Joakim Palme is a Swedish political scientist and sociologist, currently Professor of political science at Uppsala University and former Director of the Institute for Future Studies in Stockholm between 2002 and 2011. Between 2003 and 2009, he was Adjunct Professor of sociology at Stockholm University. In 2009 he was appointed Adjunct Professor at the Centre for Velfærdsstatsforskning at the University of Southern Denmark.

1)      Could you tell us about your work?

For almost ten years my work has focused on comparing welfare states, trying to work out how welfare state programmes, excluding healthcare, impact on inequalities in society. Several years ago my colleagues and I started working as part of the Marmot Commission on Social Determinants of Health, looking at how welfare state programmes relate to people’s health and health inequalities. We took a life-cycle approach and looked at how family policies affect child mortality, how social insurance affects mortality among the working-age population and the links between pension systems and mortality among older people. This led to interesting analyses, and saw us move beyond the welfare regime approach towards examination of specific welfare programmes. That’s the background to my involvement in DRIVERS.

2)      How do welfare programmes affect health and health inequalities?

Income is important because it allows people to pay for products that are good for health, such as food and quality housing. It’s therefore not surprising that levels of income are important for health. The welfare state can play a part in this, because it ensures a consistent stream of income, even when people are temporarily unable to secure them, for example when ill or unemployed. Welfare programmes can also be important in terms of reducing societal inequalities. Large income inequalities put stresses and strains of people’s lives, and the welfare state can help reduce inequalities in society. Moreover, work coming out of DRIVERS shows that welfare programmes are even beneficial to those who are not currently benefiting from them directly. This seems to be because it reduces feelings of insecurity, and provides assurance that unemployment or illness does not necessarily lead to economic disaster.

3)      We are just coming out of a period of crisis, and labour markets and social protection policies have been reformed quite drastically. What trends in social policy and social spending do you observe?

The crisis is still on, so we don’t have a final answer, but it does appear to have triggered increased diversity between European countries. This seems to come out very clearly in a recent report from the European Commission on the Employment and Social Development in Europe [1]. We see that the countries most severely affected by the economic crisis have also been those most severely affected in social terms. In order to secure loans, these countries have had to implement nationally and internationally imposed reforms to their social protection systems.

5)      When you talk about diversity, are you talking about divergence between northern and southern European member states?

Yes. So while northern European countries have been comparatively less affected by the crisis, southern ones have been more severely damaged in a number of ways. One could rightfully say that these countries performed worse before the crisis, but that the crisis has been unhelpful in terms of raising the level of their welfare spending ambitions and in putting welfare state financing on a more sustainable path.

6)      So does the economic crisis really matter for health and health inequalities, and if so, how?

Poverty has been aggravated and this increases risks to health. In addition, some groups have been more affected than others. We can see that in southern Europe youth have been severely affected by the crisis and that many have become unemployed. Many older workers have been affected by falling incomes. There have also been cutbacks in a number of countries in terms of generosity of benefits. This was not something seen in the initial phase of the crisis, but became prominent in more recent years. As public deficits increased and unemployment increased, this put a strain on welfare protection budgets and there were consequent overall cutbacks in generosity. We know that youth are a clear at-risk group. Moreover, we know that those who are not covered by welfare programmes are at risk. Worryingly, we can also see that when people do find work, their jobs often don’t provide decent pay. The phenomenon of in-work poverty seems to be increasingly important, and this is a surprise to many European policy makers who have so-far stressed the primary role of employment in combatting poverty and inequality.

7)      Would it be fair to say that the crisis has exacerbated thirty years of stagnant or even real-term cuts to many people’s wages?

I actually think the current crisis is more than that. In fact, in some countries income development has been mixed. Take Sweden, for example. While income inequalities have increased a lot we also see that pay increases among the low paid have been good, and that collectively bargained minimum wages have improved a bit, at least in terms of relationship to median income. Another example is Germany. Here we see the results of labour market reforms that were enacted at the turn of the millennium, and which have resulted not only in increased employment but four million working poor. That’s not a middle-class problem in my view, but a problem concerning the emergence of a new underclass.

