Publications

The Things that Matter Most at Work for Flourishing in Life: A Cross-Cultural Comparison of Well-being in Apparel Supply Chain Workers
Eileen McNeely, Tamar Koosed, Carlued Leon, Dorota Weziak-Bialowoska

Background

Work is an important platform for obtaining resources to flourish in life. Many studies on work and health focus only on negative consequences, such as mental or physical disability. In the apparel industry, compliance audits also monitor negative conditions only, such as human rights violations or occupational health and safety risks. In this paper, we evaluate the work conditions that contribute to positive well-being at work (happy, healthy, and engaged workers) and to positive well-being in life (meaning and purpose, social connectedness, emotional health, and character strength, in addition to financial security and physical health). We aim to understand which work resources make the greatest difference in people’s lives, especially for unskilled workers in poor regions.

Methods

We surveyed over 11,000 apparel workers across seven suppliers, 13 garment factories, and five countries between 2017 and 2019. The survey assessed well-being across several dimensions of human flourishing. It also collected information on work resources that workers perceived as supportive to their well-being, such as trust, fairness, respect, and adequate physical working conditions. We benchmarked differences across suppliers and countries. Using cross-sectional data from five countries and longitudinal data from Mexico, we also conducted a multivariate analysis of the work resources that contribute most to flourishing at work and in life.

Results

Work resources affect workers’ ability to thrive in and outside of the workplace. Each workplace resource examined affected at least one dimension of flourishing at work and of flourishing in life. The state of physical working conditions was generally the most influential factor affecting human flourishing. We also found that when workers thrive at the workplace, they also flourish in life: job satisfaction, positive mood at work, and self-reported productivity were the factors contributing the most to flourishing in life.

Link to paper coming soon. 

 

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Worker’s well-being. Evidence from the apparel industry in Mexico
Taylor & Francis Group 
Dorota Weziak-Bialowolska, Piotr Bialowolski, and Eileen McNeely

A growing body of research links working environment with employee health and well-being. We argue that greater employee well-being is associated with positive work outcomes, benefits likely vital to business performance. We have expanded the literature on this topic by evaluating these questions within a population of factory workers. To date, studies have examined well-being in the workplace in middle- and low-income countries mostly through the lens of disease and disability or have been restricted to human rights, rather than human well-being in general. This paper connects (1) job resources/work conditions and (2) worker well-being with (3) work outcomes in Mexican apparel factories belonging to the apparel supply chain. Our analysis builds on the first wave of the SHINE Worker Well-Being Survey. We examined links between working conditions, job resources, individual well-being and work outcomes using path analysis within a cross-sectional study comprising approximately 2200 Mexican factory workers. We report that job satisfaction and self-assessed work performance are positively and directly associated with worker well-being. We found that job control, trust, respect and recognition were significant correlates of all examined work outcomes (job satisfaction, work engagement and self-assessed work performance), with significant indirect effects on well-being.

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Human Flourishing in Cross Cultural Settings. Evidence From the United States, China, Sri Lanka, Cambodia, and Mexico
Frontiers in Psychology
Dorota Weziak-Bialowolska, Eileen McNeely, Tyler J. VanderWeele

This paper investigates human flourishing in five culturally distinct populations. Empirical differences in human flourishing were examined using the recently proposed Flourish Index (FI) and Secure Flourish Index (SFI). Five domains for human flourishing are proposed for FI: (D1) happiness and life satisfaction; (D2) physical and mental health; (D3) meaning and purpose; (D4) character and virtue; and (D5) close social relationships. Specification of SFI was augmented by an additional financial and material stability domain (D6). Psychometric properties of FI and SFI were examined using data from the SHINE Well-Being Survey. Between June 2017 and March 2018, a total of 8,873 respondents participated in the study – in the US (4083 participants), Sri Lanka (1284 participants), Cambodia (587 participants), China (419 participants), and Mexico (2500 participants). US participants were customers of a financial institution, while non-US participants were clothing industry workers in the supply chain of a global brand. Exploratory and confirmatory factor models were used to validate the proposed indices. An exploratory approach informed analysis for item groupings. Confirmatory factor models were used to investigate the hierarchical structure of the indices. Configural, metric, and partial scalar measurement invariance were established, which not only supported the universal character of the indices but also validated use of the indices for culturally distinct populations. Findings from our study enrich our knowledge about human flourishing in five culturally distinct populations. With the exception of happiness and life satisfaction, respondents in the US, despite enjoying the highest financial and material stability, scored the lowest in all other domains of human flourishing. Respondents in China excelled in close social relationship and health domains. In addition to life satisfaction and happiness, character and virtue were relatively high in Cambodia. Respondents in Mexico, despite having the lowest scores in financial and material stability, had the greatest meaning and purpose to their lives. Respondents in Sri Lanka were the least happy and satisfied with life.

