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AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 57:495–515 (2014)

Review Article

Work Organization, Job Insecurity, and Occupational Health Disparities

Paul A. Landsbergis, PhD , MPH , 1 Joseph G. Grzywacz, PhD , 2 and Anthony D. LaMontagne, ScD , MA , MEd 3

Background Changes in employment conditions in the global economy over the past 30 years have led to increased job insecurity and other work organization hazards. These hazards may play a role in creating and sustaining occupational health dispar- ities by socioeconomic position, gender, race, ethnicity, and immigration status. Methods A conceptual model was developed to guide the review of 103 relevant articles or chapters on the role of work organization and occupational health dispar- ities identified through a comprehensive search conducted by NIOSH. A second review was conducted of employment and workplace policies and programs designed to reduce the health and safety risks due to job insecurity and other work organization hazards. Results There is consistent evidence that workers in lower socioeconomic or social class positions are exposed to greater job insecurity and other work organization hazards than workers in higher socioeconomic positions. Likewise, racial and ethnic minorities and immigrants are exposed to greater job insecurity. Limited research ex- amining the effects of interventions targeting work organization hazards on disparities has been conducted; nonetheless, intervention strategies are available and evidence suggests they are effective. Conclusions Job insecurity and work organization hazards play a role in creating and sustaining occupational health disparities. Employment and workplace policies and programs have the potential to reduce these hazards, and to reduce disparities. Am. J.

Ind. Med. 57:495–515, 2014. 2012 Wiley Periodicals, Inc.

KEY WORDS: work organization; job stress; job insecurity; health disparities; occupational health disparities

1 State University of NewYork-Downstate School of Public Health, Brooklyn, NewYork 2 Oklahoma State University College of Human Sciences,Tulsa, Oklahoma 3 Melbourne School of Population Health, University of Melbourne, Melbourne, Victoria, Australia Contract grant sponsor: Australian National Health & Medical Research Council; Contract grant number: 375196. With contributions by: Carles Muntaner, University of Toronto Dalla Lana School of Public Health; Joan Benach, Universitat Pompeu Fabra, Barcelona, Grup de Recerca en Desigual- tats en Salut; Jane Lipscomb, University of Maryland School of Nursing, Baltimore; Jeffrey Johnson, University of Maryland School of Nursing, Baltimore; Peter Schnall, University of California, Irvine, Center for Occupational & Environmental Health; Kevin Riley, University of California, Los Angeles, Labor Occupational Safety & Health Program; Ellen Rosskam, Rosskam International Development Consulting, Geneva; Jennifer Zelnick, Touro College Graduate School of Social Work,NewYork.

2012Wiley Periodicals,Inc.

Disclosure Statement: The authors report no substantive conflicts of interest. The only funding they received for the preparation of this manuscript were travel expenses paid by the National Institute for Occupational Safety and Health (NIOSH) to attend a NIOSH- sponsored conference on this topic in 2011and to present an earlier version of this paper at the conference. *Correspondence to: Paul A. Landsbergis, PhD, MPH, Associate Professor, Department of Environmental and Occupational Health Sciences, School of Public Health, Room BSB 5-95, State University of New York-Downstate Medical Center, Box 43 450, Clarkson Ave., Brooklyn, NY11203.E-mail: paul.landsbergis@downstate.edu

Accepted 7 September 2012 DOI10.1002/ajim.22126.Published online16 October 2012 inWiley Online Library (wileyonlinelibrary.com).

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INTRODUCTION

The labor market and nature of work has changed substantially in the past 30 years, as employers seek to compete in the global economy [NIOSH, 2002]. Key manifestations of these trends include increases in ‘‘pre- carious’’ employment [Benach and Muntaner, 2007; Ferrie et al., 2008], new production systems (e.g., lean produc- tion), downsizing, outsourcing, privatization of public ser- vices, and new occupations (e.g., information processing and call center work) enabled by technological innovation [Landsbergis et al., 2011b]. The proportion of U.S. work- ers belonging to unions has declined [Kwon and Pontus- son, 2006], and sweatshop work is reemerging [Bonacich and Appelbaum, 2005]. These and other employment and labor market conditions, and the way work is organized, increase job insecurity and other psychosocial job stres- sors, and the risk of occupational injuries and illnesses [NIOSH, 2002]. Employment conditions, the organization of work, and job insecurity can also create and exacerbate occupational health disparities (inequalities) by socioeco- nomic position or status (SES) and gender, as well as by race, ethnicity, and immigration status [Ferrie et al., 2008; Benach et al., 2010c; Siegrist et al., 2011]. This review synthesizes what is known about the role work organization plays in creating and exacerbating occupational health disparities, and evaluates the effective- ness of interventions that address work organization and thus may reduce occupational health disparities. Job inse- curity is a primary focus because it is a sentinel indicator of the health and safety impact of current and future trends in employment conditions and the way work is organized. For this reason, NIOSH had requested that the authors of this article specifically review work organiza- tion, job insecurity and occupational health disparities, as one of five articles to be presented at a NIOSH conference on occupational health disparities: http://www.aoecdata. org/conferences/healthdisparities/index.html. Separate reviews of discrete domains (e.g., discrimination, harassment, abuse, and bullying) were commissioned and prepared for the conference. Thus, the current review did not address those features of work organization. A comprehensive review of the voluminous literature on work organization (including job insecurity) and health is beyond the scope of a single article. The foundations for this review include books [Schnall et al., 2009; Benach and Muntaner, 2010], major reports [Marmot, 2010], and review articles, for example [Lipscomb et al., 2006; Cummings and Kreiss, 2008; Ferrie et al., 2008; Quinlan and Bohle, 2009; Clougherty et al., 2010; Benach et al., 2010b; Muntaner et al., 2010b; Siegrist et al., 2011; Landsbergis et al., 2011b]. This review complements existing reviews by focusing on the role of job insecurity and work organization in creating or exacerbating

occupational health disparities . A more detailed and expansive version of this review is available on-line [Landsbergis et al., 2011a], http://www.aoecdata.org/ conferences/healthdisparities/.

Conceptual Overview

The conceptual foundation for thinking about job in- security, work organization, and occupational health dis- parities is complex. Like the model developed by NIOSH [NIOSH, 2002], our framework (Fig. 1) views the organi- zation of work as nested: job-specific factors serve an in- tervening role between organization-level factors and occupational health outcomes. Likewise, organizational factors (and subsequent job-specific factors) serve an inter- vening role between external factors (employment condi- tions) and occupational health outcomes. Labor stratification, the division of the workforce into groups with varying degrees of power, contributes to the development and perpetuation of occupational health dis- parities through two main processes. First, labor stratifica- tion contributes to differential exposure to job insecurity and other work organization hazards. Relative to managers and professionals, worker groups with more limited power have less opportunity to influence macro-level employment policies, organization-specific employment practices or job characteristics, thereby contributing to greater exposure among the more powerless. Differential exposure is represented in the model by the direct lines from Labor Stratification to each box reflecting dis- crete levels of work organization. Labor stratification also contributes to differential vulnerability ; that is, the health and safety effects of job insecurity and work organization differ across groups of workers. Differential vulnerability is represented in the model by dashed lines and arrows from Labor Stratification to the linkages among the dis- crete levels of work organization and health outcomes:

these dashed lines suggest that each linkage depends on where workers lie in the labor and socioeconomic hierarchy. Our conceptual framework considers occupational health to be a multidimensional outcome incorporating both positive (e.g., engagement, vitality) and negative (e.g., illness, injury) manifestations. The model also posits three primary mechanisms by which work organization can affect occupational health outcomes: physiological (e.g., sympathetic and parasympathetic responses to stress- or exposure), psychological (e.g., feelings of fear, help- lessness, or exhaustion), and behavioral (e.g., supervisory safety practices, compliance with safety protocols, or life- style factors such as physical activity and smoking). Final- ly, our model highlights modifying factors based on industry or occupational sector (e.g., explicit exemptions for agricultural workers to protections provided by the

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Work Organization and Occupational Health Disparities 497 FIGURE 1. Conceptual overview of the role of work

FIGURE 1. Conceptual overview of the role of work organization in the creation of occupational health disparities.

