The Serpent of Their Agonies: Exploitation as Structural Determinant of Mental Illness

Unpaid overtime and mental health in the Canadian working population

BACKGROUND

Unpaid overtime-describing a situation where extra hours are worked but not paid for-is a common feature of the labor market that, together with other forms of wage theft, costs workers billions of dollars annually. In this study, we examine the association between unpaid overtime and mental health in the Canadian working population. We also assess the relative strength of that association by comparing it against those of other broadly recognized work stressors.

METHODS

Data were drawn from a survey administered to a heterogeneous sample of workers in Canada (n = 3691). Generalized linear models quantified associations between unpaid overtime, stress, and burnout, distinguishing between moderate (1-5) and excessive (6 or more) hours of unpaid overtime.

RESULTS

Unpaid overtime was associated with higher levels of stress and burnout. Relative to those working no unpaid overtime, men working excessive unpaid overtime were 85% more likely to report stress (prevalence ratios [PR]: 1.85, 95% confidence interval [CI]: 1.26-2.72) and 84% more likely to report burnout (PR: 1.84, 95% CI: 1.34-2.54), while women working excessive unpaid overtime were 90% more likely to report stress (PR: 1.90, 95% CI: 1.32-2.75) and 52% more likely to report burnout (PR: 1.52; 95% CI: 1.12-2.06). The association of excessive unpaid overtime with mental health was comparable in magnitude to that of shift work and low job control.

CONCLUSIONS

Unpaid overtime may present a significant challenge to the mental health of working people, highlighting the potential role of wage theft as a neglected occupational health hazard.

Working Conditions, Worker Rights, and Managerial Domination During the COVID-19 Pandemic: Assessing Their Toll on Precariously Employed Workers and Family Well-Being

Precarious Employment (PE) is characterized by job, income, and benefit insecurities. Studies surrounding PE and well-being have been predominantly quantitative, leaving a gap in rich descriptions of employment experiences. We recruited a sample of 40 adults aged 25-55 who were involved in PE during the beginning of the COVID-19 pandemic or lost employment due to the pandemic. Semi-structured interviews were administered. Employment and income insecurities were common and had negative impacts on the well-being of participants and their families. Uncertainty about future employment prospects and job and income loss resulted in chronic distress. Other insecurities-access to benefits, violation of worker rights, worker safety-was also reported as impacting well-being. The COVID-19 pandemic deepened insecurities, hardships, and distress among workers with PE conditions. Given the myriad insecurities experienced by those engaged in PE, the focus of precarious work research should also include working conditions, violation of worker rights, and managerial domination.

Differential effects of healthcare worker burnout on psychotropic medication use and misuse by occupational level

PURPOSE

Burnout has been well examined among physicians and other high-wage, high-autonomy healthcare positions. However, lower-wage healthcare workers with less workplace autonomy (e.g., medical assistants, nurses' aides) represent a substantial proportion of the workforce, but remain understudied. We aimed to examine the effects of burnout on psychotropic medication use and misuse and whether these effects differed by occupational level.

METHODS

In March 2022, we collected data from a diverse sample of US healthcare workers (N = 200) and examined the cross-sectional relationship between burnout and changes in prescribed psychotropic medication (i.e., starting, stopping, and/or having a change in the dose/frequency) during the COVID-19 pandemic. We also separately examined the relationship between burnout and psychotropic medication misuse (i.e., without a prescription, in greater amounts, more often, longer than prescribed, and/or for a reason other than prescribed). We stratified models by occupational level (prescribers/healthcare administrators vs. other healthcare workers).

RESULTS

Greater burnout was associated with higher odds of changes in prescribed psychotropic medication among prescribers/healthcare administrators (aOR = 1.23, 95% CI 1.01, 1.48), but not among other healthcare workers (aOR = 1.04, 95% CI 0.98, 1.10). Greater burnout was not associated with psychotropic medication misuse among prescribers/healthcare administrators (aOR = 0.96, 95% CI 0.82, 1.12) but was associated with increased odds of psychotropic medication misuse among other healthcare workers (aOR = 1.07, 95% CI 1.01, 1.14).

CONCLUSIONS

Potential disparities in help-seeking and healthcare access might manifest in non-medical use of prescription drugs among some healthcare workers, which has implications for worker safety and well-being.