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The Impact of Workplace Harassment on Health in a Working Cohort
Frontiers in Psychology
Sara Gale, Irina Mordukhovich1, Sami Newlan and Eileen McNeely

Background: Workplace abuse, including sexual harassment, is frequently experienced worldwide and is related to adverse mental health outcomes, and injuries. Flight attendants are an understudied occupational group and are susceptible to harassment due to working in a feminized, client-facing occupation with few protections or sanctioned responses against aggressive behaviors.

Objective: We investigated the relationship between workplace abuse and health in a cohort of cabin crew. We also aimed to characterize perpetrator profiles.

Methods: We conducted our study among 4,459U.S. and Canada-based participants from the Harvard Flight Attendant Health Study using multivariate logistic regression. Our exposures of interest were episodes of workplace abuse in the past year. We evaluated several mental and physical health outcomes, including depression, fatigue, musculoskeletal injuries, and general workplace injuries.

Results: We report that exposures to verbal abuse, sexual harassment, and sexual assault are common among cabin crew, with 63, 26, and 2% of respondents, respectively, reporting harassment in the past year alone. Workplace abuse was associated with depression, sleep disturbances, and musculoskeletal injuries among male and female crew, with a trend toward increasing odds ratios (ORs) given a higher frequency of events. For example, sexual harassment was related to an increased odds for depression (OR = 1.91, 95% confidence interval [CI]: 1.51–2.30), which increased in a dose response-like manner among women reporting harassment once (OR = 1.44, 95% CI: 0.93–1.95), 2–3 times (OR = 1.83, 95% CI: 1.29–2.38), and 4 or more times (OR = 4.12, 95% CI: 3.18–5.06). We found that passengers were the primary perpetrators of abuse.

Conclusions: Our study is the first to comprehensively characterize workplace abuse and harassment and its relation to health in a largely female customer-facing workforce. The strong associations with health outcomes observed in our study highlights the question of how workplace policies can be altered to mitigate prevalent abuses. Clinicians could also consider how jobs with high emotional labor demands may predispose people to adverse health outcomes, educate patients regarding their psychological/physical responses and coping strategies, and be aware of signs of distress in patients working in such occupations in order to direct them to the appropriate treatments and therapies.

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[Flourishing] Flourish Index and Secure Flourish Index – Validation in workplace settings
Cogent Psychology
Dorota Weziak-Bialowolska, Eileen McNeely, Tyler J. VanderWeele 

Psychometric properties of the Flourish Index (FI) and Secure Flourish Index (SFI) were examined in the workplace setting. Psychometric properties for two instruments were already assessed on a community sample of 4200 respondents and initial evidence on the validity, reliability, and applicability was provided. This current paper is thus focused on validation in workplace settings. Questionnaire responses from 5565 office and manufacturing employees of two US Fortune 500 manufacturing companies provided data for this study. Correlation analysis and factor analysis were used to investigate item groupings. Second-order factor model was applied to investigate the hierarchical structure of the indices. Our results confirmed groupings of items into domains of flourishing as well as hierarchical structure of both indices. Support for their internal consistency was found. Initial evidence of validity and reliability (α = 0.89 for FI; α = 0.86 for SFI) of both indices were provided. This study provided support that FI and SFI can be used in empirical research in workplace settings.

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[Flight Attendant Health] Legacy health effects among never smokers exposed to occupational secondhand smoke
PLOS One
Eileen McNeely, Irina Mordukhovich , Steven Staffa, Samuel Tideman, Brent Coull

Objectives
Secondhand tobacco smoke (SHTS) is a tremendous public health hazard, leading to morbidity and premature mortality worldwide, with racial and ethnic minorities and those of lower socioeconomic status disproportionately affected. Flight attendants were historically exposed to high levels of SHTS in the aircraft cabin. The health effects of active smoking are known to persist for up to a lifetime, but the legacy effects of SHTS exposure have not been well characterized.

Design
We aimed to evaluate the legacy health effects of occupational SHTS exposure among never smoking workers using the resources of the Harvard Flight Attendant Health Study, a large study of cabin crew health. We evaluated associations between SHTS exposure and a range of diagnoses using multivariate logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs), employing a case-control sampling method and applying the bootstrap method to increase accuracy and precision of results.