National Fair Labor Standards Act [Runyan, 2000]) that bear on occupational health.

Definitions and Inter-Relationships

Job insecurity

Job insecurity has been defined in various subjective and objective ways, and at various levels of Figure 1. It can be defined as a psychosocial stressor at the job level, caused by employment conditions and work organization, and reflecting a worker’s perceptions of fear of job loss or job instability. ‘‘Precarious’’ or ‘‘contingent’’ employment conditions provide the clearest illustration of an objective measure of job insecurity. ‘‘Precarious’’ employment rep- resents the explicit or implicit absence of a permanent or enduring employment contract. Workers in precarious jobs face employment uncertainty; they generally lack control over future work and income opportunities, and they have fewer rights [Benach and Muntaner, 2007]. While a number of measures of precarious employment and job insecurity exist, the most comprehensive measure is the Employment Precariousness Scale, which assesses six aspects of precarious work: temporariness, disempow- erment, vulnerability, wages, rights (to benefits, such as paid holidays, family leave, pension), and exercising rights [Vives et al., 2010]. This measure highlights that objec- tively insecure work can be harmful to health through

perceived or subjective job insecurity as well as through other pathways. The U.S. Department of Labor defines ‘‘contingent’’ workers as those who do not expect their jobs to last, and defines a separate category of workers in ‘‘alternative work arrangements,’’ such as independent contractors, on-call workers, temporary agency, and con- tract firm workers [Bureau of Labor Statistics, 2005]. Research on health and safety effects of job insecurity has focused on three types of factors, which can be considered ‘‘overlapping facets of the new flexible labor market’’ [Ferrie et al., 2008, p. 105]: (1) temporary em- ployment ; (2) job instability (objective conditions, i.e., workforce reductions or workplace closure is expected or occurring) and job insecurity (a worker’s perceptions of fear of job loss or job instability) [Probst, 2005]; and (3) downsizing , restructuring and outsourcing, including pri- vatization of public services [Ferrie et al., 2008; Siegrist et al., 2011]. Downsizing research has focused on workers who re- main with their employer rather than those who have lost jobs [Ferrie et al., 2008]. Downsizing can result in in- creased workload, job insecurity, and physical hazards [Kivimaki et al., 2000; Ferrie et al., 2007] and reduced job control [Kivimaki et al., 2000; Rugulies et al., 2006] for those who remain on the job. ‘‘Temporary work’’ may benefit workers when it allows them to control their work time, sample job experi- ences, use it as a ‘‘stepping stone’’ into permanent

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employment [Ferrie et al., 2008] or supplement retirement income after benefitting from earlier career standard employment [Clarke et al., 2007]. However, temporary workers are more likely to work at high speed, make repetitive movements, have no control over the pace of work, and have less training [Paoli and Merllie´, 2001]. Whatever task control they may have is likely reduced when economic pressures force them to work harder and longer [Quinlan et al., 2001]. Temporary workers have fewer opportunities for the informal social networking and support at work that enhance collective efforts to improve working conditions [Richardson, 2008]. To the extent that temporary workers are desperate to achieve targets that would secure future work or permanent employment, their grow- ing prevalence can undermine the resistance of permanent workers to work intensification [Quinlan et al., 2001]. Many temporary workers are not protected by laws designed to ensure proper pay and safe, healthful and non-discriminatory workplaces, and many are not covered by workers compensation [GAO, 2006]. In addition, the development of extended national and international con- tracting networks (supply chains) diffuse employer respon- sibility and pose a serious threat to occupational health and safety of temporary workers, many of whom are low- wage, ethnic minority, and immigrant workers [Quinlan and Sokas, 2009].

Work Organization and Job Characteristics

Work organization research has focused primarily on work schedule factors such as long work hours [Johnson and Lipscomb, 2006] and evening or night shift work [Bambra et al., 2008], and psychosocial job stressors, such as job strain (high demand-low control work) [Karasek and Theorell, 1990; Belkic et al., 2004], lack of social support [Johnson, 1989; Richardson, 2008], effort–reward imbalance (high efforts combined with low rewards at work) [Siegrist et al., 2004], and job insecurity [Ferrie et al., 2008]. Newer research has examined organizational injustice , particularly, the health effects of ‘‘procedural and relational injustice’’ [Elovainio et al., 2002, 2006], and workplace incivility [Lim et al., 2008; Lim and Lee, 2011]. Additional research has focused on threat-avoidant vigilant work, which involves continuously maintaining a high level of vigilance in order to avoid disaster, such as loss of human life. Very little health research has studied produc- tion and management systems, such as lean production [Landsbergis et al., 1999], new public management [Besosa, 2007], piece rate pay systems [Brisson et al., 1989], or electronic performance monitoring [Smith et al.,

1992].

STATE OF THE EVIDENCE

Job Insecurity and Health and Safety

Temporary employment has been associated with psy- chological distress [Virtanen et al., 2005] although null studies also exist [Ferrie et al., 2008]. Studies of physical health outcomes have produced mixed results, with associ- ations seen with occupational injuries [Silverstein et al., 1998; Mayhew and Quinlan, 1999; Meyer and Muntaner, 1999; Virtanen et al., 2005; Benavides et al., 2006; Ferrie et al., 2008], including needlestick injuries [Aiken et al., 1997], absenteeism, fatigue [Benach et al., 2004; Ferrie et al., 2008], mortality [Kivimaki et al., 2003] and muscu- loskeletal disorders [Silverstein et al., 2002; Benach et al., 2004]. However, temporary work is sometimes related to better health [Virtanen et al., 2003], perhaps reflecting dif- fering national regulatory and social welfare systems, the variety of circumstances which lead people to take on temporary work [Siegrist et al., 2011] or the ‘‘healthy worker effect’’ (most temporary workers are not entitled to paid sick leave) [Ferrie et al., 2008]. Job instability and job insecurity have shown consis- tent associations with psychological ill health, but weaker evidence of association in cross-sectional studies of physical health [Sverke et al., 2002; Ferrie et al., 2008]. However, chronic job insecurity appears to have a dose–response relationship with self-reported health and physical symptoms, and increases the risk of minor psy- chiatric morbidity [Heaney et al., 1994; Dekker and Schaufeli, 1995; Marmot et al., 2001; Ferrie et al., 2002; Muntaner et al., 2008]. Some studies have shown associa- tions with occupational injuries [Probst and Brubaker, 2001; Probst, 2002] and with poor self-rated health [Laszlo et al., 2010]. A good organizational safety climate may attenuate the relationship between job insecurity and injuries [Probst, 2004]. Downsizing and restructuring : Downsizing ‘‘survi- vors’’ have increased rates of sickness absence, musculo- skeletal disorders, medical symptoms, psychological distress, sleeping problems [Ferrie et al., 2008; Siegrist et al., 2011], use of prescription psychotropic drugs [Kivimaki et al., 2007], injury [Kelsh et al., 2004], and exposure to workplace violence [Flannery et al., 1997]. One study of Finnish public employees showed elevated cardiovascular mortality [Vahtera et al., 2004] among downsizing survivors. However, another study of a long- term follow-up of downsizing survivors in Finland did not show increased mortality [Martikainen et al., 2008], suggesting that long-term job stability may compensate for the more temporary stress of downsizing [Siegrist et al., 2011]. Privatization: One study of British civil servants, whose agency was privatized, showed a 90% elevated risk

