Population Health: Behavioral and Social Science Insights

Labor Policy and Work, Family, and Health in the Twenty-First Century

By Lisa F. Berkman

Abstract

Socioeconomic disparities in health can be identified with some precision, yet solutions to reduce inequalities and improve overall population health are not as easily specified. Solutions centered on helping poor and lower wage men and women stay in the paid labor market may have health benefits, reduce inequalities in health, and improve overall population health. The Earned Income Tax Credit, pro-family work policies and practices, parental leave, and retirement policies are examples of labor policies that impact the health and well-being of working families. Policies enabling adults to participate in the paid labor force while not risking the health and well-being of themselves or their family members show particular value. Metrics for evaluating social and economic policies do not currently include health metrics. The health outcomes, which are spillovers of such policies, would increase the benefits of those policies in any cost-benefit equations. Developing sound health metrics for the evaluation of seemingly "non-health-related" social and economic policies is essential to improving population health. Such metrics will, however, need to be very specific and tailored to the policies they are intended to evaluate. We want to ensure that Americans, particularly those living in poverty and the working poor, aren't robbed of healthy years of life.

Introduction

The United States has continued to experience modest increases in life expectancy (LE) over the past decades; however, LE in the United States also has declined dramatically in cross-country rankings. It is important therefore to consider what conditions shape patterns of LE in the United States and elsewhere.1 While most attention has focused on changing behavioral risks (notably smoking), here we explore the interactions between working conditions, labor force participation, and family dynamics, especially for women, because these conditions have enormous potential to influence population health. Furthermore, women's LE has fared worse than men's in these international rankings. When the interactions between work and family are coupled with the major demographic transitions in the world today, they may be among the most powerful social determinants of health.

Fundamentally, the United States, along with most nations, faces a number of very serious demographic transitions, including the aging of their societies, increased numbers of older workers, increased labor force participation among women, and changing patterns of fertility. Re-imagining how work might be organized and constructing innovative approaches to work that acknowledge the shifting demographics and new constellations of families in the 21st century may enable the United States to become not only a healthier nation but also a more productive one.

Here in the United States, for the most part, work and many labor policies are organized as if we were still living as people did in the 1940s when many work policies were established. During that era, there usually was one breadwinner in each family, and people had a LE of 66. In the middle of the 20th century, just over half of Americans who reached the age of 21 could expect to reach age 65. Many workers paying into Social Security would never live long enough to receive benefits, especially African Americans whose life expectancy was just over 50 in 1935. Men retiring today can expect to live about 17 additional years, or about 4-5 years longer than they did in 1940.2 Women's LE is even longer. These changes are so dramatic that it is no surprise that our expectations cannot fathom them. Furthermore, in the mid-20th century, few men had any caretaking responsibilities while working or in retirement. The contemporary scenario is dramatically different, with most women in the paid labor force and caregiving needs spread out across three or even four generations. Among men, home responsibilities have taken on increased significance over the last years, and work life strains have increased for both men and women.3 Thus, both men and women may need accommodations in the workplace to incorporate caregiving responsibilities. Furthermore, families with young children, as well as older workers with other family caregiving needs, share the need for increased workplace flexibility.

Many social policies developed in the mid-20th century that appeared to be optimal at the time, may now be costing us in terms of both economic and health gains. Yet, we have rarely evaluated the health impact of these policies and practices. The premise in this chapter is that the limited evaluation of the health impacts of such social policies and the subsequent lack of implementation of new policies based on best evidence to enable both men and women to maintain active work and family lives have cost the United States a great deal in terms of poor health.

U.S. Life Expectancy: Low International Rankings and Rising Inequality

To briefly set the stage for this exploration, overall LE in the United States has lost ground compared to that of other nations in the last decades, especially for women. I was a member of a recent National Academy of Sciences panel on diverging trends in longevity. The panel found that the United States ranked at the bottom among 21 developed, industrialized nations,1 and poor rankings were particularly striking for women. In the 1980s, U.S. rankings were in the middle among Organization for Economic Co-operation and Development (OECD) countries.1 While it is true that LE improved during this time by 5.6 years for men and 3.6 years for women, other countries gained substantially more in terms of LE, leaving us behind. Furthermore, almost all of those gains were concentrated among the most socioeconomically advantaged segments of the U.S. population, and they were more substantial for men than for women. The poorest Americans experienced the greatest health disadvantage compared to those in other countries.4,5 At a recent National Institutes of Health (NIH) conference, the discussion was focused on the steps required for the United States to reach the OECD average—not even the top—in the next 20 years. It seems we have given up on achieving better than average health.

