“Extensive research has documented that CVD is more common not only among people facing work stressors [11, 12], but also among people of lower social class or socioeconomic position (SEP), for example, lower levels of education, income, or occupational status (see chapter 3). One possible explanation for the social class differences in CVD is greater exposure to unhealthy working conditions among lower SEP groups. For example, job control was “the biggest factor contributing to the socioeconomic gradient” in heart disease “risk across civil service employment grade” in a major study of British civil servants [14, 15] (see Figure 2). The higher CVD risk among men and women in lower SEP groups, for example, blue-collar workers, began to appear in the 1950s [16-18] and has risen progressively since then . Among U.S. men aged 25-64, in 1969-70, low SEP men had a 30% greater risk of dying of CVD than high SEP men of the same age. However, it had increased to an 80% greater risk by 1997-98 . Differences between higher and lower SEP groups in new cases of CVD, whether fatal or not, are also increasing [20, 21].”
Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.
11. Karasek, R. and T. Theorell, Healthy Work: Stress, Productivity, and the Reconstruction of Working Life, Basic Books, New York, 1990.
12. Schnall, P., K. Belkic, P. A. Landsbergis, and D. E. Baker, The Workplace and Cardiovascular Disease, in Occupational Medicine: State-of-the-Art Reviews, Hanley and Belfus, Philadelphia, PA, 2000a.
14. Kawachi, I. and M. Marmot, What Can We Learn from Studies of Occupational Class and Cardiovascular Disease?, American Journal of Epidemiology, 148, pp. 160-163, 1998.
15. Marmot, M. G., H. Bosma, H. Hemingway, E. Brunner, and S. Stansfeld, Contribution of Job Control and Other Risk Factors to Social Variations in Coronary Heart Disease Incidence, Lancet, 350, pp. 235-239, 1997.
16. Gonzalez, M. A., F. R. Artalejo, and J. R. Calero, Relationship between Socioeconomic Status and Ischaemic Heart Disease in Cohort and Case-Control Studies: 1960-1993, International Journal of Epidemiology, 27:3, pp. 350-358, 1998.
17. Marmot, M., A. M. Adelstein, N. Robinson, et al., Changing Social Class Distribution of Heart Disease, British Medical Journal, 2, pp. 1109-1112, 1978.
18. Wing, S., P. Dargent-Molina, M. Casper, W. Riggan, C. G. Hayes, and H. A. Tyroler, Changing Association between Community Structure and Ischaemic Heart Disease Mortality in the United States, Lancet, 2:8567, pp. 1067-1070, 1987.
19. Singh, G. K. and M. Siahpush, Increasing Inequalities in All-Cause and Cardiovascular Mortality among US Adults Aged 25-64 Years by Area Socioeconomic Status, 1969-1998, International Journal of Epidemiology, 31, pp. 600-613, 2002.
20. Hallqvist, J., M. Lundberg, F. Diderichsen, and A. Ahlbom, Socioeconomic Differences in Risk of Myocardial Infarction 1971-1994 in Sweden: Time Trends, Relative Risks and Population Attributable Risks, International Journal of Epidemiology, 27,
pp. 410-415, 1998.
21. Tuchsen, F. and L. A. Endahl, Increasing Inequality in Ischaemic Heart Disease Morbidity among Employed Men in Denmark 1981-1993: The Need for a New Preventive Policy, International Journal of Epidemiology, 28, pp. 640-644, 1999.
Social class position is a powerful predictor of illness and death from many forms of both chronic and infectious disease. Those in the upper class live longer and are healthier while doing so. Those in lower classes die at a younger age and are considerably less healthy over their entire life course (Evans, 1994). Moreover, numerous studies have found that a “gradient” exists along the social class continuum – with increasingly higher class position, health improves, and with descending class position health deteriorates (Marmot et al, 1978, Lynch & Kaplan, 2000). Although there continues to be a considerable discussion as to what explains this class gradient, there is an emerging consensus that social class is a “fundamental determinant” of population health. (Link & Phalen, 1995) Together with race and gender, class constitutes a core social structure (House & Williams, 2003). SSocial class is more than a property of individuals, rather, , it is more than a ‘position’ one occupies — it is also an expression of macro-societal forcessystem that “produces” stratified hierarchies within modern societies. As a societal structure social class is associated withpositions. It is a social structure that creates the enormous inequalities that we observe in nearly every aspect of human existence across the entire life course. Social class is also intimately bound up with work and the labor process (Johnson & Hall, 1995, Wright, 1988). It is through our work, and the work of our parents, that we enter into the life chances and circumstances of a particular social class.