Results
We found no evidence of positive associations between SHTS and any cancer, but observed associations between SHTS and cardiac outcomes, including myocardial infarction (OR = 140, 95% CI: 1·04, 3·27) and peripheral artery disease (OR = 1·27, 95% CI: 1·00, 1·97). We also found associations between SHTS exposure and repeated pneumonia (OR = 1·06, 95% CI: 1·02, 1·10).

Conclusions
Our study reports associations between legacy SHTS exposure going back decades and severe cardiac and respiratory health outcomes. Given the high prevalence of ongoing and historical SHTS exposure, our findings, if confirmed, have important implications for smoking cessation efforts, health education, and clinical guidelines.

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[Flourishing] Reimagining Health - Flourishing
Journal of the American Medical Association (JAMA)
Tyler J. VanderWeele, PhD, Eileen McNeely, PhD; Howard K. Koh, MD, MPH

linicians spend substantial time monitoring patients for adverse outcomes. By assessing patients for high blood pressure, abnormal blood glucose levels, or cancer recurrence, clinicians may equate absence of disease with health. Public health officials, meanwhile, regularly track rates and leading causes of mortality, morbidity, or risk factors (eg, tobacco use, obesity, drug overdoses) that similarly apply a “deficits” framework to health. These approaches, while necessary and valuable, can fall short of capturing what is most important to people in their daily lives. A patient cares not only about physical health and test results “within normal limits” but also more broadly about being happy, having meaning and purpose, being “a good person,” and having fulfilling relationships.

If health truly is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (as defined by the World Health Organization 70 years ago), measurements must better capture outcomes that people consider central components of well-being. Clinicians now can consider a proliferation of more holistic measures of “well-being” from medicine, psychology, economics, sociology, and government.1 Such measures come closer to capturing an individual’s complete well-being but often still fall short. Long-standing efforts to gauge life satisfaction—including shorter-term patient satisfaction surveys—can sometimes reflect whether patients received the care they wanted,2 rather than whether that care actually enhanced well-being; they can be socially isolated, or struggle with addiction to opioids, for example, despite good patient satisfaction or life satisfaction rankings. Measuring life expectancy at birth, a common public health metric, focuses primarily on length of life, only sometimes acknowledging quality dimensions. While the health-related quality of life index developed by the Centers for Disease Control and Prevention (which includes physical health, mental health, functional limitations, pain, and vitality) is a valuable development, its operationalization usually excludes questions of purpose and meaning that serve as major components of human well-being. Meanwhile, psychological well-being measurements, whether focusing on happiness or resilience, vitality, stress, or loneliness, typically ignore physical health.

None of these metrics fully captures what people almost universally regard as essential to well-being. Furthermore, questions of character, defined as moral excellence and long viewed as central to well-being in almost all philosophical and religious traditions, are also often neglected. The term flourishing, used for thousands of years and literally meaning “to grow” or “to prosper,” represents a powerful way to view health in its fullest sense.1 Flourishing has for years been effectively promoted by Seligman in the positive psychology literature, and the PERMA model (Positive emotions, Engagement, Relationships, Meaning, Achievements) has advanced research into psychological well-being. However, because this model addresses neither physical well-being nor questions of character, a recently proposed alternative measure of well-being, “the flourishing index,” divides universally desired factors contributing to flourishing into 6 key domains1: happiness and life satisfaction, physical and mental health, meaning and purpose, character and virtue, close social relationships, and financial and material security. In contrast to many previously proposed measures that are not as comprehensive, the flourishing index addresses 5 universally desired domains that constitute ends, as well as a sixth (financial and material security) that constitutes a critical means to securing them.1 

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[Financial Well-being] The impact of savings and credit on health and health behaviours: an outcome-wide longitudinal approach
International Journal of Public Health
Piotr Bialowolski, Dorota Weziak-Bialowolska, Tyler J. Vanderweele

This study evaluated decisions related to debt and savings on physical health, emotional health and health behaviours.  The longitudinal data from the Polish biennial household panel—Social Diagnosis Survey—were used. Evidence for a link between credit/savings and health/health behaviours was presented using three waves of the data and an outcome-wide regression analysis. To circumvent endogeneity, variables temporally prior to exposure were used as controls. Sensitivity analysis for unmeasured confounding, conducted using E-values, provided a check for robustness.  Debt proved a significant stressor, affecting three of five physical health measures. Over-indebted individuals suffered even more in terms of physical health outcomes. The role of savings in physical health was much less significant, yet had significant bearing on measures of emotional health. In terms of emotional health, debt (over-indebtedness inparticular) influenced loneliness and increased suicidal thoughts. With respect to health behaviours, savings appeared significant in reducing smoking and increasing uptake of sport activities, while debt had no significant effect in these areas. Recommendations are formulated to foster saving activity and develop institutional solutions for over-indebtedness.

