Can psychosocial risk factors mediate the association between precarious employment and mental health problems in Sweden? Results from a register-based study.

OBJECTIVES: The aim of this study was to examine the mediating effect of the psychosocial work environment on the association between precarious employment (PE) and increased risk of common mental disorders (CMD), substance use disorders and suicide attempts. METHODS: This longitudinal register-study was based on the working population of Sweden, aged 25-60 years in 2005 (N=2 552 589). Mediation analyses based on a decomposition of counterfactual effects were used to estimate the indirect effect of psychosocial risk factors (PRF) (mediators, measured in 2005) on the association between PE (exposure, measured in 2005) and the first diagnosis of CMD, substance use disorders, and suicide attempts occurring over 2006-2017. RESULTS: The decomposition of effects showed that the indirect effect of the PRF is practically null for the three outcomes considered, among both sexes. PE increased the odds of being diagnosed with CMD, substance use disorders, and suicide attempts, among both men and women. After adjusting for PE, low job control increased the odds of all three outcomes among both sexes, while high job demands decreased the odds of CMD among women. High job strain increased the odds of CMD and suicide attempts among men, while passive job increased the odds of all three outcomes among women. CONCLUSION: The results of this study did not provide evidence for the hypothesis that psychosocial risks could be the pathways linking precarious employment with workers` mental health. Future studies in different social contexts and labour markets are needed.

Causal effect of shifting from precarious to standard employment on all-cause mortality in Sweden: an emulation of a target trial.

BACKGROUND: We aimed at estimating the causal effect of switching from precarious to standard employment on the 6-year and 12-year risk of all-cause mortality among workers aged 20-55 years in Sweden. METHODS: We emulated a series of 12 target trials starting every year between 2005 and 2016 using Swedish register data (n=251 273). We classified precariously employed individuals using a multidimensional approach at baseline as (1) remaining in precarious employment (PE) (73.8%) and (2) shifting to standard employment (26.2%). All-cause mortality was measured from 2006 to 2017. We pooled data for all 12 emulated trials and used covariate-adjusted pooled logistic regression to estimate intention-to-treat and per-protocol effects via risk ratios (RRs) and standardised risk curves (the parametric g-formula). RESULTS: Shifting from precarious to standard employment decreases the 12-year risk of death by 20% on the relative scale (RR: 0.82, 95% CI: 0.73; 0.93), regardless of what happens after the initial shift. However, we estimated a 12-year risk reduction of 30% on the relative scale for workers shifting from precarious to standard employment and staying within this employment category for the full 12 years (RR: 0.71, 95% CI: 0.54; 0.95). CONCLUSIONS: This study finds that shifting from low to higher-quality employment conditions (ie, stable employment, sufficient income levels and high coverage by collective agreements) decreases the risk of death. Remaining in PE increases the risk of premature mortality. Our results emphasise the necessity of ensuring decent work for the entire working population to accomplish the 2030 Agenda for Sustainable Development.

Unequal access? Use of sickness absence benefits by precariously employed workers with common mental disorders: a register-based cohort study in Sweden.

OBJECTIVE: This study compares the use of sickness absence benefits (SABs) due to a common mental disorder (CMD) between precariously employed and non-precariously employed workers with CMDs. DESIGN: Register-based cohort study. PARTICIPANTS: The study included 78 215 Swedish workers aged 27-61 who experienced CMDs in 2017, indicated by a new treatment with selective serotonin reuptake inhibitors (SSRIs). Excluded were those who emigrated or immigrated, were self-employed, had an annual employment-based income <100 Swedish Krona, had >90 days of unemployment per year, had student status, had SABs due to CMDs during the exposure measurement (2016) and the two previous years, had an SSRI prescription 1 year or less before the start of the SSRI prescription in 2017, had packs of >100 pills of SSRI medication, had a disability pension before 2017, were not entitled to SABs due to CMDs in 2016, and had no information about the exposure. OUTCOME: The first incidence of SABs due to CMDs in 2017. RESULTS: The use of SABs due to a CMD was slightly lower among precariously employed workers compared with those in standard employment (adjusted OR [aOR] 0.92, 95% CI 0.81 to 1.05). Particularly, women with three consecutive years in precarious employment had reduced SABs use (aOR 0.48, 95% CI 0.26 to 0.89), while men in precarious employment showed weaker evidence of association. Those in standard employment with high income also showed a lower use of SABs (aOR 0.74, 95% CI 0.67 to 0.81). Low unionisation and both low and high-income levels were associated with lower use of SABs, particularly among women. CONCLUSIONS: The study indicates that workers with CMDs in precarious employment may use SABs to a lower extent. Accordingly, there is a need for (1) guaranteeing access to SABs for people in precarious employment and/or (2) reducing involuntary forms of presenteeism.

