Abstract
Temporary workers’ health problems in China have raised concerns recently. This study aimed to assess the relationship between temporary employment and three health outcomes with gradient severity and explore mediating mechanisms. Data was obtained from a national cross-sectional survey (China General Social Survey 2018). Compared with regular workers, temporary workers reported more frequent mood disorders (β = 0.197) and disturbance of daily activities (β = 0.132), however, there was no significant difference in serious health risks (inpatient treatment) between temporary and regular workers. Income poverty, subjective social status, and family relative socioeconomic status were significant mediators. The results suggest that temporary workers have higher general health risks, and economic deprivation is the main mechanism. Therefore, Chinese policymakers should provide more inclusive preventive health services beyond the existing health care system focused on critical illness to reduce the general health risks of grassroots workers.
What We Already Know
Employment status is a major determinant of workers’ health.
Temporary employment has a negative impact on the physical and mental health of workers.
Economic deprivation, social integration, and information acquisition are pathways by which temporary employment affects health outcomes.
What This Article Adds
This article is the first to use nationwide representative data to explore the association between temporary employment and workers’ health outcomes with gradient severity in China.
Compared with regular workers, temporary workers reported higher general health risks (mood disorders and disturbance of daily activities), but no higher serious health risks (inpatient treatment).
Economic deprivation primarily mediated the relationship between temporary employment and general health risks, while social isolation and information divide mediated insignificantly.
Introduction
Employment status is a major determinant of workers’ life quality and health. However, since the 1970s, labor market risks have shifted from employers to employees, resulting in increasingly unstable employment relationships. One manifestation of this trend is the rise of temporary employment, which refers to short-term and flexible employment relations. 1 Common types of temporary employment include fixed-term contract work, project work, seasonal work, on-call work, and gig work. 2 According to the International Labour Organization, two billion workers were engaged in various forms of temporary jobs in 2019, accounting for 60.1% of global employment. 3 These jobs are generally characterized by low pay, limited career prospects, and lack of labor protection. Recent studies have further highlighted the salience of health risks in these jobs.
Numerous empirical studies have provided evidence of the association between temporary employment and adverse health outcomes and occupational injuries among workers.4,5 Temporary workers tend to exhibit higher levels of burnout, psychological disorders, and occupational diseases, as well as increased exposure to work-related injuries, compared with regular workers. Work instability can also impair workers’ job performance and satisfaction, and exacerbate their psychological distress and stress levels. A longitudinal survey in the United States revealed that respondents who had experienced temporary work suffered from more severe depressive symptoms. 6 Similarly, temporary workers in Italy showed greater consumption of psychotropic prescription drugs. 7 Moreover, studies indicated that temporary workers faced significantly higher risk of various chronic occupational diseases due to insufficient safety training and protection. 8 Especially during the pandemic, temporary workers also experienced higher rates of COVID-19 infections and mortality than other workers. 9
More and more studies clearly identified temporary employment as a key determinant of workers’ health and continue to investigate its potential mechanisms. 10 They attributed the poor health outcomes of temporary employment to precarious economic and social status, low health literacy, and lack of social support. 11 Typically, temporary employment is associated with low income and low benefits. Due to economic deprivation, temporary workers are less likely to have health insurance and to afford quality medical care. 12 Their health is jeopardized if the workplace itself does not provide a minimum level of safety and protection. Furthermore, temporary workers often face challenges in developing professional networks due to the short contract cycle, which restricts their access to social support from peers and aggravates their job stress and feelings of powerlessness. 13 Some researchers have also pointed out that temporary workers are at a disadvantage in terms of access to occupational health information. 14 High-quality occupational health information is mainly derived from vocational training and education, which is scarce in temporary employment arrangements. Inadequate access to health information further hinders the ability of temporary workers to make advisable health decisions.
Temporary work arrangements are becoming prevalent worldwide. As the country with the largest employed population in the market economy, the health of China’s temporary workers is also gaining attention. 15 According to the National Bureau of Statistics of China, the flexible employee population approached 200 million by the end of 2021, accounting for approximately 25% of the total employed population. 16 Most have only short-term contracts or lack regular contracts, and are usually excluded from statutory labor protection. 17 Many employing companies value work productivity over workfare, cutting occupational health and safety training and job security for temporary workers. 18 The result is that temporary workers report lower participation rates in labor insurance, but more workplace injuries and occupational illnesses. Some recent studies found that health problems are more pronounced among specific temporary workers, 19 such as rural-to-urban migrant workers, construction subcontractors, and digital platform workers. But overall, many questions remain unresolved: How severe is the health disadvantage of temporary workers compared with regular workers? How do such disadvantages arise?
