Arch Womens Ment Health (2003) 6: 115126 DOI 10.

1007/s00737-002-0177-8

Original contribution Occupational conditions exceed the importance of non-occupational conditions and ill health in explaining future unemployment among women and men
C. Bildt1 and H. Michlsen2
1 2

Gender and Work, National Institute for Working Life, Stockholm, Sweden Department of Education, Stockholm University, Stockholm, Sweden

Received July 28, 2002; accepted November 20, 2002 Published online January 31, 2003 Springer-Verlag 2003

Summary
Background: Unemployment is relatively common today, but the importance of work characteristics in relation to future unemployment has seldom been studied. Methods: The relation between occupational and nonoccupational factors, as well as ill health, in 1993 and unemployment in 1997 has been examined using an exploratory approach. Both analyses of associations and cluster analysis have been performed. Results: Reduced psychological well-being and some occupational factors mainly related to job insecurity and, among women, also few opportunities for development at work were found to be risk indicators for unemployment later on. To some extent, also earlier unemployment periods predicted unemployment in 1997. The inuence of reduced psychological well-being and earlier unemployment periods on the associations between occupational factors in 1993 and 1997 consisted mainly of a decrease of the inuence of job insecurity. Seven clusters were identied. One of them was male dominated, where the level of unemployment was very high and the individuals had reduced psychological well-being, insecure working conditions and demanding living conditions. The female equivalent was characterised by a high level of unemployment, multi-demands at work and poor musculoskeletal health. Conclusions: Reduced psychological well-being and job insecurity were risk indicators for later unemployment among both genders, as were also few opportunities for development at work among women. These factors predicted unemployment, also when age and other non-occupational factors were taken into consideration. The cluster analysis identied groups of individuals with highly demanding occupational and nonoccupational conditions in 1993 and a high level of unemployment in 1997. Keywords: Analyses of association; cluster analysis; gender differences; gender segregation.

Introduction Unemployment is a reality for many people. Today it is not uncommon that individuals experience one or more periods of unemployment during their working life without being permanently discarded from the labour market. The risk of becoming unemployed in the future is higher for those who have once been unemployed (Arrow, 1996; Westberg, 1998), and the more periods of unemployment, the higher the risk of becoming unemployed again (Korpi, 1998). Of course, to work within a declining industry involves a very high risk of becoming unemployed in the future, such as when the shipbuilding industry in Sweden closed down in the 1970s and many workers were made redundant. Another major risk is when a company cuts down on its activities or implements organisational changes involving reduction of staff. During the last decade, the public sector in Sweden has undergone substantial reorganisation and staff rundowns, not least within the female-dominated health care sector. Parallel to many people losing their jobs, higher demands with regard to working performance were also made on those still employed and there was also a shortage of personnel (AhlbergHultn, 1999). The poorer working conditions within the health care sector have especially affected the lowest educated personnel, mainly women. It should

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be noted that these changes to a large extent have taken place as a result of political decisions, rather than as a consequence of market development (Korpi, 1998). Performing low-qualied work tasks may be a risk factor for unemployment in the future. When such positions are reduced, those performing these jobs may be too poorly qualied to move on to other available positions within the organisation (Westberg, 1998). Also increasing demands for exibility at work, both in terms of working hours and work content, have become a risk factor in terms of unemployment (Westberg, 1998). In this context, certain groups of people are especially vulnerable, for example mothers of young children. The relation between unemployment and health has been extensively discussed and studied, very often focusing on health consequences of unemployment (Bolton and Oatley, 1987; Dew, 1992; Broman et al., 1995; Jin et al., 1995; Leana and Feldman, 1995; Dooly et al., 1996; Goldsmith et al., 1997; Liira and Leino-Arjas, 1999). In some studies, tested hypotheses have been more complex. For example psychological ill health has been analysed both as causal to unemployment and as an effect of poor anchorage in the labour market (Bartley, 1994; Hallsten, 1995; Ross and Mirowsky, 1995; Hammarstrm and Janlert, 1997). Both hypotheses have received support from the results in one of the studies just mentioned (Hallsten, 1995). In other studies, risk indicators for unemployment have been examined, focusing mainly on nonoccupational factors (Leana and Feldman, 1995; Lynd-Stevenson, 1999; Payne et al., 1996; Tuomi, 1994; Temple et al., 1991; Wiener et al., 1999). Factors studied as potential risk indicators for unemployment have been alcohol consumption, smoking, marital status, coping strategies and motivational factors. There are also examples of studies where ill health has been analysed as a potential predictor of unemployment (Arrow, 1996; strand, 1987; Dooly et al., 1996; Jenkins et al., 1982; Mastekaasa, 1996). However, occupational factors have seldom been analysed as potential risk indicators for later unemployment (Liira and Leino-Arjas, 1999; Leino-Arjas et al., 1999). Nevertheless, it could be expected that certain work characteristics can be risk indicators for unemployment, and also that certain characteristics can be protective against unemployment.

