Building on previous multilevel studies in social epidemiology, this cross-sectional study examines, simultaneously, the contextual effects of workplace exploitation and area-of-residence economic inequality on social inequalities in health among low-income nursing assistants. A total of 868 nursing assistants recruited from 55 nursing homes in Kentucky, Ohio, and West Virginia were surveyed between 1999 and 2001. Using a cross-classified multilevel design, the authors tested the effects of area-of-residence (income inequality and racial segregation), workplace (type of nursing home ownership and managerial pressure), and individual-level (age, gender, race/ethnicity, health insurance, length of employment, social support, type of nursing unit, preexisting psychopathology, physical health, education, and income) variables on health (self-reported health and activity limitations) and behavioral outcomes (alcohol use and caffeine consumption). Findings reveal that overall health was associated with both workplace exploitation and area-of-residence income inequality; area of residence was associated with activity limitations and binge drinking; and workplace exploitation was associated with caffeine consumption. This study explicitly accounts for the multiple contextual structure and effects of economic inequality on health. More work is necessary to replicate the current findings and establish robust conclusions on workplace and area of residence that might help inform interventions.
Get full access to this article
View all access options for this article.
References
1.
BuellP., and BreslowL.Mortality from coronary heart disease in California men who work long hours. J. Chron. Dis.11: 615–626, 1960.
2.
EngelsF.The Condition of the Working Class in England, ed. and trans. HendersonW. O. and ChalonerW. H.. Stanford University Press, Stanford, CA, 1958.
3.
DuncanC.JonesK., and MoonG.Psychiatric morbidity: A multilevel approach to regional variations in the UK. J. Epidemiol. Community Health49(3): 290–295, 1995.
4.
O'CampoP.Violence by male partners against women during the childbearing year: A contextual analysis. Am. J. Public Health85(8, Pt 1): 1092–1097, 1995.
5.
O'CampoP.Neighborhood risk factors for low birthweight in Baltimore: A multilevel analysis. Am. J. Public Health87(7): 1113–1118, 1997.
6.
Diez-RouxA. V.Neighborhood environments and coronary heart disease: A multilevel analysis. Am. J. Epidemiol.146(1): 48–63, 1997.
7.
SöderfeldtB.Does organization matter? A multilevel analysis of the demand-control model applied to human services. Soc. Sci. Med.44(4): 527–534, 1997.
8.
GoldsteinH.Multilevel mixed linear model analysis using iterative generalised least squares. Biometrika73: 43–56, 1986.
Diez-RouxA. V.Multilevel analysis in public health research. Annu. Rev. Public Health21: 171–192, 2000.
11.
PickettK. E., and PearlM.Multilevel analyses of neighbourhood socioeconomic context and health outcomes: A critical review. J. Epidemiol. Community Health55(2): 111–122, 2001.
12.
WilkinsonR. G.Unhealthy Societies: The Afflictions of Inequality. Routledge, New York, 1996.
13.
Diez-RouxA. V.The study of group-level factors in epidemiology: Rethinking variables, study designs, and analytical approaches. Epidemiol. Rev.26(1): 104–111, 2004.
14.
O'CampoP.Invited commentary: Advancing theory and methods for multilevel models of residential neighborhoods and health. Am. J. Epidemiol.157(1): 9–13, 2003.
15.
MuntanerC.Commentary: Social capital, social class, and the slow progress of psychosocial epidemiology. Int. J. Epidemiol.33(4): 674–680, 2004.
16.
de JongeJ.Comparing group and individual level assessments of job characteristics in testing the job demand-control model: A multilevel approach. Hum. Relat.52(1): 95–122, 1999.
17.
ElovainioM.Organizational and individual factors affecting mental health and job satisfaction: A multilevel analysis of job control and personality. J. Occup. Health Psychol. 5(2): 269–277, 2000.
18.
Van YperenN. W., and SnijdersT. A.A multilevel analysis of the demands-control model: Is stress at work determined by factors at the group level or the individual level?J. Occup. Health Psychol. 5(1): 182–190, 2000.
19.
de JongeJ.Variation in hospital length of stay: Do physicians adapt their length of stay decisions to what is usual in the hospital where they work?Health Serv. Res.41(2): 374–394, 2006.
20.
