Lancet series calls for greater attention to work as social determinant of health

Researchers, including at IWH, call for greater policy attention to work as social determinant of health

Published: November 14, 2023

Work has long been considered a social determinant of health. Like housing, education, income security and other matters of economic and social policy, work can be a key factor in creating, maintaining or exacerbating unequal health outcomes across different societal groups.

But work is too often overlooked as a lever for addressing health inequities, according to a series on work and health published in October in the medical journal, The Lancet.

Major gains in population health and reductions in health disparities can be made by an increased focus on improving the work environment, argue the series authors, who include leading work and health scientists from around the world, among them the Institute for Work & Health (IWH) president Dr. Peter Smith.

Recent advances in data and study methods allow us to ask ‘what if’ questions about policy measures related to working conditions—and explore the potential impact of these measures on broader population health, says Smith.

The three papers in the open-access series review the evidence to date on the relationships between work and health in high-income countries. In each paper, the authors outline recommendations for decision-makers in public health, medical, labour and legal spheres to ensure working conditions will give rise to healthy and safe work for diverse populations.

Historical examples of work interventions that improve public health certainly exist. The series points to the 1919 Hours of Work Convention, where International Labour Organization member states agreed to limit working hours to improve health. But such examples remain infrequent, the authors note.

Instead, occupational health tends to be siloed from broader population health, and occupational health and safety activity tends to remain too focused on visible work hazards related to injuries and illnesses. Less attention is paid to the role that work conditions and environments play in creating, worsening or even alleviating health inequities, according to the first paper in the series.

Text shown next to a blurry image of people crossing a sidewalk. The text reads: "Recent advances in data and study methods allow us to ask 'what if' questions about policy measures related to working conditions-and explore the potential impact of these measures on broader population health." Dr. Peter Smith, President, Institute for Work & Health, Co-author of the Lancet Series on Work and Health.

That paper also lists major changes that will continue to shape the nature of work and its impact on population health. These include:

  • Telework. The rise in telework or remote work can lead to reduced psychosocial support from colleagues and greater social isolation. It may also erode responsibility by both employers and regulators for ensuring health and safety of those working from home.
  • International migrant workers. Refugees, immigrants and temporary migrant workers experience different labour market and health trajectories after arrival in Canada. Policy-makers need to pay attention to the distinctive patterns of health inequities experienced by different groups of migrant workers and provide tailored protective measures for each group.
  • Intersections between gender, age, race, ethnicity and social class. Researchers and policy-makers need to pay attention to the compounding effects that different social stratifiers have on the types of jobs (and subsequent differences in physical and psychological exposures at work) available to different groups in society, and identify opportunities to address these differences.
  • Precarious employment. With the continued erosion of full-time, permanent jobs and the rise of platform-based gig work, precarious work continues to spread across the global labour force. Precarious work is associated with greater workplace hazards and fewer protections, but there is no reason this needs to be the case, says Smith. We need to develop and implement innovative approaches, such as portable benefits, to make this type of work relationship safer.
  • Long and irregular work hours. Working long or irregular hours is associated with higher risks of stroke and heart disease, greater alcohol use and work injuries. Although regulations on working time are a central theme of labour rights and labour protections, the relationship between working time and worker health depends on social context. While those in secure and stable work may see health benefits from working fewer hours, for those in freelance, contract, self-employed and other similar arrangements, reduced hours can mean less income security.
  • Climate change. The effects of climate change on work are difficult to predict, though potentially severe. While increased ambient temperature, air pollution, ultraviolet radiation exposure, extreme weather and the spread of vector-borne diseases will directly impact some industries and occupations, the flow-on effects across the labour market are less clear. Policy-makers need to ensure these effects are not disproportionately impacting those in the lowest-paid jobs, who likely have the least resources to withstand the challenges.

Mental health and work

The second paper of the series examines workplace mental health. It finds the research literature on this topic still relatively young, with large epidemiological studies going back only to the late 1990s. However, findings have consistently shown a statistical link between certain working conditions and mental disorders. One such condition is job strain—defined as a condition when the demands of the job are high but workers have little control over how the work is done. Studies have also shown associations between bullying, violence and threats and mental disorders.

Whether such links can be shown to be causal is an ongoing debate in research circles, the authors acknowledge. But already, policy-makers have enough evidence to make the case for policies and programs to address working conditions, say the authors. They note as well that too much focus to date has been on programs targeting individual workers—not enough on the working conditions that may contribute to the illnesses, despite this broader focus likely leading to greater gains at the workforce level.

Labour market inclusion

In the third paper of the series, the authors provide an overview of the research literature on labour market inclusion. Work has intrinsic values that might contribute to better health, but the labour market’s continuing shift towards greater flexibility and informal work means a rise of poor working conditions, low pay and inadequate social protections. Three important groups face barriers to the labour market, the authors note. These are: workers with chronic diseases, workers with impairing disabilities, and workers over 50 years old. In debates on labour market regulations, such as on work contracts, precarious work, and pension reforms, health considerations unfortunately still have a minor role, write the authors. Future changes in the way we work will have substantial effect on the population health and health inequities. 

Regulations about hazards at work have been the exclusive domain of occupational health and safety specialists for too long, the authors argue. Addressing the broader aspects of work and working conditions that are social determinants of health will need greater involvement from other fields, including economic, law, social and political science. Moreover, occupational health needs to work hand-in-hand with other sectors, including but not limited to public health (and in Canada, across the federal/provincial division of responsibilities, notes Smith) to develop, implement and evaluate policy solutions that will help make the work people do, and the environments they work in, healthier and more equitable.