Overall, situations differ between countries. In some we see large numbers of people who borrowed money to buy a house before the crisis and now run the risk of becoming homeless. Such people constitute a group that were considered comfortably well-off before the crisis, but who find themselves in a very different situation today. In fact, it is possible to say that the crisis has been of such a magnitude that it has affected very broad parts of the overall European population, though groups traditionally at risk remain so: less education people, newcomers to the labour market, youth, migrants and also women.

8)      What kinds of social policies could help reduce health inequalities?

It is important not to demand the complete overhaul of the system of social protection, because more modest improvements could lead to improved health. First I would suggest a minimum income safety net. The second thing is unemployment protection, with wide coverage and replacement rates. The European Commission has done interesting work on minimum income safety nets and unemployment insurance, showing that they are important not only for the health of a population but also for macro-economic stability [2]. Countries without protection systems fared much worse in the crisis, and social protection systems can be built up on this basis.

Youth is an extremely important issue. It is the only area where the European Union has mobilised common resources to help victims of the crisis. In my view, youth is the big social question of our time. We already know how to combat poverty among children and old people and about how to maintain good unemployment insurance systems, but less about how to facilitate the transition from youth to adulthood and from education to the labour market. I fear that the resources being mobilised will not match needs, and that there will be a scarring effect on the generation entering the labour market for decades to come unless something much more ambitious is attempted.

9)      You mentioned the importance of wages earlier. Do you think collective bargaining is important in maintaining decent levels of pay? Or are legislated levels more important?

Different European countries have very different labour markets. Some countries have national legislation on minimum levels of pay that is important, while in others such as the Scandinavian countries, collective bargaining is important. However, when we look at risk factors for poor health we also see that job quality is important. It should not be forgotten that collective bargaining is a way to ensure a decent level of income and a means of ensuring job quality.

10)   What role does scientific research have in all of this then? Does science have a primary role in informing policy?

This is what we hope, that politicians are informed and willing to take action on the basis of research. I’m quite optimistic on this. We know that the collection of health statistics was tremendously important in the emergence of the first welfare state programmes a century ago; this was the case in Britain, Norway, Sweden, and other countries. I think it is hard for politicians today to run away from facts, and communication of research is very important. In this respect I’m certainly hopeful that research can be a trigger for political change. If we take climate change, for example, we can see that for a time it was possible for politicians to deny the science, but eventually it could barely be denied. I think that health is of real importance, and I hope that research on health will help in terms of promoting desirable policy change.

11)   What kind of research methodologies are needed to help science progress on these issues?

I’m very much in favour of what might be termed mixed-methods. It is important to compare countries because it is often at the country level that policies differ, and it is important to study and evaluate when countries reform their policies because that’s a source of important evidence. I also think it’s important to combine country-level information with detailed information at the individual level. The European Union can be seen as a kind of laboratory for different kinds of policy, between nations, and I think that there is great potential for exploiting this laboratory for enhancing our understanding of what policies are good and bad for health.

12)   We’re nearing the end of the interview. Is there anything you would like to add?

In relation to your question on the links between research and policy, I’d like to stress the importance of having policy advocates, who do not necessarily belong to the political establishment, but who can challenge political parties aiming to get into government. It always takes a lot of time and effort to make reforms, and governments often find there is very little room for manoeuvre. However, there are windows of opportunity when politicians open their minds to what is possible, and when advocates can persuade them that policy change is possible and desirable too.

13)   We are currently involved in a strand of research within DRIVERS focused on advocacy for health equity. What risks do scientists face when involved in policy advocacy?

The risk for scientists is being associated with particular political strategies, rather than being associated with the ambition to reduce ill-health or mortality. However, researchers regularly have to formulate policy recommendations, whatever the research question. I think the more serious risk is that researchers detach themselves from policy making because they’re afraid of losing their integrity as a scientist. That would be an unfortunate development, and in my view unnecessary. I think we should challenge the research community much more when it comes to advocacy and policy making. Speaking from the Swedish perspective, I think the research community is too isolated from policy. We need to work and create an arena for interactions between researchers and policy makers. This arena could play an important role in provoking both politicians and researchers to address the same kinds of issues.

[1] European Commission (2014), Employment and Social Developments in Europe 2013 http://ec.europa.eu/social/main.jsp?catId=738&langId=en&pubId=7684

[2] European Commission (2013), Paper on Automatic Stabilisers
http://ec.europa.eu/social/BlobServlet?docId=10964&langId=en

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Prof. Johannes Siegrist

Professor of Medical Sociology at the University of Düsseldorf
Work Package Leader ‘Fair Employment’
 

What have been the main academic issues your team has worked on in the past?