The panel found that the United States ranked at the bottom among 21 developed, industrialized nations and poor rankings were particularly striking for women.

More concerning is the widening gap in mortality rates between those at the bottom and those at the top of the economic ladder in the United States. This gap has widened over the last 25 years. These patterns are evident whether we look at education, income, or wealth differentials. Because the evidence is clearest that education itself is causally linked to health and functioning,6,7 in this chapter I will focus on these associations. For instance, the mortality rate for men with less than a high school education in 2007 was about 7 per 100. For those with 16 years or more of education, the rate was less than 2 per 100. This corresponds to a 3.5-fold risk of dying in 2007, compared to 2.5 times the risk in 1993. For less educated women, their mortality risk actually increased absolutely during this time, giving rise to an increased risk from 1.9 to 3 in 2007.8 This pattern holds even if we confine our analyses to white women.9 While it is true that fewer adults are in the less educated pool in later years, giving rise to questions about selection issues, it is also true that adults in the highest educational categories have grown over this same time period, suggesting increased compositional heterogeneity in these groups. Overall, while selection into education level occurs, it does not appear to completely explain this widening gap.

Although mortality gaps in socioeconomic status have existed for centuries, the magnitude of these differences has grown substantially over time in the United States. These widening disparities suggest that either disparities in the underlying determinants of illness and mortality have also been growing over time or that support to buffer these stressful conditions has changed. In either case, while we may not be able to eliminate health disparities, the fact that the size of the risks varies so much suggests that such large inequalities are not inevitable or innate, giving us hope that there are ways to reduce the burden of illness for our most vulnerable citizens.

Work and Family Strain: A New Model

What can account for such diverging trends? The National Academy of Sciences Panel on Explaining Divergent Levels of Longevity in High-Income Countries1 was convened to try to reconsider what might account for those diverging trends, and the panel—of which I was a member—considered a very broad range of conditions. Several members identified important behavioral trends, most critically tobacco consumption. Several others examined the role of social networks and economic inequality. These factors seemed to account for either none or very small portions of these diverging trends, although they continue to be significant risk factors for mortality within countries. Smoking clearly accounts for some of the diverging trends, but the full explanation for the diverging trends seemed still to be a mystery. At this time, we must start to consider what else has happened, especially to women, between 1980 and today, and how experiences over the last few decades might account for such diverging trends. One of the factors that must be acknowledged is that the vast majority of women have joined the workforce during this period, including those with young children. In the United States, fertility patterns have changed slightly, but they continue to be relatively steady compared to many other countries, although there is also a substantial rise is single parenthood. This pattern led to the development of a model in which work and family systems combine to influence health. Most importantly, it seemed likely that social and economic policies and practices enacted in many European countries might protect or buffer women from the strain experienced by growing demands from both work and family.

The United States differs from virtually all European and most other industrialized countries in its very low levels of social protection in the face of demographic trends related to women's labor force participation, population aging, and rather steady trends in fertility. Except for the Family Medical Leave Act (FMLA) that extends unpaid leave to those in the labor force (under certain conditions), there are virtually no federally mandated parental or family leave policies in the United States. There are selected State- and city-level polices and many private corporate policies that may protect women and potentially men from the joint strains of work and family demands. This situation makes the United States relatively unique among industrialized countries.

With support from the National institute on Aging, I launched a project to better examine this issue. The project involved an international set of colleagues, including economists, social epidemiologists, and demographers on social protection and women's health. We have created a work-family strain model built closely on the model of job demands and job control developed by Karasek.10 In this model (Figure 1), job demands are defined by both physical and psychological demand, whereas control is defined as the degree to which an employee can shape work hours or pace or generally have control over his or her schedule or workplace situations. In the Karasek model, often the combination of high job demands and low job control is associated with the worst health outcomes. A third dimension of job strain related to workplace social support was incorporated into the model after initial work. Here we envision a situation in which risks of poor health are particularly high among working women with dependent children or older family members who experience high demands with low control and minimal formal or informal support. We explicitly add to the job strain model a dimension related to the family.

Figure 1. Work/family/support demand control model

Figure illustrates a work-family strain model in which a combination of high demands in the workplace or within the family combined with low support and control in the workplace or family puts individuals in a high-risk category for worse health outcomes.

As we started to look at women's experiences in other countries, we found that very few of the women experience all three of these conditions together, e.g. high work demand, high family demand, and low formal or informal support. For instance, while France is similar to the United States in terms of trends in fertility and work, the country has very strong social protection policies. In other countries, women join the workforce, but when they do, their fertility drops. This general framework helped us to evaluate the specific health risks and protections that were important.

