Unemployment and young people's health

Stephen L Morrell, Richard J Taylor and Charles B Kerr

Morrell, Taylor and Kerr, from the University of Sydney's Department of Public Health, review the evidence of an association between unemployment and psychological and physical ill-health in young people aged 15-24 years. Aggregate data show youth unemployment and youth suicide to be strongly associated. Youth unemployment is also associated with psychological symptoms, such as depression and loss of confidence. Effects on physical health have been less extensively studied; however, there is some evidence for an association with raised blood pressure. Finally, the prevalence of lifestyle risk factors (cannabis use and, less consistently, tobacco and alcohol consumption) is higher in unemployed compared with employed young people. (MJA 1998; 168: 236-240)

Introduction - Health outcomes and determinants - Is there a remedy? - References - Authors' details
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Introduction	The postwar boom of 1953-1974 in Australia, when a family could be supported on a single income, inflation was low, and unemployment rates varied between 1% and 5%, was the exception rather than the rule of 20th- century economic life. During every other period of this century between 6% and 10% of the workforce has been without a job.1 From 1966, when the Australian Bureau of Statistics began collating age-specific unemployment rates, until about the mid 1970s, younger and older age groups tended to have about the same unemployment rates, except for 15-19 year olds, whose rates have been consistently higher.2 From the mid 1970s, unemployment rates for people in their early 20s, and, by the 1980s, people in their late 20s to early 30s, also began to surpass those for older age groups; by the 1990s high unemployment affected also the oldest age groups (55 years), leaving those 35-54 years the least affected.2 High youth unemployment rates are not simply an artefact of the shrinking pool of 15-19 year olds in the labour market because of greater involvement in further education and training; the official rate in men aged 20-24 years also remains high (15% in July 1997).3 During the 1980s and 1990s unemployment in youth (15-24 years) approached 30%-35%, and in some parts of Australia, such as the Illawarra-Wollongong Statistical District in 1992, official male youth rates exceeded 40%.4 Here, we examine the evidence for unemployment contributing to ill-health in young people (15-24 years of age) (as Mathers and Schofield have done for adults5) and address some of the methodological issues in youth unemployment and health research. The broader effects of unemployment (eg, relationship or family breakdown, income loss or resort to crime) are beyond the scope of our review. These may act as intermediate factors between unemployment and health outcomes. Also, possible effects of unemployment rates on populations are not necessarily the same as their effect on individuals. High unemployment rates can lead people into, for instance, taking jobs they may not like, or, conversely, an individual's experience of unemployment may be ameliorated by living in an area where this has been the norm historically, or worsened where it is the exception. We define unemployment, as distinct from non-employment, as being without paid work, seeking work, and in a position to accept a job if one is offered, in line with official definitions of unemployment.6 The effects of unemployment on health are examined in the categories suicide and parasuicide (attempted suicide), psychological disturbance, physical health, and adverse risk factors for health. We conducted literature searches using MEDLINE and the PsychInfo databases, supplemented by references in key publications.
Health outcomes and determinants	Parasuicide and suicide Some of the strongest evidence for an association between unemployment and parasuicide (attempted suicide) comes from a study of parasuicide rates in men over 15 years of age in Edinburgh between 1968 and 1982.7 Data on admissions to a treatment centre for poisoning were used to estimate relative risks for parasuicide among unemployed compared with employed men. The relative risk estimates for different years ranged from 9.5 to 25. A strong linear association was found between unemployment duration and relative risk of parasuicide. A study of self-poisoning and self-injury among youth in Oxford found unemployment to be a significant contributing factor in men, along with alcohol and drug abuse, but in women it was relationship break-up.8 Very few psychiatric disorders were reported. A strong secular correlation between aggregate data on suicide and unemployment in Australian men aged 20-24 years, both directly9 and especially in relative terms,10 has been shown to have existed since annual age-specific unemployment figures were first available in 1966. The ratio of suicide rate in men aged 20-24 years to the overall male suicide rate is highly correlated (r=+0.9) with the ratio of the unemployment rate for men in this age group to the overall unemployment rate. This relationship does not apply to women, and remains just as strong up to 1996 as when first reported (Figure).11 Relationships based on aggregate data provide evidence for association, not causation. Moreover, secular associations at the national level break down when smaller geographic areas are analysed (eg, time trends in Scottish suicide rates at regional levels were found not to correlate with corresponding time trends in unemployment levels, despite significant secular correlations at a national level).12 A study in Victoria found higher male suicide rates in non-metropolitan regions with higher levels of unemployment, although it was claimed that a general rise in unemployment was not accompanied by an increase in the suicide rate.13 Biochemical models of mental illness and social factors influencing mental health are sometimes seen as counterposed hypotheses.14 While biological pathways are necessary for relating social phenomena to health outcomes, they are intervening variables, and do not explain the epidemiological variability of suicide rates. Claims have also been made that psychiatric illness is a factor in almost all youth suicides;15 however, previous population-level psychological autopsy