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[Workplace Well-being] Turning the Mirror on the Architects: A Study of the Open-Plan Office and Work Behaviors at an Architectural Company
Frontiers in Psychology
Dorota Weziak-Bialowolska, Zhao Dong, Eileen McNeely

Following the rising cost of real estate and a desire to increase collaboration and communication among employees, the open-plan office has been trending over the past decades. Research about the impact of the open-plan office on humans is equivocal in endorsing this trend. The mixed results are further confounded following the specific job requirements, such as the need for privacy in jobs requiring a high level of concentration or, in contrast, the need for open workspace in jobs benefitting from team work and knowledge sharing.

This study aims to understand the relationship between perceptions of three characteristics of the open-plan office (acoustical privacy, visual privacy, and office density), and the impact they yield on employees' judgment as well as affect-driven behaviors. The study benefits from the data from 456 employees located in 20 regional office locations within the same architectural firm. The restriction to employees of a design firm enables examinations of participants, who are already sensitive to the impacts of space by the nature of their work. The variables of interest included employee perception of the workspace (privacy, office density, and fit into workspace), employee rating of social relationships, self-reported mood (irritability) and optimal functioning (number of limited ability days), and work impacts (job satisfaction, work engagement, and job performance).

The Model of behavior in an open-plan office setting based on affective events theory is adopted. Mediation roles of irritability and perception of fit into the workspace are examined. Structural equation modeling is applied to test the joint significance of the association between independent and dependent variables (direct effect) and the association between independent variables, mediator, and dependent variables (indirect effect). Nested structure of the data is accounted for by adjusting the standard errors for clustering. The significance of indirect and total effects is evaluated by the bootstrapping method.

Our results show that working in the open-plan office limits the experience of privacy and intensifies the perception of intrusion among employees of an architectural company, mostly architects and designers. Additionally, employees' perception of lack of privacy and high office density negatively affect job satisfaction, work engagement, and internal work relation as well as increases the number of limited ability days. Interestingly, the lack of privacy and high office density seem to positively affect expressive personal relations among coworkers and job performance. We find supporting evidence for mediation roles of negative emotions, that is, irritability and perception of fit into the workspace.

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[Flight Attendant Health] Cancer prevalence among flight attendantscompared to the general population
Environmental Health
Eileen McNeely, Irina Mordukhovich, Steven Staffa, Samuel Tideman, Sara Gale and Brent Coull

Flight attendants are an understudied occupational group, despite undergoing a wide range of adverse job-related exposures, including to known carcinogens. In our study, we aimed to characterize the prevalence of cancer diagnoses among U.S. cabin crew relative to the general population.  In 2014–2015, we surveyed participants of the Harvard Flight Attendant Health Study.  We compared the prevalence of their self-reported cancer diagnoses to a contemporaneous cohort in the National Health andNutrition Examination Survey (NHANES 2013–2014) using age-weighted standardized prevalence ratios (SPRs). We also analyzed associations between job tenure and the prevalence of selected cancers, using logistic regression andadjusting for potential confounders.  We observed higher rates of specific cancers in flight attendants compared the general population, some of which were related to job tenure.  Our results should be interpreted in light of self-reported health information and across-sectional study design. Future longitudinal studies should evaluate associations between specific exposures andcancers among cabin crew.

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[Well-being] A new approach to the well-being of factory workers in global supply chains: Evidence from apparel factories in Mexico, Sri Lanka, China and Cambodia
OECD
Eileen McNeely, PhD, Dorota Weziak-Bialowolski PhD, Tamar Koosed, and Carlued Leon

Most factory studies focus only on minimal safety and health at work or on “compliance audits with minimal standards”. Compliance audits typically aim for achieving minimum standards versus striving for excellence. The audit criteria are set to tackle violations only rather than to understand process of improvement, efficiencies, and the effectiveness of corrective actions.