Our team of researchers reviewed some evidence on demographic trends and related family policy. There are clear and steady demographic trends regarding the growing number of women in the labor force with young children in United States. In the 1940s and 1950s, when most of our work policies were designed, there were very few women with young children in the workforce. Now, the vast majority of women are in the labor force. By 2008, 71 percent of mothers with children under 18 and 60 percent of mothers with children age 3 or younger were working.11 At the same time, there was no formal U.S. Federal policy for granting weeks of paid parental leave between 1980 and 2000; most other countries had increased leave policies substantially during this period.

Evidence that Labor Policies and Practices Impact Health

In this section, recent work related to work and family policies is reviewed in terms of health impacts. For the last 10 years, I have been a member of the Work, Family, & Health Network, which was convened by NIH and the Centers for Disease Control and Prevention (CDC).a This network has produced some important findings about how work/family dynamics impact health based on both observational and experimental evidence. In addition, I will discuss evidence suggesting that several labor policies, specifically the Earned Income Tax Credit (EITC) and maternity leave policies, impact adult health in addition to bettering the lives of very young children. Finally, some of the recent findings on retirement and cognition shed further light on the range of ways in which work might influence health.

First, it is important to acknowledge that most evidence suggests that people who work and people who have children are healthier than those who do not work and who do not have children.9 Both selection into these "states" and the causal effects of work and family life on health are likely operating. Understanding these dynamics is important. For these purposes however, we are most interested in the interface of work and family, particularly for women who may experience role strain if formal social protection or informal social support does not buffer the demands of work and family or who may experience the benefits of multiple roles if demands are not overwhelming.

The working hypothesis of the Work, Family, & Health Network is that both work and family can be health promoting in the presence of social protection or support enabling some flexibility during times when heavy work and family demands compete with each other and become stressful. We suspect this is true for all working families. We further hypothesize that in general, low and middle income working class families will benefit more from many social policies than better off families because they have less exposure to corporate social and economic policies that would be of benefit, and they have fewer financial resources to maintain work life balance. A more precise evaluation of these interactions between socioeconomic conditions and social policies is beyond the scope of this chapter but is of central importance in the long-running policy debates.

In an observational study of employees working in nursing homes (also called extended care or long term care facilities), we found that workers whose managers were attentive to work-family issues had half the cardiovascular risks as assessed by objective biomarkers from blood or clinical exam and healthier patterns of sleep compared to those who worked for less family-friendly managers.12 Specifically, employees whose managers maintained family friendly practices were less likely to be overweight, had lower risk of diabetes, and lower blood pressure. Based on objective measures of sleep using actigraphy monitors, these same employees slept almost 30 minutes more per night than their counterparts. A critical aspect of this study was that we interviewed managers about their practices and coded their responses. Respondents themselves were not reporting on manager's practices, thus eliminating a selective reporting bias. In an ongoing randomized controlled trial that was built on these initial findings, we will be able to evaluate whether changing workplaces practices for managers and employees will alter cardiometabolic risks.

The Work, Family & Health Network is also concerned about whether such practices are actually good for the company that implements them. We hypothesize that schedule control, job flexibility, and work-family flexibility are good for the bottom line and good for workers. Here we are concerned specifically with work redesign to reduce work-family conflict. Lead investigators from the University of Minnesota, Moen and Kelly, worked with ROWE (Results Only Work Environment) as it began as an innovation developed and championed by insiders at Best Buy Co., Inc. Cali Ressler and Jody Thompson, both human resources (HR) employees at Best Buy's corporate headquarters, created ROWE. Within 5 years, ROWE had been implemented in the vast majority of departments in the Best Buy corporate headquarters and in other firms as well. In 2005, Moen and Kelly established a research partnership with Best Buy. From 2006 to 2008, Moen, Kelly, and their colleagues observed ROWE sessions and conducted surveys of employees before and after they began ROWE, as well as surveying employees in departments that continued with traditional work practices.13-15

Results of this workplace initiative indicate the workplace redesign had positive impacts for the organization and for employees' work, personal lives, and health. Workplace units that experienced ROWE compared to those that did not had reduced turnover, with 6 percent of employees in ROWE leaving the organization within the study period as compared to 11 percent of employees in traditional departments, as well as employees' plans to leave in the future.12 Employees in the intervention group reported significantly increased schedule control and decreased work-family conflict,13,14 as well as increased sleep, energy, and self-reported health.16 There also were positive impacts on smoking, drinking, and exercise frequency.17 Overall, members of the Work, Family and Health Network have seen that workplace practices that provide schedule control and opportunities to reduce work-family conflict turn out to be health-promoting for employees, and evidence indicates such policies are good for the organization as well.