This study aimed to describe and assess the relationship between temporary employment and health outcomes with gradient severity, including two general health risks and one serious health risk, by analyzing national cross-sectional survey data from China. Moreover, this study explored whether these relationships were mediated by economic deprivation, social isolation, and information divide. We bridged the lack of empirical evidence from the literature on health disparities among employment patterns in China and provided a basis for health policy-making.
Methods
Data
This study was a secondary analysis based on data from the China General Social Survey (CGSS). The survey is a national cross-sectional survey initiated by Renmin University of China in 2003 and conducted annually or biennially as part of the East Asian Social Survey and the International Social Survey Programme. 20 The data for this study were derived from the 2018 survey (CGSS2018), which was released to the public in 2022. It used a three-stage stratified random sampling method to randomly select samples from 31 provinces at the district, neighborhood committee, and household level, resulting in 4000 households and 12 787 respondents, with a gross response rate of over 90%. After excluding the non-working-age, unemployed, nonemployed, and samples containing missing values, we ended up retaining 3071 respondents (see Supplementary Figure 1).
Measures
Health outcomes
This study examined three health outcomes with gradient severity, with mood disorders and disturbance of daily activities as general health risks, and inpatient treatment as a serious health risk. Specifically, the first two variables were measured in the CGSS2018 using two questions from the Frequency Likert Scales: “In the past four weeks, how often did you feel depressed or anxious?” and “In the past four weeks, how often did health problems affect your work or other daily life?” The options for both were “1 = always, 2 = often, 3 = sometimes, 4 = rarely, 5 = never.” Thereafter, the options were reverse-coded (the most frequent option was coded “always,” represented by 5, etc). These variables were considered continuous variables, with higher scores indicating greater health risk. In the context of inpatient treatment, CGSS2018 asked respondents, “In the past 12 months, how many times have you been hospitalized due to illness or injury?” As very few respondents have undergone multiple hospitalizations, this option was coded as a dummy variable (1 = has inpatient treatment, 0 = no inpatient treatment).
Temporary employment
Temporary employment served as the key independent variable in this study; it was measured as unstable or flexible paid employment relationships. Specifically, it was coded as a binary indicator of whether the work is temporary. In CGSS2018, the employment relationship was derived from the following questions: “Which of the scenarios better fits your current work situation?” Two responses were available: employed with a fixed employer and employed without a fixed employer (e.g., part-time job, casual job). The former and latter were coded as 0 and 1, respectively.
Mediators
The existing literature guided the structure of our mediation analysis. 10 The set of mediators included economic deprivation, social isolation, and information divide. Economic deprivation comprises three indicators: income poverty, subjective social status, and family relative socioeconomic status. Income poverty was treated as a dichotomy and defined by a person whose annual income is less than 60% of the median income of the entire population. Subjective social status was measured with the following question: “What is your socioeconomic status in the present society” (from “upper class = 1” to “lower class = 5”). Family relative socioeconomic status was assessed by the following question: “What is the financial status of your family in your area?” (from “well above average = 1” to “well below average = 5”). Social isolation was measured with three reverse coding items of social integration, including how often one met socially with neighbors and friends (from “every day = 1” to “never = 7”), and how often one participated in cultural activities (from “every day = 1” to “never = 5”). Information divide was measured with three reverse coding items including how often one used broadcast, television, and the internet (all from “very often = 1” to “never = 5”).
Covariates
The covariates were sex, age, educational attainment, marital status, resident status, and party membership. These variables comprise the confounding factors that affect both individual employment and health status. Specifically, age was measured in years while educational attainment was based on a four-category indicator, namely, primary school and below, junior high school, high school or equivalent, and college and above. Furthermore, marital status was coded as binary (nonmarried = 1, other = 0). Similarly, resident status and party membership also presented binary variables (for the former, urban = 1, rural = 0; for the latter, Chinese Communist Party = 1, other = 0). We also added provincial dummy variables to control for regional fixed effects.
Analytical Strategy
We conducted regression analyses to investigate the relationship between temporary employment and health outcomes. The ordinary least squares regression model was run for the mood disorders and disturbance of daily activities. The logistic regression model was run for the inpatient treatment.
Three approaches were used to confirm the robustness of our main analysis. First, we adopted an instrumental variable (IV) estimation to address the reverse causality bias. The share of temporary employment by province, calculated based on CGSS2017 data, was used as an external IV. Given that this IV is at the aggregated level, we referred to Baum and Lewbel 21 and constructed an additional internal IV using the heteroskedasticity of the error terms. Thus, our model combines both internal and external IVs. Second, we conducted coarsened exact matching (CEM) to handle selection bias derived from employment status. We ensured that the treated and control groups were comparable in terms of their characteristics. Third, we focused on the two subsamples that made up the majority of temporary workers, namely, prime working-age and full-time workers. The subsample regression results provided a reference for the main findings.
