Ramifications of Precarious Employment for Health and Health Inequity: Emerging Trends from the Americas.

Precarious employment (PE), which encompasses the power relations between workers and employers, is a well-established social determinant of health that has strong ramifications for health and health inequity. In this review, we discuss advances in the measurement of this multidimensional construct and provide recommendations for overcoming continued measurement challenges. We then evaluate recent evidence of the negative health impacts of PE, with a focus on the burgeoning studies from North America and South America. We also establish the role of PE in maintaining and perpetuating health inequities and review potential policy solutions to help alleviate its health burden. Last, we discuss future research directions with a call for a better understanding of the heterogeneity within PE and for research that focuses both on upstream drivers that shape PE and its impacts on health, as well as on the mechanisms by which PE causes poor health. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Experiences of insecurity among non-standard workers across different welfare states: A qualitative cross-country study.

In recent decades, economic crises and political reforms focused on employment flexibilization have increased the use of non-standard employment (NSE). National political and economic contexts determine how employers interact with labour and how the state interacts with labour markets and manages social welfare policies. These factors influence the prevalence of NSE and the level of employment insecurity it creates, but the extent to which a country's policy context mitigates the health influences of NSE is unclear. This study describes how workers experience insecurities created by NSE, and how this influences their health and well-being, in countries with different welfare states: Belgium, Canada, Chile, Spain, Sweden, and the United States. Interviews with 250 workers in NSE were analysed using a multiple-case study approach. Workers in all countries experienced multiple insecurities (e.g., income and employment insecurity) and relational tension with employers/clients, with negative health and well-being influences, in ways that were shaped by social inequalities (e.g., related to family support or immigration status). Welfare state differences were reflected in the level of workers' exclusion from social protections, the time scale of their insecurity (threatening daily survival or longer-term life planning), and their ability to derive a sense of control from NSE. Workers in Belgium, Sweden, and Spain, countries with more generous welfare states, navigated these insecurities with greater success and with less influence on health and well-being. Findings contribute to our understanding of the health and well-being influences of NSE across different welfare regimes and suggest the need in all six countries for stronger state responses to NSE. Increased investment in universal and more equal rights and benefits in NSE could reduce the widening gap between standard and NSE.

Work, Health, and the Ongoing Pursuit of Health Equity.

The many facets of work, including employment relationships and attendant employment quality, the day-to-day conditions experienced in any given job, and the evolution of one's working circumstances over time can support or detract from health, and combine in myriad ways to impact worker well-being [...].

Investigating Employment Quality for Population Health and Health Equity: A Perspective of Power.

Employment quality (EQ) has gained increasing attention as a determinant of health, but the debate among occupational health researchers over the measurement of EQ poses a challenge to advancing the literature. This is especially problematic when the concept is used across social, cultural, and national borders, as EQ is shaped by power dynamics within sociopolitical and economic contexts that are specific to each society. Investigating EQ in context could help develop a clearer understanding as to why EQ is configured in certain ways, how best EQ could be measured, how EQ impacts health, and ultimately how EQ could be improved. In this paper, we propose that attention to social context-and in particular power-may help advance the research on EQ and health. We present an allegory, or a visual description, that articulates the power balance in the employer-worker relation as well as in the sociopolitical context in which the employer-worker relation takes place. We end by proposing specific approaches for occupational health researchers to incorporate a perspective of power in EQ research that may clarify the concept and measurement of EQ. A clearer recognition of EQ as a product of power in social context aligns with the research approach of addressing work as a social structural determinant of health.

Non-Standard Employment and Unemployment during the COVID-19 Crisis: Economic and Health Findings from a Six-Country Survey Study.

The COVID-19 crisis is a global event that has created and amplified social inequalities, including an already existing and steadily increasing problem of employment and income insecurity and erosion of workplace rights, affecting workers globally. The aim of this exploratory study was to review employment-related determinants of health and health protection during the pandemic, or more specifically, to examine several links between non-standard employment, unemployment, economic, health, and safety outcomes during the COVID-19 pandemic in Sweden, Belgium, Spain, Canada, the United States, and Chile, based on an online survey conducted from November 2020 to June 2021. The study focused on both non-standard workers and unemployed workers and examined worker outcomes in the context of current type and duration of employment arrangements, as well as employment transitions triggered by the COVID-19 crisis. The results suggest that COVID-19-related changes in non-standard worker employment arrangements, or unemployment, are related to changes in work hours, income, and benefits, as well as the self-reported prevalence of suffering from severe to extreme anxiety or depression. The results also suggest a link between worker type, duration of employment arrangements, or unemployment, and the ability to cover regular expenses during the pandemic. Additionally, the findings indicate that the type and duration of employment arrangements are related to the provision of personal protective equipment or other COVID-19 protection measures. This study provides additional evidence that workers in non-standard employment and the unemployed have experienced numerous and complex adverse effects of the pandemic and require additional protection through tailored pandemic responses and recovery strategies.

