Employment Status and Inequalities in Health Outcomes : Population-based Studies from Gävleborg County

Sammanfattning: Background and objectives: From a public health perspective, it is important not only to improve and maintain health, but also to promote equality in health. Epidemiological research has showed the importance of work and unemployment in the development of socio-economic health inequalities, and peoples life chances are suggested to be conditioned by participation or exclusion from the labour market. The most recent economic recession has brought further changes to the labour market that might have aggravated the already multifaceted image of inequalities in health. Gävleborg County was one of the hardest hit counties in Sweden, which experienced a myriad of changes in the labour market that went beyond those of the Swedish national average, in terms of increase in flexible forms of employment, factory closures, and lay-offs. The overall objective of this thesis was to investigate the relationship between employment status and health-related inequalities in Gävleborg County, Sweden. In addition, the Specific objectives for the thesis were to: assess the relationship between employment status and self-reported health in Gävleborg (Study I); to estimate the relationship between employment status and suicidal ideation during the economic recession in Gävleborg (Study II); to estimate the prevalence of anxiety and depression among economically active people living in the Municipality of Gävle (Study III) and to assess experiences and perceptions of well-being after involuntary job loss in Gävle (Study IV).Methods: Study I and II in this thesis used data from the 2010 Health in Equal Terms survey, a cross-sectional survey carried out in Gävleborg County in Sweden. A total of 4,245 individuals, aged 16–65 years were included in the analyses. Study III was performed in Wave 1 (baseline survey) of the Gävle Household, Labour Market Dynamics and Health Outcomes survey (GHOLDH), a panel survey with household as the follow-up unit. A total of 241 persons completed a self-administered postal questionnaire which collected information on the employment status and psychological health (anxiety and depression) among persons aged 18–65 years. The thesis used descriptive analyses and logistic regression models to describe and explore the relationship between employment status, self-reported health and suicidal ideation in Gävleborg County (Studies I and II). Descriptive analysis of means and a multiple regression analysis for adjusted means of HADS, were used in order to estimate the prevalence of anxiety and depression among economically active persons residing in the Gävle Municipality (Study III). Study IV used a qualitative approach to gain a deeper understanding of how involuntarily unemployed persons in Gävlexperceive their well-being. Sixteen unemployed men and women aged 28–62 were interviewed face-to-face. A purposeful sampling strategy was used in order to suit the research question and to increase the variation among informants. The interview texts in Study IV were analysed using thematic analysis.Results: In Study I, the prevalence of poor self-reported health (SRH) was twice as high in the group of people who were not employed (42%) compared to the employed group (21.6%). Individuals outside the labour market had odds of poor health of 2.64 (Cl 2.28–3.05) compared to their employed counterparts. Controlling for other covariates reduced the risk slightly to 2.10 (1.69–2.60), but remained statistically significant. Moreover, other variables such as long-standing illness, age, income and lack of social support were associated with self-reported poor health. In Study II, among those not employed, 11.2% had been in a situation where they had seriously considered taking their life (at some time during the past 12 months). The corresponding figure for those employed was 2.9%. Unadjusted results of the logistic regression analysis revealed that people who were not employed had about a four times higher risk of suicidal ideation, with an OR of 4.21 (CI: 3.14–5.64) compared to their employed counterparts. Controlling for other covariates, reduced the risk from 4.21(CI 3.14–5.64) in model I, to 1.73 (CI 1.16–2.57) in model IV, but remained statistically significant. In addition, other variables were associated with suicidal ideation. In Study III, the prevalence and risk of anxiety and depression were high among people who were out of work. In the multiple regression analysis, compared to employed people, those who were not employed had a risk of anxiety of 7.76 (5.97–9.75) and 4.67 (3.60–5.74) for depression. Study IV revealed six different themes from the interviews: Work was perceived as the basis for belonging; loss of work affected people’s social life and consumption patterns due to changes in their financial situation. Feelings of isolation, loss of self-esteem, and feelings of hopelessness were reported, affecting the respondents’ physical well-being. Longer duration of unemployment increased the respondents’ negative emotions. Activities, structure, and affiliation in other contexts were reported as part of their strategy for coping with poor mental health.Conclusion: This thesis found a statistically significant relationship between being outside the labour market and poor SRH, a high risk of suicidal ideation, anxiety, and depression during the recent economic recession. The relationship between employment status and SRH was partially explained by socioeconomic, demographic and lifestyle variables. In addition, the relationship between employment status and suicidal ideation was, for the most part, explained by demographic, socio-economic and self-reported psychological variables. Atxithe municipal level, the prevalence of anxiety and depression was higher among those who were out of the labour market as compared to those who were employed and the odds of anxiety and depression were higher among people out of the labour market, but this was less prominent for depression than for anxiety. Job loss created feelings of loss of dignity and belonging as a human being. The participants experienced feelings of worry, insecurity, and stress due to their changed financial situation, which in turn led to isolation and loss of self-esteem. Social support and having activities other than work gave structure and meaning to everyday life. The results of this thesis indicate a need for early detection and potential treatment of people out of the labour force and for being aware of the increased risk of poor health symptoms and disorders among unemployed individuals. The findings also indicate a need for primary prevention strategies, implying that policy-makers must pay attention to the health status of those who are out of work, especially during times of combined economic hardship and labour market fluctuations. However, longitudinal studies are warranted to shed further light on the mechanisms through which employment status and conditions impact physical and psychological health outcomes.