Furthermore, we performed a causal mediation analysis 22 to explore the mediation effects of economic deprivation, social isolation, and information divide. We used the bootstrapping method to calculate the total, direct, indirect, and average causal mediation effects (ACME) and their standard errors. Stata Version 17.0 software was used for all analyses.
Results
The descriptive characteristics of the analytic sample are shown in Table 1. The respondents comprised 357 (11.62%) temporary workers and 2714 (88.38%) regular workers. The analysis of means comparison demonstrated that temporary workers reported significantly more frequent mood disorders than regular workers. Similar findings were reported for disturbance of daily activities. In contrast to regular workers, the work and life of temporary workers were plagued more significantly by health problems. However, no significant difference was found in the likelihood of inpatient treatment. However, significant differences were found between temporary and regular workers among a range of sociodemographic factors. Temporary workers have a significantly higher likelihood than regular workers of being male and married, having a low level of education and nonparty membership, and living in a rural area.
Comparison of Overall Characteristics Across Temporary and Regular Workers (N = 3071).
Abbreviations: CCP, Chinese Communist Party; ref, reference group.
A t-test was used to compare the demographic characteristics of temporary and regular workers.
P < .05. **P < .01. ***P < .001.
We applied a stepwise strategy of adding control variables in the regression models. Table 2 shows that temporary workers suffered mood disorders significantly more frequently than regular workers (β = 0.228; 95% confidence interval [CI] = [0.125, 0.331]; model 1). When controlled for additional demographic variables and provincial fixed effects, the effect of temporary employment reduced slightly (β = 0.197; 95% CI = [0.093, 0.302]; model 3). Following the same approach, we found that temporary workers experienced the disturbance of daily activities more frequently (β = 0.132; 95% CI = [0.028, 0.237]; model 6). However, no significant difference in inpatient treatment was found between the two types of workers (β = −0.172; 95% CI = [–0.588, 0.244]; model 9).
Regression Analysis Results of the Relationships Between Temporary Employment and Health Outcomes With Gradient Severity.
95% CI in parentheses.
Abbreviations: CCP, Chinese Communist Party; CI, confidence interval; ref, reference group.
In models 7 to 9, all estimated coefficients transformed to average marginal effects.
P < .05. **P < .01. ***P < .001.
We adopted three approaches to check robustness (shown in Supplementary Figure 2). First, we employed heteroskedasticity-based IV estimation to solve the reverse causality bias and obtained similar results (for mood disorders, β = 0.191, 95% CI = [0.072, 0.309]; for disturbance of daily activities, β = 0.195, 95% CI = [0.080, 0.309]). Second, we used CEM to address the potential endogeneity of employment status. The results demonstrated that the general health risks have changed somewhat but remain significant (for mood disorders, β = 0.201, 95% CI = [0.098, 0.303]; for disturbance of daily activities, β = 0.171, 95% CI = [0.069, 0.273]). Third, we performed subgroup analysis by restricting the target population to prime working-age and full-time workers. We found that temporary workers still reported higher general health risks instead of serious health risks.
We further used a causal mediation method to examine whether economic deprivation, social isolation, and information divide mediated the relationship between temporary employment and general health risks among workers. Looking at Table 3, only economic deprivation played a significant mediating role. Specifically, the indirect effect of temporary employment on mood disorders through income poverty (ACME = 0.013; 95% CI = [0.002, 0.026]), subjective social status (ACME = 0.025; 95% CI = [0.011, 0.040]), and family relative socioeconomic status (ACME = 0.037; 95% CI = [0.021, 0.054]) was significant among workers. These three mediators accounted for 6.6%, 13.0%, and 19.0%, respectively, of the relationship between temporary employment and mood disorders. In terms of the disturbance of daily activities, income poverty (ACME = 0.017; 95% CI = [0.007, 0.030]), subjective social status (ACME = 0.015; 95% CI = [0.006, 0.025]), and family relative socioeconomic status (ACME = 0.020; 95% CI = [0.009, 0.033]) have a statistically significant, indirect effect. These three mediators of economic deprivation explained 13.5%, 11.4%, and 15.8%, respectively, of the total effect of temporary employment on disturbance of daily activities.
Mediation Effects of Economic Deprivation, Social Isolation, and Information Divide on the Association of Temporary Employment With General Health Risks.
95% CI in parentheses.
Abbreviations: ACME, average causal mediation effects; CI, confidence interval.
The frequency of neighborhood interaction, friends interaction, participation in cultural activities, broadcast use, television use, internet use are reverse-coded.
Discussion
In this study, we extended prior literature on the health consequences of temporary employment in the context of developing economies. Using national cross-sectional data, we examined the association between temporary employment and three health outcomes with gradient severity among Chinese workers. The main findings suggested that, compared with regular workers, temporary workers reported higher general health risks instead of serious health risks, with economic deprivation as the major mechanism. Specifically, three valuable findings deserved further attention and discussion.