Longitudinal plasmode algorithms to evaluate statistical methods in realistic scenarios: an illustration applied to occupational epidemiology

INTRODUCTION

Plasmode simulations are a type of simulations that use real data to determine the synthetic data-generating equations. Such simulations thus allow evaluating statistical methods under realistic conditions. As far as we know, no plasmode algorithm has been proposed for simulating longitudinal data. In this paper, we propose a longitudinal plasmode framework to generate realistic data with both a time-varying exposure and time-varying covariates. This work was motivated by the objective of comparing different methods for estimating the causal effect of a cumulative exposure to psychosocial stressors at work over time.

METHODS

We developed two longitudinal plasmode algorithms: a parametric and a nonparametric algorithms. Data from the PROspective Québec (PROQ) Study on Work and Health were used as an input to generate data with the proposed plasmode algorithms. We evaluated the performance of multiple estimators of the parameters of marginal structural models (MSMs): inverse probability of treatment weighting, g-computation and targeted maximum likelihood estimation. These estimators were also compared to standard regression approaches with either adjustment for baseline covariates only or with adjustment for both baseline and time-varying covariates.

RESULTS

Standard regression methods were susceptible to yield biased estimates with confidence intervals having coverage probability lower than their nominal level. The bias was much lower and coverage of confidence intervals was much closer to the nominal level when considering MSMs. Among MSM estimators, g-computation overall produced the best results relative to bias, root mean squared error and coverage of confidence intervals. No method produced unbiased estimates with adequate coverage for all parameters in the more realistic nonparametric plasmode simulation.

CONCLUSION

The proposed longitudinal plasmode algorithms can be important methodological tools for evaluating and comparing analytical methods in realistic simulation scenarios. To facilitate the use of these algorithms, we provide R functions on GitHub. We also recommend using MSMs when estimating the effect of cumulative exposure to psychosocial stressors at work.

A tutorial on a marginal structural modeling approach to mediation analysis in occupational health research: Investigating education, employment quality, and mortality

Life expectancy inequities between more- and less-educated groups have grown by 1 to 2 years over the last several decades in the United States. Simultaneously, employment conditions for many workers have deteriorated. Researchers hypothesize that these adverse conditions mediate educational inequities in mortality. However, methodological barriers have impeded research on the role of employment conditions and other hazards as mediating factors in health inequities. Indeed, traditional mediation analysis methods are often biased in occupational health settings, including in those with exposure-mediator interactions and mediator-outcome confounders that are caused by exposure. In this paper, we outline-and provide code for-a marginal structural modeling (MSM) approach for estimating total effects and controlled direct effects originally proposed elsewhere, which can be applied to common mediation analysis settings in occupational health research. As an example, we apply our approach to assess the extent to which disparities in employment quality (EQ)-a multidimensional construct characterizing the terms and conditions of the worker-employer relationship-explained educational inequities in mortality in a 1999-2015 US Panel Study of Income Dynamics sample of workers with mortality follow-up through 2017. Under certain strong assumptions described in the text, our estimates suggest that over 70% of the educational inequity in mortality would have been eliminated if EQ had been at the 80th percentile (100th  = best) across exposure groups.

History of Low Hourly Wage and All-Cause Mortality Among Middle-aged Workers

Importance

Earning a low wage is an increasingly recognized public health concern, yet little research exists on the long-term health consequences of sustained low-wage earning.

Objective

To examine the association of sustained low-wage earning and mortality in a sample of workers with hourly wage reported biennially during peak midlife earning years.

Design, Setting, and Participants

This longitudinal study included 4002 US participants, aged 50 years or older, from 2 subcohorts of the Health and Retirement Study (1992-2018) who worked for pay and reported earning hourly wages at 3 or more time points during a 12-year period during their midlife (1992-2004 or 1998-2010). Outcome follow-up occurred from the end of the respective exposure periods until 2018.

Exposures

Low-wage-less than the hourly wage for full-time, full-year work at the federal poverty line-earning history was categorized as never earning a low wage, intermittently earning a low wage, and sustained earning a low wage.

Main Outcomes and Measures

Cox proportional hazards and additive hazards regression models sequentially adjusted for sociodemographics, and economic and health covariates were used to estimate associations between low-wage history and all-cause mortality. We examined interaction with sex or employment stability on multiplicative and additive scales.

