Precarious Employment and Psychosocial Hazards: A Cross-Sectional Study in Stockholm County.

Precarious employment (PE) has been linked to adverse health effects, possibly mediated through psychosocial hazards. The aim of this cross-sectional study is to explore if higher levels of PE are associated with psychosocial hazards (experiences of violence, sexual harassment, bullying, discrimination, high demands, and low control) and to explore gender differences in these patterns. The study is based on survey- and register data from a sample of 401 non-standard employees in Stockholm County (2016-2017). The level of PE (low/high) was assessed with the Swedish version of the employment precariousness scale (EPRES-Se) and analysed in relation to psychosocial hazards by means of generalized linear models, with the Poisson family and robust variances. After controlling for potential confounders (gender, age, country of birth, and education), the prevalence of suffering bullying (PR 1.07, 95% CI: 1.01-1.13) and discrimination (PR 1.52, 95% CI: 1.00-2.32) was higher among individuals with a high level of PE. Regarding the demand/control variables, a high level of PE was also associated with low control (PR 1.59, 95% CI: 1.30-1.96) and passive work (the combination of low demands and low control) (PR 1.60, 95% CI: 1.23-2.08). Our findings suggest that workers in PE are more likely to experience psychosocial hazards, and these experiences are more prevalent among women compared to men. Future longitudinal studies should look further into these associations and their implications for health and health inequalities.

Childbirth, morbidity, sickness absence and disability pension: a population-based longitudinal cohort study in Sweden.

OBJECTIVE: To investigate associations of morbidity with subsequent sickness absence (SA) and disability pension (DP) among initially nulliparous women with no, one or several childbirths during follow-up. DESIGN: Longitudinal register-based cohort study. SETTING: Sweden. PARTICIPANTS: Nulliparous women, aged 18 to 39 years and living in Sweden on 31 December 2004 and the three preceding years (n=492 504). OUTCOME MEASURES: Annual mean DP and SA days (in SA spells >14 days) in the 3 years before and after inclusion date in 2005. METHODS: Women were categorised into three groups: no childbirth in 2005 nor during the follow-up, first childbirth in 2005 but not during follow-up, and having first childbirth in 2005 and at least one more during follow-up. Microdata were obtained for 3 years before and 3 years after inclusion regarding SA, DP, mortality and morbidity (ie, hospitalisation and specialised outpatient healthcare, also excluding healthcare for pregnancy, childbirth and puerperium). HRs and 95% CIs for SA and DP in year 2 and 3 after childbirth were estimated by Cox regression; excluding those on DP at inclusion. RESULTS: After controlling for study participants' prior morbidity and sociodemographic characteristics, women with one childbirth had a lower risk of SA and DP than those who remained nulliparous, while women with more than one childbirth had the lowest DP risk. Morbidity after inclusion that was not related to pregnancy, childbirth or the puerperium was associated with a higher risk of future SA and DP, regardless of childbirth group. Furthermore, morbidity both before and after childbirth showed a strong association with SA and DP (HR range: 2.54 to 13.12). CONCLUSION: We found a strong positive association between morbidity and both SA and DP among women, regardless of childbirth status. Those who gave birth had lower future SA and DP risk than those who did not.

Inequalities in employment rates among older men and women in Canada, Denmark, Sweden and the UK.

