Health and Safety Issues for Workers in Nonstandard Employment
Summary and Keywords
Standard employment arrangements—where the relationship between employers and employees is clear and employment is full-time, understood to be lasting, and with full protections—coexist with nonstandard employment (NSE) relationships. A variety of terms have been used to describe specific types of NSE including temporary, contingent, contract, freelance, on-call, gig, and app-based employment. These forms of employment, in combination with larger social and economic forces, structural power dynamics, and advances in technology, can work together to limit the ways in which employment supports health, and undermine workplace health protections. Nonstandard employment brings with it particular concerns for health and safety related to work, and in a broader public health sense. Health can be protected in NSE through intervention at national, state and province, and local levels to proactively shape the quality of employment arrangements.
Keywords: nonstandard employment, standard employment, precarious employment, contract employment, temporary employment, employment conditions, working conditions, perceived job insecurity, health, occupational health, mental health, safety, social-ecological model, ecological systems theory, policy
Work—both employment arrangements and the conditions under which work is performed—is an important determinant of health for individuals and populations and interacts with health in multiple ways. The physical requirements and demands of a job, interactions among people in the workplace, whether workers are exposed to hazards at work, and the ways in which people are employed can all either provide a healthful setting at one end of the spectrum or harm workers at the other end. Furthermore, work can provide social connectedness, control, and resources that permit healthy living standards. Here, the focus is on various forms of employment arrangements that differ from standard employment that is full-time, understood to be lasting in duration, and fully protected. While a variety of terms have been used to describe these employment arrangements including temporary, contingent, contract, freelance, on-call, and, more recently, “gig” and “app-based” employment, the term “nonstandard employment” (NSE), adopted by the International Labour Organization, is used here (ILO, 2016). While jobs with characteristics of NSE relationships have long existed, ongoing declines in organization and bargaining for workers, economic and labor market deregulation, privatization, and changes related to globalization of markets and advances in technology have undermined both protections to health and the health-enhancing benefits of work that had been achieved in the 20th century. Therefore, the focus here is one that suggests a broadened purview for occupational safety and health to include employment arrangements, and for the incorporation of this broader perspective on work and its relationships to health within a public health framework.
To discuss the interactions between NSE and the health of workers, some definitions that may be useful to public health researchers and practitioners are provided. A brief overview of the historic evolution of employment arrangements and estimates of the burden of NSE in several world regions follow. Third, a summary of what is known about the ways in which NSE relationships interact with health is presented. Because most of this research has been done on specific formulations or experiences of NSE arrangements, such as temporary employment or perceived job insecurity, the focus is on that body of research. This section is followed by presenting frameworks that may be useful to public health practitioners and researchers who wish to include employment relationships as part of a broader multilevel context that can contribute to the development of interventions. Recognizing the lack of information about the public health impacts of other forms of NSE, the major research gaps are summarized. Finally, strategies for intervention, which may help to improve employment-related health, are outlined.
Recent changes in the world economy and accompanying restructuring of organizations and workplaces have heightened the awareness of public health researchers to the necessity for considering employment relations as a critical influence on public health, and an important element for designing occupational safety and health studies and intervention programs. NSE exists in broader political, economic, and social realities that have globalized the production of goods, services, and the need for labor, as well as created new forms of employment that differ from what has been called the standard employment relationship (SER)—work that is stable and full-time, with the full workplace and social protections afforded by the context in which the employment exists, and in which the employer and employee are clearly known (Benach et al., 2014; Walters, 2005). Nonstandard employment departs from those conditions, often through arrangements that are not stable, where wages and hours are not sufficient to provide for economic security, and where relationships between employer and employee are unclear. Nonstandard employment forms can allow companies to decrease labor costs by adjusting and reducing employment during periods of low production and by limiting costs related to social security and worker benefits, such as health insurance and pensions (Quinlan, 2005; Quinlan, Mayhew, & Bohle, 2001). The specific elements of SERs or NSE relationships will vary by place and level of economic development. For this reason, organizations such as the ILO have proposed qualities of employment and work to which countries should aspire across all economic and social contexts (ILO, 2016). It is important to distinguish two additional terms: formal and informal labor. Formal labor is recognized and therefore expected to conform to current norms and rules. Informal labor, conversely, is not recognized officially and therefore not regulated or protected. Standard and nonstandard employment here refer to the formal sector.
In addressing the public health consequences of NSE, it is important to first recognize the distinction between employment conditions (a less well-studied aspect of public health) and working conditions, the traditional focus of occupational safety and health researchers and public health practitioners. Employment conditions describe the nature of the connection between a buyer of labor (most commonly an employer) and the seller of labor (the employee or worker). The conditions established under this relationship determine what each party is expected to give and receive in the relationship—the rights and responsibilities each owes the other (Benach, Puig-Barrachina, Vives, Tarafa, & Muntaner, 2012). Working conditions, in contrast, are those circumstances that result from the nature of the work, including the way work is organized, where and how it is performed, and the physical and social environmental conditions. Poor working conditions may include physical, chemical, or biological hazards and the existence of psychosocial stressors in the workplace that may lead to injury or illness for workers. The nature of the employment relationship determines and can interact with working conditions to promote or compromise the health and safety of employees. For example, a contracted or temporary employee may not be as a well-trained or as familiar with the work environment and therefore may be at greater risk for a work-related injury or illness compared to longer-term and permanent employees. Similarly, harassment by a supervisor is associated with adverse mental health outcomes among employees but those mental health outcomes can be heightened when a temporary worker is afraid to report this treatment because of fear of job loss.