Results

Of the 4002 workers (aged 50-57 years at the beginning of exposure period and 61-69 years at the end), 1854 (46.3%) were female; 718 (17.9%) experienced employment instability; 366 (9.1%) had a history of sustained low-wage earning; 1288 (32.2%) had intermittent low-wage earning periods; and 2348 (58.7%) had never earned a low wage. In unadjusted analyses, those who had never earned low wages experienced 199 deaths per 10 000 person-years, those with intermittent low wages, 208 deaths per 10 000 person-years, and those with sustained low wages, 275 deaths per 10 000 person-years. In models adjusted for key sociodemographic variables, sustained low-wage earning was associated with mortality (hazard ratio [HR], 1.35; 95% CI, 1.07-1.71) and excess deaths (66; 95% CI, 6.6-125); these findings were attenuated with additional adjustments for economic and health covariates. Significant excess death and elevated mortality risk were observed for workers with sustained low-wage exposure and employment fluctuations (eg, for sustained low-wage × employment fluctuated, HR, 2.18; 95% CI, 1.35-3.53; for sustained low-wage × stable employment, HR, 1.17; 95% CI, 0.89,-1.54; P for interaction = .003).

Conclusions and Relevance

Sustained low-wage earning may be associated with elevated mortality risk and excess deaths, especially when experienced alongside unstable employment. If causal, our findings suggest that social and economic policies that improve the financial standing of low-wage workers (eg, minimum wage laws) could improve mortality outcomes.

Employment trajectories and mental health-related disability in Belgium

OBJECTIVES

An individual's quality of employment over time has been highlighted as a potential determinant of mental health. With mental ill-health greatly contributing to work incapacities and disabilities in Belgium, the present study aims to explore whether mental health, as indicated by registered mental health-related disability, is structured along the lines of employment quality, whereby employment quality is assessed over time as part of individuals' labour market trajectories.

METHODS

Using administrative data from the Belgian Crossroads Bank for Social Security over 16 quarters between 2006 and 2009, transitions between waged jobs of varying quality (based on dimensions of income, working time, employment stability and multiple jobholding), self-employment, and unemployment are considered among individuals in the labour force aged 30-40 at baseline (n = 41,065 women and 45,667 men). With Multichannel Sequence Analysis and clustering, we constructed ideal types of employment trajectories. Fitting Cox regressions, we then evaluated individuals' hazard of experiencing a disability from a mental disorder between 2010 and 2016.

RESULTS

Our analysis highlights various gender-specific trajectories. Among both genders, individuals exposed to near-constant unemployment over the initial 4 years showed the highest hazard of subsequent mental health-related disability compared to a group characterised by stable full-time employment, single jobholding, and above-median income. Trajectories involving a higher probability of subsidised and non-standard employment and (potential) spells of unemployment and lower relative income were also strong predictors of cause-specific disabilities. Health selection and confounding might, however, be contributing factors.

CONCLUSIONS

Our study shows a gradient of mental disorders resulting in a disability along trajectory types. Our findings highlight the predictive power of labour market trajectories and their employment quality for subsequent mental disorder-related disability. Future research should examine the mechanisms, including selection effects in this association.

The social determinants of ideal cardiovascular health: A global systematic review

This systematic review synthesizes research published from January 2010-July 2022 on the social determinants of ideal cardiovascular health (CVH) carried out around the world and compares trends in high-income countries (HICs) to those in low- and middle-income countries (LMICs). 41 studies met inclusion criteria (n = 28 HICs, n = 13 LMICs). Most were from the United States (n = 22) and cross-sectional (n = 33), and nearly all evaluated associations among adults. Among studies conducted in LMICs, nearly all were from middle-income countries and only one was carried out in low-income country. Education (n = 24) and income/wealth (n = 17) were the most frequently examined social determinants in both HICs and LMICs. Although most studies assessed ideal CVH using reliable and valid methods (n = 24), only 7 used criteria pre-defined by the American Heart Association to characterize ideal levels of each CVH metric. Despite heterogeneity in how outcome measures were derived and analyzed, consistent associations were evident between multiple markers of higher social status (i.e. greater education, income/wealth, socioeconomic status, racial/ethnic majority status) and greater levels of ideal CVH across both country contexts. Gaps in the literature include evidence from LMICs and HICs other than the United States, longitudinal research, and investigations of a wider array of social determinants beyond education and income/wealth.