BACKGROUND: In most developed countries, governments are implementing policies encouraging older persons to work past 65 years to reduce the burden on societies related to disability benefits and pension payments. Despite this push to extend working lives, we know little about who already works past this age and any inequalities that may exist. Our study investigates the employment rates of those aged 65-75 years of age by educational level, health status and sex in Canada (CAN), Denmark (DK), Sweden (SE) and the United Kingdom (UK). Secondly, we aim to relate findings on employment rates to prevailing policies in the different countries, to increase the understanding on how to further extend working lives. METHODS: We used nationally representative cross-sectional survey data from the 2012-2013 Canadian Community Health Survey, 2013/14 Survey of Health, Ageing and Retirement in Europe for Denmark and Sweden and the 2013 English Longitudinal Study of Ageing to examine employment rates for those aged 65-75 years by sex, educational level and health status (having limiting longstanding illness (LLI) or not). RESULTS: Employment rates decline by age, but we see a linear decline in CAN and the UK compared to an initial decline then a plateau of employment rates from 66 to 68 years in DK and SE. Employment rates among persons aged 65-75 years were lower in the UK than in CAN, DK and SE. Among women, employment rates were highest in SE. Women with low education and a LLI had considerably lower employment rates than men with low education and a LLI (employment rates for men ranged from 27% to 12% compared with employment rates for women which ranged from 12% to 0%). CONCLUSIONS: Our results suggest that educational level, sex and health all play a role in extending working lives. The variation in employment rates between the four countries implies that policies do matter, but that social differentials show that policies cannot be 'one size fits all'. Policy-makers must consider different groups (i.e. low-educated women with a LLI) when designing policies to extend working lives.

Involving the public in epidemiological public health research: a qualitative study of public and stakeholder involvement in evaluation of a population-wide natural policy experiment.

BACKGROUND: Public involvement in research is considered good practice by European funders; however, evidence of its research impact is sparse, particularly in relation to large-scale epidemiological research. OBJECTIVES: To explore what difference public and stakeholder involvement made to the interpretation of findings from an evaluation of a natural policy experiment to influence the wider social determinants of health: 'Flexicurity'. SETTING: Stockholm County, Sweden. PARTICIPANTS: Members of the public from different occupational groups represented by blue-collar and white-collar trade union representatives. Also, members of three stakeholder groups: the Swedish national employment agency; an employers' association and politicians sitting on a national labour market committee. Total: 17 participants. METHODS: Qualitative study of process and outcomes of public and stakeholder participation in four focused workshops on the interpretation of initial findings from the flexicurity evaluation. OUTCOME MEASURES: New insights from participants benefiting the interpretation of our research findings or conceptualisation of future research. RESULTS: Participants sensed more drastic and nuanced change in the Swedish welfare system over recent decades than was evident from our literature reviews and policy analysis. They also elaborated hidden developments in the Swedish labour market that were increasingly leading to 'insiders' and 'outsiders', with differing experiences and consequences for financial and job security. Their explanation of the differential effects of the various collective agreements for different occupational groups was new and raised further potential research questions. Their first-hand experience provided new insights into how changes to the social protection system were contributing to the increasing trends in poverty among unemployed people with limiting long-standing illness. The politicians provided further reasoning behind some of the policy changes and their intended and unintended consequences. These insights fed into subsequent reporting of the flexicurity evaluation results, as well as the conceptualisation of new research that could be pursued in a future programme.

The recommodification of healthcare? A case study of user charges and inequalities in access to healthcare in Sweden 1980-2005.

BACKGROUND: User charges in Swedish healthcare have increased during recent decades. This can be seen in terms of the recommodification of healthcare: making healthcare access more dependent on market position. This study investigates whether the increase in user charges had an impact on educational inequalities in access to healthcare in Sweden between 1980 and 2005. METHODS: Data from the Swedish Living Conditions Survey were used to calculate the odds ratios of access to healthcare for the low and higher educated in Sweden, and the results were stratified by health status (Good and Not good health) for each year 1980-2005. These odds ratios were correlated with the average user charge for healthcare. RESULTS: There were no educational differences in healthcare access in the group with Good health. In the group with Not good health, the higher educated had higher rates of healthcare access than the lower educated. Inequalities in access to healthcare were relatively stable over time, with a slight increase among those with Not good health. DISCUSSION: Recommodification has had only a small association with access to healthcare in Sweden. The Swedish system has integral protections that protect the vulnerable against rising healthcare costs. This is an important caveat for other countries that are considering introducing or raising user charges.

Recommodification, Unemployment, and Health Inequalities: Trends in England and Sweden 1991-2011.

