Factors that influence health: An introduction

5 Living and working conditions

Social and community influences on health have been recognised for some time, but it is also important to consider the conditions in which people live and work. Graham?s (1993) research on women and smoking, for example, showed that those who were poorest ? low-income lone parents ? were the most likely to smoke and that smoking was used as a strategy to cope with poverty and social exclusion. As one respondent in Graham?s study stated: ‘I smoke more if I?ve got bills coming in, I tend to get worried. Like Christmas is coming and I?m not able to afford the things I want? (Quoted in Graham, 1993).

Psycho-social explanations emphasise the way in which hard-to-manage stress, such as bringing up children alone and in poverty, can lead to health damagingbehaviours.

Other living conditions can also cause stress for people who are excluded or at risk of social exclusion. For example, whereas moving house can be a positive social and economic experience for some people, for people in transition such as those leaving hospital or care, and for traditionally mobile groups such as Gypsies, Travellers and seasonal workers, moving accommodation can compound the barriers they face. A report published by the Social Exclusion Unit (2004) found that instability in accommodation could:

• act as a barrier to securing work or training
• make accessing key services, such as health or social care, more difficult
• disrupt education
• and negatively affect physical and mental health.

Some of the findings of this report are outlined in Box 5 below.

Box 5 Accommodation instability, social exclusion and health

• One in three of the households who moved at least three times in the past year were not in work.
• Relationship breakdown is a major cause of homelessness: 13 per cent of statutory cases involve domestic violence.
• 30 per cent of young homeless people are estimated to have been in care.
• Shortage of site provision for Gypsies and Travellers is a major cause of frequent moving for these groups ? between 1996 and 2003 there was a total net loss of 596 pitches for Gypsies and Travellers while the size of the Traveller population grew.
• There are significant gaps in achievement between mobile and non-mobile pupils.
• 9 per cent of households accepted as homeless are in priority need because of a mental health problem.
• An estimated 40 per cent of single homeless people have multiple needs, e.g. a mental health problem and one or more issues such as drug or alcohol misuse.

People living in poverty and social exclusion often have the greatest need for good healthcare, education, jobs, housing and transport. However, a report from the Joseph Rowntree Foundation (Wheeler et al., 2005) found evidence of the ‘inverse care law? (Tudor Hart, 1971) ? whereby those with the greatest need have least access to good quality services. Using data from the Millennial Census, the report compares the relationship between needs and supply across England, Wales, Northern Ireland and Scotland. Some of the key issues identified are detailed below:

• Areas with the highest levels of poor health have the lowest numbers of doctors, dentists and other health professionals living and working there.
• Areas with the greatest proportions of young people with no qualifications have the lowest availability of working teachers per head of population.
• The UK is divided between ‘work rich? and ‘work poor? areas. In areas with low unemployment, the people who have jobs are more likely to be working very long hours that may affect their health and wellbeing. In areas of higher unemployment those with jobs are less likely to work long hours, but unemployment itself is associated with physical and mental health problems.

As partly identified by the Joseph Rowntree Foundation report, harmful working conditions, such as poor ergonomic design and physical job demands, as well as work stresses related to effort / reward imbalance, can also lead to health-damaging behaviours and illness more generally. A survey analysis of working conditions conducted in Sweden (Hemström, 2005), for example, concluded that the work environment is an important means by which socio-economic class influences inequalities in health.

Interest in levels of sickness absence has been growing in recent years and absenteeism has been identified as an important public health issue, not just because such levels provide evidence of morbidity in the population but because absenteeism is costly for both the private and public sectors. According to a survey of over 1,000 employers by the Chartered Institute of Personnel and Development (CIPD, 2005), the most common cause of sickness absence for all workers was minor illness, followed by stress for non-manual employees, and back pain for manual staff. Box 6 outlines some of the key findings from a UK analysis of labour market trends and sickness absence (ONS, 2005b).

Box 6 Sickness absence

• In the three months from March to May 2004 some 1.7 million scheduled working days were lost to sickness absence among employees. Some 2.9 per cent of employees took at least one day off work because of sickness or injury.
• The days lost to sickness were fairly evenly spread across the weekdays. This is counter to the common perception that sickness absence is higher on Monday and Fridays as a result of non-genuine absence.
• Female employees and younger employees aged 16 to 34 were more likely than other groups to take at least one day off sick.
• Lone mothers had the highest rate of sickness absence, followed by women with no dependent children (4.4 per cent and 3.4 per cent respectively). Men without dependent children had the lowest rate of absence.

Recognising some of these issues, in a press release on 26 September 2005 the Government announced its plans to appoint a national director for occupational health (jointly appointed by the Departments of Health and of Work and Pensions) to oversee the implementation of the ‘Health, Work and Wellbeing Strategy? (DfWP, 2005).

It is important to recognise, of course, that work stress should not just be tackled at the level of the individual but as noted in Choosing Health:

The real task is to improve the quality of jobs by reducing monotony, increasing job control and applying appropriate HR practices and policies ? organisations need to ensure that they adopt approaches that support the overall health and wellbeing of their employees.

More recently researchers have also begun to develop an interest in presenteeism, a concept describing how individuals work through illness and injury in spite of the need to be away from work. This, they argue, can lead to further morbidity and mortality which has encouraged some commentators to argue that more attention should be paid to presenteeism. However, a study of presenteeism in New Zealand (Dew et al., 2005) found that workers encounter very different organisations and relationships to management and other workers, and that this will influence the type of presenteeism that exists. For example, one of the respondents in their study ? a nurse working in a public sector hospital ? stated:

‘I think nurses are a bit terrible like that. We actually go [to work when sick] and then can?t even make it to lunchtime ... we are all determined to be here to not let anybody down.?

Dew et al. argue that presenteeism is expressed differently between social groups and operates in a distinct way according to social class and job market position.

Thinking point: reflect on your own work / life balance and consider the impact of this on your health.

Modern patterns of work tend to increasingly blur the boundaries between work and private space and time with employees often working longer and longer hours to the detriment of their health and lives. Whether your experience concurs with this or not, you may find that your work/life balance shifts over time and across your lifecourse. It will also relate to your own position with respect to factors such as age, gender, socioeconomic status and whether or not you have caring responsibilities.

Concern with this ‘work/life balance? is also evident in policy and strategy. For example, in 2000 the Department for Trade and Industry launched the ‘Work?Life Balance Campaign? to help employers recognise the benefits of flexible working patterns, enabling staff to better balance their work with other aspects of their lives and, thus, be more productive. The Long Hours Working Partnership Project, administered by the Equal Opportunities Department, also has a remit for addressing work/life balance, focusing on issues such as high client demand (for example, 24-hour service provision), presenteeism and flexible working (DTI, 2005).

Living and working conditions are essential to the daily life experiences of individuals and groups. However, we will now move on to consider more general social conditions and their impact on health.