1 University of Tampere, Medical School, Finland.
2 Finnish Institute of Occupational Health, Finland.
3 University of Helsinki, Department of Psychology, Finland.
4 University of Turku, Department of Public Health, Finland.
Correspondence: Pekka Virtanen, Medical School, University of Tampere, 33014 University of Tampere, Finland. E-mail: pekka.j.virtanen{at}uta.fi
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Abstract |
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Methods A sample of 15 468 employees or job seekers from a population survey. Their perceived health, diseases, and depression were measured.
Results Compared with permanent employees, the odds for poor health were highest among the unemployed with low incomes irrespective of adjustments, across all health indicators and in both men and women. High odds were also found among the less disadvantaged unemployed and the employed with atypical contracts, but not among fixed-term employees.
Conclusions Rather than between the employed and the unemployed, it seems that health inequalities prevail across different labour market groups within the employed and the unemployed. Future studies should employ a more detailed classification of employment situation.
Accepted 15 August 2003
The last decades of the 20th century saw two major changes in the labour markets of all Western societies, i.e. a sharp increase in the jobless rate and a breakdown of the traditional industrial structures, which began to give way to more diverse employment patterns. For a growing part of the workforce, post-industrial organizations have necessitated (or opened up an opportunity for) a career that involves more or less continuous movement between different occupations, work places, and job contracts, each with their sources of material and psycho-social well-being as well as distress and environmental health hazards. Frequent labour market passages also increase the probability of health-based selection.
The traditional division of the workforce into employed and unemployed is not sensitive enough to describe the ever greater complexities of modern working life. For the purposes of studying the associations between labour market status and health, we would need to have a more detailed analysis of employment situations. However, the simple dichotomy of unemployed versus employed does provide an adequate starting point for specifying the scope of this article.
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Unemployment and health |
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The industrial prototype of an unemployment episode with clear-cut exit from and re-entry to permanent work is rare. The spell of unemployment is often interrupted by various re-employment programmes or vocational training courses, resulting in a labour market status somewhere in the middle ground between genuine employment and genuine unemployment. Moreover, employment policy measures may blur the natural process of health-based selection to and from unemployment, and the social and health care services provided may slow down the natural deterioration of health.9,10 However, specific health effects may depend on ways in which these services are administered and perceived by the recipients,11,12 and on the level and conditions of unemployment benefits.13
In sum, figures on past unemployment provide only a relatively crude measure of unemployment exposure. Socioeconomic contexts and re-employment prospects are probably just as significant to the well-being of the unemployed as the corresponding factors and perceptions, i.e. job insecurity, are to employed individuals.14
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Precarious work and health |
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The concept of job insecurity can be applied to both permanent and precarious jobs. However, most empirical research has relied on insecurity attributed to or perceived by permanent employees, also reviews on job insecurity18,19 have only mentioned briefly the question of employment security among fixed-term and other employees with unstable labour market status. The job insecurity concept and methods of assessing it should be developed to discern job-loss insecurity from job-feature insecurity,20,21 and even then there is reason to ask whether job insecurity is the best theoretical approach to understand the new workplace reality.22 Research on the associations between precarious employment and health is still scarce. Most of the few studies that have been published have compared permanent and fixed-term wage earners,15,2325 but there are no unequivocal results.
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Study question |
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Material and Methods |
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A random sample (n = 52 739) from the Finnish Population Register Centre, stratified according to gender and four age groups (2024, 3034, 4044, and 5054 years), were asked to participate in the HeSSup-project. A total of 21 101 people answered the baseline questionnaire. The response rate (40%) was satisfactory taking into account that the participants were asked to give their consent for access to several register data and to follow-up surveys. The participants recruited represented relatively well the age- and gender-adjusted Finnish population.28 The present study is based on the data obtained from this survey.
Respondents labour market status
This study comprises those 15 468 respondents who were at work or seeking a job. A set of questions concerning labour market status was used as criteria for inclusion in the study and for classification of status as follows.
1 A multi-choice question inquired about main activity in relation to work with 12 options. Those engaged in full time work (20 h/week), those getting earnings-related unemployment allowance (see below, including laid-off employees), and those getting basic unemployment allowance (see below) were included in this study, while students, pensioners, full-time mothers and fathers, and other non-working respondents were excluded.
2 Wage earners labour market status was further explored with a multi choice question which specified the following options: permanent, deputizing, or locum, fixed-term, subsidized, temporary (hired), freelance, probation, seasonal work, on-call work, apprenticeship, other non-permanent situation.
3 If there was any discrepancy between the previous items (e.g. unemployed in one and subsidized in another), a separate question (Are you currently unemployed or laid-off?) was used to make the final decision on employment status.
On the basis of this set of questions the employed respondents were classified into three groups.
Permanent employees
Wage-earners with a permanent contract and all entrepreneurs, the self-employed, and farmers.
Fixed-term employees
Including deputizing, locum, and fixed-term employment, i.e. all those whose contract was going to expire at a given point in time.