Recommodification, the withdrawal of social welfare, has been going on for some decades in both Sweden and England. Recommodification disproportionately affects the unemployed because of their weak market position. We investigated the impact recommodification has had on health inequalities between the employed and unemployed in Sweden and England. Using national surveys, odds ratios for the likelihood of reporting less than good health between the employed and unemployed were computed annually between 1991 and 2011. The correlation between these odds ratios and net replacement rates was then examined. Health inequalities between the employed and unemployed were greater in 2011 than in 1991 in both countries. Sweden began with smaller health inequalities, but by 2011, they were in line with those in England. Sweden experienced more recommodification than England during this period, although it started from a much less commodified position. Correspondingly, correlation between unemployment benefit generosity and health inequalities was stronger in Sweden than in England. Recommodification is linked to ill health among the unemployed and to the health gap between the employed and unemployed. We propose that further recommodification will be associated with increased health inequalities between the employed and unemployed.

Employment and income among first-time cases diagnosed with non-affective psychosis in Stockholm, Sweden: a follow-up study 2004/2005-2010.

PURPOSE: Non-affective psychoses (F20-F29) are serious conditions causing a high degree of disability. Loss of income and increasing costs for personal care and treatment are severe consequences following the disorders, but less is known about employment and income in different social strata. The aim was to study these conditions among persons with non-affective psychosis compared to the general population, and possible social differentials. METHODS: A population-based follow-up study with 530,350 persons (aged 18-44), including 756 first-time cases diagnosed with non-affective psychosis registered in in- or outpatient psychiatric care in 2005 or 2006. Age-standardised rates of non-employment, disability pension, social assistance and poverty were calculated at baseline and at follow-up in 2010. Odds ratios of poverty were estimated using logistic regression, adjusting for employment status, age, education and country of birth. RESULTS: Before diagnosis, rates of non-employment, disability pension and social assistance were higher among persons with non-affective psychosis compared to the general population. At the follow-up, rates of disability pension had doubled, most pronounced among women with only compulsory education. Rates of social assistance were twice as high for foreign-born women. Among persons with non-affective psychosis, non-employment, lower education (among men) and being foreign born (among women) were associated with an increased risk of poverty at follow-up. CONCLUSIONS: Poor employment and income conditions were found among persons with non-affective psychosis, but the social insurance system seemed to alleviate the poor income conditions. Early and preventative support to encourage employment and income security is needed, which could support recovery.

ALL IN IT TOGETHER? THE EFFECTS OF RECESSION ON POPULATION HEALTH AND HEALTH INEQUALITIES IN ENGLAND AND SWEDEN, 1991-2010.

This article is the first to comparatively examine the effects of two recessions on population health and health inequalities in the two historically contrasting welfare states of England and Sweden. Data from 1991-2010 on self-reported general health, age, gender, and educational status were obtained from the Health Survey for England, the Swedish Survey of Living Conditions, and the European Union Survey of Income and Living Conditions, for individuals aged over 16. Generalized linear models were used to test the effects of recessions on self-reported health and educational inequalities in health. Overall, recessions had a significant positive effect on the health of women--but not men-in both England (4%) and Sweden (7%). In England, this improvement was only enjoyed by the most educated women, with the health of less educated women declining during recession. In contrast, in Sweden, the health of all women improved significantly during recession regardless of their educational status, although the most educated benefitted the most. Relative educational inequalities in self-reported health therefore increased during recessions in both countries by 14 percent (England) and 17 percent (Sweden) but for different reasons. This study suggests that Sweden's welfare state protects the health of all during recessions.

Do 'flexicurity' Policies Work for People With Low Education and Health Problems? A Comparison of Labour Market Policies and Employment Rates in Denmark, The Netherlands, Sweden, and the United Kingdom 1990-2010.

People with limiting longstanding illness and low education may experience problems in the labor market. Reduced employment protection that maintains economic security for the individual, known as "flexicurity," has been proposed as a way to increase overall employment. We compared the development of labor market policies and employment rates from 1990 to 2010 in Denmark and the Netherlands (representing flexicurity), the United Kingdom, and Sweden. Employment rates in all countries were much lower in the target group than for other groups over the study period. However, "flexicurity" as practiced in Denmark, far from being a "magic bullet," appeared to fail low-educated people with longstanding illness in particular. The Swedish policy, on the other hand, with higher employment protection and higher economic security, particularly earlier in the study period, led to higher employment rates in this group. Findings also revealed that economic security policies in all countries were eroding and shifting toward individual responsibility. Finally, results showed that active labor market policies need to be subcategorized to better understand which types are best suited for the target group. Increasing employment among the target group could reduce adverse health consequences and contribute to decreasing inequalities in health.

