PH201x: Health and Society

Psychosocial Work Environment

and Health
Ichiro Kawachi, MD, PhD
Monica Wang, ScD, MS
Harvard School of Public Health

Lesson objectives
1. Define job strain, and describe the Karasek demands/
control model of stress
2. Critically appraise the association between job
insecurity and poor health
3. Discuss the role of work/life balance and employee
health

Adam Smith on the division of labor

1776

Left: http://commons.wikimedia.org/wiki/File%3AAdamSmith.jpg, PD; Right: http://commons.wikimedia.org/wiki/File%3AWealth_of_Nations.jpg, PD

Scientific Taylorism
Principles of Scientific
Management (1911):

Replace rule-of-thumb work methods

with methods based on a scientific study
of the tasks

Scientifically select, train, and develop

each employee rather than passively
leaving them to train themselves

Provide detailed instruction and

supervision of each worker in the
performance of that worker's discrete
task

Frederick Winslow Taylor

(1856-1915)

http://commons.wikimedia.org/wiki/File:Frederick_Winslow_Taylor_crop.jpg, PD

Division of labor in the service economy

McDonalds call centers

McDonalds
Call Center,
500 miles
away

McDonalds call centers

McDonalds remote call centers

Employee work pace and demands
Each worker receives up to 100 orders/hr. during peak hrs
10 sec. between taking and entering an order before receiving next
customer at a different location

Employee monitoring
Software tracks productivity and speed
At random intervals, a red box appears on the screen to test
alertness level of workers (must be clicked within 1.75 sec.)
Computer screen in employee restroom lets workers know amount
of time elapsed since leaving their work stations
Source: NY Times, April 2006

Ingredients of job stress

What would you desire in a job?
Ability to set work pace
Having a variety of tasks
Acquisi8on and applica8on of new skills
Autonomy
Connec8on and fulllment to the products of your
labor

Ingredients of job stress

What would you desire in a job?

What would lead to stress?

1. SeAng the pace of your work

Machine-paced work

2. Variety of tasks

Monotony & repe88on

3. Learning new skills & applying them

De-skilling (i.e. being trained only to perform one 8ny

component of a job).

4. Autonomy

Lack of personal control

5. Meaning & sense of connec8on

to the products of your labor

Aliena8on

Mans search for meaning: the case of

Legos
Journal of Economic Behavior & Organization 67 (2008) 671-677
Dan Ariely, Emir Kamenica, Drazen Perlec

40 Harvard male undergrads

Declining unit payment schedule for building
Bionicles:
$2.00 for first piece, $1.89 for 2nd
2 conditions: Meaningful vs. Meaningless
Floodllama, Waspix, http://www.flickr.com/photos/38446022@N00/5892902730/, CCBY

Adrienne's Bionicles 3, Bill Ward, http://www.flickr.com/photos/billward/3412823919/, CCBY

Ryan McFarland, LEGO Bionicle, http://www.flickr.com/photos/zieak/2769518370/, CCBY

Mean = 10.6

Mean = 7.2
Meaningless

Ariely, D. et al. Journal of Economic Behavior & Organization 67 (2008) 671-677

Healthy Work: Stress,

Productivity, and the
Reconstruction of
Working Life
Robert Karasek and
Tores Theorell
Basic Books, 1990

Work stress is caused by the

interaction of two factors
1. Psychological demands
2. Decision latitude (control)

Demands/Control model of job stress

Decision Latitude (Control)
High

Psychological Demands
Low

High

Low

Karasek job content questionnaire

Psychological Demands

Job requires working fast

Job allows for enough time to get job done
Degree of concentration required
Job involves excessive amount of work
Proportion of work performed under pressure
Worker free from conflicting demands from others
www.uml.edu/Dept/WE/research/jcq

Karasek job content questionnaire

Decision Latitude = Skill Utilization + Decision Authority
Skill Utilization
Job allows for variety of different tasks vs. repetitive tasks
Job requires learning new things
Job involves opportunities to develop special skills; occasions for
creativity
Job involves high level of skill
Decision Authority
Job allows worker to make own decisions
Worker ability to influence what happens on the job

Karasek demand/control model

PSYCHOLOGICAL DEMANDS

High
Low

DECISION
LATITUDE
(CONTROL)

Low

High

LOW STRAIN

ACTIVE

PASSIVE

HIGH STRAIN

Meta-analysis of job control and common mental disorders

Low vs. High Decision Authority

Low vs. High Job Control

Stansfeld & Candy, Scand J Work Environ Health 2006;32(6):443-62.

