Introduction
Research Questions
- How does employment relate to health among low-income adults and their children?
- For low-income employed adults, what is the relationship between their work environment and their health?
- For low-income employed single parents, what is the relationship between their work environment and the health of their children?
Decades of research have produced convincing evidence of a strong relationship between having a job and enjoying good health. But does employment cause health outcomes or does health cause employment outcomes? If employment can cause health outcomes, does working make health better or worse? That is, it could be that:
- Employment affects health. Employment could be good for health because working people earn money, have access to health insurance, and enjoy psychological benefits like social status. On the other hand, the benefits of working could depend on the nature and quality of a job. A favorable work environment could improve health, and an unfavorable one could worsen it.
- Health affects employment. People in poor health might have trouble getting or keeping a job. Conversely, people in good health might be more productive, making them more likely to find a job and keep it.
Alternatively, both these relationships could be true and mutually reinforcing—or another factor or factors such as a person’s education level, neighborhood, or exposure to adverse childhood experiences may actually be driving the employment-health relationship.
We distilled the findings from a voluminous literature to draw what conclusions we could from research about the causal relationship between employment and health. That is, we were interested in research evidence that could demonstrate whether a change in employment is responsible for a change in health or vice versa. We also examined the causal relationship between work environment and health, because the relationship between employment and health may depend on the nature and quality of a job, as well.
The literature review was part of a larger project, the Employment Strategies for Low-Income Adults Evidence Review, funded by the Office of Planning, Research, and Evaluation (OPRE).
Purpose
Policymakers, administrators of human services programs, and employers all have an interest in understanding the relationship between employment and health. Findings from this literature review can help inform decisions about the design of programs directed towards improving health or employment outcomes for low-income adults and children in the United States, and also lay the groundwork for future research. A clear review of the causal literature can support ACF’s mission to foster the health of low-income families.
Key Findings and Highlights
- Little research has been done on the causal relationship between employment and health among low-income Americans. Instead, the existing research is mostly correlational: it does not shed light on whether a change in employment is responsible for a change in health (or vice versa) because it cannot rule out the possibility that other factors are actually causing the changes in both. Much of the existing research is also based outside the United States and/or on a general population and its findings may not apply to low-income adults and families in the United States.
- The causal research that does exist typically does not directly test the effects of employment on health or vice versa. Instead, most of the research tests the impact of welfare-to-work programs, which offer a bundle (or package) of employment services, on health. This is problematic because we cannot say definitively whether changes in health were caused by being employed or by some effect of the welfare-to-work services accessed through the program.
- On the whole, the studies we reviewed suggest that the welfare-to-work programs, although they did help people find jobs, did not affect mothers’ well-being or have lasting effects on their children’s development. There was some evidence, however, that health programs that provided case management can help people find jobs.
- Although we did find that aspects of the work environment were correlated with health, there was little causal evidence about this relationship. For example, high job demands and a lack of autonomy or control over one’s work were correlated with lower well-being. Among children of low-income single parents, mothers’ nonstandard schedules were correlated with adverse outcomes for children.
These findings are based on just a few studies, however, limiting our ability to draw definitive conclusions.
Methods
The literature review had three steps:
- Searching electronic databases for published research released from 1990 through 2018, and searching for articles and reports that would not be in the electronic databases
- Screening the studies we found for their relevance by using the titles and abstracts; we emphasized causal studies but also included correlational studies
- Reviewing studies relevant to the research questions—for research question 1, we reviewed 19 studies, 11 of which used a causal design. For research questions 2 and 3, we reviewed 11 and 7 studies, respectively, and all but two were correlational.
Recommendations
This review identifies gaps in the existing research literature on the relationship between employment and health for low-income individuals. Addressing those gaps through the development of carefully designed causal studies that focus on low-income individuals and families in the U.S. could considerably strengthen what we know about the relationship between employment and health. As the research base grows, researchers could do a meta-analysis to tease out how distinct employment program component affects health. Finally, reviewing or conducting qualitative research on the specific means through which employment may affect health, and the aspects of the work environment that matter to different people, could guide the focus of quantitative studies.
Citation
Sama-Miller, E., Kleinman, R., Timmins, L., and Dahlen, H. (2019). Employment and Health Among Low-Income Adults and their Children: A Review of the Literature. Office of Planning, Research, and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Washington, DC.