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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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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

Work Organization and Occupational Health Disparities


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

498 Landsbergis et al.

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.,



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

Work Organization and Occupational Health Disparities


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].


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

Work Organization and Occupational Health Disparities


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.,


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.


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






Differential vulnerability

Job insecurity




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


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


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



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


Racial and ethnicminority workers

Workingwomen Immigrantsworkers Racial and ethnicminority workers Precariously employedworkers

Precariously employedworkers




Reducedifferential vulnerability to health impacts ofpoorpsychosocial working conditions

Reducedifferential exposuretopoor

psychosocialworking conditions


Work Organization and Occupational Health Disparities


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.,


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


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



having little meaningful influence on worker empow- ’’


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


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.


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


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.


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.


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-


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?


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-


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


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


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


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


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


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


Adarga MS, Becerril LC, Champion CD. 2010. Gender, Aging, and Work: Aging Workers’ Strategies to Confront the Demands of Production in Maquiladora Plants in Nogales, Mexico. New Solut


Aiken LH, Sloan D, Klocinski JL. 1997. Hospital nurses’ occupa- tional exposure to blood: Prospective, retrospective, and institutional reports. Am J Public Health 87:103–107.

Akhavan S, Bildt C, Wamala S. 2007. Work-related health factors for female immigrants in Sweden. Work 28(2):135–143.

Artazcoz L, Corte` s I, Escriba` -Agu¨ ir V, Cascant L, Villegas R. 2009. Understanding the relationship of long working hours with health status and health-related behaviours. J Epidemiol Community Health


Bambra C, Egan M, Thomas S, Petticrew M, Whitehead M. 2007.

The psychosocial and health effects of workplace reorganisation. 2.

A systematic review of task restructuring interventions. J Epidemiol

Community Health 61:1028–1037.

Bambra CL, Whitehead MM, Sowden AJ, Akers J, Petticrew MP. 2008. Shifting schedules: The health effects of reorganizing shift work. Am J Prev Med 34:427–434.

Bambra C, Gibson M, Sowden AJ, Wright K, Whitehead M, Petti- crew M. 2009. Working for health? Evidence from systematic reviews on the effects on health and health inequalities of organisa- tional changes to the psychosocial work environment. Prev Med


Baum F. 2007. Cracking the nut of health equity: Top down and bottom up pressure for action on the social determinants of health. Promot Educ 14:90–95.

Belkic K, Emdad R, Theorell T. 1998. Occupational profile and car- diac risk: Possible mechanisms and implications for professional drivers. Int J Occup Med Environ Health 11:37–57.

Belkic K, Landsbergis P, Schnall P, Baker D. 2004. Is job strain a major source of cardiovascular disease risk? Scand J Work Environ Health 30:85–128.

Benach J, Muntaner C. 2007. Precarious employment and health:

Developing a research agenda. J Epidemiol Community Health 61:


Benach J, Muntaner C. 2010. Empleo, Trabajo y Desigualdades en Salud: Una Vision Global (Employment, work, and health inequal- ities: A global perspective). Barcelona: Icaria Editorial.

Benach J, Amable M, Muntaner C, Benavides FG. 2002. The conse- quences of flexible work for health: Are we looking at the right place? J Epidemiol Community Health 56:405–406.

Benach J, Gimeno D, Benavides FG, Martinez JM, Torne Mdel M. 2004. Types of employment and health in the European union:

Changes from 1995 to 2000. Eur J Public Health 14:314–321.

Benach J, Solar O, Santana V, Castedo A, Chung H, Muntaner C. 2010c. The role of employment relations in reducing health inequal- ities. A micro-level model of employment relations and health inequalities. Int J Health Services 40:223–227.

Benavides FG, Benach J, Muntaner C, Delclos GL, Catot N, Amable M. 2006. Associations between temporary employment and occupa- tional injury: What are the mechanisms? Occup Environ Med 63:


Besosa M. 2007. New Public Management. Academe 93.

Blau F, Ferber M, Winkler A. 2002. The economics of women, men and work. Upper Saddle River, NY: Prentice Hall.

Bonacich E, Appelbaum R. 2005. The return of the sweatshop. In: Kleniewski N, editor. Cities and society. New York: Blackwell Publishing, pp 127–143.

Borrell C, Muntaner C, Benach J, Artazcoz L. 2004. Social class and self-reported health status among men and women: What is the role of work organisation, household material standards and household labour? Soc Sci Med 58:1869–1887.

Bosma H, Marmot MG, Hemingway H, Nicholson AC, Brunner EJ, Stansfeld SA. 1997. Low job control and risk of coronary heart disease in Whitehall II (prospective cohort) study. Br Med J 314:


Bosma H, Peter R, Siegrist J, Marmot M. 1998. Two alternative job stress models and the risk of coronary heart disease. Am J Public Health 88:68–74.

Brisson C, Vinet A, Vezina M, Gingras S. 1989. Effect of duration of employment in piecework on severe disability among female gar- ment workers. Scand J Work Environ Health 15:329–334.

Brisson C, Laflamme N, Moisan J, Milot A, Masse B, Vezina M. 1999. Effect of family responsibilities and job strain on ambulatory blood pressure among white-collar women. Psychosom Med 61:


Broughton A, Tyers C, Denvir A, Wilson S, O’Regan S. 2009. Man- aging stress and sickness absence. Progress of the Sector Implemen- tation Plan—Phase 2. Research Report RR694 Sudbury: HSE books.

Brunette M. 2004. Construction safety research in the United States:

Targeting the Hispanic workforce. Inj Prev 10:244–248.

Bureau of Labor Statistics. 2005. Contingent and alternative employ- ment arrangements. Washington, DC: Bureau of Labor Statistics.