Kivimaki et al. Job strain as a risk factor for coronary heart disease:
a collaborative meta-analysis of individual participant data. Lancet 2012.

Source: Karasek & Theorell,

1990, p. 66

Social epidemiologist

Source: Karasek & Theorell,

1990, p. 66

Social epidemiologist

Source: Karasek & Theorell,

1990, p. 66

Job stress as a mediator of the relationship

between SES and health

X
SES

Y
Poor Health

Job Stress

Policy implication: Job re-design is a potential

approach to address socio-economic disparities
in health.

Psychological and physiological stress reactions of male and

female assembly workers: a comparison between two different
forms of work organization

Volvo replaced the Taylor-oriented assembly line with a

more flexible work organization based on team
production

Journal of Organizational Behavior 20, 47-61 (1999)

Bo Melin, Ulf Lundberg, Jens Soderlund, and Marlanne Granqvist

Layout of traditional
assembly line work:
Engines mounted on carriers that
move along a magnetic track on
floor
Tacks stops for 60-90 secs. at
each work station where new parts
fitted
If a worker works slower than his
co-workers, the carriers pile up
The final product is inspected at
end of line by a supervisor not
involved in the assembly work
Journal of Organizational Behavior 20, 47-61 (1999) Bo Melin, Ulf Lundberg, Jens Soderlund, and Marlanne Granqvist

Flexible work organization scheme

Journal of Organizational Behavior 20, 47-61 (1999) Bo Melin, Ulf Lundberg, Jens Soderlund, and Marlanne Granqvist

Flexible work organization scheme

Each team composed of 7-9 members
Each worker can see the whole process and help each other if
necessary (i.e. they learn each others tasks)
Each team is responsible for the entire assembly process,
including functional testing of the completed engine
Aim is to increase the amount of control, decrease the
monotony of assembly line work & increase social interaction
between workers

N = 36 male and N = 29 female assembly line workers

Journal of Organizational Behavior 20, 47-61 (1999) Bo Melin, Ulf Lundberg, Jens Soderlund, and Marlanne Granqvist

Stress markers during and after work-day

* No difference in cortisol levels.

Journal of Organizational Behavior 20, 47-61 (1999) Bo Melin, Ulf Lundberg, Jens Soderlund, and Marlanne Granqvist

Lesson objectives
1. Define job strain, and describe the Karasek demands/
control model of stress
2. Critically appraise the association between job
insecurity and poor health
3. Discuss the role of work/life balance and employee
health

Can job insecurity make us sick?

The demand for more labor flexibility in the global
economy has resulted in:
More out-sourcing, subcontracting
More non-standard work, including part-time, casual,
temporary, contingent work
More job insecurity

Types of non-standard work in the USA work force

Part time work ~ 20%

Temporary help agency ~ 2.5%
Fixed-term contract work, including on-call
labor (nurses, substitute teacher) ~ 3.0%
Independent contractor (self-employed)
~ 7.0%
Source: Kalleberg, Annu Rev Sociol (2000)

Pros and cons of non-standard work

Benefits
Flexibility allows
employers to cut labor
costs during slack times
Employers can screen
workers before hiring
them permanently
(training costs)
Workers may be able to
control their schedules

Drawbacks

Pros and cons of non-standard work

Benefits
Flexibility allows
employers to cut labor
costs during slack times.
Employers can screen
workers before hiring
them permanently
(training costs).
Workers may be able to
control their schedules.