Precarious employment and occupational injuries in Sweden between 2006 and 2014: a register-based study.

BACKGROUND: Precarious employment (PE) has been suggested as a risk factor for occupational injuries (OIs). However, several issues such as under-reporting and time at risk pose obstacles to obtaining unbiased estimates of risk OBJECTIVE: To investigate if PE is a risk factor for OIs in Sweden. METHODS: This register-based study included employed workers aged 18-65, resident in Sweden between 2006 and 2014. PE was operationalised as a multidimensional construct (score) and by its five items (contract insecurity, contractual temporariness, multiple jobs/multiple sectors, income level, collective bargaining agreement). Our outcome was OI in the following year. Pooled ORs for OIs in relation to PE and PE items were calculated by means of multivariate logistic regression models for women and men separately. RESULTS: Precarious workers were at lower risk of OIs as compared with non-precarious workers among both males and females (OR <1) also when applying weights for under-reporting and adjusting for time at risk (part-time work). Male agencies workers had a higher risk of OIs (OR 1.19, 95% CI 1.15 to 1.23), as did male and female workers in multiple jobs/sectors (OR 1.25, 95% CI 1.23 to 1.28 and OR 1.10, 95% CI 1.07 to 1.13 respectively), and female workers in the low-income groups (OR 1.11, 95% CI 1.09 to 1.12). Low coverage of collective bargaining agreements was associated with a lower risk of OIs for both men and women (OR 0.30, 95% CI 0.29 to 0.31 and OR 0.26, 95% CI 0.24 to 0.27, respectively). CONCLUSIONS: While several mechanisms may explain why precarious workers in Sweden present lower risks of OIs, several dimensions of PE such as temp agency work and multiple job-holding could be important risk factors for OIs and merit further research.

Trends in Precarious Employment in Sweden 1992-2017: A Social Determinant of Health.

The aim of this study was to identify trends in precarious employment in the Swedish workforce from 1992 to 2017. This is a repeated cross-sectional study, analyzing the total working population aged 16-75 in Sweden at five-year intervals. We used version 2.0 of the Swedish Register-based Operationalization of Precarious Employment, covering the following dimensions: employment insecurity, income inadequacy, lack of rights and protection. The proportion in precarious employment increased from 9.7 to 12% between 1992 and 2017, a relative increase of 24%. The prevalence was higher among those of lower age, of low education, and immigrants. Differences between sexes converged, and there were slightly more precarious men than women in 2017. The relative increase was most pronounced among men, especially those with low educational attainment and of European origin. The increasing proportion of precarious employees is a clear challenge to the tripartite Nordic model, which requires sufficient trade-union bargaining power.

Low-quality employment trajectories and the risk of common mental health disorders among individuals with Swedish and foreign background - a register-based cohort study.

OBJECTIVE: This study aimed to examine the effects of low-quality employment trajectories on severe common mental disorders (CMD) according to Swedish and foreign background. METHODS: In this longitudinal study based on Swedish population registries (N=2 703 687), low- and high-quality employment trajectories were the main exposures observed across five years (2005-2009), with severe CMD as outcome variable (2010-2017). Adjusted hazard ratios (HR) were calculated by means of Cox regression models and stratified according to Swedish and foreign background [first-generation (i) EU migrants, (ii) non-EU migrants, (iii) second-generation migrants, (iv) Swedish-born of Swedish background] and sex. The reference group was Swedish-born of Swedish background in a constant high-quality employment trajectory. RESULTS: Second-generation migrants had an increased risk of CMD compared to Swedish-born of Swedish background when following low-quality employment trajectories [eg, male in constant low-quality HR 1.54, 95% confidence interval (CI) 1.41-1.68]. Female migrant workers, especially first-generation from non-EU countries in low-quality employment trajectories (eg, constant low-quality HR 1.66, 95% CI 1.46-1.88), had a higher risk of CMD compared to female Swedish-born of Swedish background. The risk for CMD according to employment trajectories showed little differences between first- and second-generation migrants. CONCLUSION: Low-quality employment trajectories appear to be determinants of risk for CMD in association with Swedish or foreign background of origin and sex. Our study shows a higher risk for severe CMD in second-generation and non-EU migrant compared to Swedish-born of Swedish background in constant low-quality employment. Further qualitative research is recommended to understand the mechanism behind the differential mental health impact of low-quality employment trajectories according to foreign background.