Bureau of Labor Statistics. 2010. Table 18. Employed persons by detailed industry, sex, race, and Hispanic or Latino ethnicity.

Burgard SA, Brand JE, House JS. 2009. Perceived job insecurity and worker health in the United States. Soc Sci Med 69:777–785.

Carroll D, Samardick R, Bernard S, Gabbard S, Hernandez T. 2005. Findings from the National Agricultural Workers Survey (NAWS) 2001–2002 : A demographic and employment profile of United States farm workers. Washington, DC: US Department of Labor.

Chibnall JT, Tait RC. 2005. Disparities in occupational low back injuries: Predicting pain-related disability from satisfaction with case management in African Americans and Caucasians. Pain Med 6(1):

Benach J, Castedo A, Solar O, Martinez JM, Vergara M, Amable M,


Buxo M, Demiral Y, Muntaner C. 2010a. The role of employment










relations in reducing health inequalities. Methods for the study of


comparative studies

of psychosocial




employment relations and health inequalities in a global context. Int









J Health Services 40:209–213.



Benach J, Muntaner C, Solar O, Santana V, Quinlan M. 2010b. Intro- duction to the WHO Commission on Social Determinants of Health Employment Conditions Network (EMCONET) study, with a glossa-

ry on employment relations. Int J Health Serv 40:195–207.

Choi B, Clays E, De Bacquer D, Karasek R. 2008. Socioeconomic status, job strain and common mental disorders—An ecological (occupational) approach. Scand J Work Environ Health (Suppl. 6):


510 Landsbergis et al.

Clarke M, Lewchuk W, de Wolff A, King A. 2007. This just isn’t sustainable’: Precarious employment, stress and workers’ health. Int

J Law Psychiatry 30:311–326.

Clougherty J, Souza K, Cullen M. 2010. Work and its role in shaping the social gradient in health. Ann N Y Acad Sci 1186:102–124.

Commission on Social Determinants of Health. 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organisation.

Cortina L, Magley V, Williams J, Langhout R. 2001. Incivility in the workplace: Incidence and impact. J Occup Health Psychol 6:


Cummings KJ, Kreiss K. 2008. Contingent workers and contingent health: Risks of a modern economy. JAMA 299:448–450.

De Witte H. 1999. Job insecurity and psychological well-being:

Review of the literature and exploration of some unresolved issues. Eur J Work Organ Psychol 8:155–177.

Dekker S, Schaufeli W. 1995. The effects of job insecurity on psy- chological health and withdrawal: A longitudinal study. Aust Psychol


Delp L, Wallace SP, Geiger-Brown J, Muntaner C. 2010. Job stress and job satisfaction: Home care workers in a consumer-directed model of care. Health Serv Res 45:922–940.

Dollard M, Skinner N, Tuckey M, Bailey T. 2007. National surveil- lance of psychosocial risk factors in the workplace: An international overview. Work Stress 21:1–29.

Dragano N, Verde PE, Siegrist J. 2005. Organisational downsizing and work stress: Testing synergistic health effects in employed men and women. J Epidemiol Community Health 59:694–699.

Dragano N, Siegrist J, Wahrendorf M. 2011. Welfare regimes, labour policies and unhealthy psychosocial working conditions: A compara- tive study with 9917 older employees from 12 European countries.

J Epidemiol Community Health 65:793–799.

D’Souza RM, Strazdins L, Lim LL, Broom DH, Rodgers B. 2003. Work and health in a contemporary society: Demands, control, and insecurity. J Epidemiol Community Health 57:849–854.

Eaker ED, Sullivan LM, Kelly-Hayes M, D’Agostino RB, Sr., Benja- min EJ. 2004. Does job strain increase the risk for coronary heart disease or death in men and women? The Framingham Offspring Study. Am J Epidemiol 159:950–958.

Egan M, Bambra C, Thomas S, Petticrew M, Whitehead M, Thomson H. 2007a. The psychosocial and health effects of work- place reorganisation. 1. A systematic review of organisational-level interventions that aim to increase employee control. J Epidemiol Community Health 61:945–954.

Egan M, Petticrew M, Ogilvie D, Hamilton V, Drever F. 2007b. ‘‘Profits before people’’? A systematic review of the health and safe- ty impacts of privatising public utilities and industries in developed countries. J Epidemiol Community Health 61:862–870.

Elovainio M, Kivimaki M, Vahtera J. 2002. Organizational justice:

Evidence of a new psychosocial predictor of health. Am J Public Health 92:105–108.

Elovainio M, Leino-Arjas P, Vahtera J, Kivimaki M. 2006. Justice

at work and cardiovascular mortality: A prospective cohort study.

J Psychosom Res 61:271–274.

European Agency for Safety and Health at Work. 2010. ESENER— European Survey of Enterprises on New and Emerging Risks. Luxembourg: Publications Office of the European Union.
















Craft Small and Medium-Sized Enterprises, Interest ECoEw- PPaoEoGE. 2004. Framework agreement on work-related stress. 4 pp.

Ferrie JE, Shipley MJ, Marmot MG, Stansfeld SA, Smith GD. 1998. An uncertain future: The health effects of threats to employment security in white-collar men and women. Am J Public Health 88:


Ferrie J, Shipley M, Stansfeld S, Marmot M. 2002. Effects of chronic job insecurity and change in job security on self-reported health mi- nor psychiatric morbidity physiological measures, and health related behaviours in British civil servants: The Whitehall II Study. J Epide- miol Community Health 56:450–454.

Ferrie JE, Shipley MJ, Newman K, Stansfeld SA, Marmot M.

