New screening tool helps doctors spot precarious employment

Precarious employment, defined by temporary contracts, unstable employment, or job insecurity, is increasingly common and is associated with inconsistent access to health insurance, lower incomes, and greater exposure to physical hazards and psychological stress. A team of researchers in Toronto, Canada, created and tested a new three-question screening tool to help primary care clinics identify these patients. The screener included the following three questions: 1) non-standard employment (Are you currently employed in a casual, short-term, or temporary position?); 2) violations of occupational health and safety rights and protections (Do you feel fearful that you could be fired if you raised employment concerns?); and 3) income variability (Does your pay vary a lot from month to month?).

To test the validity of their screening tool and assess the feasibility of adding these questions to social determinant screening, the research team recruited a convenience sample of 200 people in waiting rooms at seven Toronto clinics in areas with higher poverty rates than the rest of the city. Participants ranged in age from 18 to 72 years (mean 38), fluency in English, and employed, with 93 (45.6%) identifying as men and 119 (58.3%) identifying as White. Participants also completed the Poverty and Employment Precarity in Southern Ontario (PEPSO) Employment Precarity Index. The PEPSO Index uses a score ranging from 0 to 100 to categorize work status along a gradient (secure, stable, vulnerable, and precarious). A score of 38 or above suggests a precarious employment status. Those who answered yes to at least two of the questions on the researchers' survey were almost four times more likely to be precariously employed based on their PEPSO scores.

What we know: Employment is a key social determinant of health, with a significant impact on one's income, access to basic necessities, and social connectedness. While primary care physicians screen for other social determinants of health, they do not ask about employment concerns. People with chronic health issues are at greater risk of experiencing precarious employment and may face difficulty re-entering the workforce if unemployed. While it is especially important to screen for precarious employment in primary care settings, there exists no standard screening tool at this time.

What this study adds: The results of this study suggest that a simple three-question screener could help identify precarious employment among primary care patients and serve as an opening for conversations in clinical settings about employment precarity and work conditions. Implementation of this screener in primary care settings could improve how resources are targeted for managing care and how patients are connected with relevant support services; regional pooling of data collected in this way could spark policy changes on a broader scale to reduce precarious employment. The researchers note that clinicians may need direction in how and when to intervene based on their patients' responses to the screening questions, and that clinical time constraints may make it difficult to obtain more detailed information.