Some of the pathways linking lower social class position to ill health include economic deprivation, lack of educational opportunities, and adverse exposures associated with differences in geographic and community environmental characteristics such as exposure to violence and to toxic substances like lead and carbon monoxide (Lynch & Kaplan, 2000, Evans & Kantrowitz, 2002). Other pathways involve class differences in consumption patterns including unhealthy foods, cigarettes, alcohol and illicit drug usage (Cockerham, 2000)usage. Social class position is also strongly associated with access (or lack there of) to social and public resources, informal social networks, institutional resources, and inter-generational resources. Still another pathway involves differences in the nature of the social and work environments, and includes the class differences in stress from adverse labor market experiences, including unemployment, underemployment and chronic exposure to stressful work organizations (House & Williams, 2003, Seigrist & Marmot, 2004). These specific pathways linking social class to health may change over time. New causal paths might emerge, others might be removed, yet as long as the society continues to have a social class structure it is almost certain there will continue to be health “disparities” (differences) between classes – this is what is meant when we say class is a “fundamental determinant” of health (Link & Phalen, 1995).
Social class position is frequently defined with respect to one’s occupation. Until recently skill levels have been used to distinguish different occupational class groups. Frequently a 5 occupational class scheme is used: 1st Class: Upper Level Managers and Professionals; 2nd Class: Medium Level Managers and Professionals; 3rd Class: Lower Level Office and Service Workers; 4th Class: Skilled Manual Workers; 5th Class: Unskilled Manual Workers. Critics have pointed out a number of problems with this definition of social class. Some have suggested that the degree to which the work has become routine is a more meaningful distinguishing characteristic today than skill. Others argue that the degree of control over the work process is the most important underlying element of social class (Marmot & Bartley, 2002).
There are, in fact, marked differences in a number of work organization characteristics across the different social class groups (Kristensen, 2002). The degree of control at work is strongly associated with social class position (Johnson & Hall, 1995). Social support at work, by contrast is only weakly (but [but positively?)] associated with social class. Other exposures tend to be much more present in certain class groups than others. Hazardous work exposures and heavy physical job demands are often present in lower level service and manual groups while being almost non-existent in managerial/professional class groups (Johnson & Hall, 1992). When examining patterns of multiple exposures across social class groups it becomes evident that Social Class 3 (the lower level office and service workers) is much more like Social Classes 4 and 5 (manual workers) than they are like Social Classes 1 and 2 (managerial/professional workers). The managerial/professional class tends to have high psychological job demands, high levels of work control, and very low levels of physical demands and low levels of hazardous exposure. They work longer work hours and their jobs require considerable flexibility (Johnson & Hall, 1992). Working class jobs by contrast have much less control, are more routine, and have fewer psychological job demands and considerable monotony. Working class jobs also have much higher physical demands and more hazardous exposures (Johnson & Hall, 1992). In addition, recent research findings using the two most prominent conceptual models of work stress have shown that those in lower social class positions are more likely to be exposed to high demands and low control as well as experience jobs with high demands for effort coupled with low rewards (Seigrist & Marmot, 2004). WWork environment exposure comes bundled by social class, and the most meaningful distinction is between a managerial/professional class on the one hand and a working class on the other. (Johnson & Hall, 1992, 1995).