Also gender differences as risk indicators for unemployment could be expected, partly because of the gender-segregated labour market and partly because women and men have different living conditions. Only 10 per cent of all women and men in Sweden work within gender-integrated occupations, i.e. where there are 40 to 60 per cent of each gender (Westberg, 1998). Therefore, the working conditions for women and men are very different. Womens working conditions are often characterised by simple, repetitive and monotonous work tasks as well as computer work. Women also stay on in the same position within a company or organisation for many years (Kilbom and Messing, 1998). Mens working conditions are often characterised by heavy lifting, physically high demanding work tasks and vibration. During the second half of the 1990s, temporary employment became more and more common in Sweden, as well as in many other countries (Westberg, 1999). More women than men were offered work as substitutes or extra staff, while more men than women were offered project work or xed-term assignments. The level of qualications required was usually higher in the temporary employment forms that were more common among men. Having temporary employment is related to unemployment later on, as well as being a way of avoiding unemployment for the time being (Korpi, 1998). Life outside work also differs between women and men. For women, more often than for men, a large part of the total daily physical and psychosocial strains derives from activities outside work (Frankenhauser, 1991; Josephson, 1999; Lundberg et al., 1994). Gender differences in health have also been observed to a large extent. Excluding life threatening disorders and symptoms related to the reproductive system, in almost all societies more women than men report poor health and are also diagnosed as having poor health (Messing and Kilbom, 1998). The aim of this study was to assess the relative importance of occupational, non-occupational factors and ill-health conditions in predicting unemployment four years later. Gender differences were of special interest.

Method Study group

In 1969, the so-called REBUS study was undertaken of 2,579 women and men, aged 18 to 65 years, living in the county of Stockholm. The purpose was to investigate a) the need for medical

Risk indicators for unemployment among women and men and social services, b) differences between subgroups of the population in their actual needs for services and c) the steps taken so far to meet these needs (Bygren, 1974). The present study started in 1993, with a follow-up based on the youngest subgroup, between 18 and 34 years of age in 1969 (Bildt Thorbjrnsson et al., 1998). Participants invited to the follow-up in 1993 were under 59 years of age in 1993 and still living in Sweden. They had not had a musculoskeletal diagnosis or any other serious diagnoses in 1969, such as mental retardation or schizophrenia, that could be expected to decrease their chance of maintaining employment. Ofcial registers were used to trace all eligible participants, and only 22 participants could not be reached with the request for participation. Of 783 eligible participants, 484 (62%) nally participated in the follow-up in 1993. Each participant came to the institute for a one-day examination, including interviews and self-administered questionnaires on physical and psychosocial working conditions and musculoskeletal and mental problems. They also underwent laboratory tests for physical capacity and a musculoskeletal examination. The main aim in 1993 was to identify risk indicators for musculoskeletal disorders, and a second aim was to identify risk indicators for poor mental health. From the data collected in 1993, information about occupational and non-occupational conditions, as well as earlier employment status and ill health, has been included in the analyses in the present paper. In 1997, the participants were again approached and asked to participate in a second follow-up, which was completely based on self-administered questionnaire data. The level of participation was high. Almost 87 per cent (88% and 85% among women and men, respectively) of the 484 participants from 1993 participated in the follow-up, resulting in 222 women and 198 men, then between 46 and 63 years of age, in a broad range of occupations. The main aim in 1997 was to examine the predictive value of the physical and psychosocial working conditions in 1993 for musculoskeletal disorders in 1997, and a second aim was to examine the predictive value for poor mental health. From the data collected in 1997, information about current employment status has been included in the analyses in the present paper. In the present paper, the study group consisted of the individuals who participated both in the 1993 study and in the 1997 follow-up, and who were gainfully employed in 1993 (199 women and 174 men), since we wanted to study the relative inuence of occupational factors and other factors, such as poor health, on unemployment. The participants were included in the study after they had been fully informed about all parts of the study and had given their informed consent to participate. The study was reviewed and approved by the Ethics Committee of Human Research at Karolinska Institutet, Stockholm, Sweden.

