Unemployment and health: contextual-level influences on the production of health in populations

Abstract

While there is a large and growing literature investigating the relationship between an individual's employment status and health, considerably less is known about the effect on this relationship of the context in which unemployment occurs. The aim of this paper is test for the presence and nature of contextual effects in the ways unemployment and health are related, based on a simple underlying model of stress, social support and health using a large population health survey. An individual's health can be influenced directly by own exposure to unemployment and by exposure to unemployment in the individual's context, and indirectly by the effects these exposures have on the relationship between other health determinants and health. Based on this conceptualization an empirical model, using multi-level analysis, is formulated that identifies a five-stage process for exploring these complex pathways through which unemployment affects health. Results showed that the association of individual unemployment with perceived health is statistically significant. Nevertheless, this study did not provide evidence to support the hypothesis that the association of unemployment with health status depends upon whether the experience of unemployment is shared with people living in the same environment. Above all, this study demonstrates both the subtlety and complexity of individual- and contextual-level influences on the health of individuals. Our results caution against simplistic interpretations of the unemployment–health relationship and reinforce the importance of using multi-level statistical methods for investigation of it.

Introduction

Unemployment is consistently associated with poor health for individuals. Although part of this association is undoubtedly a selection effect, healthier people are more likely to be employed, sufficient evidence exists to suggest that employment protects and fosters health (Lavis et al., 2001; Dooley, Fielding, & Levi, 1996; Platt, Pavis, & Akram, 1999; Ross & Mirowsky, 1995; Kasl & Jones, 2000). Considerably less is known about the effect on this relationship of the context in which unemployment occurs. The role of population contexts on the production of health and on the relationships between individual-level ‘determinants’ and health has been emphasized in the development and application of several theoretical frameworks. However, there has been little attention given to the application of these theoretical frameworks to the relationships between unemployment and health. Few studies consider the effect of local context on the relationship between unemployment and health. Those that do consider context use local unemployment rate as the only contextual variable. For example, Iversen, Andersen and Andersen (1997) found lower relative mortality among Danish unemployed individuals in areas where the local unemployment rate was comparatively high (Iversen et al., 1997). However, Moser, Fox, Jones, and Goldblatt (1986) found an opposite effect in the UK. The adverse health effects associated with unemployment were greater in areas with higher rates of unemployment. These contradictory findings might be explained by the failure to control for variations in other contextual factors that influence the unemployment–health relationship. Alternatively, the findings might reflect different social and psychosocial processes at work in different contexts (Turner, 1995). Either way, the findings help to illustrate the complexities of the association between unemployment and health in populations.

In this paper we use a theoretical framework that incorporates contextual influences on the unemployment–health relationship to test for the presence and nature of contextual effects in the ways unemployment and health are related. The work is based on an existing model of stress, social support and health using a large population health survey of the population of the province of Québec. Under the theoretical framework adopted in the paper an individual's health can be influenced directly by own exposure to unemployment and by exposure to unemployment in the individual's context, and indirectly by the effects these exposures have on the relationship between other health determinants and health. Based on this conceptualization an empirical model is formulated that identifies a five-stage process for exploring these complex pathways through which unemployment affects health. Our intention is not to provide a comprehensive understanding of the unemployment–health relationship. Instead, we focus on the development of a theoretical framework for the unemployment–health relationship that embodies the role of population contexts and the application of the framework to population-based data. In this way we seek to explore different components of contextual effects on health and hence provide a better understanding of pathways to health in populations.

The application of the empirical model uses multi-level analysis (Goldstein, 1995), a statistical procedure that estimates differences in the association of health status and individual-level characteristics in different contexts and takes into consideration variations in health status at both the individual and contextual levels.