Social differentials in non-employment following hospital admission for musculoskeletal disorders in Sweden, 2001-2006.

The article studies social differentials in non-employment among individuals who had been employed in 2001 following hospital admission for musculoskeletal disorders, by gender, educational level, and country of birth, in Stockholm County during 2001-2006. Individually linked population registers on health service use and sociodemographic characteristics were used. Individuals ages 25 to 59, living in Stockholm County and having employment in 2001, were followed until 2006. Annual age-standardized employment rates were calculated for people admitted to the hospital and diagnosed with a musculoskeletal disorder (n = 1,888) and compared to a reference group of others in employment. Multivariate Cox regression analysis was used to calculate the hazard risks of non-employment in 2006. Both women and men admitted to the hospital had lower age-standardized employment rates compared to the reference group and were at higher risk of non-employment. The hazard risk of non-employment was significantly higher among women and men with short education and among foreign-born individuals. Employment consequences of musculoskeletal disorders seem to be unequally distributed between different social groups, with women, people with short education, and people born outside Sweden more likely to be non-employed.

Trends in poverty risks among people with and without limiting-longstanding illness by employment status in Sweden, Denmark, and the United Kingdom during the current economic recession--a comparative study.

BACKGROUND: Previous studies have found higher employment rates and lower risk of relative poverty among people with chronic illness in the Nordic countries than in the rest of Europe. However, Nordic countries have not been immune to the general rise in poverty in many welfare states in recent decades. This study analysed the trends in poverty risks among a particularly vulnerable group in the labour market: people with limiting-longstanding illness (LLSI), examining the experience of those with and without employment, and compared to healthy people in employment in Sweden, Denmark and the United Kingdom. METHODS: Cross-sectional survey data from EU-SILC (European Union Statistics on Income and Living Conditions) on people aged 25-64 years in Sweden, Denmark and the United Kingdom (UK) were analysed between 2005 and 2010. Age-standardised rates of poverty risks (<60% of national median equalised disposable income) were calculated. Odds ratios (ORs) of poverty risks were estimated using logistic regression. RESULTS: In all three countries, non-employed people with LLSI had considerably higher prevalence of poverty risk than employed people with or without LLSI. Rates of poverty risk in the UK for non-employed people with LLSI were higher than in Sweden and Denmark. Over time, the rates of poverty risk for Swedish non-employed people with LLSI in 2005 (13.8% CI=9.7-17.8) had almost doubled by 2010 (26.5% CI=19.9-33.1). For both sexes, the inequalities in poverty risks between non-employed people with LLSI and healthy employed people were much higher in the UK than in Sweden and Denmark. Over time, however, the odds of poverty risk among British non-employed men and women with LLSI compared with their healthy employed counterparts declined. The opposite trend was seen for Swedish men: the odds of poverty risk for non-employed men with LLSI compared with healthy employed men increased from OR 2.8 (CIs=1.6-4.7) in 2005 to OR 5.3 (CIs=3.2-8.9) in 2010. CONCLUSIONS: The increasing poverty risks among the non-employed people with LLSI in Sweden over time are of concern from a health equity perspective. The role of recent Swedish social policy changes should be further investigated.

Effectiveness of return-to-work interventions for disabled people: a systematic review of government initiatives focused on changing the behaviour of employers.