The impact of adverse work organization exposure also varies markedly by social class. For example, a number of studies have shown that the impact of Job Strain (high demand/low control jobs) and Iso-Strain (high demand/low control/low social support jobs) is significantly greater for individuals in working class occupations compared to those in managerial/professional jobs (Johnson & Hall, 1988; Johnson Hall & Theorell; 1989, Landsbergis et al, 2003). Moreover, research findings also indicate that class differences in adverse work organization exposure (particularly in job control, or lack thereof) may be an important causal mechanism that helps explain the relationship between social class position and health (Marmot & Theorell, 1988, Marmot et al, 1997). Recent findings from the European Science Foundation’s Study on Social Variation in Health Expectancy strongly suggest that workers in lower social class positions are more vulnerable to the impact of both Job Strain (high demands and low control) and effort/reward imbalance (Seigrist & Marmot, 2004).
In addition to looking at differences in exposure between social class groups, it is important to examine how and why these kinds of disparities exist. Clearly there are great structural differences between classes in terms of the ownership of wealth and control over workplace institutions. The class structure of modern society is an expression of dynamic political and economic forces operating over time at macro-societal and increasingly global levels (Moody, 1997; Navarro, 2002). Although social classes have been present since the agricultural revolution and early urban settlement, their present form emerged with the industrial revolution and the growing centrality of the market economy as the predominant influence over the structure of society. It has been suggested that market economies today have three fundamental social classes: (1) a very small elite made up of the most wealthy and powerful members of the society who own and control large corporations and other powerful institutions, (2) an increasingly large working class whose members provide and care for the human energy that produces the goods and services that are bought and sold in the marketplace and (3) a third class made up of managers and professionals that share some of the characteristics of both the elite class and the working class, and hence are said to occupy a “contradictory class location” in that their work involves administering bureaucratic organizations in the interests of the elite, yet their personal history, work experience and professional training and ethics may lead them to identify with the working class (Wright, 1988; Moody, 1997; Perrucci & Wysong, 1999; ).
In order to survive in dynamic and competitive environments, corporations must continue to grow by increasing the rate at which profits are generated. Historically, one important way in which this has occurred is through managerial and technological innovations focused on increasing productivity – often by changes in work organization designed to reduce labor costs. ‘Scientific Management’ or ‘Taylorism’ is perhaps the most well known example of how this process can lead to a transformation in how work is organized. (Braverman, 1974). In the late 19th and early 20th Century F.redrick W.inslow Taylor, advocated a radical program of removing planning and decision-making authority from skilled workers on the shop floor, while, at the same time centralizing mental and conceptual work in the hands of a new managerial class. By fragmenting the work process into its simplest possible components, the proponents of “scientific management” hoped to both reduce labor costs by employing fewer skilled workers and to increase productivity through their newly won control over the pace, speed and intensity of the production process itself. Work environments that have been designed in this way implicitly embody class relations. To the extent that work is fragmented and deskilled for the working class, it becomes more manageable by the employing class (Braverman, 1974, Moody, 1997). The control over pace and intensity of work performance has historically been transferred from workers to owners for the purpose of increasing the profitability of the enterprise. The technical aspects of this work transformation have been implemented by the managerial/professional class, indeed, “Scientific management” techniques became the bedrock of industrial engineering, and they continue to dominate the ways in which jobs are designed even today (Kanigel, 1997).
The work organizations created by “scientific management” are highly stressful jobs (Johnson, 1980). These workplaces produce high levels of “job strain” (see section 4A) because they have very high demands for performance and productivity and, at the same time, very low levels of control over meaningful decisions about how the work is to be performed. These principles of job design have also had an enormous influence over changes in work organizations in the health care and human service sector. Moreover, “lean production” methods (see section 2Biii) have led to an even more intensified form of Taylorism, referred to by some observers as a kind of “management by stress.” (Moody, 1997).
Managerial and technological innovations, though seemingly class-neutral, represent a kind of ‘social choice’ (Noble, 1977). The nature of specific character of these choices that have been made in the United Statesour country suggests a deep suspicion of and a fear directed toward the working class. Researchers have pointed out that the degree to which workers have been stripped of skills and authority in the workplace has far exceeded that which would in reality have been the most rational and efficient approach (Noble, 1984). This ‘irrationality’ has also been the case with the intense waves of downsizing and restructuring that have swept through work organizations over the last two decades – the health of firms, and their capacity to creatively produce has often been harmed by these types of extreme measures.
