Case 1: Inequalities in working and behaving healthy
The contribution of work and lifestyle factors to socioeconomic inequalities in
self-rated health – a systematic review (Dieker et al., 2019)
https://repub.eur.nl/pub/116984/
Behaviour and the living and working environment are important contributors to
socioeconomic status and inequalities
Two hypotheses for this include:
o “People with a low SES have a less healthy lifestyle and live and work in more
disadvantaged conditions than people with a high SES” (mediation effect)
o “The effects of unhealthy lifestyle and living and working conditions on health
is larger in those with a low SES” (moderating effect)
Previous research found that “material factors, such as housing and physical work
factors, explained the largest part of the relation between socioeconomic position
(i.e. income, occupational class, and education) and self-rated health”
o Followed by behavioural factors (e.g. smoking and physical activity) and
psychosocial factors (e.g. lack of social support)
This systematic review focuses on self-rated health and how work factors contribute
to the socioeconomic inequalities that affect self-rated health
o Quantifying the “contribution of work and lifestyle factors to socioeconomic
inequalities in self-rated health within the working population”
Found that approximately one-third of socioeconomic inequalities in self-rated
health can be explained by physical and psychosocial work factors
These work factors “contribute to these health inequalities irrespective of lifestyle
behaviours”
Behavioural determinants of health and disease (Green et al., 2017) (Scan in
general, section on socioeconomic status)
https://oxfordmedicine-com.ezproxy.ub.unimaas.nl/view/10.1093/med/
9780199661756.001.0001/med-9780199661756-chapter-14
The interaction of socioeconomic status, environments, and behaviour
Socioeconomic status (SES) is the most “pervasive, consistent, and robust”
association with behaviour and health
SES is a gradient, not several levels/thresholds
How does SES influence health-related behaviours, cultures, and environments, and
how can we intervene on these to reduce morbidity and mortality?
SES as a predisposing determinant of behaviour
In areas where the inequalities between those at the top and bottom of society were
largest also had the strongest mortality gradients
, A Canadian study found socioeconomic disparities increase with age, supporting “the
notion of a cumulative effect over time of the health- and mortality-SES gradient”
The perception of where an individual feels they fit on this gradient can demotivate
or discourage them from taking greater control over the behavioural and
environmental determinants of their health
o Two possible causes for this phenomenon include chronic pessimism among
the children of lower SES parents and ‘self-efficacy’ (self-belief)
SES as an enabling determinant of behaviour
“Socioeconomic standing also confers capabilities and resources that enable the
predisposed behaviours to be carried out, for better or for worse”
o Those with high SES have the capabilities and resources to behave in ways
that support their health, while those with low SES are limited by their
capabilities and resources no matter how motivated they are to be healthy
The educational enabling influence of SES on behaviour
“Education has for decades demonstrated the strongest association with most
health-behaviour measures”
o The essence of this is in health literacy
The relation between smoking and education was much stronger than between
smoking and income or occupational status
The cultural-environmental predisposing influence of SES
As Japanese people migrated to Hawaii or California there was increased rates of
heart disease and stroke due to ‘acculturation’ (they adopted the culture of their
new homes, including dietary behaviour)
Is it difficult for minority cultures to avoid the pervasive influences of majority
cultures, and therefore to not lose some protective health factors such as the
Japanese example
Culture “remains a conceptually useful construct for understanding the processes of
socially transmitted beliefs and values that predispose people to one choice of
behaviour over another”
SES as a reinforcing determinant of behaviour
People only repeat behaviours that produce satisfying results (reinforcements)
People can be put into association with other people and environments that produce
these reinforcements
Two examples of this include:
o The ‘status identity factor’ and social norms
People identify with and justify their place in society based on their
highest achievement
E.g. Someone with high education but low/middle income and
occupational status associate themselves with their highest
achievement = education
, They do not associate themselves with their average SES
o Denormalising behaviour
E.g. Denormalising the behaviour of smoking in restaurants,
workplaces, etc
Can be achieved by legal restrictions (although this can be difficult to
achieve)
Long-term social norms can also achieve change, and arguably more
lasting and effective change
Restrictions to smoking were easier as the health consequences occur
in others and not just the user
This idea of ‘second hand’ consequences are useful for
achieving change in other health issues
Work characteristics, socioeconomic position and health: a systematic review
of mediation and moderation effects in prospective studies (Hoven & Siegrist,
2013) (Focus on Introduction and Discussion)
https://oem.bmj.com/content/70/9/663
Introduction
The lower a person’s socioeconomic position (SEP) the higher their risk of morbidity
and impaired health
Work and employment conditions is an important consideration, with their strong
impact on everyday adult life (it’s obligations, resources and rewards)
Typical measures of SEP, such as job status, classification or grade, truly explain little
in regards to an individual’s health
Physical stressors and occupational hazards “strongly cluster among low skilled
occupations and people with atypical or precarious employment”
Negative health effects of stressful work environments due to the rapidly evolving
economy and workplaces
Mediation hypothesis: “the strength of association between SEP and health is
abolished or substantially weakened if the effect of work characteristics on health is
estimated in multivariate regression models”
Moderation hypothesis: “the effect of a predicting variable (work characteristic) on
a criterion variable (health) varies according to the level of a third variable (SEP)”
o “In this case, stronger effects of adversity at work on health are expected
among employed people in less privileged as compared to more privileged
socioeconomic conditions”
Discussion
Some empirical support in favour of both mediation and moderation hypotheses
Mediation hypothesis:
, o Majority of studies support that adverse working conditions mediate (bring
about) the association of SEP with health
o This is particularly true in studies that combined physical stressors with
psychosocial stressors
o Studies using “occupational categories or employment grades as indicators of
SEP provided more robust findings than those using education or income as
indicators”
From the tutorial:
o