studies do not support this.16 There is no population-based evidence specific to contemporary youth in Australia to base these claims on. Psychological disturbance Cohort studies of psychological health and youth unemployment have found deficits in the psychological well-being of unemployed young people, but these are less severe and in some cases different from those experienced by unemployed adults.17,18 For example, an Australian study found that unemployed middle-aged adults had significantly higher levels of psychological disturbance (as measured by the General Health Questionnaire) and lower levels of life satisfaction, but more job involvement, than young unemployed counterparts. However, perceived levels of social support were lower than in younger people.18 Australian cohort studies in the 1980s and 1990s found psychological morbidity associated with unemployment in previously psychologically healthy young people, including school leavers.19 Self-esteem, particularly among school leavers, has been shown to be lower in unemployed and underemployed young people, compared with those in full-time employment, after controlling for known confounders such as job satisfaction, education levels and aptitude, sex, ethnicity, and geographic location.20 One of the largest Australian cohort surveys of young people, the Australian Longitudinal Survey (ALS) of youth (16-25 years of age), conducted by the Federal Department of Employment, Education and Training during the mid to late 1980s, provided evidence for unemployment being causally linked to a 50% increase in risk of psychological disturbance,21 as measured by the 12-item psychological component of the General Health Questionnaire. Respondents were chosen for analysis in such a way as to minimise a "selection effect" from illness predisposing to unemployment. Survey participants analysed had been employed formerly, had no pre-existing psychological morbidity or physical illness, and reported no other life event or situation to account for their psychological disturbance. Psychologically well young men who became unemployed reported feeling unhappy and depressed, whereas young women reported loss of confidence; both complained of not having a useful role in their lives. A reverse of the effect was also found; that is, those who initially were psychologically disturbed and unemployed had similar odds of recovery from psychological disturbance at the succeeding survey point, if by that time they had gained employment, as those who developed psychological disturbance because of unemployment.21 In this particular cohort survey, finding a job was the only consistently effective means of recovery from psychological disturbance. The symmetry of this effect has implications for arguments about the direction of causation between unemployment and psychological disturbance. If the association were solely due to psychologically disturbed individuals self-selecting into unemployment, then re-employment of those who are unemployed and psychologically disturbed would not be associated with recovery from psychological disturbance. That recovery has been shown to occur, and that increased psychological disturbance was associated with job loss, suggest that the psychological health of young people is strongly influenced by their employment status. A number of longitudinal studies of psychological health in youth and unemployment duration have produced conflicting findings. While no evidence of an effect of duration of unemployment was found in the ALS study quoted above,21 a South Australian study in the late 1980s found that psychological ill-health in unemployed youth worsened significantly after nine months of unemployment.22 The effects of unemployment may also have a more generalised influence on the psychological health of populations; that is, the unemployment rate, not necessarily the individual experience of unemployment, could be indirectly responsible for individual psychological ill-health. For example, high unemployment levels can force more people to accept unfavourable working conditions or jobs they would rather not do. An Australian study by Graetz, using data from the ALS, found higher rates of psychological disturbance in employed young people who did not like their job compared with those who did.23 A similar finding emerged from the 10-year cohort study of South Australian school-leavers. Each year young people who were dissatisfied with their jobs were just as psychologically disturbed as those who were unemployed.24 High levels of unemployment also influence job security. The psychological effect of job insecurity on youth was investigated in the United Kingdom.25 Unemployed young people and young people on Youth Opportunity Schemes (YOS) (who are placed either on specific projects or in temporary work with employers) were compared with employed apprentices; the Beck Depression Inventory and the Eysenk Personality Inventory were used. Young people on specific projects were more disillusioned than the temporary work placement youths, but all the YOS participants showed similar feelings of fatalism to the unemployed group (ie, insurmountable outside forces leading to perceived lack of control causing stress), but these feelings were not present in the employed apprentices. This has obvious implications for "work-for-the-dole" schemes and, more generally, for those employed in temporary, or "stop-gap", jobs compared with jobs with some measure of security. Physical health Links between unemployment and various physical symptoms have been documented in cohort studies of adults, and similar physical effects may occur in unemployed young people, but there are few cohort studies of youth. In Australia, the cross-sectional National Health Survey (1989-90) noted that young unemployed people reported fair to poor health (about 65% for men and about 80% for women), and serious chronic illness (62% for males and 35% for females) significantly more often than employed people.26 A five-year prospective study of school leavers (n=1083) in the industrial town of Lulea (northern Sweden) showed evidence of cardiovascular effects of unemployment on youth. The mean increase in systolic blood pressure in long-term unemployed young men was significantly higher than in those who experienced short-term or no unemployment during the study