

The expanding peripheral job market includes many self-employed, temporary and part-time workers with insecure access to hours of work. It accounts for one-quarter to one-third of total adult employment in Canada. Job insecurity is high, particularly in small firms in the highly competitive consumer services sector (retail, accommodation and food services) and in the expanding social services sector (elder care, child care, home care). Typically, the skills and bargaining power of these workers are low, and there is limited access to collective bargaining, training, and career development opportunities. Many students, younger workers with limited educations, women and workers of colour, are trapped in precarious low-wage jobs in the peripheral market that are highly routine and boring.

Most Canadian unions have adopted formal policies relating to workplace health and safety, work/family balance, work reorganization and access to training, and have paid some attention to all of these quality of work-life issues in bargaining. However, there are continuous pressures to increase productivity to maintain employment and wages, which tend to militate against an agenda of creating more healthy workplaces.

Factors that Affect the Issue

The following working conditions have been identified as central to whether a job is healthy or not:

Job and employment security

Precariously employed workers, such as temporary employees, part-time workers and people working in low-wage survival jobs while they are trying to find better jobs more suited to their skills, face high levels of job insecurity and frequent short-term unemployment. Working poor families tend to move above and below the poverty line as they find and lose jobs, but rarely finding long-term jobs or income security (Finnie, 2000). These risks are compounded by:

• a lack of access to employer-sponsored pensions and health benefits: less than half of non-union workers have access to medical, dental and disability coverage

• fear of job loss

• recent increases in the qualifying hour requirements in the employment insurance program that cut-off most precariously employed workers who need income support the most

• a lack of training programs for unemployed workers and those at risk: public spending on training in Canada amounts to 0.2% of GDP in comparison to 6% in Denmark and 4% in Sweden (Jackson and Robinson, 2000).

Physical conditions at work

Unsafe working conditions are still prevalent in Canadian workplaces. Physical injuries are associated with physically demanding jobs, especially in manufacturing and construction. But, injury rates are also high in sectors such as retail, health and social services. Sullivan (2000) argues that workers' compensation practices, which were designed to address physical trauma in a world of manual, blue-collar, male work, have not changed to sufficiently recognize the growing reality of less visible physical injuries that develop over a period of time. Soft tissue injuries, such as repetitive strain injuries affecting female clerical and service workers, are under-reported and under-compensated. In the 1991 General Social Survey, one-in-three (34.1%) of workers reported some negative health impacts from exposure to a workplace hazard, and a significant minority of workers were exposed to dust, dangerous chemicals, loud noise, and poor quality air. More recent data is not available. Workers compensation boards are slow to recognize lung diseases and cancers caused by exposure in the workplace, except in very specific cases where a causal linkage can be clearly shown (Jackson, 2002).

Work pace, control and stress

In 2000, 35% of Canadian workers reported experiencing stress at work from "too many demands or too many hours," up from 27.5% in 1991. Stress from this source is highest among professionals and managers, at 49% and 48% respectively, but is still high among blue-collar workers (28%) and sales and service workers (29%). By industry, the incidence of stress from "too many demands or hours" is highest in education, health and social services at over 40%. Women are more likely than men to report high levels of stress from overload, and low or medium levels of influence on decision-making at work. (Canadian Policy Research Networks, 2002).

Working time

Over the past decade, there has been an increase in daily, weekly and annual hours for many core workers in full-time jobs. Long hours are most prevalent among professional and managerial employees and public and social service workers (who frequently work overtime without pay), and among skilled blue-collar workers (who frequently work paid overtime). Self-employed workers also tend to work very long hours.

A major study of core workers found that the incidence of work weeks of more than 50 hours rose from 10% to 25% between 1991 and 2001 (Duxbury and Higgins, 2001). These employees now average the equivalent of one day per week of unpaid overtime. Long commutes and an expectation of taking work home often compound the time crunch. Almost one-in-five working Canadians now regularly work at home in addition to their normal hours (Jackson and Robinson, 2000).