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.

Poor-quality employment and health: How a welfare regime typology with a gender lens Illuminates a different work-health relationship for men and women.

In the growing literature on employment quality and health, poor quality of employment is generally associated with poor health. However, this association may not be uniform for men and women if unpaid caregiving labor is taken into consideration. How paid and unpaid labor is performed varies across societies because of differences in both state support for families and labor market penalties for women. Applying a gender lens to a welfare regime typology, we investigated the relationship between poor-quality employment and poor health for men and women. For each of five welfare regime types, we hypothesized if men or women would be more strongly affected by poor-quality employment based on the regime's family support policies and labor practices. Our analysis of 18 countries using the 2015 European and American Working Conditions Surveys data largely supported our hypotheses. In countries that support traditional gender roles with high state expenditure and have labor markets that penalize women, the association between poor-quality employment and health was stronger for men. The association was stronger for women in countries that rely on women to provide unpaid caregiving without substantial state support. In countries with apparently gender-neutral expectations for both paid work and unpaid caregiving work, no difference was found between men and women in the association of poor-quality employment with poor health. We discuss the importance of institutional perspectives to understand work as a gendered experience that impacts health. We suggest more comprehensive welfare regime typologies that recognize women both as caregivers and workers. Expanding the scope of research on work and health to include this integrated view of life could make a stride toward gender health equity.

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 .

Sociopolitical values and social institutions: Studying work and health equity through the lens of political economy.

Work contributes to health and health inequity in complex ways. The traditional exposure-disease framework used in occupational health research is not equipped to address societal contexts in which work is embedded. The political economy approach to public health directly examines macro-level societal contexts, but the attention to work in this literature is mostly on unemployment. As a result, we have limited understanding of work as a social determinant of health and health inequity. To fill this gap, we propose a conceptual framework that facilitates research on work, health, and health equity in institutional contexts. As an illustration of different social institutions creating different work-related health, we present characteristics of work and health in the United States and the European Union using the 2015 Working Conditions Surveys data. The results also highlight limitations of the traditional exposure-disease approach used in occupational health research. Applying the proposed framework, we discuss how work and health could be investigated from a broader perspective that involves multiple social institutions and the sociopolitical values that underpin them. Such investigations would inform policy interventions that are congruent with existing social institutions and thus have the potential for being adopted and effective. Further, we clarify the role of research in generating knowledge that would contribute to institutional change in support of population health and health equity.

Constrained choices: Combined influences of work, social circumstances, and social location on time-dependent health behaviors.

BACKGROUND: Physical activity and sleep are two time-dependent behaviors with important health implications. The amount of time people have to engage in these behaviors may vary based on their everyday work, social circumstances (e.g., parenthood), and social location (e.g., gender). AIMS: The current study aimed to explore the ways work, social circumstances, and social locations combine that lead to heterogeneity in the time-dependent health behaviors of physical activity and time spent in bed (i.e., sleep) among a young adult population. We drew upon two conceptual frameworks-Constrained Choices and an intersectionality perspective-and examined multiple work characteristics (e.g., number of jobs), social circumstances (e.g., household income), and social locations (e.g., U.S. nativity) relevant to young adulthood. METHODS: 2015-2016 data from a Minneapolis-St. Paul, U.S. cohort of 1830 young adults (25-36 years) were analyzed using conditional inference tree (CIT)-a data-driven approach which identifies population sub-groups that differ in their outcome values as well as in the interacting factors that predict outcome differences. Sensitivity analyses to evaluate CIT robustness were also performed. RESULTS: CITs revealed four relevant sub-groups for physical activity (sub-group averages ranged = 2.9-4.9 h per week), with working mothers achieving the least activity, and six relevant sub-groups for time in bed (range = 7.8-8.7 h per day), with full-time working men obtaining the least. In both models, parent status and employment status/hours were found to consistently differentiate behavior among women but not men. CONCLUSION: According to these data, time to engage in physical activity and time in bed was constrained by particular everyday contexts (work and parent status) and the extent to which these contexts mattered also depended on gender. If replicated in other studies, results suggest equitable strategies are necessary to assist all parents and workers in engaging in these time-dependent health behaviors for long-term health.