Turning next to the health impacts of State and national policies, two policies are of special interest: the first related to the EITC in the United States and the second related to variations over time and place in maternal leave policies in Europe. Strully and colleagues18 assessed whether treating the EITC primarily as a natural experiment for low-income mothers would reveal a causal effect of prenatal poverty on birth weight and selected maternal outcomes. Expansions of the EITC in conjunction with the 1996 Welfare Reform that happened under President Clinton can be seen as part of a much broader trend of liberalizing U.S. welfare policy, making it so that cash assistance more frequently depends on labor market participation and wages. During this time, there was a huge rise in the EITC permitting an analysis of the EITC compared with the Temporary Assistance for Needy Families (TANF) program. TANF is a cash assistance program for low-income families that does not require employment by the recipient to receive the benefit.

The EITC for unmarried mothers with less than a high school education increased their market wages in significant ways. It also increased the birth weight of infants by almost 16 grams, which is a very remarkable birth weight increase. Even more interesting, it decreased smoking among mothers during this time. The comparison that Strully and colleagues draw in this study between EITC and TANF is related to the differential effects of the policies on smoking.18 TANF actually increases smoking in mothers. That is, they use that extra income to buy cigarettes, whereas tobacco consumption decreases by 5 percent among unmarried women who receive EITC. Thus, Strully reports a beneficial effect of the EITC for disadvantaged women, allowing them to be in the market, keep earning money, have healthier babies, and improve their health behaviors. This is one example of a set of policies that has been evaluated for the unanticipated spillover effects that social policies may have on health.

Recent evidence from several studies of maternity leave policies in the United States and Europe suggests that, by protecting employment among mothers in the period around birth, maternity leave leads to better long-term labor market outcomes after maternity leave, including wage level and growth, career prospects, labor market attachment, and employability.19-22 Thus, not only may maternity leave policies benefit children and mothers around the period of birth, they also may have long-term benefits for mothers that extend for decades in later adulthood. Recent work from our group23 using data from the Study of Health and Retirement in Europe (SHARE), coupled with data from national policies, shows that maternal leave policies in Europe are associated with significant reductions in depression in later life for women who were working and had their first child while living in countries with generous maternity benefits.

Finally, turning to recent research on men and women at a different point in the life course, recent work on retirement policies shows their potential impact on cognition.24 Retirement may well turn out to have heterogeneous outcomes, with retirement for people working in very physically demanding jobs versus those in less dangerous and/or physically arduous jobs having different health impacts. As we identify more consistent patterns here, policies may well need to identify two trajectories to retirement: one for those who are able to continue working and the other for those with disabilities limiting their capacity to work or those who work in occupations that are physically demanding. The evidence here is not conclusive but rather intriguing. Rohwedder and Willis24 have looked at SHARE and the U.S. Health and Retirement Study (HRS) to explore the associations between retirement and what they call "mental retirement." They examine the associations between the percent of people not working for pay among 60- to 64-year-olds in a number of countries and cognitive decline in those countries. As countries increase the percent of men aged 60-64 not working for pay, cognitive function among men in this cohort declines. The authors report an association between cognitive function and not working for pay at a country level.23

There is a substantial literature on social engagement and cognition suggesting that as people stay socially engaged, their cognitive function is more likely to be maintained.25,26 Thus, working may be one way that people stay socially engaged.

Directions for Future Research

Health impact evaluations for social and economic policies are rarely conducted, and few methods or metrics have been adapted for such evaluations. In the future, such evaluations will be essential for us to identify the exact health impacts and related costs and benefits so that we can incorporate health impacts into bottom-line evaluations related to economic benefits. Cross-country evaluations are particularly valuable in this regard as they permit us to assess the benefits of national policies across time and place. Health metrics will need to be developed and tailored to policies. For instance, we might anticipate that some policy changes, for example EITC and family leave benefits, will impact health outcomes across the life course and among multiple generations.

Other policies, for instance those related to older workers, might influence outcomes critical at older ages. The development of health impact and related health metrics in early stages and encouraging NIH, the National Science Foundation, and other funding entities to invest in the rigorous health evaluation of current and past policies would yield important information. Such policies are likely to have both spill-over and cross-over effects—that is, they may influence multiple outcomes for individuals, as well as cross over to impact others beyond those directly affected by the policy. Additionally, it would be enormously beneficial to invest in the development of workplace strategies and novel policies and practices that enable women and men to remain in the workforce while also attending to the roles and responsibilities related to caretaking in their families and communities. If these innovations rest on solid experimental or quasi-experimental designs, they will provide policymakers with strong evidence. We have only to look at the case of the woman employed by United Parcel Service (UPS) who was pregnant and needed to take unpaid leave to understand that our country needs to develop more family friendly work based policies.27 We need much more work on the development of randomized or quasi-experimental studies to identify new, real world policies and practices to enable men and women across the life course with diverse demographic profiles to maintain their engagement in the labor force and care for their families.

