Health and re-employment in a two year follow up of long term unemployed

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JrournalofEpidemiology and Community Health 1993; 47: 14-18

Health and re-employment in

^a

two

year

follow

up

of long term unemployed

Bj0rgulf Claussen, Arild Bj0rndal, Peter F Hjort

National Institute of PublicHealth,Unit forHealthServices Research,Oslo, Norway BClaussen ABj0rndal P FHjort Correspondenceto:

DrClaussen,at:University ofOslo, Departmentof Community Medicine, Unit of SocialInsurance Medicine,POBox95 UllevalSykehus,N-0407 Oslo, Norway

Acceptedforpublication July1992

Abstract

Study objective-The aim was to examine re-employment and changes in health during a two year follow up of a representative sample of long term unemployed.

Design-This was acrosssectional study and a two year follow up. Health was measured bypsychometric testing, Hopkins symptom checklist, General health questionnaire, and medical examination. Health related selection to continuous unemploy- mentand recovery by re-employment was estimated by logistic regression with co- variancesdeduced from the labour market theories of human capital and segmented labour market.

Setting-Four municipalities in Gren- land, southern Norway.

Subjects-Participants were a random sample of17 to63 yearold people registered as unemployed for more than 12weeks.

Main results-In thecrosssectional study, the prevalence of depression, anxiety, and somatic illness was from four to 10 times higher than inacontrol group of employed people. In the follow up study, there was considerable health related selectionto re- employment. A psychiatric diagnosis was associated witha

70%

reduction inchances of obtainingajob.Normalperformanceon psychometrictesting showeda twotothree timesincreased chance ofre-employment.

Recovery of health following re-employment wasless thanexpectedfromprevious studies.

Conclusions-Health related selectionto longtermunemploymentseems toexplaina substantial part of the excess mental morbidity among

unemployed people.

An increased proportion of the long ^term unemployed will be vocationally handi- cappedasyears pass,puttinga heavybur- den onsocial services.

JEpidemiol Community Health 1993;47: 14-18

Increasing unemployment is a challenge to the health service inmostWestern countries.Excess morbidityandmortality among

unemployed

are well

documented,'

2 although we do not know much about the

explanation.

There is growing evidence for the view that unemployment damages health,3 even if some

researchersdoubt that lack ofpaidworkpersecan causesickness.4 5 Another

explanation

isthatbad health predisposes to unemployment, either

by

job loss

(SI

in the figure) or by selection to

re-employment(S2 in the

figure).

Selection has been less investigated than the causal hypothesis56 and is not found in most investigations.78Even so manyresearchers find it probable that health related selection explains some of the excessmorbidity among the unem-

ployed.1

If this factor is large, it should have implications for the social and health services.

Handicapped job seekers will constitute an increasing proportion of the long term unemployed, as they are repeatedly scrutinised by personnel mangers over the years. Caring for them will be achallenge ofincreasing significance.

Westudied health and re-employment in a two yearfollowup of a representative sample of long term unemployed in Norway. Our aims were primarilytoassess the selection tore-employment on account of mental distress and of medical diagnoses.Itisscarcely possible to measure S, in the figure, because that would demand baseline health data forhuge numbers of employees before any redundancies are known.6 We think, however, that S2 (selection to continuous unemployment) is more important on today's labour market. The reason is that redundancies have reachedamassive scale, while the exit gate from unemployment is narrow and well guarded by personnel managers.

Secondly, we wanted to determine recovery from mental distress following re-employment, which may indicateacausalrelationshipbetween job loss and mental health. Againthe measureis indirect.C,inthefigure would betherealcausal relationship, but this proportion cannot be entangled from S2 without baseline data.

Methods

The study was carried out in the four municipalities of Grenland, a relatively urban district of Norway, partly because the district resembles thecountry,but also because oneofthe authors hadbeen ageneralpractitioner therefor 10 years. Thirty two per cent of the 92 940 inhabitants are workers, compared to 24% in Norwayas awhole.Otherwise the differencesin the labour market structure are

small.9

The unemployment rate in the area increased from

266%

^{when the}studystartedduringthespringof 1988to 5-1% intheautumn of1990,whichwas near the national levels of 2 0 and

488%

respectively.