Life-course and population health perspectives to fill gaps in migrant health research.

This article highlights categories and dichotomies used in the study of the health of migrants, including migrant motivation, migrant type, pre- and post-migration time periods, and health as biomedically or socially determined. The authors suggest that the full spectrum of migrants and migration be considered more thoroughly in order to improve our understanding of migrant health. This paper challenges simple conceptions of migration, mobility, and migrant experience. To fill gaps in knowledge left by these conceptions, researchers must recognize the decisions migrants make as a process which plays out both over time (in migrant life-courses) and also across personal, national, and international contexts which connect the individual to larger structures and phenomena. The authors argue that, in this reality, research questions related to migrant health are best addressed using life-course perspectives which recognize health as a continuum of socially-constructed statuses.

Human Factors Affecting Logging Injury Incidents in Idaho and the Potential for Real-Time Location-Sharing Technology to Improve Safety.

Human factors, including inadequate situational awareness, can contribute to fatal and near-fatal traumatic injuries in logging, which is among the most dangerous occupations in the United States. Real-time location-sharing technology may help improve situational awareness for loggers. We surveyed and interviewed professional logging contractors in Idaho to (1) characterize current perceptions of in-woods hazards and the human factors that lead to injuries; (2) understand their perspectives on using technology-based location-sharing solutions to improve safety in remote work environments; and (3) identify logging hazard scenarios that could be mitigated using location-sharing technology. We found production pressure, fatigue, and inexperience among the most-common factors contributing to logging injuries from the perspective of participants. Potential limitations of location-sharing technology identified included potential for distraction and cost. Contractors identified several situations where the technology may help improve safety, including (1) alerting workers of potential hand-faller injuries due to lack of movement; (2) helping rigging crews to maintain safe distances from yarded trees and logs during cable logging; and (3) providing a means for equipment operators to see approaching ground workers, especially in low-visibility situations.

The housing first technical assistance and training (HFTAT) implementation strategy: outcomes from a mixed methods study of three programs.

BACKGROUND: This paper discusses the initial testing of the Housing First Training and Technical Assistance (HFTAT) Program, a multifaceted, distance-based strategy for the implementation of the Housing First (HF) supportive housing model. HF is a complex housing intervention for serving people living with serious mental illness and a substance use disorder that requires significant individual- and structural-level changes to implement. As such, the HFTAT employs a combined training and consultation approach to target different levels of the organization. Training delivered to all organizational staff focuses on building individual knowledge and uses narrative storytelling to overcome attitudinal implementation barriers. Consultation seeks to build skills through technical assistance and fidelity audit and feedback. METHOD: We employed a mixed method design to understand both individual-level (e.g., satisfaction with the HFTAT, HF knowledge acquisition and retention, and HF acceptability and appropriateness) and structural-level (e.g., fidelity) outcomes. Quantitative data were collected at various time points, and qualitative data were collected at the end of HFTAT activities. Staff and administrators (n = 113) from three programs across three states participated in the study. RESULTS: Satisfaction with both training and consultation was high, and discussions demonstrated both activities were necessary. Flexibility of training modality and narrative storytelling were particular strengths, while digital badging and the community of practice were perceived as less valuable because of incompatibilities with the work context. HF knowledge was high post training and retained after 3-month follow-up. Participants reported training helped them better understand the model. Attitudes toward evidence-based interventions improved over 6 months, with qualitative data supporting this but demonstrating some minor concerns related to acceptability and appropriateness. Fidelity scores for all programs improved over 9 months. CONCLUSION: The HFTAT was a well-liked and generally useful implementation strategy. Results support prior research pointing to the value of both (a) multifaceted strategies and (b) combined training and consultation approaches. The study also provides evidence for narrative storytelling as an approach for changing attitudinal implementation barriers. The need for compatibility between specific elements of an implementation strategy and the work environment was also observed.