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expressed as good, quite good, rather supercial, supercial, or meagre. The inter-rater agreement (based on duplicate analyses of tape recordings from 24 interviews, percentage agreement, made by another psychologist) was 85 per cent (Bildt Thorbjrnsson et al., 1999). The participants coping strategies in troublesome situations were evaluated on the basis of psychodynamic theory in the same interview. Each participant was asked to describe one or several difcult situations they had experienced, and also to describe how they had tried to cope with, and to solve, the problems they experienced. The choice of coping strategies was categorised according to its quality, expressed as adequate and mature, adequate but less mature, adequate but weak, depressive, or schizoid/paranoid. The inter-rater agreement was 75%. The cut-off points for non-occupational factors are described in Appendix 2. Low back pain and neck/shoulder pain in 1993 were dened in terms of the subjects having received medical consultation and treatment by a doctor, physiotherapist or chiropractor during the 12 months preceding the follow-up in 1993. Information about symptoms of depression during the 12 months preceding the examination in 1993 was obtained by a psychologist in an interview. The questions posed to the participant during the interview were based on DSM-III-R (American Psychiatric Association, 1987) and included questions about lack of interest, lack of energy, sleeping problems, restlessness, poor self-esteem, poor ability to concentrate, worries and thoughts of suicide. According to the diagnostic manual, a diagnosis of major depression required at least ve symptoms. In the present paper, sub-clinical depression was dened as comprising at least two depressive symptoms at any time during the past year. The inter-rater agreement of the depression estimation (based on duplicate analyses of tape recordings from 24 interviews, percentage agreement) was 90% (Bildt Thorbjrnsson et al., 1999). Reduced psychological well-being was dened as belonging to the highest 75th percentile when answering the General Health Questionnaire (Banks et al., 1980). The denition of high alcohol consumption was based on selfreported consumption of alcohol, expressed as consumed grams of alcohol per week. The denition of high consumption was different for women and men because of gender differences in vulnerability (Rydberg et al., 1993). A consumption of more than 105 g alcohol per week among women, and 140 g per week among men, was considered as a high level of consumption. Demanding life events was dened as the death of a husband/ wife/cohabiting partner or a close friend or relative.

Data analyses
The data included in the analyses in the present paper could be expected to reect important harmful, or protective, aspects of occupational and non-occupational factors in 1993 in relation to unemployment in 1997. In order to get a broad picture of the situation, both a variable-oriented and a person-oriented approach were chosen in the present paper. In the variableoriented approach, the information about occupational and nonoccupational conditions in 1993 was analysed as potential risk indicators for unemployment in 1997. In the person-oriented approach, the data from 1993 was analysed to identify clusters of individuals with similar occupational characteristics.

Data collection procedure

Information about occupational factors in 1993, unemployment earlier than 1993 was collected in 1993 and employment status in 1997 was collected in 1997, by a self-administered questionnaire. The responses to most of the questions about occupational conditions were dichotomised and the cut-off points are described in Appendix 1. The responses to some of the physical and psychosocial questions were included in indices, which are also described in Appendix 1. Information about quality of social contacts and coping strategies was collected in an interview by one psychologist, who estimated the participants ability to maintain social relations with friends and relatives. The participant was asked to describe her/his relations with friends and relatives, both at the time and in the past. Social ability was categorised according to its quality,

Variable-oriented approach
Both bivariate and multivariate analyses of associations have been performed. In the bivariate analyses, age-group-adjusted (4655

