Future uncertainty and socioeconomic inequalities in health: the Whitehall II study

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Abstract

Over the past 20 years, socioeconomic inequalities in mortality have widened, while job security and financial security have decreased. This paper examines the Whitehall II study, a longitudinal study of white-collar British civil servants. In the Whitehall II cohort socioeconomic gradients in morbidity and cardiovascular risk factors at Phase 5 (1997–99) were generally steeper than at Phase 1 (1985–88). We examine the contribution of job and financial insecurity to these at Phase 5 in 6770 women and men, all of whom were white-collar civil servants at Phase 1. Steep, inverse employment grade gradients were observed for all health measures at Phase 5, except cholesterol and systolic blood pressure in women. Gradients in the sub-population of non-employed participants tended to be steeper than gradients for participants in employment, although, with the exception of self-rated health and General Health Questionnaire (GHQ) score in men, differences were non-significant. Steep gradients in job insecurity were observed among employed participants (p⩽0.01), and in financial insecurity among both employed and non-employed participants (p⩽0.001), particularly non-employed men. With the exception of depression, adjustment for job insecurity had little effect on the employment grade gradients in morbidity. However, financial insecurity contributed substantially to gradients in self-rated health, longstanding illness, and depression in both employed and non-employed men, and additionally to GHQ score and diastolic blood pressure in the latter. Adjustment for financial insecurity in non-employed women substantially attenuated gradients in self-rated health, GHQ score and depression. These findings imply that the specific effects of job insecurity in this cohort may be less important than the more general effects of financial insecurity in determining inequalities in health.

Introduction

Over the past 20 years, against a backdrop of overall declines in mortality rates, analyses of population data have shown that the social gradient in mortality in the United Kingdom (UK) has increased (Acheson, 1998, Shaw, Dorling, Gordon, & Davey Smith, 1999). However, although socioeconomic gradients in various measures of morbidity are well documented (Acheson, 1998, Marmot, et al., 1991, Erens & Primatesta, 1999), there has been relatively little research examining trends in these measures over time. Most of the evidence to date has concentrated mainly on traditional risk factors for cardiovascular disease and indicates that socioeconomic differences are static or narrowing (Bartley, Fitzpatrick, Firth, & Marmot, 2000, Iribarren, Luepker, McGovern, Arnett, & Blackburn, 1997, Vartiainen et al., 1998, Bennet, 1995, Osler et al., 2000).

Steep socioeconomic gradients in measures of morbidity and cardiovascular risk factors have long been demonstrated in the Whitehall II study, a longitudinal cohort of white-collar British civil servants, in which socioeconomic position is assessed by grade of employment (Marmot et al., 1991). Over 11 years follow-up of the Whitehall II cohort up to 1998, inequalities in health between those in the lowest employment category and those in the highest have widened slightly and marked increases in the gradient have been documented in minor psychiatric morbidity in both sexes and cholesterol in men (Ferrie, Shipley, Davey Smith, Stansfeld, & Marmot, 2002).

Additionally during the 1980s and 1990s in the UK, patterns of employment, job security and welfare provision associated with the social order since the second world war have undergone and continue to undergo major change. The future, for many people, is less certain than it used to be (Sennett (1994), Hutton (1995) Sennett, 1998).

Two markers of future uncertainty have previously received some attention in relation to health; job insecurity and financial insecurity. Self-perceived job insecurity has been shown to be associated with increased mental and physical ill-health (Platt, Pavis, & Akram, 1998, De Witte, 1999, Ferrie, 2001) and there is evidence from Finland that it is inversely associated with socioeconomic position (Kinnunen & Natti 1994, Lynch, Kaplan, & Salonen, 1997). In addition, job insecurity attributed to workplace closure and downsizing has been shown to be associated with increased psychological morbidity, self-reported ill-health, long spells of sickness absence and health service use (Ferrie, 2001).

A considerable body of work has documented the deleterious effect of unemployment-related financial strain on health, particularly psychological health (Warr, Banks, & Ullah, 1985, Kessler, Blake Turner, & House, 1987, Ensminger & Celentano 1988, Whelan, 1992). However, little work has examined the wider role of financial insecurity. Research to date shows poor financial security to be associated with minor psychiatric morbidity (Romans, Walton, McNoe, Herbison, & Mullen, 1993, Jackson, Iezzi, & Lafreniere, 1997) and weight gain (Gerace & George, 1996).

Data on financial insecurity and on job insecurity for the whole cohort were first collected during Phase 5 (1997–99) of the Whitehall II study. The aims of this paper are to determine socioeconomic gradients in job and financial insecurity in the Whitehall II cohort, and the contribution of these to socioeconomic inequalities in morbidity and cardiovascular risk factors at Phase 5.

Section snippets

Participants

The target population for the Whitehall II study was all London–based office staff, aged 35 – 55, working in 20 Civil Service departments. With a response rate of 73%, the final cohort consisted of 10,308: 6895 men and 3413 women (Marmot et al., 1991). Sub–samples of non-responders indicated that approximately 4% of those invited were not eligible for inclusion, suggesting that the true response rate was higher. Although mostly white–collar, respondents covered a wide range of grades from

Results

Data on current employment status was provided by 7197 of those who completed the Phase 5 questionnaire—(Box 1). Overall, just under half of the respondents were still working in the Civil Service. The majority who had left were non-employed, but a sizable minority were employed elsewhere.

Employment grade gradients in morbidity and cardiovascular risk factors: In the whole Phase 5 population steep inverse employment grade gradients were seen for all measures in both sexes (p=0.04 to p<0.001),

Methodological considerations

As employment grade at Phase 1 was used to determine the gradients, our measure of socioeconomic position is not contemporaneous with our morbidity and risk factor measures at Phase 5. Baseline grade was chosen as it is available for all participants, and analyses using last known grade produced findings little different from those using grade at Phase 1 (data not shown). We felt that use of last known grade as the measure of socioeconomic position posed problems. It reflects mobility for those

Acknowledgements

The Whitehall II study has been supported by grants from the Medical Research Council; British Heart Foundation; Health and Safety Executive; Department of Health; National Heart Lung and Blood Institute (HL36310), US, NIH: National Institute on Aging (AG13196), US, NIH; Agency for Health Care Policy Research (HS06516); and the John D and Catherine T MacArthur Foundation Research Networks on Successful Midlife Development and Socio-economic Status and Health.

JF was supported by the Economic and

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