The counterpart to longer hours of work among core workers is unpredictable hours among precarious workers. The majority of part-time employees work at nights and on weekends, and as many as one-third have unpredictable shifts. Currently, three-out-of-ten employed Canadians (30% of men and 26% of women) have nonstandard work schedules. The incidence of shift work is well above average in manufacturing (25% of workers) and health care and social assistance (25.8%).

Vacation entitlements and phased-in retirement provisions in Canada are quite limited compared to many European countries. These factors have direct implications for stress and for physical and mental health (Jackson, 2000).

Opportunities for self-expression and individual development at work

Many young Canadians and recent immigrants with high levels of education are seriously under-employed in peripheral jobs (Livingstone, 2002; Lowe, 2000). They also have little access to training on the job that provides opportunities for advancement to more challenging and rewarding work. A lack of investment in training tends to perpetuate routine, low-skill employment and poor working conditions.

Participation and relationships at work

Although social relationships are an important aspect of working life, little hard information is available on this dimension. The provisions of a collective agreement cover about one-in-three paid workers in Canada. Coverage is highest in the public sector and in large private sector firms, particularly in primary industries, manufacturing, transportation and utilities.

Work-life balance

Longer and more unpredictable hours combined with high job demands are particularly likely to cause stress in families where both partners work, and for single-parent families. In both cases, women bear the brunt of the burden (Jackson, 2002).

Increased working-time has been a critical factor in maintaining real incomes in a labour market marked by more precarious employment and stagnating wages. While long hours may result in higher incomes, work/family time conflict may affect the physical and mental health of parents and also influence the well-being of children and older relatives who need care. These pressures are greater in Canada than in many other countries because of the relative under-development of publicly financed and delivered early childhood, elder care and home care programs (Esping-Anderson, 1999).

Work/family conflicts also arise because of the frequent incompatibility of work and home schedules. While some employers offers flextime arrangements that are responsive to the family needs of employees, the great majority of part-time jobs do not (Jackson 2002).

Effects of the Working Conditions on Health

High levels of workplace stress have been linked to an increased risk of physical injuries at work, high blood pressure, cardiovascular disease, depression and other mental health conditions, and increases in negative personal health practices such as smoking and drinking (Jackson, 2002). In various studies, levels of job strain have been found to be predictive of a range of health outcomes: mental health, cancer, pregnancy outcomes, periodontal disease (Jones, Bright, Searle, & Cooper, 1998; Kristensen, 1995). Many studies have found relationships between job strain and coronary heart disease (CHD) outcomes and predictors (Karasek & Theorell, 1990). A review by Schnall and colleagues (1994) found that 16 of 22 studies supported an association between job strain and CHD. A more powerful relationship has been found among blue collar (versus white-collar workers), and a more consistent relationship has been found with men than with women (Theorell, 2001). Specific consequences related to the working conditions previously identified include the following:

Job insecurity - Precarious employment is a source of stress due to a lack of income and meaningful work, uncertain prospects for the future, and its potential to undermine social support networks (World Health Organization, 1999). A longitudinal study of U.K. government workers showed that those experiencing job insecurity had worse self-rated health and higher rates of hypertension, longstanding illness, mild psychiatric morbidity and general illness symptoms than those not experiencing insecurity (Ferrie et al, 1998).

Physical environment - In 1998, there were 793,000 officially recorded workplace injuries (more than three times the total number of traffic injuries) and 798 workplace fatalities. There has been a sharply rising incidence of repetitive strain injuries among clerical and industrial workers (Jackson, 2002).

Work pace, control and stress - There is a link between a combination of high psychosocial demands and low levels of control over working conditions, to negative health effects and higher rates of work injuries (Karasek and Theorell, 1990). Even where work is physically demanding, there is less risk of injury if workers can vary the pace of work, take breaks when needed, and have some say in the design of work stations (Jackson, 2002).

