The Healthy People 2020 Social Determinants of Health topic area is organized into 5 place-based domains:
- Economic Stability
- Health and Health Care
- Neighborhood and Built Environment
- Social and Community Context
Employment is a key issue in the Economic Stability domain.
Every day, many Americans are either working or looking for work.1, 2, 3 Multiple aspects of employment—including job security, the work environment, financial compensation, and job demands—may affect health. This summary describes how several of these aspects of employment influence health.
The Bureau of Labor Statistics (BLS) defines the labor force as including individuals who are either employed (i.e., those who are working for pay or profit) or unemployed (i.e., those who are jobless but are available to work and have actively looked for work in the past 4 weeks).2, 4 People who are neither employed nor unemployed are not part of the labor force.2, 4 As of October 2017, approximately 254 million people in the United States were eligible for the labor force.2 Of those, 63% participated (i.e., were employed or unemployed); the remaining 37% were out of the labor force (e.g., retired).2
In addition, some workforce participants are underemployed, a term that indicates “involuntary part-time employment, poverty-wage employment, and insecure employment (i.e., intermittent unemployment).”5 Underemployment includes situations where the social status and income of a job does not match an employee’s education, abilities, and skills.6, 7, 8
Job benefits such as health insurance, paid sick leave, and parental leave can affect the health of employed individuals. In 2017, 70% of civilian workers and 67% of private industry workers had access to health insurance, while 89% of state and local government employees had access.9 Two key functions of health insurance are access to affordable medical care and financial protection from unexpected health care costs.10, 11 Paid sick leave, another benefit offered by some employers, allows employees to seek medical care for themselves or dependent family members without losing wages.12 In addition, some employers offer maternity leave after the birth of a child; this leave is frequently unpaid. Maternity leave has been associated with a number of positive health outcomes for both women and children.13
In 2016 and 2015, respectively, there were 2.9 million nonfatal and 4,836 fatal injuries at work,14, 15 an indicator of how harmful workplace conditions, including psychosocial stress, can increase the risk for negative health outcomes.1, 16, 17 Workers are prone to injuries and illness if their job includes repetitive lifting, pulling or pushing heavy loads,1, 18 poor quality office equipment (e.g., keyboards and chairs),1, 19 long-term exposure to harmful chemicals such as lead, pesticides, aerosols, and asbestos,1, 20, 21 or a noisy work environment.1, 22, 23 In addition, highly demanding jobs and lack of control over day-to-day work activities are sources of psychosocial stress at work.16 Other sources of workplace stress include high levels of interpersonal conflict,24 working evening shifts, working more than 8 hours a day, and having multiple jobs.1, 25 These stressors put people at risk for mortality26 and depression,27 and they may be correlated with increased parent-child conflict and parental withdrawal.28 People in highly stressful jobs may also exhibit unhealthy coping skills such as smoking or alcohol abuse.29
Education is linked to disparities in employment because it affects the type of work people do, the working conditions they experience, and the income they earn. Workforce participants have different skill levels and educational backgrounds, which creates inequalities in wages, opportunities for advancement, job security, and other work benefits.30 Individuals with less education have fewer employment choices, which may force them into positions with low levels of control, job insecurity, and low wages.8 Individuals with less education are also more likely to have jobs that are physically demanding or include exposure to toxins.8
Gender is also an influential source of workplace disparities. Men are more likely to work longer hours, hold higher-status jobs, and have more physically demanding jobs. However, women report more work-related physical and mental health problems.31 Men tend to receive less support from coworkers and supervisors,31 while women are more likely to experience sexual harassment32, 33 and related alcohol abuse.32, 34
Racial and ethnic disparities also exist in the workforce. White people are more likely to work in white-collar clerical jobs and to assume managerial positions, while black people are more likely to work in blue-collar service jobs.30 African Americans are also more likely than white people to be unemployed.35 One study showed that African American males who graduated from high school were 72% more likely to be involuntarily unemployed than white people of the same educational background.36 This disparity increased to 124% for individuals who had completed 4 or more years of college.36 Additionally, 21% of African Americans work in jobs that put them at high risk for injury or illness, compared to only 13% of white people.37, 38 Workplace inequalities among racial and ethnic minorities may cause anxiety, depression, and physical pain.34
Unemployment can also have negative health consequences. Those who are unemployed report feelings of depression, anxiety, low self-esteem, demoralization,5, 7 worry, and physical pain.39 Unemployed individuals tend to suffer more from stress-related illnesses such as high blood pressure,40, 41, 42, 43 stroke, heart attack, heart disease, and arthritis.7, 44, 45 In addition, experiences such as perceived job insecurity, downsizing or workplace closure, and underemployment also have implications for physical and mental health.7
Additional research is needed to better understand the beneficial effects of employment on health—and to promote interventions that address disparities in employment and health. This additional evidence will facilitate public health efforts to address employment as a social determinant of health.