Drawbacks
Non-standard jobs are
often bad jobs poor
pay, lack of health
insurance and pension
benefits
Job insecurity
Lack of protection from
unions and labor laws

FedEx Ground truck drivers

Considered independent
contractors, not employees
Required to purchase their own
truck ($37,800), insurance, and
gas
Drivers must wear FedEx
uniform, and prescribed hairstyle
No union representation,
because drivers are considered
independent contractors
David Guo, http://www.flickr.com/photos/76969036@N02/8962915478/, CCBY

Jeans story
Gross income advertised by company as $60,000
However, after paying $800 per month for the truck,
$125 per week for gas, $4,000 per year for insurance
policies, net pay is about $32,000 per year (or $10.25
per hour)
After Jean developed ovarian cancer and stopped work
for surgery and chemotherapy, she lost her job
She is not protected by the Americans with Disabilities
Act, because she is an independent contractor

Are non-standard jobs damaging to workers health?

Non-standard job

Y
Health

Does X really cause Y?

Alternative Hypothesis #1:
Reverse causation.

Insecure job

reverse

Health (e.g.
angina symptoms)

Alternative Hypothesis #2:

The association between non-standard jobs & health is
confounded by some other unobserved variable(s)

reverse

Y
u = temperament,
ability, personality

Endogeneity
Suppose we find an association between bad job
conditions and poor health
But employers recruit the most capable/healthy employees by
offering attractive working conditions
Employees also compete for the best working conditions. The
healthiest keep interviewing at different places until they find the
best job
Meantime, the less healthy have to take whats offered
The result: Healthy workplaces attract healthy workers

How would you go about testing the causal relationship

between job conditions & workers health?

By manipulating job conditions, e.g.

- Randomized trials
- Observing natural experiments (including use of
instrumental variables)
- Propensity score matching

Is non-standard work damaging to health?

4th wave of Korean Labor and Income Panel (KLIP) Survey, 2001.
Myoung-hee KIM
(courtesy of Dr. Kawachi)

1991 male and 1378 female workers with information

on employment type, work hours, and contract terms
Precarious work: Part-time, temporary/daily, and
contingent (fixed-term contract) work
Outcome: Poor self-rated health
Source: MH Kim, CY Kim, JK Park & I Kawachi. SSM, 2008;67(12):1982-1994.

Causal inference problem

Workers select into different types of work
Several of these selection factors e.g.
education level, marital status, preexisting health conditions also
determine health
Therefore, comparison of precarious and
non-precarious workers may be biased

Propensity score
PS = Prob (E =1| Zi)
Probability of being exposed (E=1) in this instance,
becoming a precarious worker given the individuals
observed covariates (Zi), which are used to balance
covariates across comparison groups to reduce bias
Logit model, where Zi included: Age, marital status, previous
health status, education, household income, occupation,
industry
MH Kim, CY Kim, JK Park & I Kawachi. SSM, 2008;67(12):1982-1994.

Analytical strategy

MH Kim, CY Kim, JK Park & I Kawachi. SSM, 2008;67(12):1982-1994.

Distribution of propensity scores prior to matching

1.00
Precarious

Estimated Probability

Non-precarious

0.00
200

200

400

Number of observations

MH Kim, CY Kim, JK Park & I Kawachi. SSM, 2008;67(12):1982-1994.

600

800

Distribution of propensity scores after matching*

1.00
Precarious

Estimated Probability

Non-precarious

0.00
200

200

400

600

Number of observations

*with greedy algorithm with caliper width 0.1.

MH Kim, CY Kim, JK Park & I Kawachi. SSM, 2008;67(12):1982-1994.

800

Unadjusted logistic regression

3

OR Poor Health

2.5
2
1.5
1
0.5
0
Male

MH Kim, CY Kim, JK Park & I Kawachi. SSM, 2008;67(12):1982-1994.

Female

Propensity-matched GEE regression

3

OR Poor Health

2.5
2
1.5
1
0.5
0
Male

Female

Unmatched
MH Kim, CY Kim, JK Park & I Kawachi. SSM, 2008;67(12):1982-1994.

Male

Female

Matched

Lesson objectives
1. Define job strain, and describe the Karasek demands/
control model of stress
2. Critically appraise the association between job
insecurity and poor health
3. Discuss the role of work/life balance and employee
health

Source: Karasek & Theorell,

1990, p. 66

Source: Karasek & Theorell, 1990

But wait a minute

If women report higher job strain, how come they have
lower CHD risk than men?