Wage theft and life expectancy inequities in the United States: A simulation study

Wage theft - employers not paying workers their legally entitled wages and benefits - costs workers billions of dollars annually. We tested whether preventing wage theft could increase U.S. life expectancy and decrease inequities therein. We obtained nationally representative estimates of the 2001-2014 association between income and expected age at death for 40-year-olds (40 plus life expectancy at age 40) compiled from tax and Social Security Administration records, and estimates of the burden of wage theft from several sources, including estimates regarding minimum-wage violations (not paying workers the minimum wage) developed from Current Population Survey data. After modeling the relationship between income and expected age at death, we simulated the effects of scenarios preventing wage theft on mean expected age at death, assuming a causal effect of income on expected age at death. We simulated several scenarios, including one using data suggesting minimum-wage violations constituted 38% of all wage theft and caused 58% of affected workers' losses. Among women in the lowest income decile, mean expected age at death was 0.17 years longer in the counterfactual scenario than observed (95% confidence interval [CI]: 0.11-0.22), corresponding to 528,685 (95% CI: 346,018-711,353) years extended in the total 2001-2014 age-40 population. Among men in the lowest decile, the estimates were 0.12 (95% CI: 0.07-0.17) and 380,502 (95% CI: 229,630-531,374). Moreover, among women, mean expected age at death in the counterfactual scenario increased 0.16 (95% CI: 0.06-0.27) years more among the lowest decile than among the highest decile; among men, the estimate was 0.12 (95% CI: 0.03-0.21).

Cumulative exposure to state-level structural sexism and risk of disordered eating: Results from a 20-year prospective cohort study

BACKGROUND

Gendered inequities in disordered eating are well-documented, yet few studies have examined their structural drivers. To help fill this gap, we investigated whether cumulative exposure to state-level structural sexism from childhood through young adulthood potentiates differences in disordered eating risk between cisgender girls/women and boys/men.

METHODS

Participants came from the Growing Up Today Study (N = 16,875), a cohort of children aged 9-14 years in 1996 who we followed through 2016. Using a composite index of relevant state policies and social inequalities from the Institute for Women's Policy Research, we categorized states as having high or low levels of structural sexism and summed the number of years participants had lived in a high structural sexism state during the study period to quantify their cumulative exposure. We fit sequential conditional mean models to estimate the effect of cumulative exposure on risk of four outcomes (chronic dieting, purging, binge eating, and overeating), controlling for individual- and state-level confounders via propensity scores. We then tested whether effects differed between girls/women and boys/men by including cumulative-exposure-by-gender-identity interaction terms and calculating the relative excess risk due to interaction (RERI).

RESULTS

In the full sample, each additional year of living in a high structural sexism state was associated with a 5% increased risk of purging (95% confidence interval (CI): 3%, 7%), an 8% increased risk of binge eating (95% CI: 6%, 10%), and a 9% increased risk of overeating (95% CI: 8%, 11%). Risk increases were larger on average for girls/women than for boys/men, and girls/women who had lived in a high structural sexism state for four or more years had excess risk of chronic dieting (RERI: 0.64, 95% CI: 0.18, 1.10), purging (RERI: 2.64, 95% CI: 1.24, 4.30), and binge eating (RERI: 2.21, 95% CI: 0.93, 3.50).

CONCLUSIONS

Structural sexism may contribute to inequities in disordered eating between cisgender girls/women and boys/men. Future research should include transgender and gender diverse participants, explore intersectional effects, and identify underlying mechanisms to inform policy-oriented interventions.

Free agents or cogs in the machine? Classed, gendered, and racialized inequities in hazardous working conditions

INTRODUCTION

Few epidemiologic studies have used relational social class measures based on control over productive assets and others' labor to analyze inequities in health-affecting working conditions. Moreover, these studies have often neglected the gendered and racialized dimensions of class relations, dimensions which are essential to understanding population patterns of health inequities. Our study fills these gaps.