Atypical employees
A residual group comprising temporary (hired), freelance, probation, seasonal, on-call, apprenticeship, and other non-permanent workers.
Further information requested from the employed respondents included spells of unemployment or lay-off during past 3 years and length of the employment in the current work place. The unemployed respondents were also classified into three groups.
Compensation-income unemployed
This category comprised the unemployed who were in receipt of earnings-related daily allowance. The system of earnings-related benefits is based on voluntary membership of unemployment funds collected during periods when people are working. The daily allowance depends progressively on income level prior to redundancy. Eligibility for earnings-related allowance continues for 500 working days, i.e. about 2 years. If this period expires, the employee will have to work for more than 10 months without interruption in order to regain eligibility.
Subsidy unemployed
This category comprises those respondents who reported that they were employed under a scheme to re-employ long-term unemployed job seekers. Eligibility for this scheme requires that the person has been out of work for a minimum of 12 months, but in most cases this will be a much longer period. Re-employment lasts for 6 months, and follow-up studies29 have shown that after this period more than 90% of the participants will remain out of work. In other words, although the subsidy unemployed are working, their labour market status of interrupted unemployment is perhaps most appropriately described as a sort of unemployment.
Low-income unemployed
Job seekers who are not in receipt of earnings-related allowance are entitled to a basic allowance at a lower and fixed level. It is paid out under the national unemployment insurance scheme to all job seekers for unlimited time. Recipients of this minimum allowance form the hard core of unemployment within the labour market structure studied. At the individual level this means a situation characterized by a low income level, several years of unemployment experiences, and poor prospects for re-employment.
Health indicators
Presented with a list of 26 chronic diseases and an option for some other disease, the respondents were asked to check diseases diagnosed by a doctor (yes/no). A dichotomous variable (no disease versus at least one disease) was formed.
Self-rated health was classified as good (good or fairly good) and poor (average, fairly poor or poor) health.
Depression was assessed using the 21-item version of Becks Depression Inventory (BDI).30 This questionnaire has been established as a valid and reliable method for detecting depressed respondents. A dichotomous variable was constructed with the score 10 indicating depression.
Background variables
In addition to gender and age group, other demographic variables included in the analysis were marital status (married or cohabiting versus not) and level of education (no vocational education, vocational school, college, university). The psychosocial factors measured were size of social network (small 010, intermediate 1120, and large >20)31,32 and optimism-pessimism (three groups using Q1 and Q3 as cut-offs).33 Health risk behaviours were assessed on the basis of overweight (body mass index >27 kg/m2), alcohol intake (non-drinking, moderate drinking [1175 g weekly in women and 1263 g weekly in men] and heavy drinking), and smoking (non-smoking, daily smoking 119 cigarettes, daily smoking 20 cigarettes).
Statistical methods
We used logistic regression analyses to study the association between employment status and health. The models were first adjusted for age, and then additionally for demographics, health risk behaviour, and psychosocial factors. Finally, all the background variables were controlled for in the fully adjusted model. Analyses were carried out separately for men and women. Gender differences in the associations between employment status and health were studied with P-values for interaction obtained from the regression models.
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Results |
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We started out by comparing the health of all the employed with all the unemployed participants irrespective of their specific labour market status. The demographics-adjusted odds ratios (OR) for poor health were 1.76 (95% CI: 1.47, 2.11) in unemployed men and 1.71 (95% CI: 1.46, 2.00) in unemployed women; the corresponding OR for chronic disease were 1.65 (95% CI: 1.40, 1.96) and 1.24 (95% CI: 1.09, 1.41), and for depression 2.89 (95% CI: 2.40, 3.47) and 1.51 (95% CI: 1.31, 1.75). As the latter figures indicate, the OR for depression was significantly higher in unemployed men.
A more detailed comparison with permanent employees revealed a health gradient over the spectrum of labour market statuses (Table 2). After adjusting for demographics, the highest odds for poor health were found in the low-income unemployed, irrespective of sex and the measure of health. Subsidy unemployed men suffered more often from depression, while their female colleagues suffered more often from poor self-rated health and chronic diseases. Among the compensation-income unemployed, men had elevated odds for chronic disease and depression and women elevated odds for poor self-rated health and depression. Employees in atypical jobs had more chronic diseases; women in this category also suffered from depression more often. No differences were found between permanent and fixed-term employees. Further adjustment for psychosocial factors and health risk behaviours had no effect on the associations between labour market status and health.
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Finally, we assessed whether the enhanced measure of labour market status fitted the data better than the dichotomous employed versus unemployed measure. The -2 log likelihood tests indicated that this was the case both in women (P-values for self-rated health 0.001, for disease 0.016, and for depression <0.001) and in men (corresponding P-values 0.022, <0.001, and 0.024).
