Work as a Key Social Determinant of Health: The Case for Including Work in All Health Data Collections

Social determinants of health (SDOH) are conditions in the places where people live, learn, work, and play. These conditions affect a wide range of health and quality of life risks and outcomes. CDC, the World Health Organization (WHO), and others recognize work as a social determinant of health.[1],[2],[3] Despite this recognition, this key SDOH is not fully integrated into public health data collections or assessments.

Work-related information is invaluable for public health.

Work influences many aspects of life that affect health, including income, workplace hazards, social status, healthcare access, housing, economic security, and more. While SDOH such as age, race, and ethnicity are routinely collected by public health data collections, variables describing work, including an individual’s employment status, occupation, and industry, are not.

Therefore, no examination of health is complete without accounting for the role of work.

Work can affect workers’ lives in many ways.

Some indicators of good jobs are[4],[5]

• Safe, healthy workplace,
• income and benefits (e.g., access to affordable healthcare, paid leave),
• work-life balance,
• employment security,
• voice in decision-making,
• opportunities to gain skills, and
• positive employment-related relationships.

Not all jobs are equal.

The benefits and risks of work are not equitably distributed among jobs (occupations), industries, and workers.[6],[7],[8] Some jobs entail exposure to hazardous substances and other adverse working conditions. Certain jobs do not provide a living wage, healthcare access, paid sick leave, or other benefits. For example, lower-wage healthcare workers tend to have limited healthcare access. These workers also tend to have more adverse health conditions.[9],[10]

Work and other social disparities overlap.

Many workers in jobs and industries that have low healthcare access and high levels of adverse health conditions are non-white, Hispanic, or foreign-born.^10,[11] These workers are often disproportionately assigned to jobs with higher risks for exposure to infectious diseases and traditional workplace hazards. For example, many workers in construction are foreign-born, lack health insurance, are employed on a temporary basis, and are not English language proficient.11,[12] Workers in construction also have a high risk of on-the-job injuries.[13]

Solution: Work is as important as other key demographic variables. Collecting work information in all health data collections permits evaluation of work-related health and health equity issues.

Inclusion of work-related information in all health data collections, including case report forms and health surveys, can lead to improved understanding of the relationships between work, safety, and health issues.

At a minimum, the key variables for making all data collections useful for evaluation of the role of work in health are:

• Employment status: employed; unemployed (not working but looking for work); not in the labor market (not working and not looking for work)
• Occupation: a person’s job
• Industry: type of business a person works for

In addition to employment status, occupation and industry, other aspects of work are closely related to health equity. Government agencies, researchers, clinicians, community groups and many others can play a role by collecting additional work-related information, including but not limited to:

• Income
• Benefits
  • Healthcare access
  • Health insurance
  • Paid leave
  • Time off
• Job quality
  • Workplace safety and health
  • Job security
  • Voice in workplace decisions
  • Work-life balance and work schedules
  • Skills building and potential for advancement
• Exposures
  • Chemical, biological, physical, or mental health hazards

Conclusion

Regular and systematic collection of work information in all data collections is key to understanding how work affects social, economic, and health circumstances. The collection of key work information starts with including employment status, occupation, and industry in all surveys and case reports. Collecting information on other aspects of work also furthers research about work as a social determinant of health and facilitates efforts to promote health equity. Please share with us how you or your organization are collecting or using worker information in your safety and health efforts.

Andrea L. Steege, PhD, MPH, is a Lead Research Health Scientist in the Health Informatics Branch of the NIOSH Division of Field Studies and Engineering and an assistant program coordinator for the Occupational Health Equity Program.

Sharon Silver, MS, MA, is a Lead Research Health Scientist in the Health Informatics Branch of the NIOSH Division of Field Studies and Engineering and co-coordinator for the NORA Healthcare and Social Assistance Sector.

Amy Mobley, MEn, is a Health Communications Specialist in the Health Informatics Branch of the NIOSH Division of Field Studies and Engineering.

Marie Haring Sweeney, PhD, MPH, is Chief of the Health Informatics Branch in the NIOSH Division of Field Studies and Engineering and coordinator for Surveillance Program.

References

[1] U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Social Determinants of Health. Accessed on 2/10/2023.

[2]  World Health Organization. Social Determinants of Health. Accessed on 2/10/2023.

[3] The Community Guide [2022]. Advancing Health Equity. Accessed on 2/10/2023.

[4] United Nations Economic Commission for Europe [2015]. Adapted from: Handbook on Measuring Quality of Employment: A Statistical Framework. United Nations, New York and Geneva.

[5] Fujishiro K [2022].What Is Employment Quality? How Can We Study It for Occupational Health Equity? NIOSH Science Blog.

[6] Landsbergis PA, Grzywacz JG, LaMontagne AD [2014]. Work organization, job insecurity, and occupational health disparities. Am J Ind Med. 57(5):495-515.

[7] Centers for Disease Control and Prevention (CDC) [2013].  Nonfatal work-related injuries and illnesses – United States, 2010. MMWR Suppl. 2013 Nov 22;62(3):35-40.

[8] Steege AL, Baron SL, Marsh SM, Menéndez CC, Myers JR [2014]. Examining occupational health and safety disparities using national data: a cause for continuing concern. Am J Ind Med. 57(5):527-38.

[9] Silver SR, Li J, Marsh SM, Carbone EG [2022]. Prepandemic Mental Health and Well-being: Differences Within the Health Care Workforce and the Need for Targeted Resources. Journal of Occupational and Environmental Medicine. Dec;64(12):1025-1035.

[10] Silver SR, Boiano JM, Li J [2019]. Patient care aides: Differences in healthcare coverage, health-related behaviors, and health outcomes in a low-wage workforce by healthcare setting. Am J Ind Med 63(1):60-73.

[11] Hornback D, Cunningham T, Guerin R [2015]. Overlapping Vulnerabilities. NIOSH Science Blog.

[12] NIOSH, ASSE [2015]. Overlapping vulnerabilities: the occupational safety and health of young workers in small construction firms. By Flynn MA, Cunningham TR, Guerin RJ, Keller B, Chapman LJ, Hudson D, Salgado C. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2015- 178.

[13] Helmick N, Petosa J [2022]. Workplace Injuries and Job Requirements for Construction Laborers. Bureau of Labor Statistics, Spotlight on Statistics.