period. No significant differences in diastolic blood pressure were found, and these differences were not found in women.27 A longitudinal study of Irish youth found that unemployed men, but not women, carried less mean body fat compared with those who were employed. The same study found that respiratory function was significantly lower in unemployed women (but not in unemployed men) than those employed.28 These effects could have been due to poverty and undernutrition in the men rather than unemployment, or may have resulted from poverty due to unemployment. A higher prevalence of smoking among unemployed women, possibly related to their unemployment, may have been responsible for their poorer lung function. Despite evidence of an association, the evidence for unemployment actually causing physical ill-health in youth is not strong and, where this exists, factors associated with unemployment, rather than unemployment itself, could also be responsible. Adverse risk factors for health Results of youth unemployment studies and risk factors for health have not been as consistent as those in adults. A Norwegian prospective study of 17-20 year olds (n approx. equal 2000) found higher rates of cannabis use, but not alcohol consumption, among unemployed than employed young people.29 Another study found a positive association with smoking: the odds ratio of taking up smoking among the long-term unemployed (> 20 weeks) was significantly higher than in those with little or no unemployment -- by 50% in men and 100% in women (after adjusting for initial smoking status, socio economic background and education level).30 A study of young people in Scotland (n=1036) found the rate of illegal drug use to be significantly, but weakly, correlated with duration of unemployment, but not alcohol or tobacco use.31 A larger British longitudinal study of young adults found the odds of heavier drinking in young men to be 38% higher among those unemployed for six months or more during the study period compared with those who were not. The same study found that teenage drinking was not significantly associated with subsequent employment experience.32 These cross-sectional studies show an association between unemployment, illicit drug and alcohol use, but do not provide evidence for causation.
Is there a remedy?	In searching for a remedy for ill-health in young unemployed people it is necessary to look first at whether a "selection effect" is operating -- young people becoming unemployed because of ill-health (Box 1) -- and then to consider the mechanisms by which unemployment could lead to ill-health. Many mechanisms are probably involved in unemployment leading to ill-health in young people: it has a direct material impact on their lives and lifestyles through curtailment of activities, a reduction in disposable income and absence of the social and psychological effects of being in the paid workforce. Sociocultural and psychological moderating and intervening factors, including isolation and perceived lack of purpose in life, can accentuate suicide and parasuicide risk and lead to risk-taking behaviours, with some level of morbidity or even death (accidental injury or poisoning) as a consequence. Health providers, and the health sector, are now, increasingly, focusing on the health needs of the unemployed, and some of the possible strategies are outlined by Harris et al in the final article in this series (MJA 1998; 16 March).36 As with many public health problems, however, solutions often come from outside the domain of health services, although the health sector often plays a large role in advocating such changes. In the past, most public health measures have involved technical or engineering solutions (such as clean water and sewage treatment facilities, immunisation, automobile seat belts), but there is a great deal more inertia when the health problems are the result of direct effects of economic (dis)organisation, and where there is no simple technical magic bullet. As a public health problem whose solution is external to the health system, unemployment challenges health professionals and public health officials either to advocate an economic solution to the problem, or to limit advocacy to more "band-aid" measures (eg, more counselling, more education, more health resources). The young might reply that all they want (and should expect) is a decent job, especially if they are told that they are expected to work. Another approach is to keep young people in the education system for longer, but this still does not address the underlying problems and only delays the inevitable because eventually they must find employment. The financial restructuring of the mid 1980s, although temporarily reducing the unemployment rate a little, also entrenched the trend towards income polarisation which began with the first oil price "shock" of 1974. The income gap between rich and poor has increased since, as has concentration of wealth in the hands of the rich, and it appears that this situation will only worsen as further harsh monetary policies, public sector depopulation, privatisation of essential services, and massive corporate "downsizing" proceed.37 What specifically economic solutions can be advocated? An eminently supportable employment measure is a program of much-needed public investment to maintain and expand physical and social infrastructure which has been left to decay for two decades, and which has not even kept abreast of population increases. Certainly, tightening the income tax system and closing off tax havens is also worthwhile, particularly as Australia is a low tax country compared with many other OECD countries. The most important aspect of the problem, however, is productivity (Box 2). Because there have not been reductions in the working week to match productivity gains to share the work around, youth in the final quarter of the 20th century have paid the price by enduring Depression-level unemployment rates which appear to have had an unfavourable impact on their physical and psychological health.
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Authors' details

Reprints will not be available from the authors.
Correspondence: Mr S L Morrell, Department of Public Health and Community Medicine, University of Sydney, Sydney, NSW 2006.

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