Initiatives Addressing Precarious Employment and Its Effects on Workers' Health and Well-Being: A Systematic Review.

The prevalence of precarious employment has increased in recent decades and aspects such as employment insecurity and income inadequacy have intensified during the COVID-19 pandemic. The purpose of this systematic review was to identify, appraise, and synthesise existing evidence pertaining to implemented initiatives addressing precarious employment that have evaluated and reported health and well-being outcomes. We used the PRISMA framework to guide this review and identified 11 relevant initiatives through searches in PubMed, Scopus, Web of Science, and three sources of grey literature. We found very few evaluated interventions addressing precarious employment and its impact on the health and well-being of workers globally. Ten out of 11 initiatives were not purposefully designed to address precarious employment in general, nor specific dimensions of it. Seven out of 11 initiatives evaluated outcomes related to the occupational health and safety of precariously employed workers and six out of 11 evaluated worker health and well-being outcomes. Most initiatives showed the potential to improve the health of workers, although the evaluation component was often described with less detail than the initiative itself. Given the heterogeneity of the 11 initiatives regarding study design, sample size, implementation, evaluation, economic and political contexts, and target population, we found insufficient evidence to compare outcomes across types of initiatives, generalize findings, or make specific recommendations for the adoption of initiatives.

Trajectories of precarious employment and the risk of myocardial infarction and stroke among middle-aged workers in Sweden: A register-based cohort study.

BACKGROUND: The aim is to identify trajectories of precarious employment (PE) over time in Sweden to examine associations of these with the subsequent risk of myocardial infarction (MI) and stroke. METHODS: This is a nation-wide register-based cohort study of 1,583,957 individuals aged 40 to 61 years old residing in Sweden between 2003-2007. Trajectories of PE as a multidimensional construct and single PE components (contractual employment relationship, temporariness, income levels, multiple job holding, probability of coverage by collective agreements) were identified for 2003-2007 by means of group-based model trajectories. Risk Ratios (RR) for MI and stroke according to PE trajectories were calculated by means of generalized linear models with binomial family. FINDINGS: Adjusted estimates showed that constant PE and borderline PE trajectories increased the risk of MI (RR: 1·08, CI95%:1·05-1·11 and RR:1·13, CI95%: 1·07-1·20 respectively) and stroke (RR:1·14, CI95%: 1·10-1·18 and HR:1·24, CI95%: 1·16-1·33 respectively) among men. A higher risk of stroke in men was found for the following unidimensional trajectories: former agency employees (RR:1·32, CI95%:1·04-1·68); moving from high to a low probability of having collective agreements (RR: 1·10, CI95%:1·01-1·20). Having constant low or very low income was associated to an increased risk of MI and Stroke for both men and women. INTERPRETATION: The study findings provide evidence that PE increases the risk of stroke and possibly MI. It highlights the importance of being covered by collective bargaining agreements, being directly employed and having sufficient income levels over time. FUNDING: The Swedish Research Council for Health, Working Life and Welfare, no. 2019-01226.

Migrant workers occupational health research: an OMEGA-NET working group position paper.