Implications for Public Health, Knowledge, and Dissemination

Our international rankings and rising levels of inequality with regard to life expectancy are well known in public health but are not widely recognized or part of the public discourse. The public often assumes—because of our high costs for health care—that the Nation is protected from major morbidity and mortality risks. Public health is an intersectoral field, with the determinants of health ranging from the physical to the social environment. The field of public health would be enhanced by wider communication of the degree to which broad policy sectors, notably labor, education, welfare, and urban planning, shape overall patterns and distributions of population health. This chapter has focused on the impact of work policies in relation to work and family life and the degree to which they may be important determinants of public health.

Conclusion

Research suggests that labor policies and practices that support men and women in the labor force, and especially help those with caregiving obligations, are health promoting. These policies and practices have health effects that are not often "counted" as we think about their costs and the broader range of their benefits. For both young parents in the work force and older workers facing retirement, work appears to be health promoting for those without disability. If we as a society optimize opportunities for work across the life course, we will simultaneously need to develop options for those with disability or in situations where work in not possible. We have not focused on this second option in this work but need to acknowledge the necessity of building policy options in this area as well.

Men and women continue to need opportunities for flexibility and schedule control to enter and remain in the labor force, given the inevitability of having to care for children, parents, or partners at some point in time. Our goal for women and men should be to enable them to be successful, both in the work force and in their family roles if they choose. Currently in the United States, we make this very difficult. Our labor policies challenge working families to remain committed to work and also to their families. For example, over half (54 percent) of low wage earners lack sick leave or vacation time to take care of family members, and around 30 percent of middle income families lack such leave.28 Even fewer have parental leave.

We have shown that we can identify the socioeconomic disparities in health with some precision. Solutions that help to maintain low income men and women and the working poor in the paid labor force have clear health benefits. The EITC, pro-family work policies and practices, parental leave, and retirement policies are examples of policies that impact the health of working families. Policies enabling adults to participate in the paid labor force while not risking the health and well-being of themselves or their family members show particular value. Metrics for evaluating social and economic policies do not currently include health metrics. The health spillovers of such policies would increase the benefits of the policies in any cost-benefit equations. We want to ensure that Americans, particularly those living in poverty and low and middle wage working families, aren't robbed of healthy years of life.

Acknowledgments

This research was conducted as part of the WFHN (www.WorkFamilyHealthNetwork.org), which is funded by a cooperative agreement through the National Institutes of Health and the Centers for Disease Control and Prevention: Eunice Kennedy Shriver National Institute of Child Health and Human Development (U01HD051217, U01HD051218, U01HD051256, and U01HD051276); National Institute on Aging (U01AG027669); Office of Behavioral and Social Sciences Research and National Institute for Occupational Safety and Health (U01OH008788 and U01HD059773). This work was also supported by a grant from the National Institute on Aging (5R01AG040248-03) and by the MacArthur Foundation Research Network on an Aging Society. The opinions expressed herein are those of the author and may not reflect the position of the Agency for Healthcare Research and Quality, the National Institutes of Health, or the U.S. Department of Health and Human Services.

Author's Affiliation

Director, Harvard Center for Population and Development Studies, Thomas D. Cabot Professor of Public Policy, Epidemiology, and Global Health and Population, Harvard School of Public Health.

Address correspondence to: Lisa F. Berkman, PhD, Harvard Center for Population and Development Studies, 9 Bow Street, Cambridge, MA 02138; email lberkman@hsph.harvard.edu

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a. For more information about the Work, Family, & Health Network, Go to http://projects.iq.harvard.edu/wfhn/home. Accessed January 7, 2015.


Lisa Berkman Lisa Berkman, PhD, is Director, Harvard Center for Population and Development Studies, and Thomas D. Cabot Professor of Public Policy, Epidemiology, and Global Health and Population at the Harvard School of Public Health (HSPH). Previously, she was Chair of the Department of Society, Human Development, and Health at HSPH. She also is the former head of the Division of Chronic Disease Epidemiology at Yale University. She has devoted much of her work to understanding determinants of population health by comparing European countries with the United States. Her research focus has been on social and policy influences on health outcomes. Dr. Berkman has authored several books and more than 200 publications.
Page last reviewed July 2015
Page originally created August 2015
Internet Citation: Labor Policy and Work, Family, and Health in the Twenty-First Century. Content last reviewed July 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/population-health/berkman.html