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and 5663 years) relative risks (RR) of unemployment in 1997, associated with different occupational and non-occupational factors in 1993, were calculated separately for women and men (using the module PROC FREQ in the SAS statistical software) (SAS, 1989). The precision of the point estimates was estimated by test-based 95% condence intervals (c.i.) (Miettinen, 1976). Only statistically signicant RRs, where at least four cases of unemployment were exposed, were discussed. In the multivariate analyses, age-group-adjusted RRs of unemployment, and multiple occupational and individual factors, were also calculated separately for women and men (modied Cox regression, using the module PROC PHREG in the SAS statistical software) (SAS, 1989). Two separate multivariate analyses were performed for each gender: one where occupational factors that were positively associated with unemployment were included, and another where non-occupational factors (positively related to unemployment in the bivariate analyses) were included in the same multivariate model as the occupational factors. If two factors were highly correlated with each other and therefore could not be included in the same model, the factor that had the largest inuence on the other included factor parameters was kept in the model.

C. Bildt and H. Michlsen clustering process could indicate a suboptimal number of clusters. We also had the criteria that the cluster solution should be interpretable, and that the distribution of unemployment in 1997 should be separated between the clusters. In this case, a 12-cluster solution was chosen with an ESS of 34%. Of these twelve clusters, ve had four or fewer participants (in total 13 individuals) and only the seven largest clusters are presented in the results (the number of included participants ranged from 9195 individuals). The distribution of unemployment in 1997 differed statistically signicantly between the seven largest clusters. Due to the small size of most clusters in this analysis, women and men were included in the same clusters. The proportion of female subjects in each cluster is presented, and will serve as an illustration of gender differences in the material. We expect to nd clusters that are dominated by women or by men, and the characteristics of those clusters will be discussed.

Results No statistically signicant differences regarding occupational and non-occupational conditions and health status between the participants and the dropouts in the 1997 follow-up were found, with the exception of sub-clinical depression among men. Among the dropouts, the prevalence of sub-clinical depression was only 3%, to be compared with 10% among the male participants. When socioeconomic status was compared among the participants and the dropouts, men belonging to the middle and high white-collar group were more common among the participants than among the dropouts (46 % and 29 %, respectively). In 1993 all participants were employed, and in 1997 25 women (11%) and 26 men (13%) were unemployed. The exposure to the various occupational and non-occupational factors, as well as ill health, in 1993 differed between the genders (Table 1). More men than women reported heavy physical workload, and more women than men reported job strain. Also, more men than women reported that they had to make difcult decisions at work. More women than men had neck and shoulder pain, and more men than women had high alcohol consumption. Variable-oriented approach Occupational factors positively associated with unemployment among women (risk indicators) were temporary employment, low occupational pride, few opportunities for on-the-job development, no training at the employers expense and threat of unemployment (Table 2). The equivalent factors among men were temporary employment and threat of unemployment.

Person-oriented approach
Cluster analysis was performed on 14 of the occupational variables of interest in the present paper, with the aim of nding groups with similar working conditions. After the clusters had been determined, the characteristics of the individuals belonging to the clusters were examined, as well as other interesting variables (such as ill-health factors and non-occupational factors). Of special interest in this study, was the distribution in the clusters of the persons who were unemployed in 1997. In other words, the aim of the cluster analysis was to nd out if a person-oriented approach could add anything new to the explanation of the relation between working conditions and unemployment. The analysis was performed with the SLEIPNER statistical package for pattern-oriented analysis developed by El-Khouri and Bergman (1995). In the analysis, where a similarity/dissimilarity measure was used, the measure was the average Squared Euclidean distance calculated on standardised variables. Data reduction was performed in several stages. Since the clustering method requires complete data (no internal loss of data), imputation of data was performed using the twin method (included in the SLEIPNER package). For a participant with missing data, a twin is searched for among the participants with complete data, and dened as the most similar case, measured with average Squared Euclidean distance, with a value of 0.5 as the upper limit for dening the participants as twins. The values imputed by the program are the twin values for these variables. Outliers were dened as having an average Squared Euclidean distance greater than 1.1 to other participants. The cluster analysis was performed on 314 individuals, 161 women and 153 men. Seventeen of the participants had data imputed by the twin method on one or two variables. Fifty-one individuals were excluded from the analysis. Reasons for exclusion were missing values on more than two variables (35), no twin found for cases with missing data (8) and identied as outliers (8). As clustering method, the average linking method was used. This is a hierarchical method, which in each step links together the two clusters whose mean distance between all individuals within the two clusters is the smallest. The number of clusters was chosen according to a recommendation by Bergman (1996), i.e. that a large relative drop in the explained sum of squares (ESS) between two following steps in the