OBJECTIVE: The aims of the study were: (1) to clarify the definitions of "migrant" used in occupational health research; (2) to summarize migrant workers' industry sectors, occupations and employment conditions; (3) to identify the occupational health and safety services available to migrant workers; (4) to summarize work-related health problems found among migrant workers; (5) to identify the methodological challenges to research into occupational health of migrant workers; and (6) to recommend improvements in migrant occupational health research. METHODS: This position paper was prepared by researchers from several European countries and Australia, working within the EU COST Action OMEGA-NET. The paper drew on two recent systematic reviews on the occupational health of international migrant workers and other literature, and also identified uncertainties and gaps in the research literature. Migrants may, for example, be temporary or permanent, moving for specific jobs migrants or other reasons. Their ethnicity and language capabilities will affect their work opportunities. RESULTS: The occupational health literature seldom adequately identifies the heterogeneity or characteristics of the migrant group being studied. Migrants tend to work in more physically and mentally demanding environments with higher exposures than native workers. Migrants tend to have an increased risk of physical and mental ill health, but less access to health care services. This has been demonstrated recently by high rates of COVID-19 and less access to health care. There have been a number of cross-sectional studies of migrant health but few long-term cohort studies were identified. Other study designs, such as registry-based studies, surveys and qualitative studies may complement cross-sectional studies. Mixed-methodology studies would be valuable in research on migrants' occupational health. Language and lack of trust are barriers to migrant research participation. CONCLUSION: Targeted research, especially longitudinal, identifying how these economically important but often-vulnerable workers can be best assisted is needed. Researchers should identify the characteristics of the migrant workers that they are studying including visa/migration circumstances (temporary, permanent, undocumented), racial and ethnic characteristics, existing skills and language abilities.

Under-reporting of non-fatal occupational injuries among precarious and non-precarious workers in Sweden.

BACKGROUND: Under-reporting of occupational injuries (OIs) among precariously employed workers in Sweden challenges effective surveillance of OIs and targeted preventive measures. OBJECTIVE: To estimate the magnitude of under-reporting of OIs among precarious and non-precarious workers in Sweden in 2013. METHODS: Capture-recapture methods were applied using the national OIs register and records from a labour market insurance company. Employed workers 18-65 resident in Sweden in 2013 were included in the study (n=82 949 OIs). Precarious employment was operationalised using the national labour market register, while injury severity was constructed from the National Patient Register. Under-reporting estimates were computed stratifying by OIs severity and by sociodemographic characteristics, occupations and precarious employment. RESULTS: Under-reporting of OIs followed a dose-response pattern according to the levels of precariousness (the higher the precarious level, the higher the under-reporting) being for the precarious group (22.6%, 95% CI 21.3% to 23.8%), followed by the borderline precarious (17.6%, 95% CI 17.1% to 18.2%) and lastly the non-precarious (15.0%, 95% CI 14.7% to 15.3%). Under-reporting of OIs, decreased as the injury severity increased and was higher with highest level of precariousness in all groups of severity. We also observed higher under-reporting estimates among all occupations in the precarious and borderline precarious groups as compared with the non-precarious ones. CONCLUSIONS: This is the first register-based study to empirically demonstrate in Sweden that under-reporting of OIs is 50% higher among precariously employed workers. OIs under-reporting may represent unrecognised injuries that especially burden precariously employed workers as financial, health and social consequences shift from the employer to the employee.

The Relation Between Precarious Employment Arrangements and Social Precarity: Findings from the PREMIS Study in Stockholm, Sweden.

Precarious employment (PE) is a well-known social determinant of health and health inequalities. However, as most previous studies have focused on physical and mental well-being, less is known about the social-related outcomes (ie, social precarity) associated with precarious arrangements. This cross-sectional study aims to investigate whether PE is associated with social precarity in a working population of 401 nonstandard employed workers in Stockholm, Sweden (2016-2017). PE was assessed with the Swedish version of the Employment Precarious Scale (EPRES-Se) and analyzed in relation to social precarity related to working life (eg, task quality and job security) and living conditions (eg, restraint in social activities and financial constraints). We found positive adjusted associations between quartiles of EPRES-Se and social precarity related to working life (eg, being locked in an occupation [aPRq4:1.33 [1.10-1.61]]) and living conditions (eg, inability to participate in social activities because of work [aPRq4:1.27 [1.10-1.46]]). Our findings suggest that individuals in PE experience social precarity, stressing that PE may have negative effects on well-being. Further studies using multidimensional constructs of PE and larger samples should analyze these findings according to social and policy contexts in order to be able to inform policymakers.

Precarious Employment and Psychosocial Hazards: A Cross-Sectional Study in Stockholm County.

