SPIDA, June 7, 2004

Making sense to policy-making:Some research examples from the intersection of labour market policy and health policy

Cam Mustard, ScDProfessor, Department of Public Health SciencesUniversity of Toronto Faculty of MedicinePresident & Senior ScientistInstitute for Work & Health

Summary of the presentation

• Context: a description of the Institute for Work & Health

• Consider some of the features of research contribution to policy-making

• Summarize three examples of current research that speak to the relationship between labour market experiences and health

Context: a description of the Institute for Work & Health

• Independently incorporated, non-statutory, not-for profit corporation

• Established in 1990 (part of the WCB Medical Rehabilitation Strategy)• Major contract funding from Workplace Safety

and Insurance Board• Additional funding (approximately 20%) from

competitive research grants, private and public sector contracts

What do we do?

Core Businesses

• Research:– Apply “state-of-the-art” research methods, primary

evaluation of programs and outcomes. Provide a training ground for research investigators.

• Research Transfer:– Develop and apply evidence-based research

transfer strategies to make knowledge accessible for application in practice, planning and policy-making to defined audiences including policy makers, workplace parties, and health care providers.

How are we governed?

• Multipartite Board of Directors:– Management, Labour, Health care, Workplace

Safety & Insurance Board, Academic leaders

• Scientific Advisory Committee:– International research leaders

• Formally affiliated with:– University of Toronto– McMaster University– University of Waterloo– York University

Who do we work with?• Primary Stakeholders:

– Workplace Safety & Insurance Board– Workplace Parties

• Employers• Employees/labour• Injured persons

– Policy-makers• Ministries of Health, Labour and Finance• Human Resources Development Canada• Health Canada

– Rehab & Health Services Community

• Other Stakeholders:– Insurance Industry (auto; life; disability)– Academic Community (educators, researchers, students)– Community Leaders– Media (commercial and trade)

SummaryWhat makes the Institute for Work & Health unique?

1. Scientific standard of excellence (staff and students hold numerous awards).

2. External sources of revenue.

3. Institutional arrangements with universities.

4. Active involvement in national research agencies and international networks.

5. Strong working relationship with business, labour and health care communities and the Workplace Safety & Insurance Board.

Some features of policy-making and thoughts on the contribution of research

The purposes of research

• Enlightenment• Research contributes new ways of

understanding

• Instrumental• Research contributes to the solution of an

immediate policy requirement

• Strategic / Political• Research is used to justify ort defend a policy

decision

The nature of policy-making

• Political elites negotiate to balance often competing goals of powerful political or economics interests

• Policy-making is usually about making a choice among competing options of equivalent merit

• A preference for a policy option over another will often will arise from additional considerations at the margin

The nature of policy-making:An example of a consideration at the margin• Labour market policies balance macro-economic

objectives with social policy objectives: economic growth vs economic security of the person

• Labour market policies will typically focus on employment flexibility, skill training, geographic mobility and income protection

• While health may be a consequence of labour market policies, it is rarely a direct objective

• Health can therefore best inform labour market policy development at the margin

The nature of policy-making:An example of a consideration at the margin

• The employment insurance illness benefit

• This policy extends benefit duration for claimants with health or functional impairment

• Acknowledges evidence that health deficits affect success in job search and re-employment

• Sickness benefits in the EI program in 2003 were $700M

Three examples:Current research that speaks tothe relationship between labourmarket experiences and health

Each of the three research questions responds to two related objectives:

1) the selection of a research design which has the potential to contribute new or more robust knowledge of the relationship between experiences in the labour market and the health of labour force participants, and

2) the definition of a research question which integrates, at least in part, an understanding of the current policy instruments applied in labour market and health policy

Case Study 1The health effects of labour market experiences relative toposition in the occupationalhierarchy

Case Study 1Prospective risk of decline in health status by position in occupational hierarchy

1

1.25

1.5

1.75

Case Study 1:Contribution of job control to social variations in coronary heart disease incidence

Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S. Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet 1997;350:235-239

Low Job Control

HighEmployment Grade

Intermediate Low

8% 27% 78%

Odds ratio for new CHD event in men

Case Study 1:Cumulative psychosocial work exposures and risk of all-cause mortality

Amick B, McDonough P, Chang H, Rogers WH, Pieper CF, Duncan G. Relationship Between All-Cause Mortality and Cumulative Working Life Course Psychosocial and Physical Exposures in the United States Labor Market from 1968 to 1992. Psychosomatic Medicine 64, 370-381. 2002.