Working time - Working very long hours is linked to high blood pressure and cardiovascular disease. Moving to longer working hours can have negative impacts on risk-taking behaviours, such as smoking, drinking and poor diet (Statistics Canada, 1999a). Long hours also create a high risk of conflict in balancing work with domestic and community life. A lack of control over work time (e.g., unpredictable hours) is also stressful. Shift work has been linked to sleep disturbances, digestive problems, cardiovascular disease, unhealthy behaviours, and stress from work/family conflict (Institute for Work and Health, 2002).

Participation and relationships at work - The lack of collective agreements in the precarious labour market undercuts the ability of workers to shape working conditions. Similarly, effective workplace health and safety committees that reduce rates of injuries and disability are largely absent from the precarious labour market (Sullivan, 2000).

Work-life balance - Reported levels of time stress and work/family stress among parents with children are very high. More than one-third of 25-44 year old women who work full-time and have children at home report that they are severely time-stressed, and the same is true for about one-in-four men. About two-thirds of full-time employed parents with children also report that they are dissatisfied with the balance between their job and home life. Fathers and mothers alike blamed their dissatisfaction on not having enough time for family (Statistics Canada, 1999b). Work-lifestyle conflicts are associated with increased stress and other negative effects (Duxbury and Higgins, 2001; Ertel, Pech and Ullsperger, 2000).

Implications for Policy, Practice and Research

Polanyi identifies four interrelated policy directions that support the development of healthy productive workplaces: increasing the availability of work; improving the adequacy of income from work; improving the appropriateness of work arrangements with respect to non-work needs and responsibilities; and increasing the appreciation or involvement of workers as active participants and valued contributors (Polanyi, 2002).

The health sector has a direct role in creating healthy working conditions for its own employees. It also has an indirect role in advocating and supporting labour market and workplace policies and practices that support health for all working Canadians. These include policies and practice that:

• Provide incentives for all workplaces to:

  • provide training and education, a living wage, enhanced job security, and employer-sponsored pensions and health benefits

  • support full-time jobs with adequate salaries and benefits, and reduce contracting out and casual employment, especially in the health sector

  • hire and provide challenging and meaningful work to young workers, new immigrants and women with skills and education

  • provide employees with adequate recognition, options that support efforts to balance home and work, and choices related to working hours.

• Encourage and support the participation of workers in effective health and safety/health promotion committees and programs, and in collective bargaining processes that enhance health and well-being.

• Encourage governments to:

  • significantly increase the availability of job training programs for Canadians who are unemployed or are vulnerable to re-occurring phases of unemployment and employment in dead-end jobs

  • enact legislation and standards that reduce workplace hazards and risks to health

  • enact legislation and standards that support equity for women and minority populations

  • encourage workers' compensation boards to sufficiently recognize and compensate repetitive strain injuries, mental health problems related to overload and family-work conflicts, and chronic diseases related to exposure to chemicals and environmental contaminants (including second-hand smoke)

  • provide for mechanisms for self-employed Canadians to attain the healthy working conditions discussed in this summary.

The health sector has a key role to play in helping employers and employees find a mutual win-win situation between the needs for productivity and for a good job. This is possible, as has been shown in Northern Europe where high labour standards and wage floors have proved to be no barrier to high levels of employment and productivity (Jackson, 2000). Creating alliances for healthy workplaces will help to strengthen the worker's voice.

The health sector can also improve workplace health by supporting broad social policy reform, including the provision of a national day care program and increased access to publicly funded help with elder care.

Research priorities include a better understanding of:

• the specific dimensions of healthy and unhealthy jobs

• when healthy working conditions and productivity go together and when they are in conflict

• gender-specific work conditions and health linkages, especially in regards to physical and psychosocial hazards in Canadian workplaces

• the costs of unhealthy working conditions to business and society in general.

References

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Canadian Policy Research Networks. See www.jobquality.ca.

Duxbury L. and Higgins C. (2001). Work-Life Balance in the New Millenium: Where are We? Where Do We Go from Here? (Discussion Paper W-12). Ottawa: Canadian Policy Research Networks.

Duxbury L. and Higgins C. (2002). The 2001 National Work-Life Conflict Study. Health Canada. See www.hc-sc.gc.ca.

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