BACKGROUND: OECD countries over the past two decades have implemented a range of labour market integration initiatives to improve the employment chances of disabled and chronically ill individuals. This article presents a systematic review and evidence synthesis on effectiveness of government interventions to influence employers' employment practices concerning disabled and chronically ill individuals in five OECD countries. A separate paper reports on interventions to influence the behaviour of employees. METHODS: Electronic and grey literature searches to identify all empirical studies reporting employment effects and/or process evaluations of government policies aimed at changing the behaviour of employers conducted between 1990 and 2008 from Canada, Denmark, Norway, Sweden and the UK. RESULTS: Few studies provided robust evaluations of the programmes or their differential effects and selection of participants into programmes may distort the findings of even controlled studies. A population-level effect of legislation to combat discrimination by employers could not be detected. Workplace adjustments had positive impacts on employment, but low uptake. Financial incentives such as wage subsidies can work if they are sufficiently generous. Involving employers in return-to-work planning can reduce subsequent sick leave and be appreciated by employees, but this policy has not been taken up with the level of intensity that is likely to make a difference. Some interventions favour the more advantaged disabled people and those closer to the labour market. CONCLUSIONS: Future evaluations need to pay more attention to differential impact of interventions, degree of take-up, non-stigmatizing implementation and wider policy context in each country.

How do macro-level contexts and policies affect the employment chances of chronically ill and disabled people? Part I: The impact of recession and deindustrialization.

Low employment rates of chronically ill and disabled people are of serious concern. Being out of work increases the risk of poverty and social exclusion, which may further damage the health of these groups, exacerbating health inequalities. Macro-level policies have a potentially tremendous impact on their employment chances, and these influences urgently need to be understood as the current economic crisis intensifies. In Part I of this two-part study, the authors examine employment trends for people who report a chronic illness or disability, by gender and educational level, in Canada, Denmark, Norway, Sweden, and the United Kingdom in the context of economic booms and busts and deindustrialization. People with the double burden of chronic illness and low education have become increasingly marginalized from the labor market. Deindustrialization may have played a part in this process. In addition, periods of high unemployment have sparked a downward trend in employment for already marginalized groups who did not feel the benefits when the economy improved. Norway and Sweden have been better able to protect the employment of these groups than the United Kingdom and Canada. These contextual differences suggest that other macro-level factors, such as active and passive labor market polices, may be important, as examined in part II.

How do macro-level contexts and policies affect the employment chances of chronically ill and disabled people? Part II: The impact of active and passive labor market policies.

The authors investigate three hypotheses on the influence of labor market deregulation, decommodification, and investment in active labor market policies on the employment of chronically ill and disabled people. The study explores the interaction between employment, chronic illness, and educational level for men and women in Canada, Denmark, Norway, Sweden, and the United Kingdom, countries with advanced social welfare systems and universal health care but with varying types of active and passive labor market policies. People with chronic illness were found to fare better in employment terms in the Nordic countries than in Canada or the United Kingdom. Their employment chances also varied by educational level and country. The employment impact of having both chronic illness and low education was not just additive but synergistic. This amplification was strongest for British men and women, Norwegian men, and Danish women. Hypotheses on the disincentive effects of tighter employment regulation or more generous welfare benefits were not supported. The hypothesis that greater investments in active labor market policies may improve the employment of chronically ill people was partially supported. Attention must be paid to the differential impact of macro-level policies on the labor market participation of chronically ill and disabled people with low education, a group facing multiple barriers to gaining employment.

How equitable is vocational rehabilitation in Sweden? A review of evidence on the implementation of a national policy framework.

PURPOSE: Under the national framework law in Sweden, all eligible people should have equal chances of receiving vocational rehabilitation. We aimed to review the evidence on (1) whether access to vocational rehabilitation is equitable in practice and (2) whether the outcomes vary for different groups in the population. METHOD: Systematic review of studies in Sweden that reported diagnostic or socio-demographic characteristics of people offered or taking up rehabilitation programmes and outcomes of such programmes for different diagnostic and socio-demographic groups. Searches of 11 relevant electronic databases, 15 organisational websites, citation searching and contact with experts in the field, for the period 1990-2009. RESULTS: A total of 11 studies were included in the final review, six of which addressed review question (1) and seven addressed review question (2). All the six observational studies of access reported biased selection into vocational rehabilitation: greater likelihood for men, younger people, those with longer-term sick leave, those with lower income, employed rather than unemployed people and those with musculoskeletal and mental disorders or alcohol abuse. Having had a rehabilitation investigation also increased the likelihood of receiving vocational rehabilitation. Differential outcome of rehabilitation was reported in seven studies: outcomes were better for men, younger people, employed individuals, those with shorter sick leave and those with higher income. Selection into vocational rehabilitation was perceived as important for successful outcomes, but success also depended on the state of the local labour market. CONCLUSIONS: There is evidence of socio-demographic differences in access to and outcomes of vocational rehabilitation in Sweden, even though the national framework law is meant to apply to everyone. Few studies have deliberately measured differential access or outcomes, and there is a need for this kind of equity analysis of population-wide policies. Studies evaluating the effects of vocational rehabilitation must consider selection into the programmes for adequate interpretation of impact results.

