Results

Table 2 shows the distribution of type of employment and health outcomes by country. Workers employed with full time permanent contracts represented almost 56% of all jobs while part time permanent contracts accounted for almost 14%, sole traders (full and part time together) and workers with precarious contracts (that is, all fixed term and temporary contracts) showed about 12% each, and small employers accounted for only 6% of the total. In Germany, Luxembourg, and the Nordic countries between 60% and 70% of the sample was in full time permanent employment, whereas small employers and full time sole traders accounted for small percentages of the total (2.5–7.5%). Greece and Spain showed especially low levels of full time permanent employment. In Greece there was a high percentage of small employers and sole traders, and in Spain, a large percentage of the sample was in precarious employment. The health outcomes investigated also varied by country. The worst outcomes were found in Greece, Spain and Portugal while low percentages for most outcomes were observed in Ireland, Belgium and Netherlands.

The distribution of health indicators by employment for the 15 countries combined is presented in table 3. Overall, persons in precarious employments had higher rates of job dissatisfaction, fatigue, backache and muscular pains than those in permanent employment. On the other hand, reported percentages of absenteeism and stress were generally higher in those with permanent employment than in those with precarious employment. Small employers reported high percentages of stress and fatigue, but absenteeism was relatively low. Sole traders generally reported high percentages of all outcomes, except for absenteeism, which was low. For each type of employment (except temporary contracts), full time workers tended to report worse health outcomes than part time workers. Among persons in temporary contracts, differences between part time and full time workers in health outcomes were not consistent for the six indicators studied.

Age and gender adjusted odds ratios (OR) for each indicator by type of employment are shown in figure 1. Patterns observed after age and gender adjustment were generally consistent with the patterns described above for unadjusted proportions. Sole traders and employees in precarious employment (fixed term and temporary contracts) were more likely to report job dissatisfaction than full time permanent workers. The strongest associations were observed for temporary workers (part time OR 2.52 95% CI: 1.79, 3.55) full time OR 2.25 95% CI: 1.70, 2.97). With the exception of full time fixed term contracts, all types of employment showed significant lower levels of absenteeism than permanent full time contracts with ORs ranging from 0.45 (95% CI: 0.33, 0.61) for part time sole traders to 0.87 (95% CI: 0.77, 0.98) for part time permanent employments. Findings for stress were somewhat inconsistent: small employers and full time sole traders were significantly more likely than full time permanent workers to report increased stress, whereas part time sole traders, fixed term contracts and temporary contracts were significantly less likely to report stress.

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Figure 1

Age and gender adjusted odds ratios (and 95% CI) of each outcome by employment categories (full time permanent employment as the reference category).

Significantly higher levels of fatigue were documented for small employers (OR: 1.55; 95% CI: 1.32, 1.81), full time sole traders (OR: 1.67; 95% CI: 1.47, 1.89), full time fixed term workers (OR: 1.44; 95% CI: 1.23, 1.69), and full time temporary workers (OR: 1.42; 95% CI: 1.07, 1.86). Full time sole traders, full time temporary workers, and full time fixed contract workers were also more likely to report backache and muscular pain than permanent full time workers (OR ranging from 1.18 to 1.66). Additional adjustment for the other individual level variables investigated (see table 1) did not substantially change these results (data not shown). Patterns for four employment categories (permanent, precarious, small employers and sole traders) were approximately similar across countries (results not shown).

The country level variables investigated were significantly heterogeneous across countries: unemployment varied from 2.9% for Luxembourg to 23% for Spain, social protection benefits varied from 15.5% for Greece to 40% for Sweden, Gross National Product per capita ranged from 11 710 ppp for Greece to 37 930 ppp for Luxembourg, and temporary contracts varied from 6% for Belgium to 33% for Spain. Countries with high percentages of unemployment and temporary contracts and low percentages of social protection benefits and Gross National Product presented the highest percentages of precarious employment.

In multilevel models there was evidence of significant variation in intercepts (after controlling for type of employment and individual level variables) and in slopes associated with precarious employment across countries for the indicators studied. However, there was no consistent evidence of a contextual effect of country variables on the outcomes or of interaction between precarious employment and the country level variables studied. Associations of precarious employment with the outcomes remained virtually unchanged after adjustment for country level variables. Figure 2 shows OR of the indicators of interest in precarious compared with permanent employment before and after adjustment for age, gender, and country level variables. Additional adjustment for other individual level variables did not substantially modify the results.

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Figure 2

Odds ratios (and 95% CI) of each outcome in precarious compared with permanent employment, adjusted for individual level (age and gender) and coutry level variables (unemployment, social protection, Gross National Product, and temporary contracts).

Discussion

This study is the first to examine the relations between various types of employment and six health related indicators for all 15 member states of the EU. As the Second European Survey on Working Conditions was not specifically designed to assess the associations between types of employment and health indicators across countries, findings are preliminary and should be considered with caution.

A number of potentially important methodological limitations should be considered in interpreting our results. Firstly, this study has faced the problems inherent in many large scale international comparative studies with limited resources. Sample sizes in individual countries were not very large and response rates showed a large amount of variation (ranging from 35% in Denmark to 81% in Austria). This limited our ability to conduct country specific analyses. Secondly, the health related indicators available were necessarily crude measures, as were many of the individual level covariates. For example, job satisfaction is not a direct measure of health status, and health-absenteeism may be a poor proxy for health outcomes. The remaining health indicators were measured with very simple and crude indicators. The use of these measures may have limited our ability to detect significant associations. Likewise, measurement error in the individual level covariates may have limited our ability to control for these variables in adjusted analyses. Thirdly, there is no strong guarantee that the different types of employment categories were similar in the different countries and no agreement on the use of types of employment categories has been reached among researchers.