A random sample of a quarter of those registered unemployed for more than 12 weeks was offered a health

examination,

except the

"early

pensioners" over 63 years. For

practical

reasons, we defined the

unemployed

as those registeredatthelabourmarket authorities.This givesa relativelyhealthy

sample,

becausea pre-

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Health andre-employmentinlongterm uneployed 15

H

H ~~~~~~~Re-e-n

E-:c;> c-: hr er Lon(

unemploved uriem

A modelofhealth related selectionto unemploymentandof unemploymentas

ofill health. H=healthy;I=ill; SI=selection tojob loss; S2=selection to cl unemployment; C, =healthy unemployedbecome illas a consequenceoflongt

unemployment; C2 sickunemployedwho improve after re-employment.

condition for registering is the ability whatever job is offered. A limit of 12 durationwas setin ordertoavoid thele related "frictional unemployment".

Three hundredand ten persons attel the first examinationin1988,83°% ofthe

Table I Backgroundcharacteristics (percentageormeans) ofthestudygrog Norwegian registered unemployed," allemployed fromGrenland9anda

representative sample oftheoccupational populationinNorwayl1

Unemployed Employed

Grenland All Grenland Na

studygroup Norwegian census san

1988 unemployed 1980a 192

(n=310) (n 56633) (n=41841) (n Age (years)

16-19 6 1 1 9 E

20-29 46 42 25 2(

30-49 37 33 42 32

50-63 12 8 24 2(

64-70 - 7 - -

Gender('Ofemale) 42 40 40 4,

Weeksregistered

0-12 - 61 - -

13-26 52 15 - -

27-52 32 16 - -

53-80 11 5 - -

81- 5 3 - -

Occupation (previous)

Professional,technical 12 11 21 24

Administrative 2 1 5 5

Clerical 8 8 9 12

Sales 10 10 9 1(

Farmers,fishermen 1 2 2 5

Transport,communication 8 7 7 E

Labourers 43 38 33 22

Service 16 12 1 1 12

Unknown - 9 3 2

Socioeconomicstatus

Unskilled workers 43 - 26 1H

Skilled workers 9 - 12 9

Salariedemployeeslow level 23 - 16 18

Salariedemployeesmedium level 22 - 20 29

Salariedemployees highlevel 1 - 7 9

Selfemployedand liberal

professions 1 - 1 3

Agricultureandfishery - - 4 7

Others 2 - 14 7

Social network(index)

Low 38 ^- ^- 33

Medium 44 - - 38

High 19 - - 29

Socialsupport(index)

Low 12 - - 15

Medium 61 - - 6C

High 27 - - 25

Education(averageyears) 10-3 - 10 6 iC

Net householdmonthlyincome per

capita (average£) 318 - 360 368

aAgestandardised after the study group, except for the first two variables

They

were

representative

of the

population

and of all

registered unemployed

in

Norway

withrespect

to the available variables in table I. The results may be

generalised

to all

Norwegian registered long

term

unemployed people.'0

^Anewexamin- ationtwo yearslaterwasattended by 291 ofthem,

giving

anoverall

participation

^rate^of

780,.

Two hundred and seventy seven answered the tests twiceand this is thetotal numberinmostof the nployed tables. They did not differ from the

original sample

in

gender (p

⁼

0354),

age

(p

=

0439),

or

H municipality(p=

0O304).

The examination consisted of a structured ...-.-. interview

by

anurse,pen andpaper tests, and the 1 doctor'sdiagnoses and advice. In order to estab- i j lish a reference group of unemployed people, gterr crucial

questions

were taken from national sur- ovec veys. Sociodemographic variables from the last

;a cause census gave data

comparable

with all

people

ontinuous

employed

in

Grenland.9

^Moredetailed informa-

term tion was obtained with variables from the Health

Survey

198512 and the Level of

Living Survey

to take 1987.13

2 weeks' The index for social network was constructed ss health from sixquestions aboutparents,spouse, child- ren, friends, andfrequencies of visits; the index nded for for socialsupportwasderived from two questions sample. aboutexpectationsof financial and practical help whenneeded.'0 Socioeconomicstatuswasdeter- minedfroma sevenstep indexbasedonoccupa- up,all tion. 13

The

Hopkins

symptom checklist is a 30 item versionof the

psychometric

testSCL-90.14Itwas

constructedfor the Health

Survey

1985andis the

tional

only test with a satisfactory Norwegian reference 87a

population

of

employed people.