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of work disability over 8 years of follow-up [Virtanen et al., 2010]. Another study showed increases in body mass index, ischemia, cholesterol, and, for women, blood pressure, but little change in health behaviors over 5 years of follow-up, compared to those who remained in the civil service [Ferrie et al., 1998]. A systematic review of 11 studies found some evidence of increases in stress-related ill health, but little evidence of increased injury rates [Egan et al., 2007b]. A thorough review of research on the health and safety implications of privatization and other manifestations of job insecurity is beyond the scope of this article.

Work Organization and Health and Safety

A substantial body of research exists linking long work hours, shiftwork, job strain, effort–reward imbal- ance, and threat-avoidant vigilance at work with illnesses and injuries. More limited data are available suggesting health and safety impacts of low workplace social support, social isolation, organizational injustice, lean production, piece rate pay systems, and electronic perfor- mance monitoring [Schnall et al., 2000, 2009; Siegrist and Rodel, 2006; Landsbergis et al., 2011b]. Typical out- comes examined in these studies include cardiovascular disease, hypertension, psychological disorders, musculo- skeletal disorders, sickness absence, unhealthy behaviors, and acute injuries. A thorough review of research on work organization and health and safety is beyond the scope of this article; readers are encouraged to consult more comprehensive reviews [Lipscomb et al., 2006; Cummings and Kreiss, 2008; Ferrie et al., 2008; Quinlan and Bohle, 2009; Clougherty et al., 2010; Benach et al., 2010b; Muntaner et al., 2010b; Siegrist et al., 2011; Landsbergis et al., 2011b].

Work Organization, Job Insecurity, and Occupational Health Disparities

NIOSH conducted a literature search in February

2011 in the following databases (PubMed, ABI/Inform,

Embase, Ergonomics Abstracts, Health & Safety Science Abstracts, NIOSHTIC-2, Web of Science, and PsycNET) for all studies published in English between 1990 and

2010 using the following search terms: (Workplace OR

Occupational Health OR Accidents OR Occupational Diseases OR Occupational Exposure OR occupational injury OR occupational injuries OR occupational illness) AND (Health Disparities OR Minority OR minorities OR Emigrants OR Immigrants OR Transients OR Migrants OR Hispanic or Hispanics OR Asian Americans OR Race Relations OR Socioeconomic Factors) AND ((job insecurity OR job instability OR Downsizing OR restruc- turing OR contingent OR precarious OR contracting OR

part time OR part-time OR temporary OR Labor Unions) OR (Piece rate OR Piece-rate OR lean production OR long work hours OR long working hours OR forced overtime OR effort reward imbalance OR effort–reward imbalance OR job strain OR job control OR Social Isolation OR Social Support)). A total of 240 articles were identified. The authors examined these articles and 103 publications were found to meet inclusion criteria for the current review; that is, studies of associations be- tween job insecurity, work organization and health and safety which provide information on differential exposures or differential vulnerability among groups at high risk of disparities. Relevant data from the articles were abstract- ed and coded by the authors. In addition, we included in- formation from recent review articles which addressed work organization, job insecurity, and occupational health disparities.

Socioeconomic Position (SEP)

Socioeconomic status (SES) refers to an individual’s ability to produce and consume resources and is frequently measured in terms of location along a continuum of several attributes (e.g., income, educational level, occupa- tional status). An alternative approach is to define a per- son’s social class, their relationship to the production of goods and services (e.g., an owner, self-employed, worker, manager, supervisor, non-managerial employee). These alternatives may show different associations with health outcomes [Muntaner et al., 1998a]. Since research contrasting such alternatives is beyond the scope of this article, we primarily use the term ‘‘socioeconomic position (SEP)’’ as a general term that includes both SES and social class definitions [Muntaner et al., 2003, 2004]. Differential Exposure: Lower SEP is consistently associated with job insecurity. Studies in Spain [Borrell et al., 2004], France [Niedhammer et al., 2011], Australia [Louie et al., 2006], and the U.S. [Hipple, 2001; Robertson et al., 2006] report that temporary work con- tracts are more common among workers in lower than in higher occupational positions. Blue-collar workers have less work predictability than white-collar workers [Vaananen et al., 2008]. Perceived job insecurity is more common among individuals with a high school education or less compared to those with greater than a high school education [Burgard et al., 2009], and more prevalent in lower SES groups [Parslow et al., 2004; Vanroelen et al., 2009; Moncada et al., 2010; Virtanen et al., 2011]. Workers in lower SEP are also disproportionately ex- posed to other work organization hazards. Low job control is inversely associated with educational level [Hintsa et al., 2006; Huisman et al., 2008; Smith et al., 2008], and is less common among workers in managerial and profes- sional occupations relative to those in service or blue

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collar occupations [Marmot et al., 1997; Gisselmann and Hemstrom, 2008; Huisman et al., 2008; Vaananen et al., 2008; Fujishiro et al., 2010]. Lower social class groups have less job control [Borrell et al., 2004; Parslow et al., 2004; Sekine et al., 2009; Vanroelen et al., 2009]. Expo- sure to high psychological job demands tends to be great- est among workers with higher SEP [Kuper and Marmot, 2003; Borrell et al., 2004; Sekine et al., 2009; Niedham- mer et al., 2011], although null associations have been reported [Hintsa et al., 2006]. Job strain is more common among workers in lower SEPs in some studies [Bosma et al., 1998; Malinauskiene et al., 2004; Hintsa et al., 2006; LaMontagne et al., 2008], but not in others [Choi, 2006; Choi et al., 2008 (Suppl. 6)]. Lower SEP workers report lower social support [Borrell et al., 2004; Moncada et al., 2010; Niedhammer et al., 2011], and greater expo- sure to effort–reward imbalance [Marmot et al., 1997; Bosma et al., 1998; Kuper et al., 2002], organizational in- justice [Kivimaki et al., 2005], threat-avoidant vigilant work [Belkic et al., 1998], and shiftwork [Steenland, 2000; Karlsson et al., 2003]. Two Scandinavian studies [Gisselmann and Hem- strom, 2008; Lahelma et al., 2009] and one British study [Marmot et al., 1997] suggest that 20–60% of SEP health disparities can be accounted for by work organization haz- ards. Others report that work organization hazards are as- sociated with poor health but they contribute little, if any, explanatory power for understanding SEP disparities in health [Huisman et al., 2008; Fujishiro et al., 2010]. Differential Vulnerability: Some evidence suggests that employees in manual (blue-collar) jobs experience greater strain due to perceived threats of unemployment compared to employees in non-manual (white-collar) jobs [Lynch et al., 1997; De Witte, 1999]. A study of Swedish men found that high demand-low control work increased risk for myocardial infarction, and that this risk was much greater in manual than non-manual workers [Hallqvist et al., 1998]. A stronger association among lower status than higher status workers was also seen for effort–reward imbalance and risk of heart disease [Kuper et al., 2002], job strain and heart disease [Johnson and Hall, 1988; Johnson et al., 1989], effort–reward imbalance and depres- sion [Wege et al., 2008], and job strain and blood pressure during working hours [Landsbergis et al., 2003]. However, some studies have failed to find such interactions [Wege et al., 2008] and, other studies suggest that higher status individuals are more affected by job strain [Laflamme et al., 1998; Virtanen et al., 2007].