“Our team has worked for several years on what aspects of modern work and employment conditions are important for health. In the past, occupational medicine mainly focused on physical and chemical noxious stimuli at work, and issues like working in shifts and the effects of noise. Today there are many other challenges such as technological progress, the increase of the service sector (and therefore service sector occupations), rising competition due to globalisation of work and employment, and also increasing job insecurity. We have analysed the adverse effects of these aspects of modern work on the health of employees, in particular focusing on the socially unequal distribution of these aspects amongst the working population.

The best way to analyse these associations is to conduct cohort studies on employed people, and to follow them prospectively over a long period of time. Our research team has been involved in several such studies. However, cohort studies require a huge effort and because of the long lengths of time they necessarily take there is only relatively slow progress in terms of scientific knowledge.”

Is there already some evidence of the impact of increased competition in the globalised world on health?

“Yes, there is. In order to identify those components within the complex work environment that really matter for health, you first need to develop a theoretical model that will allow you to analyse such associations. Our research resulted in the “effort–reward imbalance model” (Siegrist, 1996). The idea behind this model is that in modern economies workers are often forced to put a lot of effort into their job and to work in highly competitive environments. The compensation for these efforts is, however, not always adequate and proportionate. Not only in terms of salaries but also in terms of job security, promotion prospects, and the credit and recognition given by supervisors.

Research has shown that this imbalance between effort and reward (‘high cost–low gain’) is associated with an elevated risk of depression (starting for the first time in life). It also shows that for these workers the relative risk of suffering from a coronary heart disease increases by 40-60 per cent. These are substantial effects which can thus be attributed to adverse work environments for health.”

Are there, besides the “effort–reward imbalance model” that you have developed, any other models being used to study the effects of the workplace on employee health?

“Yes, there are two other theoretical approaches that have been developed to analyse health adverse consequences in modern work, in which the physical and chemical hazards are not in the first line of analysis – even though they are still important.

The first approach, which is the oldest and best known, is the so-called “demand–control model”, developed by the American sociologist Robert Karasek (1979) and the Swedish epidemiologist Töres Theorell (Karasek & Theorell, 1990). The model defines work-stress in terms of specific task profiles, which are characterised by high demands and pressure, and low control and decision latitude. The “demand–control model” therefore analyses the health of workers in a different way but has health consequences similar to those described earlier. Therefore the health risk is cumulative for those people working under conditions that characterised by both the demand–control and effort–reward imbalance models. When exposed to multiple stressors, workers thus experience an additional burden on their health.

The second model, the “organisational justice model”, is more recent and examines the association between components of organisational justice (the justice of decision-making procedures and interpersonal treatment) and the health of employees (Greenberg, 1990). For example, it deals with unfairness in promotion procedures, mobbing (bullying) at work, and interaction conflicts. The model has not yet been tested as extensively as the other two models in prospective cohort studies.”

How do health inequalities fit into all of this and why are they important?

“Adverse psychosocial work environments are unequally distributed across the working population, leaving those at the lower end of society at higher risk of suffering from adverse health effects as a result of their working conditions. Lower-skilled people are more likely to have a job which has high demands and low control, and where rewards are relatively poor compared to efforts exerted. The prevalence of some major chronic diseases also exhibits a social gradient. For example, cardio-vascular diseases are more common amongst lower-educated and lower-status people than amongst managers and higher-skilled employees. Depression occurs twice as often amongst lower-skilled blue-collar workers as amongst higher-skilled white-collar workers, and manual labour is typically associated with a higher risk of work-related accidents. There are of course other factors – such as unhealthy behaviours – that also have an impact on the prevalence of diseases and risks at work, but it is a fact that a social gradient exists and that certain diseases affect those in lower socio-economic positions more frequently.

The following three relationships have been scientifically proven: (1) a low socio-economic position is related to a high health risk; (2) a low socio-economic position is related to a high frequency of stressful psychosocial work; and (3) stressful work is related to a high health risk.