2005. Self-reported job insecurity and health in the Whitehall II

study: Potential explanations of the relationship. Soc Sci Med 60:


Ferrie JE, Westerlund H, Oxenstierna G, Theorell T. 2007. The impact of moderate and major workplace expansion and downsizing on the psychosocial and physical work environment and income in Sweden. Scand J Public Health 35:62–69.

Ferrie J, Westerlund H, Virtanen M, Vahtera J, Kivima¨ki M. 2008. Flexible labor markets and employee health. Scandinavian Journal of Work, Environ Health (Suppl. 6):98–110.

Fischbacher CM, White M, Bhopal RS, Unwin NC. 2005. Self- reported work strain is lower in South Asian than European people:

Cross-sectional survey. Ethn Health 10:279–292.

Flannery RJ, Hanson M, Penk W, Pastva G, Navon M, Flannery G.

1997. Hospital downsizing and patients’ assaults on staff. Psychiatr

Q 68:67–76.

Frohlich KL, Potvin L. 2008. Transcending the known in public health practice: The inequality paradox: The population approach and vulnerable populations. Am J Public Health 98:216–221.

Fujishiro K, Landsbergis PA, Diez Roux AV, Stukovsky KH, Shrager

S, Baron S. 2011. Factorial invariance, scale reliability, and construct

validity of the job control and job demands scales for immigrant workers: The multi-ethnic study of atherosclerosis. J Immigr Minor Health 13:533–540.

Gadinger MC, Fischer JE, Schneider S, Terris DD, Kruckeberg K, Yamamoto S, Frank G, Kromm W. 2010. Gender moderates the health-effects of job strain in managers. Int Arch Occup Environ Health 83:531–541.

GAO. 2006. Employment arrangements: Improved outreach could help ensure proper worker classification. Washington, DC: U.S. Gov- ernment Accountability Office.

Giga SI, Noblet AJ, Faragher B, Cooper CL. 2003. The UK perspec- tive: A review of research on organisational stress management inter- ventions. Aust Psychol 38:158–164.

Gisselmann MD, Hemstrom O. 2008. The contribution of maternal working conditions to socio-economic inequalities in birth outcome. Soc Sci Med 66:1297–1309.

Golden L. 2008. Limited access: Disparities in flexible work sched- ules and work-at-home. J Fam Econ Issues 29:86–109.

Gong F, Baron S, Ayala L. 2009. Formative research in occupational health and safety intervention for diverse, underserved worker popu- lations: A homecare worker intervention project. Public health reports (Washington, DC: 1974). 124 (Suppl. 1):84–89.

Gonzalez MA, Artalejo FR, Calero JR. 1998. Relationship between socioeconomic status and ischaemic heart disease in cohort and case-control studies: 1960–1993. Int J Epidemiol 27:350–358.

Government Accountability Office. 2005. Workplace safety and health: Safety in the meat and poultry industry, while improving,

Work Organization and Occupational Health Disparities


could be further strengthened. Washington, DC: US Government Accountability Office.

Greenlund KJ, Kiefe CI, Giles WH, Liu K. 2010. Associations of job strain and occupation with subclinical atherosclerosis: The CAR- DIA Study. Ann Epidemiol 20:323–331.

Grosch JW, Caruso CC, Rosa RR, Sauter SL. 2006. Long hours of work in the U.S.: Associations with demographic and organizational characteristics, psychosocial working conditions, and health. Am J Ind Med 49:943–952.

Grzywacz JG, Arcury TA, Marı´n A, Carrillo L, Coates ML, Burke B, Quandt SA. 2007. The organization of work: Implications for in- jury and illness among immigrant Latino poultry-processing workers. Arch Environ Occup Health 62:19–26.

Grzywacz J, Alterman T, Muntaner C, Gabbard S, Nakamoto J, Carroll D. 2009. Measuring job characteristics and mental health among Latino farmworkers: Results from cognitive testing. J Immigr Minor Health 11:131–138.

Hallqvist J, Diderichsen F, Theorell T, Reuterwall C, Ahlbom A.

1998. Is the effect of job strain on myocardial infarction risk due to

interaction between high psychological demands and low decision

latitude? Results from Stockholm Heart Epidemiology Program (SHEEP). Soc Sci Med 46:1405–1415.

Heaney C, Israel B, House J. 1994. Chronic job insecurity among automobile workers: Effects on job satisfaction and health. Soc Sci Med 38:1431–1437.

Hemstrom O. 1999. Does the work environment contribute to excess male mortality? Soc Sci Med 49:879–894.

Hill JJ III, Slade MD, Cantley L, Vegso S, Fiellin M, Cullen MR.

2008. The relationships between lost work time and duration of

absence spells: Proposal for a payroll driven measure of absenteeism.

J Occup Environ Med 50:840–851.

Hintsa T, Kivimaki M, Elovainio M, Keskivaara P, Hintsanen M, Pulkki-Raback L, Keltikangas-Jarvinen L. 2006. Parental socioeco- nomic position and parental life satisfaction as predictors of job strain in adulthood: 18-year follow-up of the Cardiovascular Risk in Young Finns Study. J Psychosom Res 61:243–249.

Hipple S. 2001. Contingent work in the late 1990s. Mon Labor Rev


Huisman M, Van Lenthe F, Avendano M, Mackenbach J. 2008. The contribution of job characteristics to socioeconomic inequalities in incidence of myocardial infarction. Soc Sci Med 66:2240–2252.

Hurrell JJJ, Murphy LR. 1996. Occupational stress intervention. Am

J Ind Med 29:338–341.

Inoue A, Kawakami N, Ishizaki M, Shimazu A, Tsuchiya M, Tabata M, Akiyama M, Kitazume A, Kuroda M. 2010. Organizational justice, psychological distress, and work engagement in Japanese workers. Int Arch Occup Environ Health 83:29–38.