Four major dimensions have been mentioned in the process of defining precariousness: unstable jobs, low work control, low social or legal protection, and low income levels.23 According to the European Foundation, which defined precarious workers as those who felt insecure about their job or had a temporary or fixed term contract, almost 30% of European employed workers were in a precarious work situation.24 We used a more restrictive definition that only included those with temporary or fixed term contracts, which comprises 12.5% of total employment in the EU and 15% of paid employment. However, no studies have assessed the homogeneity of these categories across countries. This misclassification of employment category (if non-differential) may have biased our estimates towards the null. It is also important to note that the health effects of different types of employment categories may differ by gender. However, gender differences were not specifically examined in these analyses. Finally, because of its cross sectional nature, this study cannot firmly establish causal relations, and the “reverse causation” hypothesis cannot be categorically ruled out.

Despite its limitations, our study did find suggestive patterns worthy of further exploration. Job dissatisfaction was consistently and positively associated with precarious employment while absenteeism and stress were generally negatively associated with precarious employment. Fatigue, backache and muscular pains also tended to be positively associated with precarious employment, particularly with full time precarious employment. Sole traders and small employers generally showed adverse indicators but low absenteeism. Associations between types of employment and health indicators almost always persisted after adjusting for several working condition variables at the individual level. Our ability to examine covariates related to the work environment as mediators or confounders of the associations observed is limited by the measures of these variables available. However, to the extent that we could adequately control for them, our findings suggest that employment contracts may have an independent effect on selected indicators of perceived health independently of the working conditions we measured. In addition, full time workers generally reported worse health outcomes than part time workers except for those in temporary contracts. This finding is consistent with the fact that part time work in permanent employments may have been chosen voluntarily whereas part time work that goes with unstable employment may add to work insecurity and to ill health.

It is interesting to consider how the patterns observed for the six outcomes studied are interrelated. Various studies have pointed out that sickness absence may reflect not only physical health, but also an employee's perception of his or her health—that is, that it can be thought of as a coping behaviour in response to illness (a subjective state, a psychological awareness of dysfunction) rather than physical disease.25 26 In our analyses, self perceived health was not directly associated with work absenteeism. Overall, permanent employments presented low levels of job dissatisfaction and health problems (that is, fatigue, backache and muscular pains) and moderate levels of stress, but absenteeism was high. This finding, which is likely to be attributable to the definition of absenteeism used in the Survey, deserves further exploration. A recent European report showed a large variation in absenteeism across countries, which may partly be attributable to its different definition across countries.27

In contrast, despite showing high levels of adverse health indicators, sole traders and small employers reported low levels of absenteeism. Previous research conducted in a population of non-industrial civil servants, where the overwhelming majority of workers were permanent, reported a strong inverse association between sickness absence and grade of employment and identified high levels of job dissatisfaction as one of the risk factors involved.25 28 We found that precarious workers, presented both high levels of job dissatisfaction and low levels of absenteeism. Although no definitive explanations can be put forward for these findings at this point, differences in job security may obviously play an important part in explaining these differences.

We also found that reported job dissatisfaction and reported stress followed quite opposite patterns in most employments. For example, precarious workers showed high levels of job dissatisfaction and low stress, while small employers reported low job dissatisfaction but high levels of stress. Although reasons for these differences are unclear, the unexpected association of low control with low reported stress documented in a previous report based on these data14 may help explain the opposite patterns observed for job dissatisfaction and stress. These issues need to be investigated further in studies with more rigorous measurements.

Cross country comparisons of the associations are difficult for several reasons: firstly, the meaning and characteristics of the employment categories may differ for each country; secondly, different degrees of selection bias may be present from country to country because of differences in response rates; and thirdly, the country specific relations between employment and health could not be studied for the full nine categories because of sample size limitations. Nevertheless, to the extent that it could be investigated, relations between the four employment categories and health were generally similar across countries. There was no evidence that country level variables modified the effects of precarious employment. Moreover, associations between employment categories and the health indicators remained virtually identical after country level variables were included in the models as main effects, suggesting that types of employment are related to the outcomes independently of these country level variables. However, because the number of countries available for analysis was small (15), a limited number of country level variables were available, and data on other (and perhaps more pertinent) geographical areas (such as regions) were unavailable, we cannot conclude from these results that country level or regional characteristics related to economic conditions and social policy do not modify the relation between type of employment and health outcomes.

The global economy is generating a new set of job insecurities for workers. As the frontier between precarious employment and unemployment is becoming blurred, research needs to move away from the comparison of unemployed versus employed towards a more dynamic characterisation of unemployed and underemployed workers versus workers with stable jobs. Although underemployment and precarious employment share some of the characteristics of unemployment, and it seems plausible that they could produce similar adverse effects on health, information on the potential impact of underemployment on health is very limited.2

To our knowledge this is one of the first studies to examine the associations of various types of employment with a series of health related indicators. However, our findings need to be refined and replicated before they are taken as causal evidence. Studies with improved measurement and more specific hypotheses are needed. We suggest that future research in this area should take into account the following issues: the need to use a standardised definition of the categories of underemployment, the need to diversify, standardise and improve the health indicators examined, the need to implement more potent epidemiological designs that integrate individual and ecological variables, and the need to include information on social security systems, incapacity benefit schemes, and other socioeconomic features at the country or regional level. The study of the potential effects of underemployment and precarious employment on health is a public health need and a challenge for researchers.