JE

Week 6: Socioeconomic Position, Employment, Work, and Education

Conceptual Framework and definitions (WHO)

  • Inequality arises as a system of social stratification or social hierarchy.
  • People attain different positions in the social stratification/hierarchy based on:
    • social class
    • occupational status
    • educational achievement
    • income level
  • People’s position in this social stratification system is summarized as their SOCIOECONOMIC POSITION (SEP).
  • Other terms for SEP include social class, social stratum, and social or socioeconomic status.

Social stratification, class, and SEP (WHO framework)

  • Social stratification refers to social hierarchies in which individuals or groups can be arranged along a ranked order of attributes (e.g., income, education) that predict health.
  • Social class may be defined by relations of ownership or control over productive resources (physical, financial, organizational).
  • SEP is meant to capture both social stratification and social class, and SEP predicts patterns of mortality and morbidity.

SEP as a SDOH (social determinant of health)

  • SEP, defined by work/occupation, employment, and educational attainment, serves as a key social determinant of health (SDOH).

SEP and the social gradient in health

  • The social gradient in health describes the phenomenon that people less advantaged in SEP have worse health (and shorter lives) than those more advantaged.

  • In the gradient, the highest social strata have better health and longer lives than the next strata down, continuing in a downward gradient to the bottom.

  • Source: Institute of Health Equity, 2014.

  • Whitehall studies (1970s, British civil servants) demonstrated a strong association between social class and health/mortality across multiple diseases; self-perceived health and symptoms were worse in lower-status jobs; employment grade differences observed in health-risk behaviors, early life environment, workplace social circumstances, and social supports.

Work, employment, and health (overview and questions)

  • Work and its role in shaping the health gradient:

    • It has long been recognized that adults with better jobs enjoy better health than those with less prestigious, lower-paying employment.
    • There is a strong association between job status and measures of chronic disease incidence, prevalence, and mortality in most Western countries.
    • Causation is not yet clear: how does work/employment influence health outcomes? Is it the job that improves health?

  • In-context synthesis (Clougherty et al., 2010) summarizes pathways linking work to health via a life-course lens (Early Adult Health, Childhood SES, Work/Unemployment, Education, Income, Benefits, Societal Status) and mediators at the workplace:

    • Work hazards
    • Psychosocial environment
    • Job demand
    • Job control
    • Work vigilance
    • Physical and chemical hazards
    • Physical environment
    • Injury
    • Context: Work organization and standard vs. non-standard settings
    • Adult health/mortality as outcomes

Work-Related Mediating Pathways (six core avenues)

(1) The role of status

  • Does position in an occupational hierarchy confer health risks or benefits in itself?
  • Anthropologic and biologic evidence suggest humans (like other primates) are hierarchical, and relative position can confer health effects.
  • Job status implies tangible benefits and hazards (income, fringe benefits, control over work, support, hazard exposure).
  • Job grade may reflect social, economic, and psychosocial risk factors:
    • White-collar: reflects workplace decision-making authority.
    • Blue-collar: reflects differences in chemical exposure, physical demands, or work pace.
  • Evidence is consistent, but possible selection bias of higher-SES individuals into better roles should be considered.

(2) Psychosocial job stressors (demand, control, reward)

  • Work entails multiple demands: physical, mental, and control/means to meet demands.
  • Chronic job strain, low job control, and stressful work conditions are linked to hypertension and elevated ambulatory blood pressure; potential effects include low promotion potential, little decision-making participation, unsupportive coworkers, and overall job dissatisfaction.
  • Stressful work experiences contribute to allostatic load (wear and tear on the body), potentially suppressing immune function over time and increasing disease risk.
  • Evidence of job strain is widespread in office/white-collar jobs; not as consistent for more physical jobs.

(3) Physical and chemical hazards

  • Work-related physical injury risks exist, plus exposure to thousands of toxic materials at the workplace.
  • A large portion of the workforce works in non-office conditions with some chemical exposure.
  • Exposure to hazardous agents tends to be negligible among better-educated salaried workers (~one-third of employees), yet poorer workers experience greater injury and broader hazardous exposures.

(4) Healthy work organization

  • Workplace safety cultures may influence injury/exposure incidence.
  • In health-care settings (e.g., nurses), job design and organizational interventions can affect worker injury and illness outcomes (e.g., needle-stick injuries).
  • High-strain jobs increase disability risk relative to low-strain jobs.
  • Lower-SES workers may be systematically exposed to worse safety cultures or disproportionately affected by them.

(5) The employment contract and worker health (unemployment/instability/contingent work)

  • Stable employment is associated with better health and survival than unstable or unemployed status.
  • Even in hazardous jobs, early retirement is linked to worse health than continued work.
  • Regular jobs confer health benefits beyond income; mechanisms include routine, responsibility, self-efficacy, or social support (routes not fully understood).
  • Job loss is associated with worse self-rated health and increased adverse health behaviors; excess mortality observed among individuals who were ever unemployed.
  • Work insecurity (prolonged unemployment risk) is more damaging for mental health and self-rated health than single episodes of job loss.

