Working conditions and health behavior as causes of educational inequalities in self-rated health: an inverse odds weighting approach

Jolinda Ld Schram, Joost Oude Groeniger, Merel Schuring, Karin I Proper, Sandra H van Oostrom, Suzan Jw Robroek*, Alex Burdorf

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

10 Citations (Scopus)
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Objective Using a novel mediation method that presents unbiased results even in the presence of exposure-mediator interactions, this study estimated the extent to which working conditions and health behaviors contribute to educational inequalities in self-rated health in the workforce. Methods Respondents of the longitudinal Survey of Health, Ageing, and Retirement in Europe (SHARE) in 16 countries were selected, aged 50-64 years, in paid employment at baseline and with information on education and self-rated health (N=15 028). Education, health behaviors [including body mass index (BMI)] and working conditions were measured at baseline and self-rated health at baseline and two-year follow-up. Causal mediation analysis with inverse odds weighting was used to estimate the total effect of education on self-rated health, decomposed into a natural direct effect (NDE) and natural indirect effect (NIE). Results Lower educated workers were more likely to perceive their health as poor than higher educated workers [relative risk (RR) 1.48, 95% confidence interval (CI) 1.37-1.60]. They were also more likely to have unfavorable working conditions and unhealthy behaviors, except for alcohol consumption. When all working conditions were included, the remaining NDE was RR 1.30 (95% CI 1.15-1.44). When BMI and health behaviors were included, the remaining NDE was RR 1.40 (95% CI 1.27-1.54). Working conditions explained 38% and health behaviors and BMI explained 16% of educational inequalities in health. Including all mediators explained 64% of educational inequalities in self-rated health. Conclusions Working conditions and health behaviors explain over half of the educational inequalities in self-rated health. To reduce health inequalities, improving working conditions seems to be more important than introducing health promotion programs in the workforce.

Original languageEnglish
Pages (from-to)127-135
Number of pages9
JournalScandinavian Journal of Work, Environment and Health
Issue number2
Publication statusPublished - 1 Mar 2021

Bibliographical note

ZonMw funded this study (no. 531001412). The funder
had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the
report; or in the decision to submit the manuscript for

Publisher Copyright:
© 2021, Nordic Association of Occupational Safety and Health. All rights reserved.


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