Alpha test results for a Housing First eLearning strategy: the value of multiple qualitative methods for intervention design.

BACKGROUND: Detailed descriptions of implementation strategies are lacking, and there is a corresponding dearth of information regarding methods employed in implementation strategy development. This paper describes methods and findings related to the alpha testing of eLearning modules developed as part of the Housing First Technical Assistance and Training (HFTAT) program's development. Alpha testing is an approach for improving the quality of a product prior to beta (i.e., real world) testing with potential applications for intervention development. METHODS: Ten participants in two cities tested the modules. We collected data through (1) a structured log where participants were asked to record their experiences as they worked through the modules; (2) a brief online questionnaire delivered at the end of each module; and (3) focus groups. RESULTS: The alpha test provided useful data related to the acceptability and feasibility of eLearning as an implementation strategy, as well as identifying a number of technical issues and bugs. Each of the qualitative methods used provided unique and valuable information. In particular, logs were the most useful for identifying technical issues, and focus groups provided high quality data regarding how the intervention could best be used as an implementation strategy. CONCLUSIONS: Alpha testing was a valuable step in intervention development, providing us an understanding of issues that would have been more difficult to address at a later stage of the study. As a result, we were able to improve the modules prior to pilot testing of the entire HFTAT. Researchers wishing to alpha test interventions prior to piloting should balance the unique benefits of different data collection approaches with the need to minimize burdens for themselves and participants.

Undergraduate Environmental Public Health Education.

Environmental, occupational, and public health in the United States are practiced across a fragmented system that makes work across those areas more difficult. A large proportion of currently active environmental and occupational health professionals, advocates, policy makers, and activists are nearing retirement age, while some of our major health challenges are heavily influenced by aspects of environment. Concurrently, programs that educate undergraduate college students in environmental health are faced with multiple, often competing demands which can impede progressive movement toward dynamic curricula for the needs of the twenty-first century. We describe our use of developmental evaluation to negotiate these challenges in our specific undergraduate education program, with the dual aims of drawing attention to developmental evaluation as a useful tool for people involved in environmental and occupational health advocacy, policy-making, activism, research, or education for change, as well as to promote discussion about how best to educate the next generation of environmental public health students.

Evaluating goals in worker health protection using a participatory design and an evaluation checklist.

Spanish-speaking immigrant workers in construction are considered hard to reach and at high risk for work-related injury and fatality. This evaluation study describes the use of participatory methods and an evaluation checklist to consider a health and safety (H&S) training program for these workers. A previously developed training manual and model were disseminated to eight worker centers (WCs) through participatory research collaboration. It incorporated H&S training for workers while strengthening the role of WCs as sources for leadership development and worker empowerment. Design, delivery, reaction, application, and extension were assessed through individual interviews with participants, trained trainers, and center staff and through observation of training sessions and partner debriefs; pre- and post-training tests assessed participant learning. Results indicate moderate learning and application by participants and strong evidence for structural gains in and among WCs. We conclude that such partnerships and models are valuable tools for collaborating with hard-to-reach workers.

Invisible work, unseen hazards: The health of women immigrant household service workers in Spain.

BACKGROUND: Household service work has been largely absent from occupational health studies. We examine the occupational hazards and health effects identified by immigrant women household service workers. METHODS: Exploratory, descriptive study of 46 documented and undocumented immigrant women in household services in Spain, using a phenomenological approach. Data were collected between September 2006 and May 2007 through focus groups and semi-structured individual interviews. Data were separated for analysis by documentation status and sorted using a mixed-generation process. In a second phase of analysis, data on psychosocial hazards were organized using the Copenhagen Psychosocial Questionnaire as a guide. RESULTS: Informants reported a number of environmental, ergonomic and psychosocial hazards and corresponding health effects. Psychosocial hazards were especially strongly present in data. Data on reported hazards were similar by documentation status and varied by several emerging categories: whether participants were primarily cleaners or carers and whether they lived in or outside of the homes of their employers. Documentation status was relevant in terms of empowerment and bargaining, but did not appear to influence work tasks or exposure to hazards directly. CONCLUSIONS: Female immigrant household service workers are exposed to a variety of health hazards that could be acted upon by improved legislation, enforcement, and preventive workplace measures, which are discussed.