“Precarious employment” is another term applied to studies examining the health impacts of temporary or contract employment. While there is no single definition of precarious employment, the features of work most commonly used to describe precariousness include low wages that do not support a minimal acceptable standard of living, no certainty of ongoing employment or income, insufficient or uncertain hours, hazardous working conditions, few or no benefits (such as for unemployment, low income, or disability), no opportunity for advancement, no protection from discrimination and exploitation, and no opportunity to participate in workplace decision making or collective bargaining (ILO, 2016). As well, employment may be precarious, to different extents, for all employment forms. For example, while temporary workers report job insecurity more frequently than do permanent workers (Catalano et al., 1986; Van der Doef & Maes, 1999; Virtanen et al., 2013), some studies find the difference to be small (De Witte & Näswall, 2003) or absent (Menéndez et al., 2007). For another example, in a study of workers in Ontario, Canada, Lewchuk (2017) found that 28% of workers who reported having “permanent” jobs also reported that they did not expect to be in that job in 12 months or were not paid any benefits beyond wages. These permanent workers expressed similar concerns about job insecurity as temporary workers.
History of Nonstandard Employment
Precarious employment has been part of capitalism since the beginning of industrialization. Employers, operating in a free market, hired “at will,” that is, hired and fired workers as they saw fit, and most workers had to accept employment on terms offered unilaterally by employers. With the rise of labor unions and the implementation of employment protection legislation, at-will hiring and firing were regulated and employers had to assume new labor costs such as social security, severance pay, and occupational health and safety insurance. This historic pattern of a movement from at-will employment to some sort of labor union and legal protection tended to appear in nations as they industrialized.
After World War II, industrialized nations established a social pact whereby the historically highest levels of employment security were achieved, a period known as the Golden Years, ranging from 1945 to the mid-1970s. In the rapidly expanding manufacturing sector, for example, the production paradigm of that brief period of years is referred to as Fordism, where mass production of standardized goods under tight managerial control was compensated by high levels of welfare secured by the state, and high and stable wages which gave workers access to new patterns of consumption, through which many workers themselves benefited from mass production (Castel, 2003; Rubery & Grimshaw, 2003; Boyer, 1993). Once hired, workers were assured a long-term relationship with the company through internal labor markets that lessened the impact of external shocks and benefited employees at all salary levels. However, not everyone benefited from these achievements. Crucially, these benefits and protections applied most clearly to workers in the male-dominated manufacturing sector, while other sectors, such as agriculture, were never included in those sorts of improved employment and social protections. In addition, people working in small companies, living in isolated settings or marginalized by race, gender, or immigrant status continued to experience more precarious employment conditions.
This era ended with the worldwide economic recessions of the 1970s and 1980s. The expectation of smooth economic cycles and predictable industrial change was broken, opening a period of economic and labor market deregulation and labor union decline. Concomitantly, a decline in the rates of profit resulting from a crisis in the Fordist mode of productive organization and the technical and social limits of mass production, rendered the inherent “rigidities” of the Fordist model problematic, calling for economic restructuring at various levels (Standing, 1999; Boyer, 1993; Neffa, 2002).
The 1980s saw the beginning of the “Washington consensus,” or what has come to be called neoliberal globalization: open markets, privatization of state-owned industries and services, global economic deregulation, and a global trend toward weakening of labor unions. These changes were extended through structural adjustments imposed by the International Monetary Fund and the World Bank, which further weakened earlier legal or union protections and eventually led to a resurgence of precarious employment. In pursuit of employment flexibility, governments relaxed labor market regulation, limited social security benefits, and weakened the bargaining power of unions, favoring the individualization of employment relations (Standing, 1999). In addition, the shift of employment from manufacturing toward service activities, a sector that tends to be characterized by weak unions, smaller firms, and higher worker mobility (Boyer, 1993), moved more workers into more nonstandard forms of employment.
In the 21st century, together with weaker employment protection through legislation and reduction in the bargaining power of unions, private industry and governments began to engage in different practices of subcontracting, or contracting out, and industrial workforces were fragmented. Generally, only the industrial and governmental cores retained aspects of standard employment relationships, while secondary or auxiliary services were contracted. This mass practice of contracting out major segments of business operations such as hiring, evaluation, pay, supervision, training, and coordination of workers has increased competition among service providers, lowering wages, and, in some sectors, has increased the likelihood for illegal and exploitive employment practices (Weil, 2014).
Burden of Nonstandard Employment
One of the challenges in tracking and studying the health effects of NSE is identifying all of its forms; that is, developing consistent criteria and mechanisms for identifying workers who fit those criteria. Given the range of different employment arrangements and labor laws, developing a consistent classification that applies globally is difficult and limits cross-country comparisons. The International Labour Organization (ILO) has recently attempted to apply a uniform classification system for NSE, which they define as employment that is not full-time and is of indeterminate duration (ILO, 2016). Most commonly included in this classification are workers employed on a temporary basis by a company and workers employed by temporary or contract agencies. The ILO does not include all self-employed independent contractors but does include “dependent” self-employed workers, also referred to as “bogus” self-employment. These are jobs dependent on employers in a similar manner to other wage workers but without the attribution of legal responsibility and additional labor costs to the employer, leaving these workers unprotected in a variety of ways such as lacking employer paid health and workers compensation benefits.
Using this definition, the ILO developed estimates of the numbers of NSE in 2004 and 2014 for Europe and other parts of the world (see ILO, 2016, Figure 2.3, p. 53). In 2014 in many regions of the world, rates of NSE exceeded 20% of workers, and in some regions, rates were much higher. In Europe, the main form of NSE was temporary employment through fixed-term contracts; countries with the highest levels included Poland, Spain, Portugal, Cyprus, and the Netherlands, all of which had levels over 20%. In countries such as Malta and Slovakia, levels of temporary employment have doubled and in Ireland, the incidence has tripled over the past decade. Most European temporary workers (62%) reported that they were working temporarily because they could not find a permanent job.