Johnson JV. 1989. Collective control: Strategies for survival in the workplace. Int J Health Serv 19:469–480.

Johnson JV, Hall EM. 1988. Job strain, workplace social support, and cardiovascular disease: A cross-sectional study of a random sample of the Swedish working population. Am J Public Health


Johnson JV, Lipscomb J. 2006. Long working hours, occupational health and the changing nature of work organization. Am J Ind Med


Johnson JV, Hall EM, Theorell T. 1989. Combined effects of job strain and social isolation on cardiovascular disease morbidity and mortality in a random sample of the Swedish male working popula- tion. Scand J Work Environ Health 15:271–279.

Kanjilal S, Gregg EW, Cheng YJ, Zhang P, Nelson DE, Mensah G, Beckles GL. 2006. Socioeconomic status and trends in disparities in 4 major risk factors for cardiovascular disease among US adults, 1971–2002. Arch Intern Med 166:2348–2355.

Karasek R, Theorell T. 1990. Healthy work: Stress, productivity, and the reconstruction of working life. New York, NY: Basic Books.

Karasek R, Brisson C, Kawakami N, Houtman I, Bongers P, Amick B. 1998. The job content questionnaire (JCQ): An instrument for internationally comparative assessments of psychosocial job charac- teristics. J Occup Health Psychol 3:322–355.

Karlsson BH, Knutsson AK, Lindahl BO, Alfredsson LS. 2003. Metabolic disturbances in male workers with rotating three-shift work. Results of the WOLF study. Int Arch Occup Environ Health


Kelsh MA, Lu ET, Ramachandran K, Jesser C, Fordyce T, Yager JW. 2004. Occupational injury surveillance among electric utility employees. J Occup Environ Med 46:974–984.

Kern JH, Grandey AA. 2009. Customer incivility as a social stressor:

The role of race and racial identity for service employees. J Occup Health Psychol 14:46–57.

Kim IH, Khang YH, Muntaner C, Chun H, Cho SI. 2008. Gender, precarious work, and chronic diseases in South Korea. Am J Ind Med 51:748–757.

Kivimaki M, Vahtera J, Pentti J, Ferrie JE. 2000. Factors underlying the effect of organisational downsizing on health of employees:

Longitudinal cohort study. BMJ 320:971–975.

Kivimaki M, Vahtera J, Virtanen M, Elovainio M, Pentti J, Ferrie J. 2003. Temporary employment and risk of overall and cause-specific mortality. Am J Epidemiol 158:663–668.

Kivimaki M, Ferrie J, Brunner E, Head J, Shipley M, Vahtera J, Marmot M. 2005. Justice at work and reduced risk of coronary heart disease among employees: The Whitehall II Study. Arch Intern Med


Kivimaki M, Honkonen T, Wahlbeck K, Elovainio M, Pentti J, Klaukka T, Virtanen M, Vahtera J. 2007. Organisational downsizing and increased use of psychotropic drugs among employees who remain in employment. J Epidemiol Community Health 61:154–


Kouvonen A, Kivimaki M, Elovainio M, Virtanen M, Linna A, Vahtera J. 2005. Job strain and leisure-time physical activity in female and male public sector employees. Prev Med 41:532–539.

Kouvonen A, Kivimaki M, Elovainio M, Pentti J, Linna A, Virtanen M, Vahtera J. 2006. Effort/reward imbalance and sedentary lifestyle:

An observational study in a large occupational cohort. Occup Environ Med 63:422–427.

Krantz G, Ostergren PO. 2001. Double exposure. The combined impact of domestic responsibilities and job strain on common symptoms in employed Swedish women. Eur J Public Health 11:


Krieger N, Waterman PD, Hartman C, Bates LM, Stoddard AM, Quinn MM, Sorensen G, Barbeau EM. 2006. Social hazards on the job: Workplace abuse, sexual harassment, and racial discrimina- tion—A study of Black, Latino, and White low-income women and men workers in the United States. Int J Health Serv 36:51–85.

Kuper H, Marmot M. 2003. Job strain, job demands, decision lati- tude, and risk of coronary heart disease within the Whitehall II study. J Epidemiol Community Health 57:147–153.

Kuper H, Singh-Manoux A, Siegrist J, Marmot M. 2002. When reci- procity fails: Effort-reward imbalance in relation to coronary heart disease and health functioning within the Whitehall II study. Occup Environ Med 59:777–784.

512 Landsbergis et al.

Kwon H, Pontusson J. 2006. Globalization, union decline and the politics of social spending growth in OECD countries, 1962–2000:

Yale University.

Laflamme N, Brisson C, Moisan J, Milot A, Masse B, Vezina M. 1998. Job strain and ambulatory blood pressure among female white- collar workers. Scand J Work Environ Health 24:334–343.

Lahelma E, Laaksonen M, Aittomaki A. 2009. Occupational class inequalities in health across employment sectors: The contribution of working conditions. Int Arch Occup Environ Health 82:185–190.

LaMontagne AD, Keegel TG. 2012. Reducing Stress in the Work- place (An Evidence Review: Full Report). Melbourne: Victorian Heath Promotion Foundation (VicHealth). 58 pp. Open access at http://www.vichealth.vic.gov.au/workplace, ISBN: 978-1-921822-


LaMontagne AD, Louie A, Keegel T, Ostry A, Shaw A. 2006. Work- place Stress in Victoria: Developing a Systems Approach Melbourne:

Victorian Health Promotion Foundation. 143 pp. Open access at www.vichealth.vic.gov.au/workplacestress, ISBN 0-9757335-3-2.

