Prof. Dr. Nico Dragano

University Clinic Düsseldorf, University of Düsseldorf, Germany

Health inequalities in

working populations:

what causes them and

what can inter-sectoral

policies to against?

http://blogs.wsj.com/economics/2014/04/18/the-richer-you-are-the-older-youll-get/

Reduce health inequalities is key to improve health

and well-being at population level (SDG 3)!

Work is a major determinant of health and also

part of the health inequality problem (SDG8)!

What can be done to make work part of the

solution?

Agenda

1. Relevance: health inequalities in Europe’s

working populations

2. Mechanisms: causes of occupational health

inequalities

3. Context: inter-sectoral policies and

occupational health inequalities

4. Conclusions

Health inequalities in the working

population

Source: Marmot et al. (1978)

JECH 32: 244-249. p. 245

Replicated in

different settings

for all cause-

mortality, fatal-

injury, and other

causes of death

as well as for

several non-fatal

outcomes like

sickness

absence

Today:

inequalities

persist or widen!

Health inequalities challenge social justice:

The example of pension schemes

22 22 23 24 26 21 21 21 22 25

45 45 45 43 41 46 46 46 45 42

10 12 14 15 18 14 18 18 20 21

0

10

20

30

40

50

60

70

80

90

<60 -80 -100 -150 >150 <60 -80 -100 -150 >150

Age(Years)

Men (income % of median) Women

Retired

Work

Edu-

cation

Estimates from GSOEP and Lampert 2007

With kind permission form Prof. Dr. Hans Martin Hasselhorn, Dept. Of Occupational Health

Science, University of Wuppertal, Germany; unpublished data, - do not share -

2,04,5 2,3

Years to work for one year of retirement

Source; https://www.flickr.com/photos/okinawa-

soba/8698810788

MechanismsModified version of Clougherty’s* et al. (2010) conceptual framework

occupational position

adult health /

mortality

*Clougherty et al. (2010) Ann.N.Y.Sci.:1186:102-124

educationearly adult health

childhood SEPLifecourse/

Selection

physical (chemical

hazards, injury, etc.) AND

psychosocial (high

demands, low control,

etc.) work hazards

Differential

exposure /

mediation

modifiers

(resources/risks)

Effect

modification

income

Confounding /

indirect effects

Life course perspective: example

Dragano N & Wahrendorf M (2014) Epidemiol Community Health 68

6.7 million of the 13 million people in poverty

are in working households, UK 2011/12

(JRF 2013 using DWP data)

Germany: >1,1 million full-

time workers receive social

welfare benefits because of

low wages

Differential exposure: example

Replicated: many

physical work hazards

are more frequent in

lower occupational

positions

Replicated: small or

even reversed

occupational inequality

for high psychological

demands

0 1 2 3 4

Average number of job-related risk factors

Non-skilled manual workers

Skilled manual workers

Self-employed

Non-manual workers

Professionals

EU-27

Men WomenReference: Dragano et al.

Bundesgesundheitsbl, 59, 2016, S. 224

.

EWCS 2010;

Occupational

Class (EGP) by

average number

16 psychosocial

and physical work

hazards (solid

evidence for

health effects)

Context: policies child care,

education,

welfarelabour

policies,

OSH

legislation &

supervision

responsible

leadership,

compliance

with OSH

regulation

welfare,

taxation,

housing

fair wages

OSH service

provision

health care

system

Active labour market policies and ‚learning

culture‘ reduce inequalities in work stress

Lunau T et al. (2015) The Association between Education and Work Stress: Does the Policy Context Matter?. PLOS ONE 10(3): e0121573.

Occupational safety policies improve workers

OSH knowledge… but monitoring is necessary

Dragano et al. 2015 OEM

Conclusions

Figure: https://commons.wikimedia.org/wiki/File:Sustainable_Development_Goals_text_only.png

• Associations between work and health

inequalities are complex.

• Several policy areas at different levels are

involved.

• Examples suggest that inter-sectoral policies may

increase resilience, enhance safety and improve

health - in particular for vulnerable workers.

https://www.flickr.com/photos/phil_g/1516087369

Supplementary

slides

Health inequalities

“Health inequities are avoidable inequalities in

health between groups of people within countries

and between countries. […] Social and economic

conditions and their effects on people’s lives

determine their risk of illness.“

WHO Key Concepts 2015

Inequalities persist or widenM

alk

i et a

l. (2014) P

LO

S O

NE

, 9:1

-8

Inequalities within societies:

a random example

Source: RKI.

GBE Kompakt

2/2014; S.2

-10,8 years LE-8,4 years LE

Between countries

Britisch Medical Bulletin, http://bmb.oxfordjournals.org/content/91/1/29/F2.expansion

Global perspective

http://www.dailyrecord.co.uk/news/uk-world-news/inside-qatar-2022-world-cup-3380568 //

http://www.spiegel.de/fotostrecke/bangladesch-viele-tote-nach-gebaeudeeinsturz-fotostrecke-95941-9.html

Effect Modification: exampleSome replications,

some conflicting

results but a small

number of studies

Source: Rugulies et al. (2012) Eur J Public Health 23: 415-420. p. 418

A national ‘culture’ of life long learning is

related to lower job stress levels

N=9917; 12 countries; SHARE study; Dragano et al. 2011

Company level risk management policies may

reduce psychocial stress at individual level

Lunau et al. 2017 IAOEH 90

Is OSH part of the solution or

part of the problem?

Dragano 2015, in press

0

10

20

30

40

50

Men Women

Upper Deciles

Lowest Decile

Data: German Workforce Survey 2005 (BIBB/BAuA), full-time workers

% of workers who were offered any measure of worksite health promotion in

the past 2 years by income (deciles)

Conclusion

Par. 11.2 (ix) “Strengthen occupational health safety

and health protection and their oversight and

encourage the public and private sectors to offer

healthy working conditions so as to contribute to

promoting health for all”

WHO Rio Declaration 2011, § 11.2

picture: http://www.mrwallpaper.com

HEN-52

• Improving access to fair employment and decent work

• • Create employment opportunities in more disadvantaged areas by expanding

• public and private infrastructure investments and investing in health services,

• social care, and education and training services. These investments can

• improve the employment potential of populations in need, enhance resilience

• and strengthen responses to crises. Such approaches need to be sustainable,

• while avoiding insecure employment and poor-quality work. • Implement good-quality active labour

market programmes (ALMPs) to support

• people into employment while enhancing resilience. ALMPs that provide job

• search assistance and vocational training, start-up finance for small businesses,

• and integrated support for disabled people are more likely to be effective. • Improve working

conditions through better worker representation, effective

• health and safety legislation, extended employment rights, an adequate

• minimum wage for healthy living and improved management practices.