12 A similar

=2638)

version is also used in unemployment research.8 The three subscalesintableIIIare

quite

likethe

corresponding

ones in the much used 58 item

6

1version.4 Here,

the cutoff

point

for

psychiatric

°

morbidity

is )1-75per

item,

which is

commonly

7 used because it gave

prevalences

of2 50o in an

American household survey.

The General health

questionnaire (GHQ)

is much used for

measuring psychological

dis-

tress,'5

and has been

applied

to the unem-

ployed.7 1-18

We used Likert

scoring

as a 4 continuousmeasurementandacutoff

point

>5in 5 the

GHQ scoring

for"case

finding"

withthis 28 2D item version.

5 The somatic

diagnoses

in table II

required

^a

2 medical condition that

gives

^an

enduring

^and

3

significant

reduction of the common level of

functioning. Psychiatric syndromes

were

diag-

3 nosed after the criteria in the

Diagnostic

and statisticalmanual

of

mental disorders

(DSM-III)

axis

I,

and

personality

disorders after axis II.

When

examining re-employment

in relationto

health,

we assumed that the most

important

7

confounding

variables couldbededuced fromthe theories ofhuman

capital (education,

yearsin

paid

3

work,

^anddurationof the

longest lasting job)

and of segmented labour market (gender, socioeconomic status, and social

network).i9

^Another

aspect of labour market conduct is personal involvement in paid work, which was measured

5 ~~~~~~~~~~~~20

8 bytheEmploymentcommitment test.

ThehypothesesweretestedbyX2forcategori-

3 calvariables andtwotailedttestsforcomparisons ofmeans.Logisticandmultiplelinearregressions

I

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BjorgulfClaussen,ArildBj0rndal,Peter F Hjort Table II Average scores per item (95q' confidence intervals)for psychometrictests

atthe health examinations in 1988 and 1990

1988 1990

Test Unemployed Employeda Unemployed Re-employed

scales (n=298) (n=4924) (n=164) (n=113)

Hopkins symptom checklist

Somatic symptoms 141 1.19 144 140

(1-38-1 45) (1-16-122) (140-148) (1-36-144)

Anxiety 140 1 13 143 130

(1 35-1 45) (1-12-1 15) (137-1-49) (126-134)

Depression 147 108 147 130

(1 41-1-53) (105-1 13) (1-41-1*53) (126-134)

General health questionnaire 0-88 - 082 069

(082-0{94) (076-0-88) (065-073)

aAhousehold health survey, age standardised after the study

group12

werecarried out bySPSS-PC.21 Covariates were thesevenvariables mentioned above.

Results

THE CROSSSECTIONAL EXAMINATION

Table Ishowsthat thestudygroup was relatively young,whilethe sex ratio was the same as among theemployed.The restofthe tables aretherefore agestandardisedafter the studygroup.

The unemployed had fewer resources like household income (p<0001), socioeconomic status(p<0001), and education(p=<001)than employed people in the Grenland area. Social network was poorer than in thenational sampleof employed (p<00001), social support about the same (p=0223).

The study group scored much higher on the Hopkins symptom checklist than the reference group (table II). The prevalences of mental disorderswerefourtotentimeshigher (tableIII).

These differences were the same for bothgenders

Table III Prevalences of sickness (percentage) afterdichotomous healthmeasure- ments atthe health examinationsin1988 and 1990

1988 1990

Health Unemployed Employed Unemployed Re-employed

measurement (n=298) (n=4924) (n=164) (n=113)

Psychometrictests

Somatic symptoms 17 4t 18 13

Anxiety 17 2t 20 12

Depression 22 21 25 13*

General healthquestionnaire 36 - 34 28

Doctor'sdiagnoses

Somatic disease 26 - 34 23*

Psychiatric syndrome 29 - 41 16t

Personalitydisorder 10 - 13 3t

*p<005;tp<0-01;

p<l0-001

^compared^to^unemployed^at^the^same^time^byX2tests

and did not depend on socioeconomic status, household income, social network, or reported alcohol consumption,asdescribed elsewhere.'0