LaMontagne AD, Keegel T, Louie AM, Ostry A, Landsbergis PA. 2007a. A systematic review of the job stress intervention evaluation literature: 1990—2005. Intl J Occup Environ Health 13:268–280.

LaMontagne AD, Keegel T, Vallance DA. 2007b. Protecting & promoting mental health in the workplace: Developing a systems approach to job stress. Health Promot J Austr 18:221–228.

LaMontagne AD, Keegel T, Vallance D, Ostry A, Wolfe R. 2008. Job strain—Attributable depression in a sample of working Austral- ians: Assessing the contribution to health inequalities. BMC Public Health 8:181.

LaMontagne AD, Sanderson K, Cocker F. 2010. Estimating the Economic Benefits of Eliminating Job Strain as a Risk Factor for Depression Melbourne: Victorian Heath Promotion Foundation (VicHealth). 37 pp. Open accessed at http://www.vichealth.vic.gov. au/jobstrain, ISBN: 978-1-921822-02-5.

LaMontagne A, Krnjacki L, Kavanagh A, Bentley R. 2011. Psycho- social working conditions: Time trends in psychosocial working conditions in a representative sample of working Australians 2000– 2008: Evidence of narrowing disparities? (abstract). Occup Environ Med 68(Suppl. 1):A22.

LaMontagne AD, Noblet AJ, Landsbergis PA. 2012. Intervention development and implementation: Understanding and addressing barriers to organisational-level interventions. In: Biron C, Karanika- Murray M, Cooper CL, editors. Improving organizational interven- tions for stress and well-being: Addressing process and context. London: Routledge/Psychology Press, pp 21–38.

Landsbergis PA. 2009. Interventions to reduce job stress and improve work organization and worker health. In: Schnall P, Dobson M, Rosskam E, Gordon D, Landsbergis PA, Baker D, editors. Unhealthy work: Causes, consequences, cures amityville. NY: Baywood Pub- lishing, pp 193–209.

Landsbergis PA. 2010. Assessing the contribution of working condi- tions to socioeconomic disparities in health: A commentary. Am J Ind Med 53:95–103.

Landsbergis P, Cahill J, Schnall P. 1999. The impact of lean produc- tion and related new systems of work organization on worker health. J Occup Health Psychol 4(2):108–130.

Landsbergis P, Schnall P, Pickering T, Warren K, Schwartz J. 2003. Lower socioeconomic status among men in relation to the associa- tion between job strain and blood pressure. Scandinavian Journal of Work, Environ Health 29:206–215.

Landsbergis P, Grzywacz J, LaMontagne A, with contributions by, Muntaner C, Benach J, Lipscomb J, Johnson J, Schnall P, Riley K,

Rosskam E, Zelnick J, 2011a. Work Organization, Job Insecurity,

and Occupational Health Disparities: An Issue Paper for Discussion

at the NIOSH Eliminating Health and Safety Disparities at Work

Conference, Chicago, Illinois.

Landsbergis P, Sinclair R, Dobson M, Hammer L, Jauregui M, LaMontagne A, Olson R, Schnall P, Stellman J, Warren N. 2011b. Occupational health psychology. In: Anna D, editor. The occupation-

al environment: Its evaluation, control, and management. Fairfax,

VA: American Industrial Hygiene Association, pp 1086–1130.

Laszlo KD, Pikhart H, Kopp MS, Bobak M, Pajak A, Malyutina S, Salavecz G, Marmot M. 2010. Job insecurity and health: A study of 16 European countries. Soc Sci Med 70:867–874.

Leka S, Cox T, editors. 2008. The European Framework for Psycho- social Risk Management: PRIMA-EF. Nottingham (UK): Institue of Work, Health & Organisations.

Leka S, Vartia M, Hassard J, Pahkin K, Sutela S, Cox T, Lindstrom

K. 2008. Best practice in interventions for the prevention and man-

agement of work-related stress and workplace violence and bullying. In: Leka S, Cox T, editors. The European Framework for Psychoso-

cial Risk Management: PRIMA-EF. Nottingham, UK: Institute of Work, Health and Organisations, pp 136–173.


Leka S, Jain A, Widerszal-Bazyl M, Z ołnierczyk-Zreda D, Zwetsloot

G. 2011. Developing a standard for psychosocial risk management:

PAS 1010. Saf Sci 49:1047–1057.

Lim S, Lee A. 2011. Work and nonwork outcomes of workplace

incivility: Does family support help? J Occup Health Psychol 16:


Lim S, Cortina L, Magley V. 2008. Personal and workgroup incivili- ty: Impact on work and health outcomes. J Appl Psychol 93:95–107.

Lipscomb HJ, Loomis D, McDonald MA, Argue RA, Wing S. 2006.

A conceptual model of work and health disparities in the U.S. Int J

Health Services 36(1):25–50.

Lipscomb HJ, Dement JM, Epling CA, Gaynes BN, McDonald MA, Schoenfisch AL. 2007. Depressive symptoms among working women in rural North Carolina: A comparison of women in poultry

processing and other low-wage jobs. Int J Law Psychiatry 30(4–5):


Lopes CS, Araya R, Werneck GL, Chor D, Faerstein E. 2010. Job strain and other work conditions: Relationships with psychological distress among civil servants in Rio de Janeiro, Brazil. Soc Psychia- try Psychiatr Epidemiol 45:345–354.

Louie A, Ostry A, Quinlan M, Keegel T, Shoveller J, LaMontagne

A. 2006. Empirical study of employment arrangements and pre-

cariousness in Australia. Relations Industrielles/Ind Relat 61:


Lynch J, Krause N, Kaplan G, Tuomilehto J, Salonen J. 1997. Work- place conditions, socioeconomic status, and the risk of mortality and acute myocardial infraction: The Kuopio Ischemic Heart Disease Risk Factor Study. Am J Public Health 87:617.