A first approach addressing links between employment and health and explaining the social gradient is called the “mediation hypothesis”. This combines these three associations and states that stress at work mediates (at least partially) the statistical relationship between a low socio-economic position and a high health risk (such as coronary heart disease or depression).

The second approach is called the “moderation hypothesis”, which is built around the idea that stressful or unhealthy work has an impact on the health of employees at all levels. The strength of the effect, however, varies. People at the bottom of the social hierarchy experience a stronger effect of workplace stress on their health compared to people from higher up the social hierarchy. The explanation given by the “moderation hypothesis” for this phenomenon is that people living in more privileged situations have better resources available and are therefore better able to cope with adverse work environments.

Both hypotheses have been tested in various studies and both have been shown to be valid. However, further research is needed to reach firm conclusions about the extent to which they contribute towards explaining the social gradient of major stress-related diseases. The reason why findings are still inconclusive is because high quality scientific evidence is needed, which can only be provided by prospective research and cohort studies. Unfortunately, few such studies have been conducted so far. A small number of cohort studies have explored some of the aspects of the two hypotheses, but since different methods and measurements were used it is difficult to compare results. Additional prospective research would be highly desirable.”

So how does the DRIVERS project enrich your work and research?

“Firstly, as part of DRIVERS we will be performing systematic reviews to collect and bring together all current evidence on the links between working conditions, social inequalities and unequal health. This adds a new component to our work, as until now we have only been involved in original research rather than systematic reviews.

In addition to that, DRIVERS provides us with the important opportunity of working together with EuroHealthNet to increase the dissemination of available research, especially among policy makers. Awareness amongst policy makers on the links between employment conditions, health and the social gradient is often limited. However, intensive dissemination of existing knowledge can’t be done by a university alone, and European or international initiatives (such as the WHO European Review on Social Inequalities in Health) therefore offer great opportunities to bridge the gap between researchers and decision makers.

Finally, DRIVERS offers us the possibility of working closely together with civil society associations, and to learn more about the work of NGOs and other organisations that focus on employment conditions and the consequences of inequalities. We’ll be conducting the DRIVERS case study work together with Business in the Community; this type of collaborative work is new and quite exciting!”

How does collaboration between the three DRIVERS research components contribute to more comprehensive scientific approaches to analysing health inequalities?

“Until now our research has mainly focused on the working conditions of individual workers and companies. This type of research is – of course – contextualised by macro-level conditions like laws and labour market policies, and also by transnational economic developments such as budgetary cuts as a result of the economic crisis. DRIVERS provides us with the opportunity of broadening the research framework we work within and moving away from concentrating on single companies or single employees to analyse the broader social context.

For example, it will be interesting to collaborate with the DRIVERS work strand on Income and Social Protection work, which is led by Professor Olle Lundberg from the Centre for Health Equity Studies in Sweden (CHESS). He has been studying welfare regimes and social security arrangements in cross-national comparative settings, and through this collaboration we will be able to further reinforce and expand the multi-level approach our team is taking.

The other DRIVERS work strand, led by Professor Peter Goldblatt and his team at University College London (UCL), focuses on early childhood and is taking a life-course approach. Again, the work–health approach is normally a more narrow approach, concentrating on people who are in their mid-life or early old age life period. It is of course important to look into the developments and experiences of people earlier in their lives before they entered into employment. It would be interesting to study the impact of inequalities in early childhood on future life trajectory, selective recruitment processes, and opportunities to have a specific occupation. Early life acts as a selective mechanism in terms of where you end up in your professional career, and is therefore an important addendum to our approach. Because of our involvement in DRIVERS we will be able to discuss such life course aspects.”

Finally, if there were one outcome that you could ideally achieve by the end of the DRIVERS project, what would it be?

“Apart from successfully delivering the work we are involved in, it would be wonderful if we could demonstrate that an evidence-based work-related intervention is capable of reducing the burden of disease in working populations and thus reduce health inequalities. This would be an ideal outcome! But it is also an outcome that is still a dream, and in order to test how realistic such a dream is we have to do some hard work.”

References:

• Siegrist J (1996) Adverse health effects of high effort/low reward conditions. J Occup Health Psychol 1: 27-41
• Karasek R, Theorell T (1990) Healthy Work. New York: Basic Books
• Greenberg J (1990) Organizational justice-yesterday, today, and tomorrow. J Manag 16:  399-432

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