In Australia, a quarter of wage employees are considered “casual,” and in Asia temporary work ranges from 24% in the Philippines to 67% in Vietnam. Casual work constitutes nearly two thirds of wage employment in Bangladesh and India, and around one quarter in Indonesia. In Latin America, Peru and Ecuador have the highest rates, with 60% of wage employees in temporary contractual arrangements. In Africa, 25% of workers in Kenya, more than one third of workers in Zimbabwe and Mali, and over 50% in Ethiopia and Tanzania are temporary (ILO, 2016).
In the United States, the Bureau of Labor Statistics has collected data to measure the size of the NSE workforce (using the label “contingent and alternative employment”) in 1995, 2001, and 2005, and found the proportion of workers remained relatively stable (United States Department of Labor, Bureau of Labor Statistics (BLS), 2005). A subsequent 2016 study by economists Katz and Krueger (2016), in collaboration with the Rand Institute, tried to replicate measures from the BLS and estimated that 15.8% of U.S. workers were employed in “alternative work arrangements,” a 50% increase since 2005. Furthermore, they estimate that all of the new employment growth in the U.S. economy from 2005 to 2015 appears to have occurred in alternative work arrangements, which include independent contractors (8.4%), on-call workers (2.6%), temporary help workers (1.6%), and workers provided by contract firms (3.1%).
Katz and Krueger (2016) also evaluated demographic and industry-specific trends. Much of the rise in alternative employment since 2005 in the United States resulted from a greater number of workers being employed by temporary agencies and contract firms. Since 2005, the educational and health services sectors have experienced the largest growth in the number of alternative workers and the percentage of women in alternative employment has doubled such that now women outnumber men in these jobs. On-call and temporary help workers in the United States are more likely to be less educated, African American or Hispanic, and have lower income compared to other workers in alternative employment.
Cranford, Vosko, and Zukewich (2003) published one of the first reviews of precarious employment in Canada in which they describe both what makes work precarious and how social characteristics—such as gender, race and ethnicity, and age—play a role. They found that while nonstandard employment stabilized in Canada in the late 1990s, the more precarious forms of NSE—temporary jobs and own-account self-employment—became more common. Full-time temporary jobs increased from 4% in 1989 to 7% in 2002, while part-time temporary and part-time permanent jobs stayed about the same. In 2002, full-time permanent jobs were still the most common type of employment but declined from 67% in 1989 to 63% in 2002. Women were more likely to work part-time (even if self-employed) and in temporary jobs than men. Job insecurity continued to rise even as the number of nonstandard jobs stopped increasing.
Nonstandard Employment and Health
Work interacts with health in many ways, including the physical conditions and requirements of the job, the interactions of people at workplaces and workers’ perceptions of them, the resources available to do the work, and whether workers are exposed to hazards; beyond these work-related risks, the employment relationship and the benefits it confers also influence health status (Marmot, 2015). On one hand, wages can give a person control over his or her life and access to living standards that are a fundamental lever for improving health (Graham, 2004; Castel, 2003) and for participating as a member of the society to which they belong. Other nonmaterial benefits of work, called latent beneficial functions (e.g., time structure, significant social relations, identity, and status), are furthermore important to health (Jahoda, 1982). Work is also a place where connections to larger structural influences on health that place people into unequal social positions materialize; that is, the employment and working conditions experienced by workers are intertwined with the fundamental causes of health status (Link & Phelan, 1995) or are fundamental themselves (Graham & Kelly, 2004; Ahonen, Fujishiro, Cunningham, & Flynn, 2018). Moreover, the influences of work on health accumulate on different social groups unevenly, making work an important contributor to observed societal health inequities (Lipscomb, Loomis, McDonald, Argue, & Wing, 2006; Dahlgren & Whitehead, 2006; Bambra, 2011).
In some circumstances NSE may not create a health-harming work arrangement. For instance, highly paid freelance or gig workers may earn enough money to cover their needs while also having a high degree of choice over the work they accept and control over the conditions and tasks they perform, and they may find meaning and reward from that work. For these workers, such health-protective factors may override the experience of uncertainty that comes with insecure employment relationships.
There is also evidence, however, that these potential protections from harm are not present for many workers in nonstandard employment, and studies from multiple different countries have documented poorer working conditions and worse psychosocial work environments, increased psychological and physical morbidity, as well as increased risk for injury on the job (Benach et al., 2014; Benach & Muntaner, 2007; Quinlan et al., 2001). A variety of reasons for this have been put forth, but not all pathways and causes are yet clear. Existing evidence does highlight the need for continued research to better understand how employment relationships affect workers, how these effects are patterned across worker groups, and the implications of these effects on broader population groups such as communities, regions, and whole countries.
The major focus of epidemiologic research has been on temporary employment and perceived job insecurity. Also, approaches to the multidimensional nature of employment precariousness have been proposed in the literature, but they have not been widely used in studies linking precarious employment to health.