Risk indicators for unemployment among women and men Table 1. Prevalence of exposure to different occupational and nonoccupational factors and of ill health in 1993: per gender Women N 222 Occupational factors Heavy physical workload Sedentary work High perceived workload Full time work Overtime work Shift work Temporary employment Low occupational pride Job strain Difcult decisions Low exibility in work Few possibilities for on-the-job development No education at employers expense Threat of unemployment Non-occupational factors Low frequency of social contacts Poor quality of social contacts Demanding life events High perceived physical load Inadequate coping strategies Earlier unemployment Ill health Low back pain Neck and shoulder pain Sub-clinical depression Reduced psychological wellbeing High alcohol consumption Men N 198

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the model. Both the included non-occupational factors remained associated with unemployment in 1997, also among men. Person-oriented approach

20 31 34 68 31 20 9 19 14 24 25 23 51 6 30 21 23 28 16 11 14 27 9 22 8

28 33 31 86 44 18 3 16 7 43 28 13 53 11 39 26 24 22 19 15 17 16 10 24 15

Among the non-occupational factors, earlier unemployment and reduced psychological well-being were risk indicators for unemployment among both women and men (Table 2). High perceived physical load outside work was also a risk indicator for unemployment among women. In the multivariate analyses, temporary employment and no training remained associated with unemployment among women, and these RRs decreased only slightly (the RR for temporary employment more than for no training) when nonoccupational factors were included in the multivariate model (Table 3). Earlier unemployment periods and reduced psychological well-being remained associated with unemployment in 1997, although the occupational factors were included in the same multivariate model. Among men, only temporary employment remained associated with unemployment in 1997, and the RR decreased considerably when earlier unemployment periods and reduced psychological well-being were included in

The individuals in the seven clusters represent very different occupational characteristics (Fig. 1). The largest cluster, cluster 7, was characterised by mixed and physically light work and a low degree of unemployed participants (Fig. 1). The smaller clusters differed to a lesser or greater extent from the largest cluster, both regarding occupational characteristics and the level of unemployment. The high risk cluster, cluster 1, where the level of unemployment was 40%, was characterised by very insecure working conditions and demanding living conditions, and was a predominantly male cluster. The female equivalent, cluster 3, was characterised by multidemands at work (both physical and psychosocial demands), an unemployment level of 12% and poor musculoskeletal health. A cluster with an unemployment level of 14%, cluster 2, was characterised by both physically demanding working conditions and very demanding living conditions. In this cluster, the gender distribution was more even. Also in cluster 4 and 5, the gender distribution was more even, but the characteristics at work differed, and the level of unemployment was nine and six per cent, respectively. In cluster 4, the work was characterised by high physical and psychosocial demands, few opportunities for development at work, and demanding living conditions, as well as poor health in some respects. It was the mental demands, or psychosocial working conditions, that made cluster 5 differ from the large cluster 7. Cluster 6 was dominated by women participants, and had no unemployment at all. The working conditions were characterised by physically light work with opportunities for development, and health problems were common.

Discussion Variable approach In the analyses with a variable approach several risk indicators could be identied, mainly related to reduced psychological well-being and job insecurity, but among women also to few opportunities for

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Table 2. Associations* between the different occupational and non-occupational factors in 1993 or earlier and unemployment in 1997 found in age adjusted analysis; per gender Women N 220 RR Occupational factors Heavy physical workload Sedentary work High perceived workload Full time work Overtime work Shift work Temporary employment Low occupational pride Job strain Difcult decisions Low exibility in work Few possibilities for on-the-job development No education at employers expense Threat of unemployment Non-occupational factors Low frequency of social contacts Poor quality of social contacts Demanding life events High perceived physical load Inadequate coping strategies Earlier unemployment Ill health Low back pain Neck and shoulder pain Sub-clinical depression Reduced psychological wellbeing High alcohol consumption c.i. Men N 198 RR c.i.