HEALTH RELATEDSELECTION TO RE-EMPLOYMENT

Fortyonepercent werere-employedwithintwo years (table IV). The differences in education, socioeconomic status, and social network show

TableIV Sociodemographiccharacteristics in1988afteremploymentstatus in1990 Re-employed Unemployed (n=118) (n=173)

Gender(females, ,,) 45 43

Age(averageyears) 32-1 34.3

Socioeconomicstatus(averageindexscore) 2-46 2 17*

Education(averageyears) 10 6 10.1*

Nethousehold income percapita(averageC) 308 331

Social network(averageindexscore) 10-5 9.6*

Social support(averageindexscore) 2 38 236

Employmentcommitmenttest(average score) 431 426

Time inpaidwork(averagemonths) 130 155

Longestlastingjob (averagemonths) 64-5 87.9*

*p<

0.05

byttest

that the moreresourcefulunemployed had better chances of getting a job when education, socioeconomic status, and social network are recognisedas resources. Gender and the Employ- mentcommitment test were not bivariately con- nected with continuous unemployment. The differences intimeof longest employment and in any paidwork disappeared after controlling for age andsocioeconomic status.

Selection to re-employment was estimated by logistic regression with dichotomised health measures as predictors (table V). The anxiety scale, the General health questionnaire, and the psychiatric diagnoses from the first examination showed a significant effect on re-employment.

The chances for getting a job were reduced to 24-470,for the sickunemployed compared to the healthyunemployed. Continuous scores in multiple linear regression gave thesame level of significance for all the test scales.

In thelogistic regressions, variables other than health had no significant effect on continuous unemployment (gender, education, time in paid work,socioeconomic status, social network, or the Employment commitment test).

RECOVERYAFTER RE-EMPLOYMENT

Table VIshowsthe probability of scoring as sick in the follow up controlled by baseline health status,makingthelogisticequation a measure of the change in relative risks ofscoring as sick in the two groups. The prevalence of mental disorders wasreducedby gettinga job.However, only the depression subscale showed significant differences. The re-employed were 45o as likely to experience depression as people who were still unemployed. The continuousmeasuresgave the same levels of significance in multiple linear regression,except for asignificantrecovery in the General health questionnaire(p=003).

Discussion

Do these figures reflect real health? The main instruments are twopsychometrictests, which are much used and well validatedasmeasuresof mental disorders.'4 15 The doctor'sdiagnoses,onthe other hand, are subject to the low reliability of clinical judgements andmust be takenforwhat theyare.

The actual result of selection to re-employment, however, supports the measurements, because health isan integratedpart of the well established humancapital theoryof labour market conduct.'9

CROSS SECTIONAL RESULTS

Psychiatric disorders are far more common among the long term unemployed than in the working population, even in affluent Norway.

This contradicts the view that poverty following lack of work is the main explanation of excess morbidity among the unemployed.5 We found that, as shown before,717 18 relatively well situ- ated groupsof Scandinavianunemployed people experience the same high degree of mental distress astheircounterparts in theUK'6andUSA.8 Thus the model in thefigureforexplainingexcess morbidityis relevant forNorwegianunemployed.

SELECTION

We found a noteworthy selectionto re-employment, both in terms of mental distress and of 16

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Health andre-employmentinlongtermuneployed

Table V Selectiontore-employment: results from logistic regression with the probabilityofre-employmentin 1990asdependentvariable and healthmeasuresin 1988 aspredictors, together with gender, socioeconomic status, social network, education, years inpaid work,durationofthelongestlasting job, and the Employment commitmenttest ascovariates

Regression -a

Predictor (O=healthy, 1= sick) coefficient (B) pvalue eB Psychometric tests

Somatic symptoms 0 14 0-69 0-87

Anxiety 101 0 01 0-36

Depression 021 0 52 0 81

General healthquestionnaire 0-76 001 0 47

Doctor's diagnoses

Somatic disease 0 51 0-08 0 60

Psychiatric syndrome 1 20 <0 001 0 30

Personality disorder 1 43 0 01 0 24

aTheodds ratioforbeingre-employedin 1990for the sickunemployedin 1988comparedto thehealthyunemployed.Thosescoringasanxious had forexample a 360o chance of

re-employmentcomparedtothenon-anxious,giventhesameage,education,etc

Table VI Recovery byre-employment: resultsfrom logistic regressionwith the probabilityof beingsick in 1990asdependentvariable andemploymentstatusin 1990 aspredictor, controlledforthesamehealthmeasurein 1988 and thecovariatesfrom table V