Precarious employment (PE) has been linked to adverse health effects, possibly mediated through psychosocial hazards. The aim of this cross-sectional study is to explore if higher levels of PE are associated with psychosocial hazards (experiences of violence, sexual harassment, bullying, discrimination, high demands, and low control) and to explore gender differences in these patterns. The study is based on survey- and register data from a sample of 401 non-standard employees in Stockholm County (2016-2017). The level of PE (low/high) was assessed with the Swedish version of the employment precariousness scale (EPRES-Se) and analysed in relation to psychosocial hazards by means of generalized linear models, with the Poisson family and robust variances. After controlling for potential confounders (gender, age, country of birth, and education), the prevalence of suffering bullying (PR 1.07, 95% CI: 1.01-1.13) and discrimination (PR 1.52, 95% CI: 1.00-2.32) was higher among individuals with a high level of PE. Regarding the demand/control variables, a high level of PE was also associated with low control (PR 1.59, 95% CI: 1.30-1.96) and passive work (the combination of low demands and low control) (PR 1.60, 95% CI: 1.23-2.08). Our findings suggest that workers in PE are more likely to experience psychosocial hazards, and these experiences are more prevalent among women compared to men. Future longitudinal studies should look further into these associations and their implications for health and health inequalities.

Low-quality employment trajectories and risk of common mental disorders, substance use disorders and suicide attempt: a longitudinal study of the Swedish workforce.

OBJECTIVE: High-quality longitudinal evidence exploring the mental health risk associated with low-quality employment trajectories is scarce. We therefore aimed to investigate the risk of being diagnosed with common mental disorders, substance use disorders, or suicide attempt according to low-quality employment trajectories. METHODS: A longitudinal register-study based on the working population of Sweden (N=2 743 764). Employment trajectories (2005-2009) characterized by employment quality and pattern (constancy, fluctuation, mobility) were created. Hazard ratios (HR) were estimated using Cox proportional hazards regression models for first incidence (2010-2017) diagnosis of common mental disorders, substance use disorders and suicide attempt as dependent on employment trajectories. RESULTS: We identified 21 employment trajectories, 10 of which were low quality (21%). With the exception of constant solo self-employment, there was an increased risk of common mental disorders (HR 1.07-1.62) and substance use disorders (HR 1.05-2.19) for all low-quality trajectories. Constant solo self-employment increased the risk for substance use disorders among women, while it reduced the risk of both disorders for men. Half of the low-quality trajectories were associated with a risk increase of suicide attempt (HR 1.08-1.76). CONCLUSIONS: Low-quality employment trajectories represent risk factors for mental disorders and suicide attempt in Sweden, and there might be differential effects according to sex - especially in terms of self-employment. Policies ensuring and maintaining high-quality employment characteristics over time are imperative. Similar prospective studies are needed, also in other contexts, which cover the effects of the Covid-19 pandemic as well as the mechanisms linking employment trajectories with mental health.

Initiatives addressing precarious employment and its effects on workers' health and well-being: a protocol for a systematic review.

BACKGROUND: Precarious employment is a significant determinant of population health and health inequities and has complex public health consequences both for a given nation and internationally. Precarious employment is conceptualized as a multi-dimensional construct including but not limited to employment insecurity, income inadequacy, and lack of rights and protection in the employment relation, which could affect both informal and formal workers. The purpose of this review is to identify, appraise, and synthesize existing research on the effectiveness of initiatives aiming to or having the potential to eliminate, reduce, or mitigate workers' exposure to precarious employment conditions and its effects on the health and well-being of workers and their families. METHODS: The electronic databases searched (from January 2000 onwards) are Scopus, Web of Science Core Collection, and PubMed, along with three institutional databases as sources of grey literature. We will include any study (e.g. quantitative, qualitative, or mixed-methods design) evaluating the effects of initiatives that aim to or have the potential to address workers' exposure to precarious employment or its effects on the health and well-being of workers and their families, whether or not such initiatives were designed specifically to address precarious employment. The primary outcomes will be changes in (i) the prevalence of precarious employment and workers' exposure to precarious employment and (ii) the health and well-being of precariously employed workers and their families. No secondary outcomes will be included. Given the large body of evidence screened, the initial screening of each study will be done by one reviewer, after implementing several strategies to ensure decision-making consistency across reviewers. The screening of full-text articles, data extraction, and critical appraisal will be done independently by two reviewers. Potential conflicts will be resolved through discussion. Established checklists will be used to assess a study's methodological quality or bias. A narrative synthesis will be employed to describe and summarize the included studies' characteristics and findings and to explore relationships both within and between the included studies. DISCUSSION: We expect that this review's findings will provide stakeholders interested in tackling precarious employment and its harmful health effects with evidence on effectiveness of solutions that have been implemented to inform considerations for adaptation of these to their unique contexts. In addition, the review will increase our understanding of existing research gaps and enable us to make recommendations to address them. Our work aligns with the sustainable development agenda to protect workers, promote decent work and economic growth, eliminate poverty, and reduce inequalities. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020187544 .