Disclaimer: This summary of the literature on employment as a social determinant of health is a narrowly defined review that may not address all dimensions of the issue.i, ii Please keep in mind that the summary is likely to evolve as new evidence emerges or as additional research is conducted.
i Terminology used in the summary is consistent with the respective references. As a result, there may be variability in the use of terms, for example, black versus African American.
ii The term minority, when used in a summary, refers to racial/ethnic minority, unless otherwise specified.
1 Robert Wood Johnson Foundation. Work matters for health; 2008. Brief No.: 4. Available from: http://www.commissiononhealth.org/PDF/0e8ca13d-6fb8-451d-bac8-7d15343aacff/Issue%20Brief%204%20Dec%2008%20-%20Work%20and%20Health.pdf
2 U.S. Department of Labor, Bureau of Labor Statistics. The employment situation: October 2017. News release; 2017. Available from: https://www.bls.gov/news.release/archives/empsit_11032017.pdf
3 U.S. Department of Labor, Bureau of Labor Statistics. American time use survey—2016 results. News release; 2017. Available from: https://www.bls.gov/news.release/archives/atus_06272017.pdf
4 U.S. Department of Labor, Bureau of Labor Statistics. Labor force statistics from the current population survey: How the government measures unemployment. News release; 2015. Available from: http://www.bls.gov/cps/cps_htgm.htm
5 Dooley D, Fielding J, Levi L. Health and unemployment. Annu Rev Public Health. 1996;17:449–65.
6 Friedland DS, Price RH. Underemployment: consequences for the health and well‐being of workers. American J Community Psychol. 2003:32(1–2), 33–45.
7 Avendano M, Berkman LF. Labor markets, employment policies, and health. In: Social Epidemiology. New York: Open University Press; 2014. p.182–233.
8 Berkman LF, Kawachi I, Theorell T. Working conditions and health. In: Social Epidemiology. New York: Open University Press; 2014. p. 153–181.
9 U.S. Department of Labor, Bureau of Labor Statistics. Employee benefits in the United States: March 2017. News release; 2017. Available from: https://www.bls.gov/news.release/archives/ebs2_07212017.pdf
10 Institute of Medicine Committee on Health Insurance. America's Uninsured Crisis: Consequences for health and health care. Washington (DC): National Academies Press; 2009.
11 Sommers BD, Gawande AA, Baicker K. Health insurance coverage and health—what the recent evidence tells us. N Engl J Med. 2017;377(6):586–593.
12 DeRigne L, Stoddard-Dare P, Quinn L. Workers without paid sick leave less likely to take time off for illness or injury compared to those with paid sick leave. Health Aff (Millwood). 2016;35(3): 520–27.
13 Burtle A, Bezruchka S. Population health and paid parental leave: what the United States can learn from two decades of research. Healthcare (Basel). 2016;4(2):30.
14 U.S. Department of Labor, Bureau of Labor Statistics. Employment-reported workplace injury and illness—2016. News release; 2017. Available from: https://www.bls.gov/news.release/archives/osh_11092017.pdf
15 U.S. Department of Labor, Bureau of Labor Statistics. Census of fatal occupational injuries summary, 2015. News release; 2016. Available from: https://www.bls.gov/news.release/archives/cfoi_12162016.pdf
16 Shain M, Kramer DM. Health promotion in the workplace: framing the concept; reviewing the evidence. Occup Environ Med. 2004;61(7):643–48.
17 Brooker A, Eakin JM. Gender, class, work-related stress and health: toward a power-centred approach. J Community Appl Soc Psychol. 2001;11(2):97–109. doi:10.1002/casp.620.
18 O'Neil BA, Forsythe ME, Stanish WD. Chronic occupational repetitive strain injury. Can Fam Physician. 2001;47(2):311–316.
19 Ross P. Ergonomic hazards in the workplace: assessment and prevention. AAOHN J. 1994;42(4):171–76.
20 Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Worker Health Chartbook, 2004. Cincinnati (OH); 2005.
21 Centers for Disease Control and Prevention. Adult blood lead epidemiology and surveillance—United States, 2003–2004. MMWR. 2006;55(32):876–79.