Regression _-a

Dependent variable coefficient (B) p value eB

Hopkins symptomchecklist

Somatic symptoms 0-65 0-14 0-52

Anxiety 0 08 0 86 0 93

Depression 0 80 0-04 045

General healthquestionnaire 0-22 0-45 0 80

aThechangefrom 1988to1990inrelativerisk forbeingsick forre-employed compared to stillunemployed.Gettingajobreduces the chance forscoringasdepressedto45', of the chance for those stillgoingunemployed

medical diagnoses. Sick unemployed people in 1988 had between a quarter and a half of the probability for re-employment in 1990 as the healthy ones. The selection was mostly due to psychiatric illness, while the somatic medical diagnoses showed alowselectioneffect.

Surprisingly, human capital variables otherthan health did not predict re-employment in our sample-not even education or work experience.

Thisprobably means that personnel managers are looking for more subtle traits than we were able to measure.Neitherdid wefindthe sexdifferences in unemployment distress that are shown in many European

countries.'

Employed women in Norway seem tobe as much devoted to paid work asmen.

Selectionto re-employment was not found in studies fromMichigan,8Finland,7 and the United

Kingdom,'6

the first of these using the Hopkins symptom checklist, the other two the General healthquestionnaire. The explanation is probably thatthey interviewed other groups living under different labour market conditions than our sample. The three samples consisted of blue collar job seekers in the 20 to 50 year age range with unemployment of any duration, while ours was a representative one of long term unemployed peopleaged 17 to 63 years. The British and the Finnish samples were followed in a stable labour market, the US sample during an upgoing busi- nesscycle. The three countries had higher unemployment rates than Norway, but none of them were increasing so rapidly. From the time we started ourstudy in1988 until today, the unemployment rate has gone up from

20/%

to a con- tinental level of

nearly

8

0h.*"

^Our

sample

^was

probably

more

heavily

selectedthan the others.

RECOVERY

If excess mental distress

disappears

on re-

employment,

thisindicates that causation is the

dominating explanation. Again, lack of baseline health datarenders exact calculationsimpossible, becausewe cannot be sure thatrecoveryis com- plete for all re-employed people.

Recovery was moderate in our study, in con- trast to thenearlycomplete recoveryin the three other investigations.7^{8 16} Againthe explanation maybe sample differences. Psychometric scores increasemostin the first three months of unemployment andthentendtogodown.7 16Thisleads to bigger differences between unemployed and re-employed people in the other three samples with alargeproportionof shorttermunemployed.

Conditions on the labour market may also be important. Many of our re-employed people enteredjobswith lesssecuritythanbefore,which mayexplainthe lowrecoveryrate.Thesevenitem socioeconomicstatusindex isacrudemeasurefor socialmobility,but here360°0 of there-employed crept downwardsand 180° upwards.

IMPLICATIONS FOR THE HEALTH SERVICE

Our findings raise the question ofwhat society should dowith agrowingpopulationofunhealthy andunsuccessfuljobseekers.Over many yearsof lowunemployment,Social InsuranceinNorway hasgrantedagreatnumberofdisabilitypensions.

Thispracticeisnowunderattack,partlybecause of the sickness inducing effect of a disability pension,22andpartlybecause ofexpenditureona growing number ofpensioners. Bothare serious problems that need attention. Society must in some way take care ofthe most unhappy participants in the labour market, and reforms should notstrikeattheweakest.

This isimportant also from a preventive view.

Sickunemployedpeopleareespecially predisposed tofurther

deterioration.'

Preventivemeasuresfor people who are unemployed in the long term because of poorhealthshould havepriority.Voca- tional rehabilitation, occupational programmes, and sheltered employmentareimportant,aslong as oursocieties donotprovide primary prevention inthisfield,ie, paid work for all.

Thisstudywassupported by the Norwegian Research Council for Scienceand the Humanities and by the CountyLabourAuthorityof Telemark.

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