Organisational factors and under-reporting of occupational injuries in Sweden: a population-based study using capture-recapture methodology.

OBJECTIVE: To estimate the magnitude of under-reporting of non-fatal occupational injuries (OIs) by different organisational factors in Sweden for the year 2013. METHODS: Capture-recapture methods were applied using two data sources: (1) the national OI register and (2) records from a labour market insurance company. To assure comparability of data sources, the analysis was restricted to the public sector and private companies with at least 50 employees. OIs were matched using personal identification number and reported injury dates (±7 days). Organisational factors were obtained from the national labour market register and injury severity (no healthcare/only outpatient/hospitalised) from the National Patient Register. Total number of OIs and ascertainment by data sources were estimated assuming data source independence. RESULTS: There were an estimated 98 493 OIs in 2013. Completeness of reporting OIs to the national register and to the insurance company was estimated at 73% and 43%, respectively. No report to either source was estimated at 15 000 OIs (~15%). Under-reporting to the national register differed by selected organisational factors, being higher among organisations in the public sector, those with more females, with a younger workforce and with a higher proportion of immigrants. Overall under-reporting was more common in agriculture (19.7%), other services (19.3%), commerce and hospitality (19.1%), health (18.4%) and education (18.4%). Under-reporting decreased as injury severity increased, with little variations across sectors of economic activity. CONCLUSIONS: Results suggest considerable under-reporting of OIs in Sweden and differential under-reporting by organisational factors. Results are relevant for official estimates of burden and for setting priorities for workplace safety and prevention.

COVID-19 and Precarious Employment: Consequences of the Evolving Crisis.

The world of work is facing an ongoing pandemic and an economic downturn with severe effects worldwide. Workers trapped in precarious employment (PE), both formal and informal, are among those most affected by the COVID-19 pandemic. Here we call attention to at least 5 critical ways that the consequences of the crisis among workers in PE will be felt globally: (a) PE will increase, (b) workers in PE will become more precarious, (c) workers in PE will face unemployment without being officially laid off, (d) workers in PE will be exposed to serious stressors and dramatic life changes that may lead to a rise in diseases of despair, and (e) PE might be a factor in deterring the control of or in generating new COVID-19 outbreaks. We conclude that what we really need is a new social contract, where the work of all workers is recognized and protected with adequate job contracts, employment security, and social protection in a new economy, both during and after the COVID-19 crisis.

Exploring multidimensional operationalizations of precarious employment in Swedish register data - a typological approach and a summative score approach.

Objectives This study aimed to explore multidimensional operationalizations of precarious employment (PE) in Swedish register data using two approaches: (i) a typological approach and (ii) a dimensional, summative scale approach. It also examined the distribution of sociodemographic and occupational characteristics of precarious employees in Sweden. Method Register data was retrieved on individuals and their employers in the Swedish workforce. Five items corresponding to three dimensions of PE were operationalized: contractual relationship insecurity, contractual temporariness, multiple jobs/sectors, income level, and lack of unionization. First, latent class analysis was applied and a typology of six employment types emerged. Second, a summative scale was constructed by scoring all PE-items. Results Three types of PE were found using the typological approach, which were characterized by direct employment, solo self-employment and multiple job holding, respectively. The summative scale score ranged between -10 and +2 (average: -1.8). Particularly poor scores were seen for solo self-employed, multiple job holders/multiple sectors, and low income. Female gender, young age, low education and foreign origin were prone to precariousness. PE was more frequent among certain economic sectors and occupations. Conclusions Using an existing register of labor market data, two operationalizations of PE were constructed and rendered promising for exposure assessment. Hence, the operationalizations could be of interest for countries with similar data structure. Both approaches highlighted precarious combinations of employment conditions and pointed towards the existence of a wide continuum of precariousness on the labor market. Etiological studies and research assessing trends over time are needed to validate these findings.

Precarious employment and general, mental and physical health in Stockholm, Sweden: a cross-sectional study.