The globalization of work and the labor process has also taken on a class character. The transfer of many jobs to low wage countries, and perhaps even more importantly, the threat that this transfer might occur, has severed much of the social contract that existed in the U.S. between classes in the post wworld wwar ttwo era. In many ways, we have returned to the starker realities of the 19th century social landscape with an increasing polarization between society’s ‘winners’ and ‘losers’. Third World Workers have also become victims of a “downward leveling” – a “race to the bottom” where we see the working conditions for most of the working class being pulled in the direction of the most desperate and least empowered (Brecher & Costello, 1994; Moody, 1997) Yet, if at the most only 20% of the society can be considered ‘winners’ in the process of economic globalization, what will become of the remaining 80%? In the past century, social movements (such as the labor movement) developed to challenge economic and political inequalities . The same kind of social movements are being mobilized today, only now on a global level. These movements for economic and global justice may transform the politics of the 21st century and could improve work organization and working conditions and reduce job stress in both developed and developing countries (Teivainen T, 2002) .
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Research into the determinants of disease morbidity and mortality during most of the 20th century has been dominated by a biological model of disease as has the practice of medicine itself. Illnesses and other physical disorders were thought to be caused by harmful agents (e.g., bacteria or viruses causing infectious diseases, toxic chemicals, tobacco smoke, cholesterol, etc.) and/or a breakdown in one or more of the body’s organ systems. Consistent with this biomedical model, primary prevention of disease has focused on reducing the population’s exposure to toxic substances and procedures to control the spread of infections – for example, ensuring a clean water supply, quarantining infected individuals, and vaccinating individuals to make them immune to specific diseases.
It was not until 1977 that Engel published his seminal article setting forth the now widely accepted biopsychosocial model of disease. This article urged physicians and researchers to acknowledge and investigate the role of social, psychological, and behavioral factors in the prevention, etiology, and treatment of both physical and mental illnesses. Despite its wide acceptance, at least in principle, the vast majority of the medical literature ignores the role of psychological and sociological factors. A review of medical school curricula or the contents of leading journals (e.g. Journal of the American Medical Association or Lancet) suggests that the medical establishment remains skeptical about the relevance of psychosocial factors in the etiology of disease.
The above not withstanding, the subfield of “psychosomatic medicine,” historically dominated by psychiatrists, has a long tradition of emphasizing mind-body connections. Increasingly, a broader array of researchers have been investigating the impact of personality, behavior, and a variety of social factors on morbidity and mortality. While the majority are psychologists, there are also physicians, social epidemiologists, sociologists, anthropologists, and others. Many of these researchers identify themselves with one or more of the interdisciplinary fields of psychosomatic medicine, “behavioral medicine,” and “health psychology.”
In this chapter I review selected empirical findings and issues from behavioral medicine that are likely to interest sociologists. The first section is primarily descriptive, reviewing the fact that the risk of many diseases, and death itself, is socially patterned. Much of the emphasis is on mortality and cardiovascular disease, but the general point applies to other causes of death and many non-fatal diseases. Since, in my opinion, the subfield of social stratification lies at the core of sociology, and this section emphasizes the link between stratification and health. While many mechanisms surely contribute to this relationship, I am particularly interested in the effect that stress may have on health and the possibility that differential exposure to stress in the social environment partially accounts for social class differences in health. The latter part of the chapter presents select findings from studies of animals and humans pertaining to the impact of social stress on health.
The MacArthur Research Network on Socioeconomic Status and Health is a multi-disciplinary collaboration comprising leading scholars from the fields of psychology, sociology, psychoneuroimmunology, medicine, epidemiology, neuroscience, biostatistics, and economics who have been working together for the last decade. The network research agenda is organized around an integrated conceptual model of the environmental and psychosocial pathways by which socioeconomic status alters the performance of biological systems, thereby affecting disease risk, disease progression, and ultimately mortality.
The network has enhanced understanding of the mechanisms by which socioeconomic factors affect the health of individuals and their communities through the development of innovative research methods, creation of significant new data sets, novel findings, and identification of new concepts, hypotheses and directions for research. Building on this work the network has contributed to discussions of economic and social policy to foster better health among individuals and communities across the socioeconomic spectrum.