Unemployment and health: contextual-level influences on the production of health in populations
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.
Section snippets
Exploring the unemployment–health relationship
Based on their review of the literature on unemployment and health Kasl and Jones (2000) made a number of suggestions for future research: (1) that the effect of economic hardship stemming from unemployment be separated from the effect of unemployment per se; (2) that unemployment may affect the health of different subgroups of the population differently; (3) that the social matrix in which unemployment is embedded, such as the interdependence of the individual with his or her family, network
Sample
The goal of the analysis is to examine the synergistic relationship between health status and individuals’ own personal experience of unemployment, given the level of unemployment and other characteristics of the individuals’ context.
Individual-level data are taken from the 1987 Santé-Québec health survey of the non-institutionalized Quebec population (Courtemanche & Tarte, 1987). In the 844 primary sample units, 13,760 households were selected. Data were provided from an
Sample characteristics
Among the study sample, 34% had levels of perceived health that formed the unhealthy category. This compared to 49% reporting having experienced some illness in the last two weeks and 14% having experienced functional disability of some form during the same period as recorded by separate questions in the survey.
The rate of unemployment in the sample was 10.5%. Unemployment in women was 7% and in men 12%. Unemployment was highest in the youngest age cohort (15–25) at 17%. Marital status was
Discussion
The goal of this paper was to examine the association of unemployment with health status within the context provided by an environment, where the individual experience of unemployment was more or less shared with others. It was also recognized that the association of unemployment and health status depended on a number of individual and contextual characteristics. These characteristics, at both the individual and the contextual levels, were taken from the stress/social support model of health.
Acknowledgements
This research has been supported by The Program for Research on Social and Economic Dimensions of an Aging Population (SEDAP). We want to thank Craig Duncan for his helpful advice in the course of this work, and John Lavis for directing us to the extensive literature on the unemployment–health relationship.
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