Gender

Differential exposure : Several studies reported similar levels of exposure among men and women to measures of job insecurity [D’Souza et al., 2003; Burgard et al., 2009],

temporary jobs [Kouvonen et al., 2006] or downsizing [Dragano et al., 2005]. However, others found greater ex- posure among women to job insecurity [Wang et al., 2008], temporary work [Borrell et al., 2004], non-standard work [Kim et al., 2008], downsizing [Kivimaki et al., 2007], or contingent work [Hipple, 2001]. Turning to other work organization hazards, long paid work hours are consistently more common in men [McCurdy et al., 2003; Grosch et al., 2006; Louie et al., 2006; Ostry et al., 2007; Artazcoz et al., 2009; Inoue et al., 2010; Thomas and Power, 2010], while longer do- mestic work hours are more common in women [Blau et al., 2002; Borrell et al., 2004; Artazcoz et al., 2009]. Women also face a higher prevalence of job strain [D’Souza et al., 2003; Ostry et al., 2007; Suominen et al., 2007; LaMontagne et al., 2008; Rostila, 2008; Wang et al., 2008, 2009; Inoue et al., 2010; Lopes et al., 2010], low job control [Hemstrom, 1999; Kuper and Marmot, 2003; Vaananen et al., 2008; Gadinger et al., 2010; Inoue et al., 2010; Thomas and Power, 2010], low job va- riety [Matthews et al., 1998; Borrell et al., 2004], fewer learning opportunities [Matthews et al., 1998], fewer promotions [Adarga et al., 2010], access to flexible work schedules [Golden, 2008], and workplace incivility [Cortina et al., 2001]. However, four studies found compa- rable levels of job strain [Greenlund et al., 2010], job con- trol [Pikhart et al., 2004], job autonomy [Borrell et al., 2004], or lack of control of pace or inflexible break times [Matthews et al., 1998] for women and men. Research focused on gender differences in other work organization factors is mixed. Studies of psychological workload demands find that, in some cases, men are exposed to greater demands than women [Kuper and Marmot, 2003; Inoue et al., 2010], whereas others find greater demands among women [Gadinger et al., 2010], and still others report no gender differences [Hemstrom, 1999; Borrell et al., 2004; Thomas and Power, 2010]. Likewise, studies of workplace social support sometimes find that women have lower support than men [Hemstrom, 1999; Gadinger et al., 2010], whereas others find no gen- der differences in support [Inoue et al., 2010] or working alone [Borrell et al., 2004]. Effort–reward imbalance is frequently found to be comparable among men and wom- en [Pikhart et al., 2004; Dragano et al., 2005; Ostry et al., 2007; Inoue et al., 2010]. However, some European sur- veys showed higher efforts and higher rewards among men [Siegrist et al., 2004]. Other studies showed no gen- der differences in levels of organizational justice [Inoue et al., 2010] and shiftwork [Ostry et al., 2007]. Differential vulnerability : The magnitude of associa- tions between job insecurity and health and safety out- comes tends to be similar for men and women [Dragano et al., 2005; Ferrie et al., 2005; Virtanen et al., 2005; Kim et al., 2008; Sousa et al., 2010]. However, stronger

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associations for men than women between job insecurity and mortality [Niedhammer et al., 2011], poor self- reported health [Borrell et al., 2004], psychotropic pre- scription use [Kivimaki et al., 2007], depression [Wang et al., 2008], psychological distress [De Witte, 1999], and musculoskeletal disorders [Kim et al., 2008] have been documented. Other studies found stronger associations of job insecurity with systolic blood pressure, smoking, BMI [Muntaner et al., 1998b], and poor mental health [Kim et al., 2008] among women than men. Still other studies find no differential effects by gender in associations of job insecurity with longstanding illness [Ferrie et al., 2005], atherosclerosis (after risk factor adjustment) [Muntaner et al., 1998b], cardiovascular disease [Kim et al., 2008], or total mortality [Martikainen et al., 2008]. Research frequently finds differential effects of other work organization factors on health outcomes by gender, but the overall pattern is ambiguous. Stronger associations were seen in men than women for job strain and sickness absence [Suominen et al., 2007; Virtanen et al., 2007], smoking [Radi et al., 2007] and psychological disorders [Wang et al., 2008], for low job control and heart disease [Kuper and Marmot, 2003], and for low skill discretion and work injuries [Salminen et al., 2003]. Stronger associ- ations were observed in women than men for low job con- trol and systolic blood pressure, smoking, BMI [Muntaner et al., 1998b], and psychosomatic complaints [Gadinger et al., 2010], for workload and injuries [Salminen et al., 2003] and for job demands and psychosomatic complaints [Gadinger et al., 2010]. Nevertheless, gender comparable health effects have been documented for long work hours [Borrell et al., 2004; Ostry et al., 2007; Artazcoz et al., 2009], job strain [Rostila, 2008; Wang et al., 2009; Lopes et al., 2010], low job control [Bosma et al., 1997; Westerberg and Theorell, 1997; Salminen et al., 2003; Kouvonen et al., 2005], and job demands [Westerberg and Theorell, 1997; Kuper and Marmot, 2003; Kouvonen et al., 2005].

Gender and Socioeconomic Position

Some evidence suggests ‘‘greater health differentials associated with blue-collar (relative to white-collar) work for women than men’’ [Clougherty et al., 2010, p. 116]. For example, among U.S. aluminum manufacturing employees ‘‘Women in hourly jobs tended to be from lower SES backgrounds, have greater financial need (e.g., single mothers), and were more likely to hold lower-grade (e.g., lower-skilled) hourly jobs, than were hourly men’’ [Clougherty et al., 2010, p. 116]. Hourly work was associ- ated with a greater risk of hypertension among women than men, adjusted for demographics. Blue-collar women are also more likely to experience harassment and discrim- ination [Clougherty et al., 2010], higher injury rates and

injury severity (controlling for job tasks) [Pollack et al., 2007], and longer time to return to work after illness and absenteeism [Hill et al., 2008] than blue-collar men. However, Framingham, MA women in high demand- high control (high SEP) jobs had a higher risk of heart disease than women in high strain (high demand-low control) jobs. With baseline data collected from 1984 to 1987, this finding may reflect a period of changing social roles—increasing labor force participation among women, including higher SEP jobs—yet with residual discrimina- tion, de facto limited authority and wage disparities [Eaker et al., 2004]. An Australian study found that, among men, depres- sion attributed to job strain decreases step-wise as SEP increases, whereas for women, job strain-attributable de- pression did not vary consistently by SEP [LaMontagne et al., 2008]. Work organization factors and job insecurity explained a larger proportion of socioeconomic inequal- ities in health among men than women in three studies [Borrell et al., 2004; Sekine et al., 2009; Niedhammer et al., 2011]. In one of these studies, material well-being at home and amount of household labor played a larger role in women’s class differences in health [Borrell et al., 2004] Thus, further research is needed on the moderating role of gender in assessing the role of work organization hazards in socioeconomic inequalities in health.

