To the Editor,
We write to augment a discussion point from our article1 recently published in AJIM, “Employment Status, Unemployment Duration, and Health-Related Metrics among U.S. Adults of Prime Working Age: Behavioral Risk Factor Surveillance System, 2018–2019.” In that discussion, we noted that “Decoupling these observed associations [between unemployment and the elevated prevalence of multiple adverse health outcomes] will require addressing 1) social and economic factors contributing to unemployment; 2) job and income insecurity; and 3) healthcare access, which in the U.S. is related to employment both directly (through employer-based coverage) and indirectly (through income).“
We have developed a visual representation of selected pathways through which work functions as a key social determinant of health (SDOH) in the United States. While the article focused on employment status, SDOH such as housing and education often also constrain the type of work a person can obtain. For example, we noted that “residential segregation [affects] access to high-quality primary and secondary education, and thus higher education, which in turn influences employment options, and attendant wages and stability.”1 In addition, employment status and type of work affect health conditions and outcomes both directly, through working conditions, and indirectly, through compensation (salary/wages, health insurance coverage, etc.). As shown, multiple feedback loops reinforce these relations.
The diagram is high-level and not comprehensive: only selected SDOH are shown; many other inputs constraining education, housing, and employment choices (including other institutionalized modes of discrimination) are not shown; lesser directional indicators are omitted in the interest of legibility; and numerous pertinent characteristics of work are omitted. However, unlike most pictorial representations of SDOH, this diagram highlights the centrality of work as a SDOH and the mutually-reinforcing pathways that complicate the path to health equity.
Work as a Social Determinant of Health (SDOH): Selected Pathways
Diagram developed from: Silver, SR, Li, J, Quay, B. Employment status, unemployment duration, and health-related metrics among US adults of prime working age: Behavioral Risk Factor Surveillance System, 2018–2019. Am J Ind Med. 2022; 65: 59– 71. doi:10.1002/aiim.23308
Acknowledgements
The authors wish to thank Marie Haring Sweeney, Rene Pana-Cryan, Jennifer Cornell, CDC; Pamela Schumacher-Young, Susan Burton, Synergy; Katrina Bicknaver, Matt Hirst, Rebecca Purdin, Elizabeth Smith, Surprese Watts, (worked performed under General Informatics, now employed by CeTechs); Jeff Purdin, Maximus (formerly ATTAIN); state BRFSS coordinators.
Funding:
The authors report that there was no funding source for the work that resulted in the article or the preparation of the article. The article is based on previously collected data.
Footnotes
Publisher's Disclaimer: Disclaimer: The findings and conclusions presented in this article are those of the authors and do not necessarily reflect the official position of the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention.
Institution and Ethics approval and informed consent: BRFSS was reviewed by the Human Research Protection Office of the Centers for Disease Control and Prevention and determined to be exempt research. Survey information was collected under OMB control number 0920–1061.
Conflicts of Interest: The authors declare no conflicts of interest.
All work was performed at National Institute for Occupational Safety and Health
Data availability:
Data used for these analyses are available in a public-use dataset from CDC at https://www.cdc.gov/brfss/annual_data/annual_2019.html
References
- 1.Silver SR, Li J, Quay B. Employment status, unemployment duration, and health-related metrics among US adults of prime working age: Behavioral Risk Factor Surveillance System, 2018–2019. Am J Ind Med. 2022; 65: 59–71. 10.1002/ajim.23308 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data used for these analyses are available in a public-use dataset from CDC at https://www.cdc.gov/brfss/annual_data/annual_2019.html