While the relationship between health and work is not new, the measurement of health and well-being as basic goals of work, in line with business outcomes, is a new bar for social impact and global health. We posit that a transparent evaluation of workforce well-being and factory conditions, which draws directly from the experience of workers instead of an external auditor, has the potential to revolutionize the current compliance audit procedures that commonly lack objectivity, a more representative view of work on the factory floor, and an understanding of the linkages between drivers and outcomes of worker well-being in factory operations.

We designed a comprehensive worker survey to monitor well-being in supply factories.  Survey results provide buyers, suppliers and workers with a snapshot of the average worker experience of well-being and factory conditions (compared to simple auditor reports). Applying definitions of well-being at work that draw from decades of research on occupational health and safety, work stress and job strain, well-being and socially supportive communities, we aimed to conduct a comprehensive assessment of worker needs. Further, worker health and well-being were considered in relation to various business outcomes, such as turnover and job satisfaction. From this perspective, we explored the potential dependencies between worker needs and business needs at the factory level.    

Our study shows that by setting out a metric for continuous process improvement that includes workers’ voice, buyers and suppliers all standing to gain – especially in the most vulnerable workforces and regions of the globe – business can choose to be a force for good by changing expectations on the factory floor.

http://www.oecd.org/statistics/Measuring-impacts-of-business-on-well-being.pdf  (Dorota's paper is found on page 130 of this report)

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[Well-being] Following Footprints: What Corporate Health Can Learn from Environmental Sustainability
American Journal of Health Promotion, 2018
Eileen McNeely

Work offers a tremendous arena for promoting thriving. Studies show that work can fill basic human needs for financial security, meaning and purpose, self-efficacy, learning and mastery, social connection, mental and physical health, in addition to health care. From this perspective, ‘‘healthy’’ work nurtures individuals to be connected to self, others, and the world around them, a necessary input for a thriving planet. Today’s challenge for corporate health is to infuse well-being and sustainability into the business, creating a handprint that makes life better for all stakeholders, and the business more profitable because of this strategy. 
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[Flight Attendant Health] Estimating the health consequences of flight attendant work: comparing flight attendant health to the general population in a cross-sectional study
BMC Public Health, 2018
Eileen McNeely, Irina Mordukhovich, Samuel Tideman, Sara Gale and Brent Coull

We observed higher rates of specific adverse health outcomes in U.S. flight attendants compared to the general population, as well as associations between longer tenure and health conditions, which should be interpreted in light of recall bias and a cross-sectional design. Future longitudinal studies should evaluate specific exposure-disease associations among flight crew. 
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[Well-Being] On the promotion of human flourishing
www.pnas.org, 2017
Tyler Vanderweele

Many empirical studies throughout the social and biomedical sciences focus only on very narrow outcomes such as income, or a single specific disease state, or a measure of positive affect. Human well-being or flourishing, however, consists in a much broader range of states and outcomes, certainly including mental and physical health, but also encompassing happiness and life satisfaction, meaning and purpose, character and virtue, and close social relationships. The empirical literature from longitudinal, experimental, and quasiexperimental studies is reviewed in attempt to identify major determinants of human flourishing, broadly conceived. Measures of human flourishing are proposed. Discussion is given to the implications of a broader conception of human flourishing, and of the research reviewed, for policy, and for future research in the biomedical and social sciences.
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[Flight Attendant Study] Symptoms Related to New Flight Attendant Uniforms
BMC Health, 2017
Eileen McNeely; Irina Mordukhovich; Steven Jaffa; Brent Coull

Flight attendants at Alaska Airlines reported health symptoms after the introduction of new uniformsin 2011. The airline replaced the uniforms in 2014 without acknowledging harm. To understand possible uniform-related health effects, we analyzed self-reported health symptoms in crew who participated in the Harvard FlightAttendant Health Study between 2007 and 2015, the period before, during, and after the introduction of new uniforms.
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[Flight Attendant Study] Estimating the Health Consequences of Flight Attendant Work: Comparing Flight Attendant Health to the General Population in a Cross-Sectional Study
BMC Health, 2017
Eileen McNeely; Irina Mordukhovich; Samuel Tideman; Sara Gale; Brent Coull

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[Flight Attendant Study] The self-reported health of U.S. flight attendants compared to the general population.
Environmental Health, 2014
Eileen McNeely; Ira Tager; Sara Gale; Steve Hecker

Few studies have examined the broad health effects of occupational exposures in flight attendants apart from disease-specific morbidity and mortality studies. We describe the health status of flight attendants and compare it to the U.S. population. In addition, we explore whether the prevalence of major health conditions in flight attendants is associated with length of exposure to the aircraft environment using job tenure as a proxy.
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