Race, Ethnicity, and Immigration Status

Differential Exposure : Job insecurity varies by race, ethnicity, and immigration status. In two nationally representative U.S. samples, more Blacks than non-Blacks experienced perceived job insecurity [Burgard et al., 2009]. Contingent workers in the U.S. are more likely to be Black or Hispanic [Hipple, 2001]. Other research indi- cates that concern about possible job loss is greater among Hispanics than Blacks and Whites [Delp et al., 2010] and that Blacks have greater perceived insecurity than non- Blacks [Wilson et al., 2006]. Evidence from the National Longitudinal Study of Youth indicated that minority work- ers are more likely than non-minority workers to experi- ence an involuntary job loss [Park and Sandefur, 2003]. Immigrant women in Sweden were more likely work in temporary jobs than native born women [Akhavan et al.,

2007].

Some research provides direct evidence that exposure to work organization hazards systemically vary by race, ethnicity, and immigration status. Workplace discrimina- tion occurs more frequently for racial and ethnic minority workers [Krieger et al., 2006], although ‘‘incivility’’ in the workplace, defined as subtle mistreatment by customers, may not differ by race or ethnicity [Kern and Grandey, 2009]. However, cultural variation in what is perceived as allowable customer behavior may mask real variation in

502 Landsbergis et al.

incivility [Gong et al., 2009]. Immigrants tend to find themselves in jobs that have less opportunity to use high-level skills [Fischbacher et al., 2005] than non- immigrants, although differences by immigration status in other work organization factors such as psychological demand, control, or social support are reported to be mod- est [Sundquist et al., 2003]. Immigrant day laborers are exposed to more occupational hazards than non-immigrant day laborers [Seixas et al., 2008]. Other studies provide indirect evidence of variation in work organization factors by race, ethnicity or immigra- tion status. Hispanics are disproportionately employed in dangerous sectors like agriculture [Carroll et al., 2005] and construction [Brunette, 2004; Bureau of Labor Statistics, 2010]. Black and Hispanic workers and immi- grants are increasingly concentrated in poultry processing jobs [Government Accountability Office, 2005]; these are jobs with low social support and decision authority, high job strain, and elevated isometric load [Grzywacz et al., 2007; Lipscomb et al., 2007]. Three-quarters of Latino poultry processing workers report that their employer has minimal concern for employee safety, and is primarily in- terested in getting the job done as cheaply as possible [Quandt et al., 2006]. Consistent with these observations, Toh and Quinlan [2009] argue that immigrant workers have substantially greater difficulty accessing occupational safety and health rights and entitlements [Chibnall and Tait, 2005]. Differential Vulnerability: There is some evidence that perceived job insecurity is associated with greater thick- ness of plaque in the carotid artery for Blacks than for Whites, but these associations may be attributed to racial variation in clinical cardiovascular disease risk factors [Muntaner et al., 1998b]. Muntaner et al. [1998b] conclud- ed that the putative explanatory value of work organiza- tion factors for cardiovascular disease may be stronger for Whites than for Blacks, due to racial discrimination. Other data suggest that, if an occupational injury occurs, Latinos may experience worse outcomes. Specifically, one study

found that Latinos are more likely to have moderate or severe occupational injuries, they are less likely to have insurance to cover care for that injury, and they have greater difficulty than whites resolving workers’ compen- sation claims [Nicholson et al., 2008].

Summary of Findings

Table I provides a summary of the state of the evidence regarding differential exposure and differential vulnerability to job insecurity and other work organization hazards by SEP, gender, race, ethnicity, and immigration status. Our review finds consistent evidence that job inse- curity is more common among workers in lower SEPs, racial and ethnic minorities, and immigrants. Further, five of the nine reviewed studies found women to be more exposed to job insecurity. Thus, there is good evidence of differential exposure to job insecurity. There is general consistency that individuals with lower SEPs are more likely to be exposed to work organi- zation hazards. There is no discernible pattern of effects for gender internationally. The small amount of research on differential exposure by race/ethnicity and immigration status does not allow firm conclusions. Limited research suggests that work organization hazards have a greater impact on the health of lower (vs. higher) SEP workers. However, there is no clear pattern of results to conclude that other groups of workers are systematically more vulnerable to the health effects of job insecurity or other work organization hazards.

STATE OF THE EVIDENCE— INTERVENTIONS TO REDUCE OCCUPATIONAL HEALTH DISPARITIES

Interventions to reduce occupational health disparities can be directed towards reducing differential exposure, re- ducing differential vulnerability, or both (Table II). A wide range of macro- and micro-level strategies can be applied

TABLE I. Summary of Research on Job Insecurity and Work Organization Hazards Contributing to Variation in Health and Safety Outcomes by Various Bases of Labor Stratification

Lower socioeconomic position

Female gender

Racial and ethnicminorities/immigrants

Differential exposure

Job insecurity

þþ

þ

Workorganization

þ

þ

Differential vulnerability

Job insecurity

þ

Workorganization

þ

The symbolsrefer to consistency ( þ) or inconsistency ( ) of findings. Shaded areas represent areas of limitedresearch inquiry (four or fewer studies).

Strengtheninglabor standards,includingraisingminimum employment conditions,unfairdismissal provisions,job security, and job quality standards National/local/organization-level job skillstraining programs Legislatingwagepremiums(higher pay) ontemporary or precarious jobs Creatingfederalrecommendationsonthereductionofwork organization hazards,with incorporation into national public health initiatives such as‘‘Healthy People’’ Tax-based intervention structured either as‘‘carrots’’(e.g., multi-year taxcredits) or ‘‘sticks’’(e.g.,penalties)to incentivize employerstobuildtheircorps ofpermanent employeeswhilereducingreliance ontemporary employees Strengtheninghumanrightsandequalopportunitylaw(e.g., toreducediscriminationbased onrace,gender,age,etc.) Strengtheningworkers’compensationsystems,including anti-poverty supportfor injured or illworkers andtheir dependents Universal healthcare coverage

Specialretrainingprograms atnational/statepolicy levelto assistreturntoworkfrominjuryor illness,orto assist employmentreentryfrom disability Raisingminimumwages(toreducetheproportion of workingpoor) Improved accesstopublictransport Increasingthe availability ofaffordable housing Food security programs

Macro-level intervention strategies(examples)

VoluntaryOH&S policy intervention

OH&Sregulatory intervention

Specialretrainingprograms atorganizationallevelto assist returntoworkfrom injuryor illness,orto assist employmentreentryfrom disability

Awareness-raisingeducationalinterventionsatpopulation,

Integratedworkplace health promotion programs(addres- singboth health behaviors andworking conditions)

Task-directed interventions(e.g.,workload,job autonomy)

Timemanagement,coping skills developmenttrainingto strengthenworkercapacity towithstand stressors

Socialrelationship-directed(e.g.,communication,social

Micro-level intervention strategies(examples)