C. Bildt and H. Michlsen

1.3 1.1 0.5 0.4 0.4 1.9 13.8 2.8 0.5 0.5 0.6 2.9 5.9 9.4 1.1 0.2 1.7 2.4 0.2 8.8 0.9 0.9 0.9 3.2 1.0

0.5, 3.9 0.4, 2.9 0.2, 1.5 0.2, 1.1 0.2, 1.4 0.8, 5.0 7.1, 27.2 1.2, 6.7 0.1, 2.6 0.2, 1.7 0.2, 1.9 1.3, 6.8 2.0, 17.3 4.3, 20.5 0.4, 2.8 0.0, 1.7 0.6, 4.3 1.0, 5.6 0.0, 2.4 5.2, 14.6 0.4, 2.4 0.3, 2.6 0.2, 4.9 1.4, 7.6 0.2, 5.4

1.6 0.2 1.9 0.7 0.8 1.1 17.4 0.6 1.6 0.4 0.8 0.7 0.7 17.8 1.4 0.8 0.3 1.4 0.7 10.7 2.2 2.1 1.1 4.8 0.6

0.6, 4.4 0.0, 0.8 0.7, 4.7 0.2, 3.6 0.3, 2.3 0.3, 4.1 7.8, 38.7 0.1, 3.3 0.3, 8.6 0.1, 1.2 0.3, 2.4 0.1, 3.5 0.2, 2.1 8.8, 35.8 0.6, 3.6 0.2, 2.8 0.1, 1.6 0.5, 4.1 0.1, 3.5 6.4, 17.7 0.9, 5.7 0.7, 6.1 0.2, 6.0 2.0, 11.4 0.2, 3.2

RR relative risk, c.i. condence intervals. * age also included in the model.

Table 3. Adjusted multivariate estimates of associations between occupational factors in 1993 or earlier and unemployment in 1997 found in analysis adjusted for non-occupational factors and age; per gender RR Final multivariate models: Women Occupational risk factors Temporary employment No education at employers expense Non-occupational risk factors and ill health High perceived physical load Earlier unemployment Reduced psychological well-being Final multivariate models: Men Occupational risk factors Temporary employment Non-occupational risk factors and ill health Earlier unemployment Reduced psychological well-being RR relative risk, c.i. condence intervals. * age also included in the model. c.i. RR* c.i.

7.5 5.1

3.4, 13.3 1.4, 17.9

5.7 4.6 2.2 2.6 2.7

2.4, 13.2 1.3, 16.5 0.9, 5.6 1.1, 6.3 1.1, 6.7

17.4

7.8, 38.7

4.5 4.2 2.5

1.4, 14.9 1.5, 11.7 1.0, 6.1

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Fig. 1. Clusters of individuals with common characteristics. In the squares are only variables where the cluster differs from the whole group presented less than the mean value for the whole group. much less than the mean value for the whole group. more than the mean value for the whole group. more than the mean value for the whole group.

development at work. In a temporary employment position, there are much fewer opportunities for onthe-job development than in a permanent employment, which of course increases the risk for the individual of being unemployed later on. One explanation for this is probably the ever-increasing demands with regard to competence and development that exist in most occupations in todays labour market (Howard, 1995; Westberg, 1998). A few years with no, or few, opportunities for development of competence may be very strongly related to unemployment later on. The situation between women and men in the present paper differed in the respect that more women than men had fewer opportunities for on-the-job development, and that

this was related to later unemployment, which was not the case among men. This might be related to the fact that women tend to stay on longer than men in hampered situations with few opportunities for development (Kilbom and Messing, 1998), a situation that has earlier mostly been discussed in relation to poor health, not to risk of unemployment. Apart from the differences in womens and mens working conditions within a certain company, we think that an important explanation of the gender differences in working conditions can be the gendersegregated labour market. The most common occupations for women in Sweden are those of secretary, day-care assistant, home-help assistant, nurse and nursing assistant. The equivalent occu-

