Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.
Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York.
JAMA. 2023 Feb 21;329(7):561-573. doi: 10.1001/jama.2023.0367.
Earning a low wage is an increasingly recognized public health concern, yet little research exists on the long-term health consequences of sustained low-wage earning.
To examine the association of sustained low-wage earning and mortality in a sample of workers with hourly wage reported biennially during peak midlife earning years.
DESIGN, SETTING, AND PARTICIPANTS: This longitudinal study included 4002 US participants, aged 50 years or older, from 2 subcohorts of the Health and Retirement Study (1992-2018) who worked for pay and reported earning hourly wages at 3 or more time points during a 12-year period during their midlife (1992-2004 or 1998-2010). Outcome follow-up occurred from the end of the respective exposure periods until 2018.
Low-wage-less than the hourly wage for full-time, full-year work at the federal poverty line-earning history was categorized as never earning a low wage, intermittently earning a low wage, and sustained earning a low wage.
Cox proportional hazards and additive hazards regression models sequentially adjusted for sociodemographics, and economic and health covariates were used to estimate associations between low-wage history and all-cause mortality. We examined interaction with sex or employment stability on multiplicative and additive scales.
Of the 4002 workers (aged 50-57 years at the beginning of exposure period and 61-69 years at the end), 1854 (46.3%) were female; 718 (17.9%) experienced employment instability; 366 (9.1%) had a history of sustained low-wage earning; 1288 (32.2%) had intermittent low-wage earning periods; and 2348 (58.7%) had never earned a low wage. In unadjusted analyses, those who had never earned low wages experienced 199 deaths per 10 000 person-years, those with intermittent low wages, 208 deaths per 10 000 person-years, and those with sustained low wages, 275 deaths per 10 000 person-years. In models adjusted for key sociodemographic variables, sustained low-wage earning was associated with mortality (hazard ratio [HR], 1.35; 95% CI, 1.07-1.71) and excess deaths (66; 95% CI, 6.6-125); these findings were attenuated with additional adjustments for economic and health covariates. Significant excess death and elevated mortality risk were observed for workers with sustained low-wage exposure and employment fluctuations (eg, for sustained low-wage × employment fluctuated, HR, 2.18; 95% CI, 1.35-3.53; for sustained low-wage × stable employment, HR, 1.17; 95% CI, 0.89,-1.54; P for interaction = .003).
Sustained low-wage earning may be associated with elevated mortality risk and excess deaths, especially when experienced alongside unstable employment. If causal, our findings suggest that social and economic policies that improve the financial standing of low-wage workers (eg, minimum wage laws) could improve mortality outcomes.
赚取低工资是一个日益受到关注的公共卫生问题，但关于持续低工资收入对长期健康后果的研究甚少。
在一个以小时工资报告的样本中，检查持续低工资收入与死亡率之间的关联，这些工人在中年（1992-2004 年或 1998-2010 年）的高峰期，每年有 3 次或更多次报告收入。
设计、地点和参与者：这是一项纵向研究，包括来自健康和退休研究（1992-2018 年）的 2 个亚队列的 4002 名美国参与者，年龄在 50 岁或以上，他们在中年期间（1992-2004 年或 1998-2010 年）的 12 年期间，每年至少工作 3 次，并且按小时计酬。从各自的暴露期结束到 2018 年进行结果随访。
低工资-低于联邦贫困线全职全职工资的工资收入-历史被归类为从未赚取低工资、间歇性赚取低工资和持续赚取低工资。
使用 Cox 比例风险和加性风险回归模型，依次调整社会人口统计学、经济和健康协变量，以估计低工资历史与全因死亡率之间的关联。我们检查了性别或就业稳定性对乘法和加法尺度的交互作用。
在 4002 名工人中（暴露期开始时年龄为 50-57 岁，结束时年龄为 61-69 岁），1854 名（46.3%）为女性；718 名（17.9%）经历就业不稳定；366 名（9.1%）有持续低工资收入史；1288 名（32.2%）有间歇性低工资收入期；2348 名（58.7%）从未赚取过低工资。在未调整的分析中，从未赚取过低工资的人每 10000 人年有 199 人死亡，间歇性赚取低工资的人每 10000 人年有 208 人死亡，持续赚取低工资的人每 10000 人年有 275 人死亡。在调整了关键社会人口学变量的模型中，持续低工资收入与死亡率（风险比[HR]，1.35；95%CI，1.07-1.71）和超额死亡（66；95%CI，6.6-125）相关；这些发现随着对经济和健康协变量的进一步调整而减弱。对于持续低工资暴露和就业波动的工人（例如，持续低工资×就业波动，HR，2.18；95%CI，1.35-3.53；持续低工资×稳定就业，HR，1.17；95%CI，0.89，-1.54；P 交互作用=0.003），观察到显著的超额死亡和升高的死亡率风险。
持续的低工资收入可能与升高的死亡率风险和超额死亡有关，特别是当与不稳定的就业同时发生时。如果是因果关系，我们的研究结果表明，提高低工资工人的经济和社会地位的社会和经济政策（例如最低工资法）可以改善死亡率结果。