First, in terms of general health risks, temporary workers are not only more likely to suffer from mood disorders but also experience health disturbances in their daily activities more frequently. According to the assumptions of activating biobehavioral and psychological mechanisms, unstable jobs exacerbate worker stress, poor sleep, and cognitive overload. 23 These workers also frequently lack support from their colleagues, making it more difficult for them to de-stress 24 and more prone to unhealthy behavioral habits such as alcohol abuse and excessive smoking. 25 Meanwhile, since many areas of China adopt a pro-market rather than pro-worker policy, temporary workers are at high risk of being replaced and fired. Many of them rarely take sick leave for fear of losing their jobs, which means they are chronically overworked and in suboptimal health. 10
Second, we discovered that economic deprivation mediated the relationship between temporary employment and general health risks. However, the expected mediating effects of social isolation and information divide failed to be supported. This suggests that temporary employment represents a form of economic vulnerability in China. Due to insufficient income, temporary workers experience a lower quality of life than regular workers and have less access to preventive health services and resources. 26 Moreover, economic poverty alters the work patterns of temporary workers. To offset their income disadvantage, they often engage in longer hours or multiple part-time jobs with less time for rest and leisure, which also undermines their ability to maintain good health. 27
Third, we also found no difference in serious health risks (namely, inpatient treatment) between temporary and regular workers. Was this because temporary workers cannot afford hospitalization services? We do not think so. China currently has a public health insurance system covering the entire population, which consists of Urban Employees’ Basic Medical Insurance and Urban and Rural Residents’ Basic Medical Insurance, designed to meet the basic medical needs. 28 Our exploratory analysis based on CGSS2018 finds that the participation rate of temporary workers’ medical insurance reaches 88%, which is not systematically different from that of regular workers. Meanwhile, one of the important features of China’s health insurance system is critical illness insurance, which aims to minimize the burden of serious disease treatment. 29 According to the China Health Insurance Bureau policy, there is no starting line or reimbursement limit for hospitalization for low-income and poor people, and medical assistance is also available. This means that the financial burden does not constitute a barrier to inpatient treatment for those who are in financial distress. Based on the Chinese context, if we do not find treatment differences between temporary workers and permanent workers, this means that they actually do not differ in terms of serious health risks.
This study has some limitations that should be acknowledged. First, the measurement of temporary employment is constrained by the use of secondary data. This study only accounted for employment instability as the main indicator of temporary employment, which may introduce measurement error. Second, the cross-sectional data we used preclude any causal inference from the associations and mechanisms observed in this study. 30 A follow-up study using panel data is needed to establish the causal relationship between temporary employment and Chinese workers’ health. Third, the data are outdated by five years. The pandemic of the last three years may have induced some changes in Chinese workers’ employment and health conditions, which call for further research based on updated data. Despite these limitations, this study contributes to the literature by examining the health consequences of temporary employment in the largest developing country in the world.
Conclusion
This study examined the relationship between employment status and workers’ health risks with gradient severity. Compared with regular workers, temporary workers reported higher general health risks (mood disorders and disruption of daily activities), mediated largely by economic deprivation. Nevertheless, due to China’s universal coverage of critical illness insurance, there was no significant difference in serious health risks (inpatient treatment) between temporary and regular workers. Therefore, this study recommends that Chinese policymakers should offer more accessible and affordable preventive medical services (e.g., psychological counseling and regular medical checkups) for temporary workers, beyond the existing medical insurance system that focuses on critical illness treatment, to prevent their general health risks from escalating into serious ones.
Supplemental Material
sj-docx-1-aph-10.1177_10105395231204181 – Supplemental material for Association Between Temporary Employment and Gradient Health Outcomes Among Chinese Workers
Supplemental material, sj-docx-1-aph-10.1177_10105395231204181 for Association Between Temporary Employment and Gradient Health Outcomes Among Chinese Workers by Long Hao and Jing Lin in Asia Pacific Journal of Public Health
Footnotes
Acknowledgements
The authors thank the editors and reviewers for their insightful comments in revising the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Social Science Foundation of Jiangsu Province (22SHC002), and Humanities and Social Sciences Youth Foundation by Ministry of Education of the People’s Republic of China (21YJC840010).
Ethical Approval
The survey data of this study were collected by the National Survey Research Center at Renmin University of China. The objectives of the survey, the scope of data collection and use, and the interests of the voluntary participants were communicated prior to the survey to ensure that each respondent provided informed consent. The Chinese National Survey Data Archive stores and provides access to the survey data. All original data are available upon request.
Supplemental Material
Supplemental material for this article is available online.
References
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