Environment-directed interventions(e.g.,worktime, organizational context)

industry,organizational,or workgroup levels Union advocacy & education programs

TABLE II. Intervention Strategies for Reducing Occupational Health Disparities ArisingThroughWork Organization and Job Insecurity

Managementtrainingprograms

support)

Effectivetreatment,rehabilitation andreturntoworkof workers adversely affectedbypoor workorganization (tertiary prevention) differentiallyprioritizing atriskworkgroups and contexts,including:

Reduce exposuretopoor workorganization/improve psychosocial job quality(primaryprevention) differentiallyprioritizing atriskworkgroups and

Strengthenworker ability towithstand stressors (secondary prevention) and

Workers in lower socioeconomic positions

Workers in lower socioeconomic positions

Objective/targets

Racial and ethnicminority workers

Workingwomen Immigrantsworkers Racial and ethnicminority workers Precariously employedworkers

Precariously employedworkers

contexts,including:

Immigrantworkers

Workingwomen

Reducedifferential vulnerability to health impacts ofpoorpsychosocial working conditions

Reducedifferential exposuretopoor

psychosocialworking conditions

Goal

Work Organization and Occupational Health Disparities

503

504 Landsbergis et al.

to this end, drawing upon political economy, health inequalities, and other macro-structural perspectives [Commission on Social Determinants of Health, 2008; Marmot, 2010; Muntaner et al., 2010a; Siegrist et al., 2011] and including primary, secondary, and tertiary pre- vention at the micro-structural-level—drawing in particu- lar from occupational and public health perspectives [LaMontagne et al., 2007b; Landsbergis, 2009; Benach et al., 2010c]. Most available evidence for addressing occupational health disparities arising from work organization and job insecurity pertains to improving psychosocial working conditions and reducing associated illness and other burdens in an absolute sense; thus, where explicit evidence is lacking on how interventions affect disparities, the available evidence requires extrapolation to how these strategies can reduce disparities. Population-level interven- tions that improve population health on average, however, can at the same time potentially exacerbate health inequal- ities in a phenomenon termed the ‘‘inequality paradox’’ [Frohlich and Potvin, 2008]. This can arise when disad- vantaged groups have less capacity to transform public health interventions into health improvements. This has been observed, for example, in the context of smoking cessation and tobacco control initiatives in the UK and Australia, where population smoking prevalence steadily declined over time but disparities in smoking prevalence by SES widened [Baum, 2007; Frohlich and Potvin, 2008]. This is not to deny the value of population approaches, but rather to highlight the need to monitor disparities in intervention impacts as well as absolute changes, to prioritize disadvantaged work groups and con- texts in population approaches, and to implement tailored intervention strategies for disadvantaged work groups and contexts to complement population approaches (Table II).

Macro-Structural Interventions

The evidence base on the impacts of macro-level interventions on work organization is underdeveloped, be- cause it is a relatively new policy area and due to method- ological challenges. Nevertheless, it is becoming an active area of investigation [Quinlan et al., 2010; Benach et al., 2010a; Muntaner et al., 2010c]. Macro-level policy and other interventions can be conducted at various levels ranging from international to national to industry/sector. They can further be divided into regulatory versus volun- tary approaches. The UK Health & Safety Executive (HSE) 2004 Management Standards provide a regulatory example. The Management Standards cover six key areas of work organization: demand, control, managerial sup- port, peer support, role relationships, and change. Formal evaluations suggest the Management Standards have sub- stantially increased the focus on the prevention of stress

among employers and other stakeholders in the UK and, as a consequence, increased organizational policies and procedures to deal with these issues [Broughton et al.,

2009].

While there are relatively few examples of regulatory standards on psychosocial hazards to date, there are a growing number of regulatory responses to temporary or precarious employment. For example, in the Australian state of New South Wales, under a 2001 law, home- based clothing workers, a highly exploited primarily immigrant workforce, were deemed employees, and thus brought under labor regulations [Quinlan and Sokas, 2009]. Similarly, a 2011 California law prohibits the ‘‘willful misclassification’’ of employees as independent contractors [Yamauchi and Allen, 2011]. An example of a voluntary macro-level intervention is a recent standard on workplace psychosocial risk management issued by the British Standards Institution, the ‘‘PAS1010’’ [Leka et al., 2011]. The guidance and recommendations in PAS1010 grew out of the European Framework for Psychosocial Risk Management (PRIMA- EF) initiative [Leka and Cox, 2008]. Labor-management voluntary agreements are an example of macro-level policy intervention at the industry or sector level. A 2004 joint labor/industry European framework agreement on work stress aimed to increase the awareness and understanding of work stress and ‘‘best practice’’ interven- tions among employers, workers and their representatives [European Trade Union Confederation et al., 2004]. Awareness-raising and policy advocacy can also be ad- vanced by individual stakeholder groups. For example, in September 2011, the Australian Council of Trades Unions launched a national campaign titled ‘‘Secure Jobs—Better Future’’ (http://securejobs.org.au), highlighting the elevat- ed percentage of workers in insecure jobs ( 27% of work- force in casual/temporary jobs, second only to Spain in the OECD), the impacts and inequities of insecure work, and the need for policy and practice reforms. Some macro-level interventions may require further research to determine appropriate intervention targets and strategies. For example, social class and gender disparities in job control exist across OECD countries (differential exposure). However, there are wider social class inequal- ities in low job control (and other work organization hazards) in Spain compared to Denmark, which has a more developed welfare state [Moncada et al., 2010]. Pre- ventive strategies to reduce social inequalities in working conditions need to consider economic and labor market structures, education and training policy, labor relations regulations, unionization, and other macro-level policies. For example, in a cohort of the Australian working popu- lation, working women reported significantly lower job control than men, and this disparity persisted over eight annual waves of observation (2001–2008) [LaMontagne

Work Organization and Occupational Health Disparities

505

et al., 2011]. However, this job control disparity was large- ly eliminated by adjustment for occupational skill level and employment arrangement (permanent, precarious, etc.). These findings suggest that differential exposure to low job control by gender in this nationally representative sample could be more systematically and effectively addressed by macro-level interventions to redress the seg- regation of women into lower quality jobs (e.g., job skills training and equal opportunity employment initiatives) over micro-level (e.g., organizational level) interventions to improve women’s job control. This is supported by the observation of smaller gender differences in job control and other work organization hazards (as well as in physi- cal and mental health) in Finland, where more gender equality policies exist, than in the UK or Japan [Sekine et al., 2011]. It is also necessary to address non-work-related ‘‘so- cial determinants’’ of health in order to reduce differential vulnerability to the effects of work organization hazards and job insecurity (Table II). Many workers in lower socioeconomic positions are also at higher risk of other forms of disadvantage, such as low income, poor housing, food insecurity, and lack of access to public transport. While these are beyond the scope of this report and are addressed in detail elsewhere [Commission on Social Determinants of Health, 2008], it is important to acknowl- edge them as potential limiting factors of the effectiveness of both macro- and micro-level interventions to address work organization and job insecurity. The UK is attempt- ing to implement such a comprehensive approach. Follow- ing on from the WHO’s global recommendations to reduce health inequalities [Commission on Social Determinants of Health, 2008], the 2010 UK Marmot Review proposed a country-specific coordinated set of pol- icies to reduce health inequalities overall, including a ma- jor policy objective to ‘‘Create fair employment and good work for all’’ alongside policy objectives for addressing other social determinants [Marmot, 2010]. One of three major arms of this policy proposal is to ‘‘Improve the quality of jobs across the social gradient’’ through: (1) en- hanced adherence to equality guidance and legislation, (2) implementing guidance on stress management (draw- ing largely on micro/organizational-level intervention re- search), (3) developing greater employment security and flexibility through greater retirement age flexibility, and (4) encouraging and incentivizing employers to create or adapt jobs that are suitable for disadvantaged workers and people with disabilities or other work limitations. Innovative approaches are being developed to investi- gate differential vulnerability and ways of addressing it at the macro-level. In a large-scale multi-country analysis, the association of high work stress and depressive symp- toms varied according to type of welfare regime, with the strongest association in a ‘‘neo-liberal’’ country, the UK