22 Hager LD. Hearing protection. Didn't hear it coming... noise and hearing in industrial accidents. Occ Health Saf. 2002;71(9):196–200.
23 Nelson DI, Nelson RY, Concha‐Barrientos M, Fingerhut M. The global burden of occupational noise‐induced hearing loss. Am J Ind Med. 2005;48(6):446–58.
24 Schieman S, Reid S. Job authority and health: Unraveling the competing suppression and explanatory influences. Soc Sci Med. 2009;69(11):1616–24.
25 Caruso CC, Hitchcock EM, Dick RB, Russo JM, Schmit JM. Overtime and extended work shifts: recent findings on illnesses, injuries, and health behaviors. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; 2004. DHHS (NIOSH) Publication No.: 2004–143.
26 Sabbath EL, Mejía-Guevara I, Noelke C, Berkman LF. The long-term mortality impact of combined job strain and family circumstances: a life course analysis of working American mothers. Soc Sci Med. 2015;146:111–19.
27 Simmons LA, Swanberg JE. Psychosocial work environment and depressive symptoms among US workers: comparing working poor and working non-poor. Soc Psychiatry Psychiatr Epidemiol. 2009;44(8):628–35. doi:10.1007/s00127-008-0479-x.
28 Repetti RL, Wang SW. Employment and parenting. Parenting. 2014;14(2):121–32.
29 Hoel H, Sparks, K, Cooper CL. The cost of violence/stress at work and the benefits of a violence/stress-free working environment. Report. Geneva: International Labour Organization; 2001:81.
30 Kalleberg AL. Good jobs, bad jobs. New York: Russel Sage Foundation; 2011.
31 Campos-Serna J, Ronda-Pérez E, Artazcoz L, Moen BE, Benavides FG. Gender inequalities in occupational health related to the unequal distribution of working and employment conditions: a systematic review. J Equity Health. 2013;12(1):57–74. doi:10.1186/1475-9276-12-57.
32 Gradus J, Street AE, Kelly K, Stafford J. Sexual harassment experiences and harmful alcohol use in a military sample: differences in gender and the mediating role of depression. J Stud Alcohol Drugs. 2008;69(3):348–51.
33 Rospenda KM, Richman JA, Shannon CA. Prevalence and mental health correlates of harassment and discrimination in the workplace: results from a national study. J Interpers Violence. 2009;24(5):819–43.
34 Okechukwu CA, Souza K, Davis KD, de Castro AB. Discrimination, harassment, abuse, and bullying in the workplace: contribution of workplace injustice to occupational health disparities. Am J Ind Med. 2014;57(5):573–86.
35 Pager D, Shepherd H. The sociology of discrimination: racial discrimination in employment, housing, credit, and consumer markets. Annu Rev Sociol. 2008;34:181.
36 Wilson FD, Tienda M, Wu L. Race and unemployment: labor market experiences of black and white men, 1968-1988. Work and Occup. 1995;22(3):245–70.
37 Doede MS. Black jobs matter: Racial inequalities in conditions of employment and subsequent health outcomes. Public Health Nurs. 2016;33(2):151–58. doi:10.1111/phn.12241.
38 Centers for Disease Control and Prevention. CDC health disparities and inequalities report—United States, 2013. MMWR. 2013;62(3 Suppl):3–128.
39 Burgard SA, Kalousova L. Effects of the Great Recession: health and well-being. Annu Rev Sociol. 2015;41:181–201.
40 Murray LR. Sick and tired of being sick and tired: scientific evidence, methods, and research implications for racial and ethnic disparities in occupational health. Am J Public Health. 2003:93(2): 221–26.
41 Kasl SV, Cobb S. Blood pressure changes in men undergoing job loss: a preliminary report. Psychosom Med. 1970;32(1):19–38.
42 Frumkin HE, Walker D, Friedman-Jiménez G. Minority workers and communities. Occup Med. 1999;14(3):495–517.
43 James SA, LaCroix AZ, Kleinbau DG, Strogatz DS. John Henryism and blood pressure differences among black men. II. The role of occupational stressors. J Behav Med. 1984;7(3):259–75.
44 Robert Wood Johnson Foundation. How does employment—or unemployment—affect health? Health policy snapshot; 2013. Available from: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf403360
45 U.S. Department of Labor, Bureau of Labor Statistics. A profile of the working poor, 2010. News release; 2012. Available from: https://www.bls.gov/opub/reports/working-poor/archive/workingpoor_2010.pdf