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Discussion |
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Health differences among the non-permanent employees
Our findings are in line with an earlier investigation among Finnish municipal employees,15 which showed that fixed-term employees may have the same or fewer health problems than permanent employees. These results may indicate health-based selection in recruitment into fixed-term employment, although the healthiest fixed-term employees seem to be recruited into permanent posts.25 We cannot rule out the possible health damaging effects of long lasting fixed-term employment either. Rather, the result raises questions about well-being and health during the processes of entries into and exits from fixed-term and other non-standard jobs.
The health difference observed between fixed-term and atypical employees gives reason to argue that the health effects of precarious employment depend upon stability of the formal contract. All the multiple employment situations defined here as atypical share in common relatively poor security, both with respect to job features and to job loss. Health-related selection into atypical jobs, both from fixed-term posts and from unemployment, may also contribute to health differentials. The majority of the non-permanent employees had relatively well regulated fixed-term contracts, and the more atypical contracts were rare. Leaving aside the evident socioeconomic advantages, this feature of the Finnish working life also seems to have health-related advantages.
Health differences among the unemployed
Although this study was carried out in a country with relatively high income replacement for the unemployed,34,35 psychosocial factors did not contribute to the association between unemployment and health. Instead of treating the unemployed as a single group or using a duration-based measure of unemployment, we distinguished between unemployed using income-based compensation, subsidized income, and fixed basic daily allowance, a measure sensitive to income differentials. The health effects of unemployment were strongest for those with greatest material disadvantage (unemployed with basic allowance). These findings are in line with the hypothesis of financial strain as a major source of poor health among the unemployed.36
In this study it is not possible to distinguish between causal and selective processes in the association between unemployment and health. Nonetheless, the fact that the subsidy and compensation-income unemployed are in relatively good health gives grounds to underline the importance of employment and social policy measures. The impacts of these measures are most clearly apparent with respect to depression, and particularly the non-elevated depression rates among women in subsidized work. This may also indicate a gender difference in the mental health promoting effect of these re-employment programmes. A recent study in the US showed a corresponding association with government entitlement benefits.37 It seems that the interruption of unemployment less effectively alleviates the socioeconomic and psychological impact of unemployment among men. All in all, the highly significant gender difference in the association between unemployment and depression may indicate that mens values are mainly work-oriented, while women may attach more importance to family and other spheres of life.
Our results showed poorest mental health in the long-term low-income unemployed. These findings, based on a dichotomized variable derived from Becks Depression Inventory, were confirmed by using a sum score measure. For instance, in permanently employed men the estimated marginal mean, adjusted as model 2 in Table 2, was 4.93 (95% CI: 4.64, 5.21), while the respective figure in the low-income unemployed men was 9.47 (95% CI: 8.64, 10.30). Many prior studies on unemployment and mental health have applied the General Health Questionnaire (GHQ)38 and found that the difference in psychological distress between the employed and unemployed partially wore off as the unemployment lengthened.36 A potential explanation for the contradictory findings might be that the GHQ measure, in contrast to the BDI, assesses recent experiences, and indicates, in addition to depression, also other aspects of mental well-being, e.g. anxiety and social dysfunction.
Most participants in the subsidized re-employment programmes come from the low-income unemployed group, which also comprises individuals who are unable to work even as subsidized employees.39 Health-related selection mechanisms may also operate for entering re-employment programmes, as the odds for physician-diagnosed disease among subsidized men were relatively low. On the other hand, their paradoxically high odds for poor self-rated health may reflect a situation where working in the subsidy programme after unemployment may reveal defects in participants functional capacity that furthermore affect their health perceptions.40
The basic allowance provides for no more than a minimal subsistence income, and there are more recipients of this type of allowance than those who recieve compensation-income benefits among the Finnish unemployed. Thus, the high prevalence of mental health problems seen in the former group is an alarming finding (e.g. 48% of the age group 4044 years were trapped in Becks depression screen). The question of whether the high odds for disease is due to previous labour market disadvantages and occupational hazards rather than actual unemployment needs to be approached with longitudinal data in future studies. The 5-year follow-up data collected by the Health and Social Support project in 2003 will give opportunities to study the predictive associations of various labour market trajectories with employee health and well-being.
Methodology
The spectrum of employment statuses among the participants in this study represents quite well the respective groups in the Finnish labour force in 1998.21 Although not very high, the response rate in the initial survey of the HeSSup yielded enough responses for the analyses of the present study. Variations in the response rate according to labour market status or health may cause bias in comparison (e.g. depression causing more non-response among the long-term unemployed than among the permanently employed). However, the expected finding of poor health among the unemployed suggests that there is no major selection bias. Moreover, the consistent findings made across the whole range of outcomesself-rated health which incorporates a variety of physical, emotional and personal components, diseases which are an indicator of permanent health problems, and the BDI which reflects poor mental health more sensitively than the question about diagnosed psychiatric diseasesmay be interpreted as lending support to the reliability of the comparative setting.
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Conclusion |
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KEY MESSAGES
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Acknowledgments |
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References |
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