(OR ¼ 2.64) and the smallest in Scandinavian countries (OR ¼ 1.69), suggesting that weak social protections may magnify the health impacts of poor work organization and job insecurity [Dragano et al., 2011]. In summary, evidence to date suggests that general social protection policies, as well as occupational health and safety protection policies, can mitigate both differen- tial exposure and differential vulnerability by gender, socioeconomic position, and possibly other factors (e.g., employment arrangement).

Micro-Structural Interventions

The research literature on interventions to improve work organization is dominated by micro-/organizational/ workplace-level studies, most likely due to the greater fea- sibility of organizational-level intervention and research. Here, we focus on those work organization interventions aiming to reduce job stressors and job stress as most germane to the topic at hand. International research on interventions to improve work organization and to reduce job stress and stress-related illness has been the subject of a number of systematic reviews. The most comprehensive review (90 intervention studies) focused on interventions wherein work organiza- tion factors were proactively addressed [LaMontagne et al., 2007a]. This review concluded that individual- focused, low-systems approaches (e.g., coping and time management skills) favorably affected individual level outcomes such as health and health behaviors, but tended not to have favorable impacts at the organizational level (e.g., no reductions in stressor exposures, sickness absence rates). However, organizationally focused high- and mod- erate-systems approaches (addressing work organization and working conditions), were beneficial at both individu- al and organizational levels (e.g., improvements in work- ing conditions as well as health). More selective Cochrane systematic reviews (with more stringent inclusion and exclusion criteria) reached similar conclusions. A 2007 review of organizational level interventions to increase job control found some evidence of health benefits (e.g., reductions in anxiety and depression) when employee control increased or (less consistently) when demands decreased or support in- creased [Egan et al., 2007a]. They also found evidence of worsening employee health from downsizing and restructuring [Egan et al., 2007a]. A second 2007 Cochrane review of task restructuring interventions [Bambra et al., 2007] found that interventions that in- creased control resulted in improved health. An ‘‘umbrel- la’’ summary of systematic reviews of the effects on health and health inequalities of organizational-level changes to the psychosocial work environment was pub- lished in 2009 [Bambra et al., 2009]. Shift work, work

506 Landsbergis et al.

scheduling, privatization and restructuring were also considered. Findings suggested that organizational level changes to improve psychosocial working conditions can have important and beneficial effects on health. Though the evidence base was limited, findings tentatively suggested that organizational level interventions on the psychosocial work environment also have the potential to reduce health inequalities. Participatory approaches were a consistent feature of effective micro/organizational-level interventions to reduce job stress, and warrant careful consideration with respect to the potential to reduce occupational health disparities [LaMontagne et al., 2007a; Landsbergis, 2009]. Participa- tion is a concrete enactment of job control, demonstrates organizational fairness and justice, and, if properly implemented, builds mutual support among workers and between workers and supervisors [LaMontagne et al., 2012]. Despite the benefits that can be gained through participatory approaches, active employee involvement tends to be the exception rather the norm in practice. The predominant approach to developing and implement- ing organizational-level interventions is to assume that employees are passive recipients of change, and to adopt a top–down approach [Nielsen et al., 2010]. This is of particular concern in relation to workers with lower lev- els of power or influence. Concerns have been voiced re- garding the extent to which attempts to gain employees’ insights are genuine and whether participatory processes address employees’ real issues. NIOSH states, for exam-

participation or involvement strate-

gies may often be more ceremonial than substantive,

ple, that

‘‘

worker

having little meaningful influence on worker empow- ’’

erment

Another factor influencing the effectiveness of partici- patory processes is the extent to which they capture the views and ideas of all relevant stakeholders. Studies exam- ining the effectiveness of participatory-based interventions indicate that the groups who are particularly vulnerable to experiencing high levels of work-related ill-health are also less likely to have the opportunity to take part in par- ticipatory processes. This includes workers in lower socio- economic positions; workers employed on a precarious/ contingent or short-term basis, particularly women; and night-shift workers [Benach et al., 2002; Rotenberg et al., 2009; Landsbergis, 2010; LaMontagne and Keegel, 2012; LaMontagne et al., 2012]. Low paid temporary or precari- ous/contingent employees, for example, are far less likely to be represented in consultative forums (e.g., OHS com- mittees) and are more likely to feel constrained by their status with respect to complaining about work hazards [Benach et al., 2002; Rotenberg et al., 2009]. They are also likely to have less knowledge about their working environments and experience more difficulty al- tering working conditions [Benach et al., 2002; Rotenberg

[NIOSH, 2002].

et al., 2009]. Further research, as well as regulatory or other intervention, is needed to develop, strengthen and support participatory mechanisms for disadvantaged workers. Taken together, the available evidence base demon- strates that effective and feasible micro-level strategies for the prevention and control of workplace psychosocial risks are available, but further research is needed, particu- larly in relation to their application among disadvantaged worker groups and their impacts on occupational health disparities.

Intervention: Promise and Practice

Available research suggests that current intervention practice lags far behind evidence-informed ‘‘best prac- tice.’’ Despite evidence supporting systems or comprehen- sive approaches as most effective, prevalent practice in most OECD countries remains disproportionately focused on individual-level interventions with inadequate attention to organizational- and higher-level interventions [Hurrell and Murphy, 1996; Giga et al., 2003; LaMontagne et al., 2006; Leka et al., 2008]. Echoing this finding, a recent survey covering over 28,000 enterprises in 31 European countries revealed that even though work-related stress was reported by managers as being among the key safety and health concerns for European enterprises, only about half the establishments surveyed reported that they inform their employees about psychosocial risks and their effects on health and safety [European Agency for Safety and Health at Work, 2010; Siegrist et al., 2011]. This suggests a need to better characterize worker and employer aware- ness, knowledge, and attitudes towards work organization and job insecurity in the US, and the need to consider population-level awareness-raising and educational inter- ventions to set the stage for more substantive interventions to address psychosocial working conditions and their health and social consequences at the regulatory, organiza- tional, and other levels.

Summary of Findings

Considering the full evidence base linking job insecu- rity and work organization hazards to health outcomes (not just as pertains to disparities), various micro- and macro-level policy and practice recommendations can be made, as outlined in Table II. While there has been limited research explicitly examining the impacts of inter- vention on exposure or health disparities , available evi- dence suggests that macro- and micro-level intervention strategies have the potential to improve health and poten- tially reduce disparities. Intervention can be implemented at various levels, including macro-structural (e.g., occupa- tional health and safety and employment rights legislation

Work Organization and Occupational Health Disparities

507

and regulation), micro-structural (e.g., union- or employer- based job stress prevention programs) and individual (e.g., coping skills development training). Notably, many of the relevant interventions lie outside public health (e.g., education, employment, anti-discrimination), but are important targets as upstream determinants of occupation- al exposures and health disparities. The UK and some European countries are currently implementing policy interventions to reduce health disparities, including work- directed as well as other intervention strategies. These may offer valuable policy intervention insights in the future.