Malinauskiene V, Theorell T, Grazuleviciene R, Malinauskas R, Azaraviciene A. 2004. Low job control and myocardial infarction risk in the occupational categories of Kaunas men, Lithuania. J Epi- demiol Community Health 58:131–135.

Marmot M. 2010. Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010. London: Marmot Review.

Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S. 1997. Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet 350:235–239.

Marmot M, Newman K, Ferrie J, Stansfeld S. 2001. The contribution

of job insecurity to socio-economic inequalities Lancaster Lancaster

University, Health Variations Programme.

Work Organization and Occupational Health Disparities


Martikainen P, Maki N, Jantti M. 2008. The effects of workplace downsizing on cause-specific mortality: A register-based follow- up study of Finnish men and women remaining in employment.

J Epidemiol Community Health 62:1008–1013.

Matthews S, Hertzman C, Ostry A, Power C. 1998. Gender, work roles and psychosocial work characteristics as determinants of health. Soc Sci Med 46:1417–1424.

Mayhew C, Quinlan M. 1999. The effects of outsourcing on occupa- tional health and safety: A comparative study of factory-based work- ers and outworkers in the Australian clothing industry. Int J Health Serv 29:83–107.

McCurdy SA, Samuels SJ, Carroll DJ, Beaumont JJ, Morrin LA. 2003. Agricultural injury in California migrant Hispanic farm work- ers. Am J Ind Med 44:225–235.


Messing K, O stlin P. 2006. Gender equality, work and health: A re-

view of the evidence. Geneva: World Health Organization.

Meyer JD, Muntaner C. 1999. Injuries in home health care workers:

An analysis of occupational morbidity from a state compensation database. Am J Ind Med 35:295–301.

Moncada S, Pejtersen JH, Navarro A, Llorens C, Burr H, Hasle P, Bjorner JB. 2010. Psychosocial work environment and its association with socioeconomic status. A comparison of Spain and Denmark. Scand J Public Health 38:137–148.

Muntaner C, Eaton WW, Diala C, Kessler RC, Sorlie PD. 1998a.

Social class, assets, organizational control and the prevalence of common groups of psychiatric disorders. Soc Sci Med 47:2043–


Muntaner C, Nieto FJ, Cooper L, Meyer J, Szklo M, Tyroler HA. 1998b. Work organization and atherosclerosis: Findings from the ARIC study. Am J Prev Med 14:9–18.

Muntaner C, Borrell C, Benach J, Pasarı´n M, Fernandez E. 2003. The associations of social class and social stratification with patterns of general and mental health in a Spanish population. Int J Epide- miol 32:950–958.

Muntaner C, Eaton W, Miech R, O’Campo P. 2004. Socioeconomic position and major mental disorders. Epidemiol Rev 26:53–62.

Muntaner C, Chung H, Kim I, Benach J. 2008. Populations at special health risk: Workers. In: Heggenhougen K, Quah S, editors. Interna- tional Encyclopedia of Public Health. San Diego: Academic Press, pp 285–301.

Muntaner C, Chung H, Solar O, Santana V, Castedo A, Benach J. 2010a. The role of employment relations in reducing health inequal- ities. A macro-level model of employment relations and health inequalities. Int J Health Serv 40:215–221.

Muntaner C, Solar O, Vanroelen C, Martinez JM, Vergara M, San- tana V, Castedo A, Kim IH, Benach J. 2010b. Unemployment, infor-

mal work, precarious employment, child labor, slavery, and health inequalities: Pathways and mechanisms. Int J Health Serv 40:281–


Muntaner C, Sridharan S, Chung H, Solar O, Quinlan M, Vergara M, Benach J. 2010c. The role of employment relations in reducing

health inequalities. The solution space: Developing research and pol- icy agendas to eliminate employment-related health inequalities. Int

J Health Serv 40:309–314.

Nicholson VJ, Bunn TL, Costich JF. 2008. Disparities in work-relat- ed injuries associated with worker compensation coverage status. Am J Indust Med 51(6):393–398.

Niedhammer I, Bourgkard E, Chau N. 2011. Occupational and behavioural factors in the explanation of social inequalities in prema- ture and total mortality: A 12.5-year follow-up in the Lorhandicap study. Eur J Epidemiol 26(1):1–12.

Nielsen K, Taris TW, Cox T. 2010. The future of organizational interventions: Addressing the challenges of today’s organizations. Work Stress 24:219–233.

NIOSH. 2002. The changing organization of work and the safety and health of working people. Cincinnati, Ohio: National Institute for Occupational Safety and Health.

Ostry A, Maggi S, Tansey J, Dunn J, Hershler R, Chen L, Louie AM, Hertzman C. 2007. The impact of psychosocial work conditions on attempted and completed suicide among western Canadian saw- mill workers. Scand J Public Health 35:265–271.

Paoli P, Merllie´ D. 2001. Third European Survey on Working Con- ditions Dublin: European Foundation for the Improvement of Living and Working Conditions.

Park H, Sandefur GD. 2003. Racial/ethnic differences in voluntary and involuntary job mobility among young men. Soc Sci Res 32:


Parslow RA, Jorm AF, Christensen H, Broom DH, Strazdins L, RM DS. 2004. The impact of employee level and work stress on mental health and GP service use: An analysis of a sample of Australian government employees. BMC Public Health 4:41.

Pikhart H, Bobak M, Pajak A, Malyutina S, Kubinova R, Topor R, Sebakova H, Nikitin Y, Marmot M. 2004. Psychosocial factors at work and depression in three countries of Central and Eastern Europe. Soc Sci Med 58:1475–1482.