METHODS

Using data from the 2002-2018 U.S. General Social Survey, we assigned respondents to the worker, manager, petit bourgeois, or capitalist classes based on their supervisory authority and self-employment status. Next, we estimated class, class-by-gender, and class-by-race inequities in compensation/safety, the labor process, control, and conflict, using Poisson models. We also estimated gender-by-race inequities among workers.

RESULTS

We identified substantial class inequities, with worse conditions for workers, which is the largest class within genders and racialized groups, but also disproportionately consists of women and people of color (POC), particularly women of color (WOC). For example, relative to workers, capitalists were less likely to report that safety is not a priority (prevalence ratio [PR]: 0.41, 95% confidence interval [CI]: 0.21, 0.82), repetitive tasks (PR: 0.36, 95% CI: 0.21, 0.61), and lacking freedom (PR: 0.11, 95% CI: 0.05, 0.24). We also identified inequities among workers, with women and POC, particularly WOC, reporting worse conditions than white male workers, especially greater discrimination/harassment (WOC PR: 1.70, 95% CI: 1.36, 2.13).

CONCLUSION

We identified substantial inequities in working conditions across intersecting classes, genders, and racialized groups. These inequities threaten workers' health, particularly among women and POC.

Union Burying Ground: Mortality, Mortality Inequities, and Sinking Labor Union Membership in the United States

BACKGROUND

Over the last several decades in the United States, socioeconomic life-expectancy inequities have increased 1-2 years. Declining labor-union density has fueled growing income inequities across classes and exacerbated racial income inequities. Using Panel Study of Income Dynamics (PSID) data, we examined the longitudinal union-mortality relationship and estimated whether declining union density has also exacerbated mortality inequities.

METHODS

Our sample included respondents ages 25-66 to the 1979-2015 PSID with mortality follow-up through age 68 and year 2017. To address healthy-worker bias, we used the parametric g-formula. First, we estimated how a scenario setting all (versus none) of respondents' employed-person-years to union-member employed-person-years would have affected mortality incidence. Next, we examined gender, racial, and educational effect modification. Finally, we estimated how racial and educational mortality inequities would have changed if union-membership prevalence had remained at 1979 (vs. 2015) levels throughout follow-up.

RESULTS

In the full sample (respondents = 23,022, observations = 146,681), the union scenario was associated with lower mortality incidence than the nonunion scenario (RR = 0.90, 95% CI = 0.80, 0.99; RD per 1,000 = -19, 95% CI = -37, -1). This protective association generally held across subgroups, although it was stronger among the more-educated. However, we found little evidence mortality inequities would have lessened if union membership had remained at 1979 levels.

CONCLUSIONS

To our knowledge, this was the first individual-level US-based study with repeated union-membership measurements to analyze the union-mortality relationship. We estimated a protective union-mortality association, but found little evidence declining union density has exacerbated mortality inequities; importantly, we did not incorporate contextual-level effects. See video abstract at, http://links.lww.com/EDE/B839.

US trends in binge drinking by gender, occupation, prestige, and work structure among adults in the midlife, 2006-2018

BACKGROUND

Rates of binge drinking have nearly doubled among US women ages 30-49 since 2006. Employment influences alcohol use and varies by the prestige and structure (e.g., authority, autonomy, expertise) of one's occupation.

METHODS

We examined trends in binge drinking among adults ages 30-49 in the labor force in 2006-2018 National Health Interview Surveys (N = 108,981) by occupation, work prestige (General Social Survey's occupational prestige score), work structure (occupational authority, autonomy, automation, expertise), and gender. We estimated odds of binge drinking by year with survey-weighted logistic regression controlled for sociodemographics, smoking, and disability.

RESULTS

In 2018, 30% of women and 43% of men reported binge drinking; drinking increased annually from 2006-2018 (OR for women = 1.08, OR for men = 1.03). Work status, prestige, and work structure modified the association. Women in high- (OR = 1.10, 95% CI: 1.09-1.12) versus low-prestige (OR = 1.05, 95% CI: 1.04-1.06) jobs had higher increases, as did men in high-prestige jobs (OR = 1.04, 95% CI: 1.03-1.05). Respondents in higher relative to lower authority, autonomy, and expertise jobs increased binge drinking.

CONCLUSIONS

Though all strata of workforce adults increased binge drinking, increases were concentrated among women in higher-status careers, implicating gendered shifts in labor as one determinant of recent national alcohol trends.