(6) Sex, gender, and occupation

  • Increasing numbers of women in traditionally male roles; differences in chemical exposures, ergonomic demands, accidents, and psychosocial stressors between sexes.
  • Blue-collar work shows larger health differentials, especially for men; for women, blue-collar work often involves hourly labor and is more common among racial minority women, immigrants, and those with lower SEP, correlating with poorer health.
  • Non-work factors (family roles, domestic responsibilities) influence susceptibility to employment-related health effects, fatigue, non-occupational stress, and return-to-work dynamics.

Precarious Employment and health outcomes (Benach et al., 2014)

  • Precarious: poorly paid, unprotected, and insecure work; no fixed legal definition, but it denotes insecure and unstable employment.
  • Precarious employment is now viewed as a social determinant of health and an employment condition affecting workers, families, and communities.
  • In wealthy countries, employment conditions are governed by labor laws or contracts; in LMICs, many agreements are unregulated, leading to more informal employment in both informal and formal sectors.
  • Precarious employment represents a continuum from secure full-time, well-compensated, and socially protected contracts to highly precarious arrangements with multiple uncertain features.

Development of Standard Employment Relationships (historical trajectory)

  • 1950–1970s (wealthy countries): standard employment relations shaped by generous welfare states, strong labor unions, and regulated employment relations; included constraints on hiring/firing, collective representation, minimum wages, pensions, etc.; but the model was not fully equitable and was biased toward male workers.
  • 1980s/1990s: privatization, downsizing, outsourcing, increased use of temporary workers, dismantling of internal labor markets; globalization and geographic dispersal of production.
  • 2008 economic crisis: labor-market reforms led to negative effects on living conditions and health:
    1) Direct staff cuts and rising unemployment causing poverty, social exclusion, and mental health problems.
    2) Quality jobs replaced by lower-wage, worse-working-conditions jobs, increasing flexible/precarious employment; immigrant/foreign guest workers heavily affected.
    3) Crisis-driven downsizing, outsourcing, and realignment increased temporary jobs even in previously protected public sectors.
    4) High unemployment reduced workers’ bargaining power; unions struggled to counter reforms that increased precarity; individuals faced insecurity and acceptance of worse conditions to remain employed.

Educational attainment and health outcomes

  • Figure: Life expectancy at age 25 by education and gender (U.S., 2006). Note: data presented for different education levels and for men vs. women; the chart shows variation by education level and gender.
  • Figure: Infant mortality rate in the U.S., by mother's education (2009). Note: infant mortality rate expressed per 1,000 live births across education levels of mothers.
  • These figures illustrate clear SEP-related health gradients: higher educational attainment is associated with better health outcomes (e.g., higher life expectancy, lower infant mortality).

Education-related mediating pathways (Shankar et al., 2014)

  • Higher educational attainment can lead to improved health because educated individuals tend to make better-informed health decisions for themselves and their families; education shapes employment opportunities, which are major determinants of economic resources.
  • More educated individuals experience lower unemployment rates, which are strongly associated with better health and lower mortality.
  • Education influences social and psychological factors such as greater perceived personal control, higher relative social standing, and increased social support.

Postsecondary education (PSE) and health resources

  • PSE is increasingly a minimum requirement for securing employment capable of providing needed resources for health and well-being.
  • Statistics: 66 ext{ \%} of Canadians having completed some form of postsecondary education.
  • Among immigrants: low income among visible minority immigrants is 3.5\times higher than the rate among the Canadian-born population, despite the fact that 52\% were skilled economic immigrants and 41\% had university degrees.

Mediating pathways schematic (educational attainment → health outcomes)

  • Educational attainment influences: health knowledge, literacy, coping and problem solving; work conditions; work-related resources; income; control beliefs.
  • Downstream health outcomes and mediators include: diet, exercise, smoking, health/disease status, exposure to hazards, and health insurance/use of sick leave and wellness programs.
  • Contextual factors that interact with education include housing and neighborhood environment; diet and exercise options; stress; coping and problem solving abilities.
  • The overall framework links educational attainment to health via social standing, social networks, perceived status, and health-related behaviors.
  • Source: Egerter et al., Braveman et al. (Education matters for health). The Robert Wood Johnson Foundation; 2011.

Closing note

  • The slides collectively connect socioeconomic position (SEP) to health through multiple, interlocking pathways: status, psychosocial stress, physical/chemical hazards, workplace organization, employment stability, gendered experiences, and education-related mediators.
  • Real-world relevance includes current debates on precarious employment, health disparities, and policy reforms aimed at improving worker health and reducing inequalities. Ethical implications center on ensuring fair work conditions, access to stable employment, and equitable education opportunities to promote population health.
  • For exam preparation, focus on:
    • Definitions of SEP, social stratification, social class, and their health implications.
    • The social gradient and classic evidence (Whitehall studies).
    • The six work-related mediating pathways and their mechanisms.
    • The concept and health relevance of precarious employment.
    • Historical shifts in standard employment relationships and health consequences of crises/reforms.
    • How education affects health via knowledge, employment, and psychosocial resources, including key Canadian statistics cited.