Pollack KM, Sorock GS, Slade MD, Cantley L, Sircar K, Taiwo O, Cullen MR. 2007. Association between body mass index and acute traumatic workplace injury in hourly manufacturing employees. Am J Epidemiol 166:204–211.

Probst TM. 2002. Layoffs and tradeoffs: Production, quality, and safety demands under the threat of job loss. J Occup Health Psychol


Probst T. 2004. Job Insecurity: Exploring a New threat to employee safety. In: Barling J, Frone M, editors. The psychology of workplace safety. Washington, DC: American Psychological Association.

Probst T. 2005. Economic stressors. In: Barling J, Kelloway E, Frone M, editors. Handbook of work stress. Thousand Oaks, CA: Sage Publications.

Probst TM, Brubaker TL. 2001. The effects of job insecurity on em- ployee safety outcomes: Cross-sectional and longitudinal explora- tions. J Occup Health Psychol 6:139–159.

Quandt SA, Grzywacz JG, Marin A, Carrillo L, Coates ML, Burke B, Arcury TA. 2006. Illnesses and injuries reported by Latino poultry workers in western North Carolina. Am J Ind Med 49:343–351.

Quinlan M, Bohle P. 2009. Overstretched and unreciprocated com- mitment: Reviewing research on the occupational health and safety effects of downsizing and job insecurity. Int J Health Serv 39:1–44.

Quinlan M, Sokas RK. 2009. Community campaigns, supply chains, and protecting the health and well-being of workers. Am J Public Health 99(Suppl. 3):S538–S546.

Quinlan M, Mayhew C, Bohle P. 2001. The global expansion of pre- carious employment, work disorganization, and consequences for oc- cupational health: A review of recent research. Int J Health Serv


Quinlan M, Muntaner C, Solar O, Vergara M, Eijkemans G, Santana V, Chung H, Castedo A, Benach J. 2010. Policies and interventions on employment relations and health inequalities. Int J Health Serv


Radi S, Ostry A, LaMontagne A. 2007. Job stress and other working conditions: Relationships with smoking behaviors in a representative sample of working Australians. Am J Ind Med 50:584–596.

514 Landsbergis et al.

Richardson C. 2008. Working alone: The erosion of solidarity in today’s workplace. New Labor Forum 17:69–78.

Robertson R, Fallavollita B, Siegel L, Peterson J, Campbell J. 2006. Employment Arrangements: Improved Outreach Could Help Ensure Proper Worker Classification [GAO-06-656]. Washington, DC: US Government Accountability Office.

Rostila M. 2008. The Swedish labour market in the 1990s: The very last of the healthy jobs? Scand J Public Health 36:126–134.

Rotenberg L, Griep RH, Fischer FM, Fonseca M, Landsbergis PA.

2009. Working at night and work ability among nursing personnel:

When precarious employment makes the difference. Int Arch Occup

Environ Health 82:877–885.

Rugulies R, Bultmann U, Aust B, Burr H. 2006. Psychosocial work environment and incidence of severe depressive symptoms: Prospec- tive findings from a 5-year follow-up of the Danish Work Environ- ment Cohort Study. Am J Epidemiol 163:877–887.

Runyan J. 2000. Summary of federal laws and regulations affecting agricultural employers, 2000. Agricultural Handbook No. 719 ed.:

Food and Rural Economics Division, Economic Research Service, US Department of Agriculture.

Salminen S, Kivimaki M, Elovainio M, Vahtera J. 2003. Stress fac-

tors predicting injuries of hospital personnel. Am J Ind Med 44:32–


Schnall P, Belkic K, Landsbergis PA, Baker De. 2000. The work- place and cardiovascular disease. Occupational Medicine: State-of- the-Art Reviews. Philadelphia, PA: Hanley and Belfus.

Schnall P, Rosskam E, Dobson M, Gordon D, Landsbergis P, Baker D, editors. 2009. Unhealthy work: Causes, consequences and cures amityville. NY: Baywood Publishing.

Seixas NS, Blecker H, Camp J, Neitzel R. 2008. Occupational health and safety experience of day laborers in Seattle, WA. Am J Indust Med 51:399–406.

Sekine M, Chandola T, Martikainen P, Marmot M, Kagamimori S.

2009. Socioeconomic inequalities in physical and mental functioning

of British, Finnish, and Japanese civil servants: Role of job demand,

control, and work hours. Soc Sci Med 69:1417–1425.

Sekine M, Tatsuse T, Kagamimori S, Chandola T, Cable N, Marmot M, Martikainen P, Lallukka T, Rahkonen O, Lahelma E. 2011. Sex inequalities in physical and mental functioning of British, Finnish, and Japanese civil servants: Role of job demand, control and work hours. Soc Sci Med 73(4):595–603.

Siegrist J, Rodel A. 2006. Work stress and health risk behavior. Scand J Work Environ Health 32:473–481.

Siegrist J, Starke D, Chandola T, Godin I, Marmot M, Niedhammer I, Peter R. 2004. The measurement of effort-reward imbalance at work: European comparisons. Soc Sci Med 58:1483–1499.

Siegrist J, Rosskam E, Leka S. 2011. Review of social determinants of health and the health divide in the WHO-European Region: Em- ployment and working conditions including occupation, unemploy- ment and migrant workers (unpublished report). Copenhagen: World Health Organization.

Silverstein B, Welp E, Nelson N, Kalat J. 1998. Claims incidence of work-related disorders of the upper extremities: Washington state, 1987 through 1995. Am J Public Health 88:1827–1833.