But wait a minute

If women report higher job strain, how come they have
lower CHD risk than men?
As a matter of fact, association between job control and
CHD risk is less consistent in women

Data on job stress & health are sparse and less

consistent for women
Relative risks of CHD incidence by job stress and
gender. 11-year follow-up of Whitehall II Study
Job control
High
Medium
Low

Men

Women

1.00
1.37 (1.08-1.74)
1.29 (1.06-1.57)

1.00
0.94 (0.66-1.34)
1.06 (0.75-1.50)

Data from: Kuper & Marmot, 2003

6-year incidence of heart disease by gender, and

control at home (Whitehall Study)

Women
High control

1.0

Low control

2.6 (1.1-5.9)

Men

Chandola T et al. The effect of control at home on CHD events in the Whitehall II study: Gender differences in
psychosocial domestic pathways to social inequalities in CHD. Soc Sci Med 2004; 58:1501-9.

6-year incidence of heart disease by gender, and

control at home (Whitehall Study)

Women

Men

High control

1.0

1.0

Low control

2.6 (1.1-5.9)

0.7 (0.4-1.1)

Chandola T et al. The effect of control at home on CHD events in the Whitehall II study: Gender differences in
psychosocial domestic pathways to social inequalities in CHD. Soc Sci Med 2004; 58:1501-9.

The Feminization of the Labor Force

Cohany, S.R. and Sok, E. (February 2007), Trends in labor force participation
of married mothers of infants, http://www.bls.gov/opub/mlr/2007/02/art2full.pdf, Monthly Labor Review, PD

Time use studies, 1965-66

N=1,243 couples, N=44 cities
Type of activity

Working women

Housework

3 hrs/day

Child-care

50 mins/day
Alexander Szalai, ed., The Use of Time: Daily Activities of Urban and
Suburban Populations in Twelve Countries (The Hague, Mouton, 1972).

Time use studies, 1965-66

Type of activity

Working women

Working men

Housework

3 hrs/day

17 mins/day

Child-care

50 mins/day

12 mins/day

Watching TV

1 hr longer

Sleep

hr longer

Alexander Szalai, ed., The Use of Time: Daily Activities of Urban and
Suburban Populations in Twelve Countries (The Hague, Mouton, 1972).

Division of labor in USA, 2004

(among 21,000 married couples, 25-54 yrs)
7.43
7.43

Sleeping

7.74
8.87

Working

Care-giving

1.55
0.83

Housework

1.44
0.73

Women
Men

2.18
2.62

Leisure

Average hours per day

10

Gender, household labor, and psychological distress: The

impact of the amount and division of housework

National longitudinal survey

1,256 adults
4-year follow-up (1990-1994)
Predictors: Hours of housework, and equity in division
of household work
Outcome: 7-item CES-D controlling for baseline MHI-5
(from SF-36)
Chloe E. Bird, Brown University, Journal of Health and Social Behavior 1999, Vol 40 (March): 32-45.

Bird, C. Gender, Household Labor, and Psychological Distress: The Impact of the Amount and Division
of Housework*. Journal of Health and Social Behavior 1999, Vol 40 (March): 32-45

Married female
average 70%

Married male average 36%

Bird, C. Gender, Household Labor, and Psychological Distress: The Impact of the Amount and Division
of Housework*. Journal of Health and Social Behavior 1999, Vol 40 (March): 32-45

Policy proposals
to promote workers health in the 21st century

1. Eliminate discrimination against non-standard

workers:
Adopt legislation like the EU Part-Time Directive
pay equity, pension benefits, training/promotion opportunities,
bargaining rights

Policy proposals

to promote workers health in the 21st century

2. Improve work-life balance for working

families:
- Expand eligibility for paid parental & sick leave
- Subsidize day care & child care

Duration of parental leave (incl. paid/unpaid leave)

Germany
Norway
France
Sweden
New Zealand
Japan
Canada
UK
USA

50

Source: Heymann, Earle, et al. 2007

100
Weeks

150

200