RESEARCH AGENDA

Further research is needed in a number of methodo- logical and substantive areas:

Surveillance

A high priority area is the development of surveil- lance tools for monitoring key indicators of work organi- zation [Dollard et al., 2007] at the organizational level as well as the worker level. We recommend that NIOSH con- vene a panel of experts to identify key aspects of work organization necessary for national surveillance, create an assessment battery for measuring these factors, and annual or biennial assessment of these factors through standard Bureau of Labor Statistics channels (e.g., Current Popula- tion Survey). In addition, NIOSH should publicly provide data on trends in work organization measures from nation- al surveys conducted in 2002, 2006, and 2010, including trends in these risk factors by SEP, gender, race, ethnicity, and immigration status. Existing channels for work organization surveillance do not adequately capture work performed by individuals in invisible segments of the labor force (e.g., immigrants). Methodological research is needed to identify alternative sampling strategies that capture workers in the full range of occupations, or the creation of sampling strategies that otherwise ‘‘enrich’’ probability samples with disadvan- taged groups including immigrants, refugees, and mem- bers of racial and ethnic minorities.

Measurement

Research is needed to ensure that individuals from different segments of society interpret job security and work organization questions similarly and use comparable cognitive evaluations when articulating a response to those questions. There is some evidence that instruments fre- quently used in this literature, such as the Job Content Questionnaire [Karasek and Theorell, 1990], have been validated in several cultural contexts [Karasek et al.,

1998]. Other research suggests that concepts like job de- mand and control have similar meaning in diverse cultural contexts and that items used to measure these concepts are appropriate [Grzywacz et al., 2009; Fujishiro et al., 2010]. Nevertheless, it is important to remain vigilant to the issue of cross-cultural measurement equivalence.

Alternative Study Designs

Further research is needed to better characterize the magnitude and mechanisms by which poor work organiza- tion contributes to occupational health disparities. Al- though the general work organization literature has many strengths in terms of study design and measurement, the literature on work organization and occupational health disparities remains underdeveloped. For example, < 10% of studies of occupational health disparities used objective indicators of either exposure (i.e., work or- ganization) or outcome, and <5% can rule out competing explanations (e.g., physical demands of discrete job tasks) of associations between work organization factors and health outcomes. Research using alternative designs (e.g., case-control, case-crossover designs), alternative sampling strategies to ensure adequate representation of ‘‘hard-to-reach’’ segments of the workforce (e.g., undocu- mented immigrants), or alternative methods (e.g., propen- sity score matching) are needed to more firmly establish the specific role work organization plays in occupational health disparities.

Interventions

Given the dearth of tested interventions focused on reducing occupational health disparities, we recommend the creation of research funding opportunities focused on systematic evaluations of micro- and macro-level interven- tions targeting the improvement of work organization fac- tors as a means of reducing disparities in psychosocial working conditions and to alleviating the associated occu- pational health disparities. Such funding opportunities should prioritize participatory-based approaches involving partnerships among worker groups, employers, community advocacy groups, governmental agencies, and researchers. The funding opportunity should emphasize process as well as outcome evaluation, the inclusion of measures of dis- parity, and the sustainability and scalability of the inter- vention strategy being tested.

Relationships Between Levels of Work Organization

More research is needed on the impact of employ- ment conditions on organizational factors, as well as the influence of organizational factors (e.g., downsizing,

508 Landsbergis et al.

subcontracting, production systems, staffing levels) on job specific factors, health and safety, and health and safety disparities. In addition, research is needed on the ways in which these relationships might vary among different sec- tors of the workforce (Fig. 1).

Key Research Questions

The research reviewed in this report leads to several important research questions:

(1) Have changes in job insecurity and work organiza- tion contributed to increasing socioeconomic health

risks among women? [Brisson et al., 1999; Krantz and Ostergren, 2001]

(6) What employment policies and work organization policies can help workers better balance work life

¨

and family life? [Messing and O stlin, 2006] What are the economic costs and benefits of organiz-

(7)

ing work in a health promotive way? In what ways do these differ by sector and occupation? [LaMontagne et al., 2010] (8) Which intervention strategies are most effective in reducing occupational health disparities? Table III provides illustrations of promising intervention strat- egies awaiting systematic evaluation.

disparities in cardiovascular disease [Gonzalez et al., 1998; Tuchsen and Endahl, 1999], hypertension, dia- betes, and smoking [Kanjilal et al., 2006]? (2) Are higher exposures to job insecurity and some work organization hazards among women, racial and ethnic minorities, and immigrants primarily due to their lower socioeconomic position?

ACKNOWLEDGMENTS

We are grateful to Sherry Baron and Andrea Steege of the National Institute for Occupational Safety and Health (NIOSH) for coordinating the production of the five re-

(3)

What factors explain differential vulnerability of in- dividuals in lower SEPs to job insecurity and work organization hazards? What role do non-work haz-

view articles on occupational health disparities and the 2011 NIOSH conference on Eliminating Health and Safety Disparities at Work. We are also grateful to George

(4)

ards play in differential vulnerability to job insecuri- ty and work organization hazards? What work organization factors may explain greater health risks among blue-collar women versus blue- collar men?

Koutsouras for his assistance in abstracting data from reviewed articles. The only financial support received by the authors from NIOSH for the preparation of this manu- script were travel expenses to attend the 2011 conference and to present an earlier version of this article at the con-

(5) To what extent do work organization hazards and domestic responsibilities interact to increase illness

ference. The only other financial support was partial sup- port for the third author (A.D.L.) provided by project

TABLE III. Intervention Research Recommendations

Type ofinterventionresearch

Specific examples

Developmentalresearch

Characterizeperceptions,knowledge, and attitudes amongworkers and employers onworkorganization,jobinsecurity, and

Implementationresearch

occupational health disparities Developevidence^basedmethodsforriskassessmentandtailoredinterventiondevelopmenttosupporttheadoptionofbestpractice interventions Developparticipatory strategiesthat areboth effective and safeforworkerswith lowerlevels orpowerorinfluence(e.g.,lowpaid workers,racial and ethnicminorities,immigrantworkers) Disseminate evidence^basedmethodsforrisk assessment andtailored intervention development, and characterizebarriers and

Effectivenessresearch

facilitators ofimplementation Participatory action and otherintervention implementationstudiestobettercharacterize successful andpotentially harmful intervention processes and strategies Characterizethebarriersto andrisks ofintervention participationforworkerswith lowerlevels ofpowerorinfluence Measure andreportnotonly absolute changes in exposure or healthmeasures outcomes askeyoutcomes,but also changes in disparities exposure or healthmeasures; Long-termstudies evaluatingthe impacts ofmacro-level legislative andregulatory interventions Organizational-level effectiveness studiesfocusing ontheparticularcircumstances ofworkergroupswith lowerlevels ofpoweror influence

Work Organization and Occupational Health Disparities

509

grant #375196 from the Australian National Health & Medical Research Council.

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