To what extent have relaxed eligibility requirements and increased generosity of disability benefits acted as disincentives for employment? A systematic review of evidence from countries with well-developed welfare systems.

BACKGROUND: Reductions in the eligibility requirements and generosity of disability benefits have been introduced in several Organisation for Economic Cooperation and Development (OECD) countries in recent years, on the assumption that this will increase work incentives for people with chronic illness and disabilities. This paper systematically reviews the evidence for this assumption in the context of well-developed welfare systems. METHOD: Systematic review of all empirical studies from five OECD countries from 1970 to December 2009 investigating the effect of changes in eligibility requirements or level of disability benefits on employment of disabled people. RESULTS: Sixteen studies were identified. Only one of five studies found that relaxed eligibility was significantly associated with a decline in employment. The most robust study found no significant effect. On generosity, eight out of 11 studies reported that benefit levels had a significant negative association with employment. The most robust study demonstrated a small but significant negative association. CONCLUSION: There was no firm evidence that changes in benefit eligibility requirements affected employment. While there was some evidence indicating that benefit level was negatively associated with employment, there was insufficient evidence of a high enough quality to determine the extent of that effect. Policy makers and researchers need to address the lack of a robust empirical basis for assessing the employment impact of these welfare reforms as well as potentially wider poverty impacts.

Interference between work and outside-work demands relative to health: unwinding possibilities among full-time and part-time employees.

BACKGROUND: Demands from work and home may interfere with one another and the stress engendered by that can be detrimental to health. PURPOSE: To study the relationship between experienced interference and subjective health, and address the impact of unwinding on these associations. METHOD: Questionnaire data from a representative sample of the Swedish population are used considering full-time and part-time employed women and men aged 25-64. The associations between negative interference (either work-home or home-work) and sleep quality, self-rated health, and the use of sleeping pills/tranquillizers are analyzed by means of logistic regressions, compiling odds ratios (ORs) with 95% confidence intervals (CIs). The impact of adjustment for lack of unwinding on these associations is assessed. RESULTS: Work-home interference is associated with suboptimal sleep quality and self-rated health for both women and men. The significance of this disappears among women after adjustment for lack of unwinding, regardless of work schedule. Among both sexes, home-work interference is associated with suboptimal sleep quality and self-rated health. When adjusting for lack of unwinding, the relationship to sleep quality disappears, but not the one to self-rated health, equally for women and men. CONCLUSION: Only among women, unwinding seems to buffer the association between work-home interference and health.

Unemployment and early cause-specific mortality: a study based on the Swedish twin registry.

OBJECTIVES: We investigated the association between unemployment and early cause-specific mortality to determine whether the relationship was modified by other risk indicators. METHODS: Female and male twins (n=20632) were followed with regard to mortality from 1973 through 1996. Questionnaire data from 1973 were used to obtain information on experience of unemployment and on social, behavioral, health, and personality characteristics. RESULTS: Unemployment was associated with an increased risk of suicide and death from undetermined causes. Low education, personality characteristics, use of sleeping pills or tranquilizers, and serious or long-lasting illness tended to strengthen the association between unemployment and early mortality. CONCLUSIONS: An increased risk of death from external causes implies a need for support for those experiencing unemployment, particularly susceptible individuals.