KrogstadU.Hospital quality improvement in context: A multilevel analysis of staff job evaluations. Qual. Saf. Health Care14(6): 438–442, 2005.
21.
DunnJ. R.Role of geography in inequalities in health and human development. in Healthier Societies—From Analysis to Action, ed. HeymannJ.Oxford University Press, New York, 2006.
22.
HaanM.KaplanG. A., and CamachoT.Poverty and health: Prospective evidence from the Alameda County study. Am. J. Epidemiol.125(6): 989–998, 1987.
23.
MarmotM. G.Health inequalities among British civil-servants: The Whitehall-II study. Lancet337(8754): 1387–1393, 1991.
24.
LynchJ. W.Income inequality and mortality: Importance to health of individual income, psychosocial environment, or material conditions. BMJ320(7243): 1200–1204, 2000.
25.
BorrellC.Social class and self-reported health status among men and women: What is the role of work organisation, household material standards and household labour?Soc. Sci. Med.58(10): 1869–1887, 2004.
26.
LeviL.Stressors at the workplace: Theoretical models. Occup. Med.15(1): 69–105, 2000.
27.
ResnickS., and WolffR. D.Classes in Marxian theory. Rev. Rad. Polit. Econ.13(4): 1–18, 1982.
28.
WrightE. O. Class. In International Encyclopedia of Economic Sociology, ed. BeckertJ. and ZafirovskyM., pp. 62–68. Routledge, London, 2006.
29.
WoolhandlerS., and HimmelsteinD. U.Patients on the auction block. Am. J. Public Health86(12): 1699–1700, 1996.
30.
WoolhandlerS., and HimmelsteinD. U.Costs of care and administration at for-profit and other hospitals in the United States. N. Engl. J. Med.336(11): 769–774, 1997.
31.
WoolhandlerS., and HimmelsteinD. U.When money is the mission: The high costs of investor-owned care. N. Engl. J. Med.341(6): 444–446, 1999.
32.
WoolhandlerS.HMO profits and quality. Health Aff. 20(5): 302–303, 2001.
33.
HarringtonC.Does investor ownership of nursing homes compromise the quality of care?Am. J. Public Health91(9): 1452–1455, 2001.
34.
CarrasquilloO.A reappraisal of private employers' role in providing health insurance. N. Engl. J. Med.340(2): 109–114, 1999.
35.
HimmelsteinD. U.Quality of care in investor-owned vs not-for-profit HMOs. JAMA282(2): 159–163, 1999.
36.
TrinkoffA. M.Staffing and worker injury in nursing homes. Am. J. Public Health95(7): 1220–1225, 2005.
37.
BoswellT., and DixonW. J.Marx's theory of rebellion: A cross-national analysis of class exploitation, economic development, and violent revolt. Am. Sociol. Rev.58(5): 681–702, 1993.
38.
WilkinsonR. G., and PickettK. E.Income inequality and population health: A review and explanation of the evidence. Soc. Sci. Med.62(7): 1768–1784, 2006.
39.
BoiceJ. D.Jr.MummaM. T., and BlotW. J.Cancer mortality among populations residing in counties near the Hanford site, 1950–2000. Health Phys. 90(5): 431–445, 2006.
40.
HolmesG. M.The effect of rural hospital closures on community economic health. Health Serv. Res.41(2): 467–485, 2006.
41.
LeClereF. B., and SoobaderM. J.The effect of income inequality on the health of selected US demographic groups. Am. J. Public Health90(12): 1892–1897, 2000.
42.
WunderlichG. S.SloanF. A., and DavisC. K.Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?Institute of Medicine, National Academy Press, Washington, DC, 1996.
43.
FonerN.The Caregiving Dilemma: Work in an American Nursing Home. University of California Press, Berkeley, 1994.
44.
GassT. E.Nobody's Home: Candid Reflections of a Nursing Home Aide. Cambridge University Press, New York, 2004.
45.
Service Employees International Union. Dignity or Disgrace—West Virginia's Choice: A Study of Nursing Home Problems in West Virginia. Washington, DC, 1995.
46.
Al-ArfajA. S.Musculoskeletal pain in the community. Saudi Med. J.24(8): 863–867, 2003.
47.
BrekkeM.HjortdahlP., and KvienT. K.Severity of musculoskeletal pain: Relations to socioeconomic inequality. Soc. Sci. Med.54(2): 221–228, 2002.