Temporary employment includes all forms of nonpermanent contracts. A Cochrane review found that temporary contracts had equivocal or negative effects on health (Kalleberg, 2009). A meta-analysis of temporary employment (Virtanen, Kivimäki, Elovainio, Vahtera, & Ferrie, 2003) found the literature was most suggestive of a relationship with increased psychiatric morbidity, reduced sickness absence, and occupational injuries. Temporary workers tend to report experiencing worse working conditions than permanent workers (Goudswaard, André, & Ekstedt, 2002; Lewchuk & Clarke, 2011), being less informed about their work environments, receiving less training for performing their tasks, having less access to safety equipment, and not being well represented in health and safety committees (Goudswaard & Nanteuil, 2000; Quinlan & Bohle, 2009, 2008). Consequently, temporary workers are at higher risk of occupational injuries (Amuedo-Dorantes, 2002; Benavides et al., 2006; Quinlan & Bohle, 2009). Such injuries have been attributed to their shorter job tenures and resulting lack of job experience and knowledge of the job’s associated risks (Benavides et al., 2006). The psychosocial environment tends to be worse for temporary workers, who report less influence on decisions regarding work arrangements and who receive less support from superiors and fellow workers than permanent employees (Aronsson, Gustafsson, & Dallner, 2002; Menéndez, Benach, Muntaner, Amable, & O’Campo, 2007; Saloniemi, Virtanen, & Vahtera, 2004), making this an area requiring more research. Also, some organizational characteristics of the places where temporary workers are more frequently employed, such as establishment size and economic activity, may contribute to adverse outcomes (Amuedo-Dorantes, 2002).
Mental health is a key outcome of insecure nonstandard employment, and findings related to mental illness and mental health are mixed (Bardasi & Francesconi, 2004; Kim, Muntaner, Chung, & Benach, 2010; Kim et al., 2012; Louie et al., 2006; Quesnel-Vallée, DeHaney, & Ciampi, 2010), but evidence indicates that psychological ill health increases with a rising degree of employment instability (Artazcoz, Benach, Borrell, & Cortes, 2005; Virtanen et al., 2006; Virtanen, Liukkonen, Vahtera, Kivimäki, & Koskenvuo, 2003). Evidence regarding self-rated health is also mixed; some studies describe negative associations (Kim et al., 2010; Kivimäki, Vahtera, Pentti, & Ferrie, 2000; Rodriguez, 2002) and others describe positive associations (Louie et al., 2006). Of note, sickness absence tends to be less frequent among temporary workers ((Benavides, Benach, Diez-Roux, & Roman, 2000; Benavides et al., 2006; Virtanen et al., 2008; Van der Doef & Maes, 1999; Virtanen, Vahtera, Nakari, Pentti, & Kivimäki, 2004), possibly reflecting sickness presenteeism, or working while ill (Vahtera, Pentti, & Kivimäki, 2004; Van der Doef & Maes, 1999). Sickness presenteeism, which may impair recovery, is thought to be caused by feelings of job insecurity or fear of job loss (Klein Hesselink & Van Vuuren, 1999; Virtanen et al., 2008).
Income instability (Ferrie, Shipley, Newman, Stansfeld, & Marmot, 2005), personal financial circumstances (Aronsson et al., 2002; Catalano et al., 2011), and perceived job insecurity may mediate the relationship between temporary employment and mental ill health, although the effects of perceived job insecurity have been equally (Virtanen et al., 2004) or more (De Witte, 1999; Virtanen et al., 2003) problematic for permanent workers.
Perceived job insecurity is generally understood as perceptions of uncertainty regarding the continuity of the current job, or perceived likelihood of job loss. Of note, while temporary workers can be considered to be in an objective state of job insecurity, permanent workers have also been reported to feel different extents of job insecurity. Job insecurity and actual job loss are in fact described as substantially different experiences, whereby the experience of job insecurity may be sustained over a long period of time, acting as a chronic stressor (Scott, 2004) with a negative health impact (Sverke, Hellgren, & Näswall, 2002; Virtanen et al., 2005). A considerably larger proportion of the workforce is subjected to job insecurity than to actual job loss (Rosenblatt, Talmud, & Ruvio, 1999).
Research on perceived job insecurity increased during the 1990s, with a relative drop-off more recently. Both dose–response and longitudinal associations with mental and physical health have been demonstrated (Burgard, Brand, & House, 2009; Ferrie et al., 2005). Regarding the former, there is evidence of an increased prevalence of minor psychiatric morbidity and generalized anxiety disorders, job dissatisfaction, and musculoskeletal complaints, among others. (De Witte, 1999; Ferrie, Westerlund, Virtanen, Vahtera, & Kivimäki, 2008; Sverke et al., 2002). Examples of the latter are worse self-reported health, greater cardiovascular risk, and moderately increased risk of nonfatal and fatal myocardial infarctions (Ferrie, 2001; Ferrie et al., 2008; Sverke, Hellgren, & Näswall, 2002; Virtanen et al., 2013).
Job insecurity may be linked not only to the perceived likelihood of involuntary job loss but also to the fear of losing other valued features of the job (Ferrie et al., 2005; Grimshaw et al., 2001; Marusic & Bhugra, 2008), and hence, job insecurity has been proposed as having multiple dimensions affecting health. However, the most important factors for health and health inequalities (Lewchuk et al., 2008) appear to be the continuity of the job itself and its associated financial insecurity (Heponiemi et al., 2010). However, knowledge about how or which organizational characteristics shape the experience of job insecurity is still limited (Quinlan & Bohle, 2008). Another limitation of the job insecurity construct is that its approach is more likely to generate findings linked to the individual than to the employment relationship (Aronsson et al., 2002; Benach, Benavides, Platt, Diez-Roux, & Muntaner, 2000).
Precarious employment is an approach that draws from Rodgers’ (1989) conceptualization, including not only the limited or uncertain duration of temporary work but also limited protection from labor-market uncertainties and unacceptable treatment at work, low wages, and limited worker control over factors such as wages and working hours. Several multidimensional approaches have been developed (Tompa, Scott-Marshall, & Fang, 2008); however, many of them tend not to make a clear distinction between employment conditions and working conditions, and most have had limited use in health-related research.