0.75

1

1.25

1.5

Job ControlLowHigh

Hazard Rate for all-cause mortality, five year lag

Case Study 2Does health in childhood influence success in the labour market in young adulthood?

Case Study 2:Childhood Health Status and Intergenerational Socioeconomic Mobility

The unequal distribution of health status among adults relative to socioeconomic position is understood to arise from two processes:

• the effects of socioeconomic disadvantage on health status (social causation), and

• the effects of health status (both current health and potentially health early in the lifecourse) on socioeconomic status (health selection)

The Ontario Child Health Study

The effect of health status deficits in childhood and adolescence on socioeconomic attainment in early adulthood is not well described in Canada

Prior to completion of 2000 OCHS Follow-up, no Canadian studies of representative samples of children followed to early adulthood with childhood measures of health and function

The Ontario Child Health Study

Occupational Position Relative to Parents

Higher than Parents 30.4%

Same as Parents 15.0%

Lower than Parents 54.6%

Educational Attainment Relative to Parents

Higher than Parents 57.0%

Same as Parents 26.1%

Lower than Parents 16.9%

Childhood Health/Behavioral Risk Factors for Downward Socioeconomic Mobility in Early Adulthood

Occupation Males Females Total

OR 95% CI OR 95% CI OR 95% CI

Downward 1.07 0.59-1.94 1.14 0.47-2.77 1.11 0.69-1.81

Stable 1.00 1.00 1.00

Upward 0.52 0.26-1.05 0.66 0.25-1.73 0.53 0.31-0.94

Education Males Females Total

OR 95% CI OR 95% CI OR 95% CI

Downward 1.91 1.11-3.27 1.47 0.56-3.85 1.96 1.23-3.10

Stable 1.00 1.00 1.00

Upward 0.61 0.36-1.04 0.42 0.20-0.88 0.51 0.33-0.78

Health/Behavioral risk factor: Hyperactivity

Socioeconomic health status inequalities in early adulthoodOdds Ratios for poor health (good, fair or poor health status)

Unadjusted Adjusted Occupation OR 95% CI OR 95% CI Unskilled Worker 2.23 1.42-3.50 2.01 1.27-3.17 Semi-skilled worker 2.24 1.48-3.39 2.04 1.34-3.10 Skilled worker 1.34 0.85-2.11 1.25 0.79-1.97 Supervisor 1.49 0.88-2.50 1.36 0.80-2.30 Semi-professional 1.04 0.68-1.60 1.05 0.69-1.62 Professional, Mgmt 1.00 1.00 Education No high school diploma 4.95 3.39-7.25 4.05 2.67-6.13 High school diploma 2.55 1.79-3.62 2.31 1.58-3.38 Some college 2.60 1.81-3.73 2.33 1.60-3.40 College completion 2.10 1.59-2.77 1.94 1.44-2.60 Some university 2.09 1.47-2.97 1.98 1.38-2.82 University completion 1.00 1.00

Case Study 3Are ‘income shocks’ (income instability orsudden changes in income) a risk factorfor decline in health status?

Case Study 3:Income dynamics and adult mortality in the United States, 1972- 1989

McDonough P, Duncan GJ, Williams D, House J. Income dynamics and adult mortality in the United States, 1972-1989. American Journal of Public Health 1997;87:1476-1483.

Adjusted odds ratios for all-cause mortality, ages 45-64, 1972-1989

Income dynamic Percent OR 95% CI

<$20K and one or more drops 4% 3.73 2.41-5.70

<$20K and no drops 10% 3.35 2.22-5.06

$20-$70K and one or more drops 6% 3.21 1.90-5.47

$20-$70K and no drops 57% 1.47 1.05-2.04

>$70K and one or more drops 2% 1.40 0.67-2.55

>$70K and no drops 21% 1.00