Silverstein B, Viikari-Juntura E, Kalat J. 2002. Use of a prevention index to identify industries at high risk for work-related musculo- skeletal disorders of the neck, back, and upper extremity in Washing- ton state, 1990–1998. Am J Ind Med 41:149–169.

Smith MJ, Carayon P, Sanders KJ, Lim S-Y, LeGrande D. 1992. Employee stress and health complaints in jobs with and without elec- tronic performance monitoring. Appl Ergon 23:17–27.

Smith PM, Frank JW, Mustard CA, Bondy SJ. 2008. Examining the relationships between job control and health status: A path analysis approach. J Epidemiol Community Health 62:54–61.

Sousa E, Agudelo-Suarez A, Benavides FG, Schenker M, Garcia AM, Benach J, Delclos C, Lopez-Jacob MJ, Ruiz-Frutos C, Ronda- Perez E, Porthe V, Project I. 2010. Immigration, work and health in Spain: The influence of legal status and employment contract on reported health indicators. Int J Public Health 55:443–451.

Steenland K. 2000. Shift work, long hours, and CVD: A review. Occup Med State Art Rev 15:7–17.

Sundquist J, Ostergren PO, Sundquist K, Johansson SE. 2003. Psy- chosocial working conditions and self-reported long-term illness: A population-based study of Swedish-born and foreign-born employed persons. Ethn Health 8:307–317.

Suominen S, Vahtera J, Korkeila K, Helenius H, Kivimaki M, Koskenvuo M. 2007. Job strain, life events, and sickness absence: A longitudinal cohort study in a random population sample. J Occup Environ Med 49:990–996.

Sverke M, Hellgren J, Naswall K. 2002. No security: A meta-analy- sis and review of job insecurity and its consequences. J Occup Health Psychol 7:242–264.

Thomas C, Power C. 2010. Do early life exposures explain associa- tions in mid-adulthood between workplace factors and risk factors for cardiovascular disease? Int J Epidemiol 39:812–824.

Toh S, Quinlan M. 2009. Safeguarding the global contingent work- force? Guestworkers in Australia. Int J Manpower 30:453–471.

Tuchsen F, Endahl LA. 1999. Increasing inequality in ischaemic heart disease morbidity among employed men in Denmark 1981– 1993: The need for a new preventive policy. Int J Epidemiol 28:


Vaananen A, Koskinen A, Joensuu M, Kivimaki M, Vahtera J, Kouvonen A, Jappinen P. 2008. Lack of predictability at work and risk of acute myocardial infarction: An 18-year prospective study of industrial employees. Am J Public Health 98:2264–2271.

Vahtera J, Kivimaki M, Pentti J, Linna A, Virtanen M, Virtanen P, Ferrie J. 2004. Organisational downsizing, sickness absence, and mortality: 10-town prospective cohort study. BMJ 328:555.

Vanroelen C, Levecque K, Moors G, Gadeyne S, Louckx F. 2009. The structuring of occupational stressors in a Post-Fordist work envi- ronment. Moving beyond traditional accounts of demand, control and support. Soc Sci Med 68:1082–1090.

Virtanen P, Liukkonen V, Vahtera J, Kivimaki M, Koskenvuo M. 2003. Health inequalities in the workforce: The labour market core- periphery structure. Int J Epidemiol 32:1015–1021.

Virtanen M, Kivimaki M, Joensuu M, Virtanen P, Elovainio M, Vah- tera J. 2005. Temporary employment and health: A review. Int J Epi- demiol 34:610–622.

Virtanen M, Vahtera J, Pentti J, Honkonen T, Elovainio M, Kivimaki M. 2007. Job strain and psychologic distress influence on sickness absence among Finnish employees. Am J Prev Med 33:


Virtanen M, Kivimaki M, Singh-Manoux A, Gimeno D, Shipley MJ, Vahtera J, Akbaraly TN, Marmot MG, Ferrie JE. 2010. Work disabil- ity following major organisational change: The Whitehall II study. J Epidemiol Community Health 64:461–464.

Virtanen P, Janlert U, Hammarstrom A. 2011. Exposure to temporary employment and job insecurity: A longitudinal study of health effects. Occup Environ Med 68:570–574.

Vives A, Amable M, Ferrer M, Moncada S, Llorens C, Muntaner C, Benavides FG, Benach J. 2010. The Employment Precariousness

Work Organization and Occupational Health Disparities


Scale (EPRES): Psychometric properties of a new tool for epidemio- logical studies among waged and salaried workers. Occup Environ Med 67:548–555.

Wang JL, Lesage A, Schmitz N, Drapeau A. 2008. The relationship between work stress and mental disorders in men and women: Find- ings from a population-based study. J Epidemiol Community Health


Wang JL, Schmitz N, Dewa C, Stansfeld S. 2009. Changes in per- ceived job strain and the risk of major depression: Results from a population-based longitudinal study. Am J Epidemiol 169:1085–1091.

Wege N, Dragano N, Erbel R, Jockel KH, Moebus S, Stang A, Sieg- rist J. 2008. When does work stress hurt? Testing the interaction

with socioeconomic position in the Heinz Nixdorf Recall Study. J Epidemiol Community Health 62:338–341.

Westerberg L, Theorell T. 1997. Working conditions and family situ- ation in relation to functional gastrointestinal disorders. The Swedish Dyspepsia Project. Scand J Prim Health Care 15:76–81.

Wilson G, Eitle TM, Bishin B. 2006. The determinants of racial dis- parities in perceived job insecurity: A test of three perspectives. Sociol Inq 76:210–230.

Yamauchi B, Allen K. 2011. New Law Ups the Ante Significantly for California Employers Who Are Caught Misclassifying Employ- ees As Independent Contractors.