One multidimensional approach specifically developed for epidemiologic research is the multidimensional Employment Precariousness Scale (EPRES) (Amable, Benach, & González, 2001; Vives, 2010). The underlying construct and resulting scale comprises the following dimensions: temporariness (employment instability), powerlessness or disempowerment (individualized vs. collective bargaining), vulnerability (worker defenselessness to unacceptable workplace practices), low or insufficient wages, limited rights (suboptimal entitlement to social security benefits and worker rights), and incapacity to exercise rights (powerlessness, in practice, to exercise workplace rights and entitlements). EPRES acknowledges the unequal power relations underlying flexible employment relations (Benach, Muntaner, Solar, Santana, & Quinlan, 2010; Brooker & Eakin, 2001) and allows for an identification of precarious jobs irrespective of type of contract, enabling an adequate classification of all kinds of salaried workers by their degree of exposure. Several cross-sectional, individual-level studies have demonstrated an association between the EPRES score and poor mental health, self-perceived health, job dissatisfaction, self-reported occupational injuries, and workplace presenteeism, as well as inequalities in attributable risk for poor mental health (Benach et al., 2014). As with temporary employment and perceived job insecurity, mental health is a key health outcome of precarious employment (Vives, 2010).
Another multidimensional model related to employment precariousness is the employment quality model, which shares theoretical and conceptual starting points with EPRES and incorporates two additional dimensions: lack of training and employability opportunities, and exposure to unpredictable or intensive working hours (Benach, Vanroelen, Vives, & De Witte, 2013). As with most forms of nonstandard employment, the distribution of employment precariousness tends to place the greater burden among those in labor market disadvantage, that is, younger workers, immigrants, manual workers, and women (Benach et al., 2015; Puig-Barrachina et al., 2014; Vives et al., 2013).
Most research on the links between temporary employment, perceived job insecurity, and precarious employment and health has been performed in high-income countries, where the vast majority of the workforce is in formal, dependent employment relationships. The focus in middle- and low-income countries would have to be on informal employment, an even more understudied topic.
Frameworks to Inform Research and Intervention
Several macrolevel frameworks and models explicitly attempt to depict the structural factors that delineate employment arrangements, how these circumstances relate to working conditions, and how all of these connect to health status (Benach et al., 2010; Muntaner et al., 2010). These frameworks provide potential directions for interventions to reduce the adverse health outcomes associated with NSE. While interventions to improve working conditions most frequently focus on implementing occupational safety and health controls and programmatic policies on the industry or facility level, interventions to address health risks from employment conditions are more complex. In the proposed frameworks, conditions of employment are the result of nested levels of influence, including national and international economic policies and trends as well as labor laws and social safety net policies. Relations among groups that wield power through institutions (e.g., corporations, interest groups, and labor unions), governmental functions (e.g., political parties), and civil society (e.g., nongovernmental or community organizations) determine the structures and policies of national labor markets and social safety net programs and services. Labor markets are key in determining which employment conditions are possible, likely, and available, and are closely linked to political and economic forces creating policies and general practices that determine who has access to different types of employment. Labor market failures may be partially offset by social safety net programs and services (e.g., unemployment benefits, healthcare, and subsidized housing) offered by government and other organizations.
Thus, employment conditions result from the following: the interaction of power relations between employers and workers, labor market forces, laws, and the social safety net. The relationship between employment and health is only completely understood in the context of structural influences: social, political, and economic forces contributing to policies that do or do not consider the health and well-being of workers.
Where power relations between employers and workers and labor markets are oriented toward the common good, the need for social safety net programs and policies is diminished. The World Health Organization Commission on the Social Determinants of Health (WHO, 2008) noted that fair employment and decent work contribute to greater societal equity in power, money, and resources—and thus better overall population health—by lowering poverty, reducing hazardous exposures at work, lessening workplace stress, and enhancing overall well-being.
The social ecological model is often used in public health to describe the interaction between and influence of personal and environmental determinants of health in order to identify leverage points for understanding and improving population health (Bronfenbrenner, 2009). Often portrayed as an expanding set of circles from the individual to interindividual, community, and society levels, the interactions between each level represent a “system” that operates bidirectionally.
An application of the social ecological model proposed by Baron and colleagues (2014) was used to consider multilevel intervention approaches to reduce the impact of precarious employment on worker health. These levels can include: (1) workers’ relationships and interactions with people at and away from work (e.g., supervisors, coworkers, family members, and friends); (2) employers’ workplace policies and programs, as well as the employers’ interactions with other actors (e.g., health, community, and local governments); (3) the impacts of business competition, government policies, lending policies, and so on, at the societal level that prevent or encourage employers to offer healthy employment and working conditions; and (4) society’s cultural values and social norms that influence and determine societal, political, economic, and other system policies.
As et Golden, McLeroy, Green, Earp, and Lieberman (2015, p. 8S) propose, because policy change is central to implementing and supporting effective public health interventions, it may be more appropriate to consider turning the social ecological model “inside out, placing health-related and other social policies and environments at the center, and conceptualizing the ways in which individuals, their social networks, and organized groups produce a community context that fosters healthful policy and environmental development.” Because employment and working conditions are largely determined by broad political and economic policies, greater attention to these higher levels of influence could lead to more effective and lasting worker population health impacts.