Objectives: To investigate the association between precarious employment and health in a sample of non-standard employees in Stockholm County, Sweden, by addressing three specific research questions: is the degree of precarious employment (low, moderate, high) associated with self-rated. . . (a) general health, (b) mental health, (c) musculoskeletal pain? Methods: Web-based respondent-driven sampling was used to recruit a sample of 415 employees in Stockholm, Sweden, during 2016-2017. Questionnaire data were collected on employment conditions (the Swedish version of the employment precariousness scale (EPRES-Se)), general health, mental health and musculoskeletal pain. EPRES-Se scores were categorised as low, moderate or high. Generalised linear models with Poisson distribution, log link functions and robust variances were applied for calculating crude and adjusted prevalence ratios (PR; aPR) with 95% confidence intervals (CIs) for all outcomes. Results: The prevalence ratios of poor self-rated general and mental health increased with increased degree of precariousness, as indicated by estimates of moderate precarious employment (a2PRModerate 1.44 (CI 0.98-2.11); a2PRModerate 1.13 (CI 0.82-1.62)), and high precarious employment (a2PRHigh 1.78 (CI 1.21-2.62); a2PRHigh 1.69 (CI 1.25-2.28)), albeit only significantly so for high precarious employment. Conclusions: This is the first study in Sweden reporting on the association between precarious employment, as measured with a multidimensional scale, and multiple health outcomes. The results add to the evidence of an association between precarious employment and self-rated poor general and mental health. Larger, representative studies with longitudinal designs using the EPRES-Se are called for in order to strengthen these results and the already existing evidence of the harm of precarious employment.

What is precarious employment? A systematic review of definitions and operationalizations from quantitative and qualitative studies.

Objectives The lack of a common definition for precarious employment (PE) severely hampers the comparison of studies within and between countries, consequently reducing the applicability of research findings. We carried out a systematic review to summarize how PE has been conceptualized and implemented in research and identify the construct's dimensions in order to facilitate guidance on its operationalization. Methods According to PRISMA guidelines, we searched Web of Science and Scopus for publications with variations of PE in the title or abstract. The search returned 1225 unique entries, which were screened for eligibility. Exclusion criteria were (i) language other than English, (ii) lack of a definition for PE, and (iii) non-original research. A total of 63 full-text articles were included and qualitative thematic-analysis was performed in order to identify dimensions of PE. Results We identified several theory-based definitions of PE developed by previous researchers. Most definitions and operationalizations were either an accommodation to available data or the direct result of qualitative studies identifying themes of PE. The thematic-analysis of the selected articles resulted in a multidimensional construct including the following three dimensions: employment insecurity, income inadequacy, and lack of rights and protection. Conclusions Despite a growing number of studies on PE, most fail to clearly define the concept, severely restricting the advancement of the research of PE as a social determinant of health. Our combined theoretical and empirical review suggests that a common multidimensional definition could be developed and deployed in different labor market contexts using a variety of methodological approaches.

Precarious employment in occupational health - an OMEGA-NET working group position paper.

Objectives The aims of this position paper are to (i) summarize research on precarious employment (PE) in the context of occupational health; (ii) develop a theoretical framework that distinguishes PE from related concepts and delineates important contextual factors; and (iii) identify key methodological challenges and directions for future research on PE and health. Methods This position paper is the result of a working group consisting of researchers from the EU, Turkey and the USA, who have discussed the issue over the course of six months (October 2018-April 2019), meeting both online and face-to-face on several occasions. Results The lack of a common theoretical framework of PE hinders it from becoming an established part of occupational and public health research. There are also issues regarding operationalization in surveys and registers. Further, previous research on PE and health suffers from methodological limitations including inadequate study designs and biased assessments of exposure and outcomes. PE is highly dependent on contextual factors and cross-country comparison has proven very difficult. We also point to the uneven social distribution of PE, ie, higher prevalence among women, immigrants, young and low educated. We propose a theoretical framework for understanding precarious employment as a multidimensional construct. Conclusions A generally accepted multidimensional definition of PE should be the highest priority. Future studies would benefit from improved exposure assessment, temporal resolution, and accounting for confounders, as well as testing possible mechanisms, eg, by adopting multi-level and intersectional analytical approaches in order to understand the complexity of PE and its relation to health.