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pations among men are building and construction worker, driver, technical/mechanical engineer, telecommunications engineer (Westberg, 1998). The demands in the typical womens and mens occupations differ considerably, as can be seen in Table 1 in the present paper. Earlier unemployment, as well as psychological ill health, was in the present paper found to be risk indicators for unemployment among both women and men, ndings that agree with results from other studies (Leino-Arjas et al., 1999; Korpi, 1998). This indicates a selection effect based on health, mainly on reduced psychological well-being (measured by the General Health Questionnaire), than on other health conditions analysed. These conditions both remained positively associated with unemployment among both genders and reduced the inuence of temporary employment on unemployment in 1997, as well as of no training at the employers expense in relation to unemployment among women. Both occupational and non-occupational factors seem to be positively associated with unemployment among both genders. Person approach The person approach analysis resulted in seven clusters, one large and six smaller clusters. The large cluster 7 consisted of participants working in different occupational sectors of the labour market, such as the technical, the administrative, the health care and the manufacturing sector. The smaller clusters, at least the rst two, represented a somewhat more homogenous occupational pattern. In the male-dominated, high risk, cluster 1, administrative work was the most common occupation. In the physically demanding cluster 2, the female participants worked within education or health care, and the male participants mostly within transportation or manufacturing. The all-female cluster, cluster 3, showed a more diversied pattern, with participants working in the education, the technical, the health care and the service sector. Also clusters 4, 5 and 6 showed a more diversied occupational pattern, with participants working in many different sectors of the labour market. This shows that it is not solely low education, or a rather low socio-economic status, that can explain unemployment. In our study, this was especially true among women. Neither did complementary analyses show an association between low socio-economic status (blue-collar work)

and unemployment. On the other hand, among men the risk of being unemployed in 1997 was 2.7 times higher among blue-collar workers than among whitecollar workers. The various clusters also differed regarding prevalence of health problems. The individuals in the male-dominated high risk cluster 1 had a high prevalence of both low back pain and reduced psychological well-being, but in cluster 2, also maledominated, it was high alcohol consumption that had a higher prevalence than in the rest of the group. In the female-dominated cluster 3, the individuals had a higher prevalence of both low back pain and neck and shoulder pain, and in cluster 6 of both neck and shoulder pain and of sub-clinical depression. Since the working and living conditions differ considerably between the individuals in these clusters, the difference in health status is reasonable. Because of the gender-segregated labour market, the women and men who became unemployed in 1997 did not work within the same occupational sectors (as has been shown in the cluster analysis). The most common occupations among the female unemployed participants were within administration, service and health care, and among the male participants within manufacturing and administration. A third of the unemployed women in 1997 worked within administration, one fth within service and another fth within health care in 1993. In 1993, more than half of the men who were unemployed in 1997 were employed within the manufacturing sector, and a quarter of them within administration. The rest of the participants who were unemployed in 1997 were rather evenly distributed in various occupational sectors in 1993. Methodological considerations The longitudinal design of the study prevented misclassication both of exposure to nonoccupational factors and of ill health due to unemployment at the time when the information was collected. The study group is a population sample, which increases the possibility of drawing generalised conclusions from the results. The study group in the present paper was rather small, and therefore the condence intervals in the analyses of associations were sometimes wide. The results therefore serve more as indicators of possible associations than as indicators of causal associations.

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In cluster analysis, there are many different techniques which all have their different limitations, and it is hard to know how well the chosen technique describes the true structure of the data. There are no general rules for deciding on the clustering technique or the optimal number of clusters. The advantages are that groups of individuals with similar important characteristics can be identied, and thereby groups of individuals at risk for example of being unemployed can be identied and interventions can be carried out. Even if the cluster homogeneity in this study might be questioned, we are satised with our solution on the basis of the meaningfulness of the clusters, and that the variable unemployment 97 is well separated. The person approach (cluster analysis) contributed with knowledge about the total life situation for different groups of individuals, even though the small size of some of the clusters makes it hard to generalize out from the results. In our view, the result of the cluster analysis is to be treated as tendencies, as indications of what groups there might be in the general population, regarding characteristics related to unemployment. And as such, they might serve as indications of where societal recourses are needed to decrease unemployment among vulnerable groups. