Background Studies from single countries suggest that local labour market conditions, including rates of employment, tend to be associated with the health of the populations residing in those areas, even after adjustment for individual characteristics including employment status. The aim of this study is to strengthen the cross-national evidence base on the influence of regional employment levels and individual worklessness on health. Our objectives are to investigate whether higher regional employment levels are associated with better health over and above individual-level employment. This could be due to pathways such as weakening community cohesion, increasing place-based stigma and declining regional income.

Methods Individual-level data (n=20 485 aged 15 to 64 years) were taken from 16 countries in the European Social Survey (2014/15) and regional employment rates extracted from Eurostat. Health outcomes included self-reported heart or circulation problems, high blood pressure, self-rated health, depressive symptoms, obesity and allergies (as a falsification test). Our exposures of interest included worklessness, defined as individuals who did not report being in paid work. At the regional level we included the average employment rate of those aged 15 to 64 years from 2008 to 2013. We calculated multilevel Poisson regression models for the binary outcomes (calculating the incidence rate ratio (IRR)), which included individuals nested within NUTS regions and linear multilevel regression models for continuous measures, controlling for potential confounding variables.

Results Between 2008 and 2013 the employment rate declined the most in Spain and increased the most in Germany. Increased average regional employment rates were associated with better health outcomes: heart/circulation problems IRR=0.970 (95% CI 0.950 to 0.990); high blood pressure IRR=0.981 (95% CI 0.965 to 0.997); poor self-rated health IRR=0.974 (95% CI 0.956 to 0.992); obesity IRR=0.971 (95% CI 0.960 to 0.982); depressive symptoms b=0.992 (95% CI 0.987 to 0.997), allergies IRR=0.995 (0.977 to 1.013). Individual worklessness was associated with all health outcomes, most strongly with poor self-rated health. In models including both individual worklessness and the average regional employment rate, the latter remained associated only for obesity.

Discussion Lower regional employment levels and worklessness are associated with adverse health outcomes across European countries. When accounting for both individual- and regional-level employment variables, a separate association between the regional employment level was suggested for obesity. The key strength of our study was the use of comparable cross-national data that integrated individual- and regional-level variables, but is limited by the use of self-reported data. Further exploration of potential causal mechanisms is needed.