48.
HuangT. T.Home environmental hazards among community-dwelling elderly persons in Taiwan. J. Nurs. Res.13(1): 49–57, 2005.
49.
RethelyiJ. M.Comorbidity of pain problems and depressive symptoms in young women: Results from a cross-sectional survey among women aged 15–24 in Hungary. Eur. J. Pain.8(1): 63–69, 2004.
50.
SaagK. G.Arthritis health service utilization among the elderly: The role of urban—rural residence and other utilization factors. Arthritis Care Res. 11(3): 177–185, 1998.
51.
CrawfordL.GutierrezG., and HarberP.Work environment and occupational health of dental hygienists: A qualitative assessment. J. Occup. Environ. Med.47(6): 623–632, 2005.
DainoffM. J.The effect of an ergonomic intervention on musculoskeletal, psychosocial and visual strain of VDT entry work: Organization and methodology of the international study. Int. J. Occup. Saf. Ergon.11(1): 9–23, 2005.
54.
EngstC.Effectiveness of overhead lifting devices in reducing the risk of injury to care staff in extended care facilities. Ergonomics48(2): 187–199, 2005.
55.
KangS. K.AhnY. S., and KimK. J.Recent advances in occupational health research in Korea. Ind. Health.42(2): 91–98, 2004.
56.
HuangG. D.Individual and combined impacts of biomechanical and work organization factors in work-related musculoskeletal symptoms. Am. J. Ind. Med.43(5): 495–506, 2003.
57.
HuangG. D., and FeuersteinM.Identifying work organization targets for a work-related musculoskeletal symptom prevention program. J. Occup. Rehabil.14(1): 13–30, 2004.
58.
PranskyG.RobertsonM. M., and MoonS. D.Stress and work-related upper extremity disorders: Implications for prevention and management. Am. J. Ind. Med.41(5): 443–455, 2002.
59.
MacDonaldL. A.Covariation between workplace physical and psychosocial stressors: Evidence and implications for occupational health research and prevention. Ergonomics44(7): 696–718, 2001.
60.
WahlstedtK. G.The effects of a change in work organization upon the work environment and musculoskeletal symptoms among letter carriers. Int. J. Occup. Saf. Ergon.6(2): 237–255, 2000.
61.
CarayonP.SmithM. J., and HaimsM. C.Work organization, job stress, and work-related musculoskeletal disorders. Hum. Factors.41(4): 644–663, 1999.
62.
KilbomA.Possibilities for regulatory actions in the prevention of musculoskeletal disorders. Scand. J. Work Environ. Health.25(Suppl. 4), 5–12, 1999.
63.
SznelwarL. I.Ergonomics and work organization: The relationship between Tayloristic design and workers' health in banks and credit cards companies. Int. J. Occup. Saf. Ergon.5(2): 291–301, 1999.
64.
LoewensonR. H.Health impact of occupational risks in the informal sector in Zimbabwe. Int. J. Occup. Environ. Health.4(4): 264–274, 1998.
65.
FerreiraM.Jr.ConceicaoG. M., and SaldivaP. H.Work organization is significantly associated with upper extremities musculoskeletal disorders among employees engaged in interactive computer-telephone tasks of an international bank subsidiary in Sao Paulo, Brazil. Am. J. Ind. Med.31(4): 468–473, 1997.
66.
BernardB.Job task and psychosocial risk factors for work-related musculoskeletal disorders among newspaper employees. Scand. J. Work Environ. Health.20(6): 417–426, 1994.
67.
LareseF., and FioritoA.Musculoskeletal disorders in hospital nurses: A comparison between two hospitals. Ergonomics37(7): 1205–1211, 1994.
68.
ChavalitsakulchaiP., and ShahnavazH.Musculoskeletal disorders of female workers and ergonomics problems in five different industries of a developing country. J. Hum. Ergol.22(1): 29–43, 1993.
69.
ChavalitsakulchaiP., and ShahnavazH.Ergonomics method for prevention of the musculoskeletal discomforts among female industrial workers: Physical characteristics and work factors. J. Hum. Ergol.22(2): 95–113, 1993.
70.
KruzichJ. M.Empowering organizational contexts: Patterns and predictors of perceived decision-making influence among staff in nursing homes. Gerontologist35(2): 207–216, 1995.