Knowledge Gaps and Limitations
In recent decades, knowledge about the ways in which employment arrangements interact with health and safety of workers has grown substantially, and several major works have compiled that information, highlighted gaps in understanding of these relationships (Benach, Muntaner, & Santana, 2007; Peterson & Mayhew, 2005; CSDH, 2008), and proposed priorities to work toward improvement (CSDH, 2008; ILO, 2013). Areas where continued effort is necessary include more and better data to monitor relationships between NSE and health at the population level, research that elucidates pathways and mechanisms linking employment and health, and stronger theoretical development demonstrating how those relationships function. Ideally, monitoring, surveillance, and research should be mutually nutritive, such that research provides information on what ought to be included in monitoring and surveillance, and monitoring provides descriptive data that may be used to develop new research questions. Specific needs include:
• more and better sources of data for generating information and monitoring the relationships between employment arrangements, safety, and health;
• more nuanced understanding of paths and mechanisms that create employment conditions and that connect conditions of employment to health status;
• better theoretical development that includes the ways in which macrolevel structures influence the development of specific employment conditions;
• studies of employment conditions and health that link multiple levels of influencing variables and include multiple research methods; and
• exploration of the broader family, community, and societal-level health impacts of different employment arrangements.
Many of these areas are interconnected, and addressing these gaps is critical to the ability to intervene to protect and improve public health.
The Need for Data
In most settings, inadequate data for monitoring and surveillance of employment and health is a challenge. Most surveillance systems for occupational injury and illness were designed to monitor outcomes clearly and unequivocally related to work, such as acute injury after a fall or diseases with very clear etiologies (e.g., coal workers’ pneumoconiosis), in an era where jobs with standard employment relationships were dominant. As a result, more complex conditions such as stress-mediated health problems, depression, and anxiety—all conditions related to employment arrangements—are often not included. In addition, as Quinlan (2005) and others have discussed, data on even traditional reportable occupational health and safety outcomes may not be organized to allow a focus on specific employment relationships, meaning that delineating these outcomes along lines of employment relationships is challenged. Moreover, it is well-known that even these classic occupational safety and health impacts are underreported (NASEM, 2018). At a minimum, surveillance systems would be more useful to monitoring employment-related health if they included data on the employment arrangement and type of employer. Other data, such as that from workers’ safety net (unemployment benefits) or compensation programs for injured, ill, or disabled workers, often don’t capture many of the contract and temporary workers because they are not eligible (Quinlan, 2005).
Conditions of employment are sometimes captured in broader public health surveillance systems along with other social determinants of health, but often are scattered across unconnected sources or not collected in such a way as to adequately categorize employment arrangements because they were developed for other purposes (Benach et al., 2012). The limited ability of surveillance systems to estimate the population-level burden and severity of health problems as they relate to employment is an important impediment to progress in public health. Because of this lack of information on population burden and severity, comparison across groups and contexts is also limited. Comparison would facilitate clearer understanding of the ways in which employment arrangements interact with health for different groups. Some countries have added regular population-based surveys (e.g., the European Working Conditions Survey) to fill gaps in understanding. This is a good and important step that also allows comparison across countries, but care must be taken to include adequate queries of employment arrangements and health.
Finally, these data challenges are those largely of high-income countries. In many places, particularly low- and middle-income countries, there is little regulation, and data about work are limited (Benach et al., 2010; Quinlan, 2005). In places where public and occupational health and safety surveillance already exists, efforts at evolving existing systems or developing new ones suited to assessing employment arrangements and health will need to take account of some of the problems briefly described here. In places where these systems are nonexistent, such factors could be considered from the beginning in the design and planning of health surveillance or other data collection systems.
The Need for Research
Several areas of health and safety are understudied with regard to employment arrangements such as temporary and contract employment and other types of NSE. Many nonoccupationally focused studies aiming to understand social determinants of health leave work out, instead focusing on economic indicators, income, education, and race and ethnicity (Ahonen, Fujishiro, Cunningham, & Flynn, 2018). Furthermore, circumstances common in NSE, such as multiple job holding and rapid turnover (“job churning”), make it difficult to relate health problems to work in general or to any specific employment relationship. As a result, many questions remain. For instance, how might burdens of ill health related to employment patterns vary depending on economic and social safety nets available from place to place? More specifically, how might the impact of NSE vary with more or less generous economic safety nets such as unemployment insurance? In another example, research in most national contexts shows that women are more likely to be in temporary, contract, and other forms of NSE arrangements. At the same time, prevailing social roles and norms mean that they are still also more likely to carry the larger load of unpaid or non-market-based work. What do these realities mean for the health of employed women?
Paths and Mechanisms
Gaps in understanding of paths and mechanisms related to NSE and health and well-being exist on at least two levels. First, the ways in which certain macrolevel structures create the existence of different employment conditions must be better understood in order to create circumstances under which healthful employment is available and likely. In addition, because access to employment under specific conditions is not distributed equally across population subgroups, clarity on these mechanisms would help us to understand uneven patterning of employment arrangements. Second, information about many of the specific mechanisms that tie together particular employment conditions and specific health outcomes is lacking.
Further Theoretical Development
Theoretical development that takes a broad view of the ways in which employment conditions are distributed and experienced requires the contribution of multiple research disciplines. The challenges of such work are known and long-standing. However, such multidisciplinary perspectives advance understanding of the relationships between employment conditions and health status by prompting examinations of these issues at multiple levels and by using mixed and multiple research methods. Such nuanced understanding would provide a clearer sense of where to intervene to ameliorate unwanted outcomes.
Broader Health Impacts of Employment Arrangements
In addition to understanding the relationships between employment arrangements and health, there are information gaps about how NSE may impact other parts of economies relevant to health. For instance, it may be that the expansion of NSE in the formal economy contributes to growth in the informal economy. If people are employed in circumstances that, by their definition, do not last, personal economic stability may be difficult. In such a scenario, people must seek additional ways to support themselves; this gap may be filled in part by working informally (Quinlan, 2005). Conversely, it is also possible that NSE influences workers employed in more standard employment forms through the conditions of work, such as by prompting work intensification and longer hours (Quinlan & Bohle, 2009).
