The changing nature of work in the 21st century as a social determinant of mental health
Authors: Ichiro Kawachi
Journal: World Psychiatry (2024)

An extensive literature has documented the association of psychosocial work stressors – e.g., job strain, effort-reward imbalance, organizational injustice, long working hours, job insecurity, shift work, workplace harassment and bullying – with mental health problems1-4. However, the implications for population mental health of the changing nature of work in the 21st century have not been sufficiently highlighted. The classical job strain model captures job task-related exposures (e.g., the combination of excessive psychological demands with lack of autonomy), but does not speak to the broader picture of what has been happening in the workplace during the era of globalization, automation, and the rise of alternate forms of work (e.g., casual and part-time work). Three trends are exemplary in this respect: digital enforcement, just-in-time scheduling, and workplace fissuring. Each of these trends represents a potential social determinant of mental health at the population level. Digital surveillance has become widespread across workplaces in some countries, whether in the form of tracking devices worn by employees in Amazon warehouses ("fulfillment centers") to meet their daily quotas, or the monitoring software installed on the desktop computers of remote employees during the pandemic. One of the most intensely surveilled occupations in the US is trucking, which employs about 3 million drivers. Truck drivers are already at high risk of mental health problems, due to the excessive hours of work, lack of sleep, and social isolation5. Since the deregulation of the US trucking industry in the 1980s, they have also had to contend with the burden of low wages, due to a shift in compensation from salaried work to piece rate compensation. Truck drivers are paid for miles driven, not for the hours they spend on the road stuck in congested traffic or the hours waiting for their cargo to be loaded/unloaded. As a result of the switch to piece rate compensation, truckers' wages dropped by 44% between 1977 and 19955. In order to make a living, drivers have been forced to spend longer hours on the road, which increases the risk of accidents. In response, lawmakers in 1997 mandated the installation of electronic logging devices on all trucks. These devices have helped to enforce "hours of service" regulations in the trucking industry, which dictate that truckers may drive no more than eleven hours a day, after which they must take a mandatory rest break. However, despite the industry-wide improvement in compliance with hours of service limits, the introduction of digital enforcement paradoxically increased the rate of crashes, because drivers responded by speeding to make up for lost productivity6. In terms of worker autonomy, the same time-logging devices are bundled with other capabilities which enable employers to monitor driver performance in areas such as fuel usage, frequency of changing lanes, and adherence to travel routes. This has nothing to do with compliance with safety regulations, but is all about extracting efficiency and maximizing productivity. The concept of just-in-time scheduling originally began as a management strategy in the manufacturing sector to align the delivery of raw-material supplies with production schedules. Subsequently it spread to the retail and service industry, where employers use it to manage labor costs by scheduling employees based on fluctuating consumer demand. For example, if a store manager believes that his/her shop will be unusually busy ahead of a national holiday, he/she can update scheduling on the fly and ask additional employees to come in. Under just-in-time scheduling, workers typically receive their schedules on short notice, and may have their shifts changed or canceled at the last minute. Employers may put workers on call with no guarantee that there will be work available for them. According to the American Time Use Survey, an estimated 45% of wage and salary workers over the age of 15 are given their schedules less than a month in advance, while 20% are told about their schedules less than one week in advance7. In addition to making it difficult to arrange childcare, attend school, or hold a second job, irregular work hours also result in income volatility for hourly wage workers. Variable work hours in turn jeopardize access to many safety net programs (e.g., food assistance programs in the US) which require a minimum number of hours of work per week. A study in South Korea found that workers with unpredictable work hours had a significantly increased risk of depressive symptoms8. A third example of the changing nature of work is workplace fissuring, which refers to the management practice of outsourcing parts of the organization which are not viewed as "core competencies" of the firm9. For example, most cleaners, laundry workers and kitchen staff in the hotel industry are not employees of the brand-name hotels, but are "independent contractors" hired by third party companies. Customer service departments of major corporations have been spun off to third party companies, which in turn hire an army of independent contractors to perform the work. The independent contractor is responsible for purchasing the assets required to perform the work (home office equipment such as a computer, headsets and a dedicated phoneline), and must pay for the costs of training to become a customer service representative for the brand name corporation, as well as pay a monthly fee to use the digital platform that connects him/her to customers. At the same time, the independent contractor classification means that the worker receives none of the benefits of being a salaried employee, such as a pension or health insurance. These workers are typically paid for the time they spend responding to customer calls, not for the hours waiting for customers to call in. An estimated 1 in 5 people in the US workforce are engaged in the fissured workforce – including hotel and hospitality, telephone operators, home health care, janitors, security guards, and fast food restaurants. The consideration of working conditions as a social determinant opens up the possibility for an expanded set of structural interventions to promote population mental health, e.g., changing laws to protect the rights, welfare and safety of employees. It forces the question: what is the role of corporations and employers in generating mental ill-health, and what is the potential for work-based interventions, policies and regulations to promote mental health? Businesses (and shareholders) profit from wringing maximum productivity out of workers through low pay, long work hours, unpredictable schedules, digital surveillance, and shifting the costs of doing business on to workers. Consumers also benefit from lower prices, but, in many cases, consumers are also workers being exploited by the same system. It is time for us to consider the changing nature of work in the 21st century as a significant social determinant of mental health, and to make a substantial effort to develop interventions addressing it.