ChaixB., and ChauvinP.Tobacco and alcohol consumption, sedentary lifestyle and overweightness in France: A multilevel analysis of individual and area-level determinants. Eur. J. Epidemiol.18(6): 531–538, 2003.
73.
GruenewaldP. J.JohnsonF. W., and TrenoA. J.Outlets, drinking and driving: A multilevel analysis of availability. J. Stud. Alcohol.63(4): 460–468, 2002.
74.
KleinH., and PittmanD. J.Regional differences in alcohol consumption and drinkers' attitudes toward drinking. Am. J. Drug. Alcohol Abuse19(4): 523–538, 1993.
75.
MurrayD. M., and ShortB.Intraclass correlation among measures related to alcohol use by young adults: Estimates, correlates and applications in intervention studies. J. Stud. Alcohol.56(6): 681–694, 1995.
76.
NelsonT. F.The state sets the rate: The relationship among state-specific college binge drinking, state binge drinking rates, and selected state alcohol control policies. Am. J. Public Health95(3): 441–446, 2005.
77.
SinghG. K., and HoyertD. L.Social epidemiology of chronic liver disease and cirrhosis mortality in the United States, 1935–1997: Trends and differentials by ethnicity, socioeconomic status, and alcohol consumption. Hum. Biol.72(5): 801–820, 2000.
78.
CrumR. M.Occupational stress and the risk of alcohol abuse and dependence. Alcohol Clin. Exp. Res.19(3): 647–655, 1995.
79.
YenI. H., and KaplanG. A.Poverty area residence and changes in depression and perceived health status: Evidence from the Alameda County Study. Int. J. Epidemiol.28(1): 90–94, 1999.
80.
MuntanerC.Psychosocial dimensions of work and the risk of drug dependence among adults. Am. J. Epidemiol.142(2): 183–190, 1995.
81.
PeckJ.Work-Place: The Social Regulation of Labor Markets. Guilford, New York, 1996.
82.
KaplanG. A.Inequality in income and mortality in the United States: Analysis of mortality and potential pathways. BMJ312(7037): 999–1003, 1996.
83.
OhlsonC. G.Stress markers in relation to job strain in human service organizations. Psychother. Psychosom.70(5): 268–275, 2001.
84.
SchwartzJ. E.PieperC. F., and KarasekR. A.A procedure for linking psychosocial job characteristics data to health surveys. Am. J. Public Health78(8): 904–909, 1988.
85.
KesslerR. C.Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch. Gen. Psychiatry.51(1): 8–19, 1994.
86.
Center for Medicare and Medicaid Services. Nursing Home Compare. Washington, DC, 2000.
RasbashJ.A User's Guide to MlwiN. Multilevels Models Project, Institute of Education, University of London, London, 2000.
89.
EstesC. L., and LinkinsK. W.Devolution and aging policy: Racing to the bottom in long term care. in Critical Gerontology, ed. MinklerM. and EstesC. L., pp. 169–183. Baywood, Amityville, NY, 1999.
90.
ElgarF. J.Income inequality and alcohol use: A multilevel analysis of drinking and drunkenness in adolescents in 34 countries. Eur. J. Public Health15(3): 245–250, 2005.
91.
BlomgrenJ.The effects of regional characteristics on alcohol-related mortality: A register-based multilevel analysis of 1.1 million men. Soc. Sci. Med.58(12): 2523–2535, 2004.
92.
HendersonC.The effects of US state income inequality and alcohol policies on symptoms of depression and alcohol dependence. Soc. Sci. Med.58(3): 565–575, 2004.
93.
BabazonoA.A prospective study on the influences of workplace stress on mental health. J. Occup. Health.47(6): 490–495, 2005.
94.
MuntanerC., and O'CampoP.A critical appraisal of the demand/control model of the psychosocial work environment: Epistemological, social, behavioral and class considerations. Soc. Sci. Med.36(11): 1509–1517, 1993.
MuntanerC.EatonW. W., and GarrisonR.Dimensions of the psychosocial work environment in a sample of the US metropolitan population. Work Stress7(4): 351–363, 1993.
97.
HansonS., and PrattG.Gender, Work, and Space. Routledge, London, 1995.
98.
KuhD., and DaveySmith G.When is mortality risk determined? Historical insights into a current debate. Soc. Hist. Med.6(1): 101–123, 1993.