NSE impacts protection and supportive systems for workers in ways that could be better delineated. First, fragmentation of economic structures, labor markets, and changes in the way work is organized pose challenges to the ways worker protection has been carried out. Walters (2005) has argued that the decreasing regulation of all of those areas on the part of many countries, combined with under-resourcing, draws into question the ability of governments to protect workers through regulation and enforcement in ways they have in the past. Second, the economic and eligibility logic of many supportive systems for workers, such as workers’ compensation and other legal remedies for workplace harm, was developed under the assumption of more standard employment structures and patterns that are now much less frequent (Quinlan, 2005).
NSE may also color the view of the status of occupational health and safety for everyone. First, for factors that are tracked in occupational data or surveillance systems, the fact that many workers in NSE jobs are not included or are included but with frequent interruptions in job history, may mean that the overall occurrence of these problems appears to be smaller than it is. Further, workers in short-term or closed-ended jobs may manifest health problems derived from the job once they have left or changed jobs (Virtanen et al., 2005; Arrighi & Hertz-Picciotto, 1994). For research on occupational health and safety, frequent worker turnover and repeated phases of selection into jobs means some people “fall out” of the employed population because of ill health. This means that the influence of employment factors on health may be underestimated because some portion of the affected people are no longer in employment to be counted. Beside the implications this has for understanding the interactions between employment arrangement and health, there is also the risk of consequences for the adequate resourcing of agencies in charge of occupational safety and health; if circumstances appear better than they are, such agencies run the risk of becoming under-resourced or incorrectly allocating their resources based on biased surveillance data (Quinlan, 2005).
The family and community impacts of NSE, particularly job instability and low pay, are important ones for any society. Even those short-term jobs that are well-paid are still insecure in terms of the duration and intensity of market demand for that work. Such “externalities” (Quinlan, 2005, p. 59) impact whole communities through inadequate housing quality and upkeep, family savings, educational choices for children, health care options, and eligibility for supportive entitlements. Over time, these conditions may perpetuate disinvestment and community instability, with its ties to social fragmentation (Quinlan, 2005). Yet, these concerns also cross jurisdictional and funding boundaries such that research that may illuminate the broader consequences of precarious employment is challenging to fund and conduct.
Interventions, initiatives, and actions at the structural and societal levels (beyond the workplace), are presented first because these are where the overarching, structural causes of NSE and precarious jobs occur, after which potential initiatives at the industry or enterprise level are considered.
National Laws and Regulations
Concern for employment arrangements is central to several major global initiatives, including the World Health Organization Global Plan of Action on Workers’ Health (WHO, 2007), the International Labour Organization’s Decent Work Agenda (Ghai, 2006), and the United Nations Sustainable Development Goals (UN, 2015). Equity is a major focus across each of these initiatives, and employment is recognized, along with conditions of work, as central to tackling inequity in social conditions and status as well as in health. These initiatives gather and summarize evidence, establish goals and priorities for action, and suggest strategies for monitoring progress toward goals.
The earliest of these reports identifies five objectives: policies for protecting workers, safe working and employment conditions, access to improved occupational health services, building evidence for worker health actions, and consideration of worker health in nonoccupational policies (WHO, 2007). A baseline assessment of these objectives found that substantial efforts are required in terms of employment arrangements. Two thirds of surveyed countries did not have occupational health services for all workers, and few countries have comprehensive workplace health surveillance systems. Mental health was included in the work-related policy frameworks of only 62% of surveyed countries (WHO, 2013).
As defined by the ILO, decent work pays a fair wage, occurs in a safe workplace, offers social protections and opportunities for personal development, allows people to express their concerns, organize, and participate in workplace decisions, and offers equal opportunities and treatment for everyone (ILO, 2016). The ILO Decent Work Agenda includes four “pillars” central to healthy and productive human lives: employment creation, social protection, rights at work, and social dialogue. The UN incorporated these pillars into its 2030 Sustainable Development Goals (UN, 2015). Goal 8—Decent Work and Economic Growth—specifically highlights the need to protect the rights, security, safety, and income of workers employed in precarious jobs. This goal also recognizes that “poverty eradication is only possible through stable and well-paid jobs” (emphasis added). Other UN sustainable development goals related to poverty, hunger, health and well-being, gender equality, and social inequality also make explicit reference to decent work.
A recent ILO (2016) report on NSE suggests that policy interventions for improving nonstandard, precarious employment should be focused on two things: (1) making jobs better, and (2) supporting all workers. To make jobs better, countries should have legislative policies that ensure equal and comparable treatment, guarantee minimum hours and work schedule advance notice, address employment misclassification, restrict use of nonstandard employment, protect freedom of association and collective bargaining, and build union capacity for organizing and representing workers in nonstandard employment.
To support all workers, countries should consider how well social protections—both those tied to and independent of employment—ensure short- and long-term security and health regardless of employment status. As well, countries should consider economic policies that promote full employment, including public employment programs, employment assistance and training, and support for family care responsibilities.
Changing the Enforcement Paradigm
As Weil (2014) notes: “The modern employment relationship bears little resemblance to that assumed in core US workplace laws” (p. 44). This likely applies to most countries and economies and means that ultimately, if the current trends in restructuring of employment relations persist, new labor laws will be needed that assure protections irrespective of the employment relationship. In the absence of new laws or regulations, creative approaches are needed to ensure that all workers receive adequate protection and treatment. Examples include:
• focusing enforcement efforts at the main company where policies and practices determine employment conditions at subsidiary locations;
• building links with model or “high road” companies and brands to create positive employment standards for their industry;
• using fair labor standards to embargo goods across state-provincial-national lines to alter supply chain behavior;
• establishing outreach, education, and monitoring agreements with lead businesses to ensure fair and equitable employment conditions at all locations;
• raising consumer awareness about unacceptable labor practices, as this can be a powerful motivator for companies concerned that loss of reputation will impact the bottom line; and
• establishing guidance to existing labor laws that clarify enforcement and other policies across various employment arrangements, such as the U.S. Occupational Safety and Health Administration’s 2014 guidance regarding temporary employees (OSHA, 2014).
Local and State Laws, Policies, and Programs
When a country fails to enact nationwide laws and policies that ensure decent work for all its citizens, entities at state, provincial, and local levels may undertake to address the impacts of various features of precarious jobs (Siqueira et al., 2014). These could include:
• laws to raise the minimum wage or prevent wage theft, labor protection ordinances such as leave policies, whistleblower protection, and scheduling;
• community benefit agreements between developers and community groups that ensure local residents receive economic and other benefits from major developments;
• cooperative enforcement efforts across government and community agencies;
• coordinated healthcare for workers between community clinics, healthcare systems, workers compensation systems, etc.; and
• partnerships between unions, worker centers, and occupational health and safety professionals that build support for unrepresented workers.
Partnerships are an important feature of many such initiatives. Several examples from the United States may serve as nonexclusive examples. An in-depth review of the 2010 Domestic Worker Bill of Rights in New York State offers some insights into how such partnerships can be successful. Domestic Workers United (DWU)—an entirely worker-led organization—built a campaign and alliance of organizations and individuals (Hobden, 2010). Starting with a New York City law requiring employment agencies placing domestic workers to obtain a signed code of conduct from employers, followed by a convention involving more than 200 domestic workers, DWU partnered with a university immigrant rights clinic to draft a preliminary bill of rights.
DWU spent several years introducing and advocating at the state legislature, collecting cosponsors, educating legislators, gaining the support of union and community leaders—and eventually employers—and raising public awareness. This initiative was successful because of strong commitment and leadership from domestic workers; DWU’s alliance with a wide variety of organizations, many of which undertook to educate their members about the bill of rights; collaborating with supportive employers willing to advocate actively with legislators; building alliances with unions; framing a broad message in addition to targeted communications; and using the media to educate and reach legislators and the public. This initiative required both cultural and policy changes to be successful, as many precarious jobs have their roots in cultural and social expectations about paid and unpaid “work.”
What this and other similar initiatives illustrate, however, is the difficulty workers in precarious jobs face in exercising their voice through collective bargaining and union organizing (Meeting the Challenge of Precarious Work, 2013). Unions, as well, encounter many barriers when trying to organize or bargain for people in jobs outside of the standard employment relationship. Some unions have been successful in the international and national arenas, but such efforts require lots of effort and time to build coalitions with workers, employers, legislators, and community organizations. Avenues available to unions seeking to deal with precarious jobs include collective bargaining agreements, litigation, legislation, organizing, and media campaigns. Often one or several of these are required to bring about positive change.
One example of these kinds of collaborations was first initiated following a major natural disaster in the United States, but its success resulted in an ongoing collaboration between the United Steelworkers labor union, the National Day Labor Organizing Network (a national network of organizations that advocate for nonunion construction laborers), and a New York-based academic research center. This partnership established a successful occupational safety and health training program for construction day laborers that has served more than 10,000 workers and built alliances with the local district attorney’s office to prosecute wage theft and occupational safety and health violations for nonunion temporary construction laborers (Cuervo, Leopold, & Baron, 2017).
Interventions at the Individual and Employer Levels
The decision to use nonstandard jobs, whether precarious or not, has implications for human resources, managers and supervisors, and coworkers. Recruitment, retention, and training costs will be lower for nonstandard jobs and reliance on such jobs may require different types of management to ensure organizational alignment and coworker teamwork and support. The potentially positive aspects of NSE for employers need to be balanced against the documented adverse physical and mental health effects that may negatively affect employee productivity and morale. People with nonstandard jobs report higher levels of attachment to organizations that offer some degree of job autonomy and opportunities for development. The “blended workforce” has both positive and negative features for an organization. Offering greater flexibility for adjusting to seasonal or other changes in economic conditions, at some point a large number of workers in NSE will be viewed negatively by those in standard jobs and as a signal that their own jobs may be less secure (ILO, 2016).
For those responsible in an organization for the assurance of worker health, there may be significant ethical and moral—and perhaps legal—conflicts when people doing the same job but having different employment relationships are treated differently with respect to workplace health and safety programs and policies, workers compensation, benefits, etc. For example, offering an ergonomic workstation for someone in a standard job while denying a similar setup for a worker in a temporary job does not conform with the basic right for all workers to a safe and healthy workplace. Given the recent expansion in NSE worldwide, researchers and public health practitioners can make a contribution by developing initiatives to expand inter- and intraorganizational interventions that, if not eliminating the existence of precarious jobs, could mitigate their impacts on the health and well-being of workers. In this effort, occupational safety and health practitioners may be aided by working closely with human resources professionals, who also have a stake in creating health-supporting workplace policies and practices, and whose expertise and perspectives may complement those of occupational health and safety and public health professionals.
NSE relationships are increasing in their frequency, exposing larger populations to potential unwanted health outcomes related to the undermining of health-supporting benefits associated with employment and with the creation of poorer working conditions. Employment is an important structural and social determinant of health but is frequently left out of broader public health efforts. To understand its health effects, public health researchers and practitioners should treat NSE as a multidimensional phenomenon that influences the physical and mental health status of populations through various pathways. The social ecological model, ecological systems theory, and other systems-thinking frameworks with which public health professionals are familiar highlight the need for intervention at the structural level, looking beyond specific workplaces to improve employment conditions for entire populations.
The authors wish to thank Katherine Cheesman for her excellent bibliographic support and Daniel La Botz for his review and comments for the section on the history of NSE.
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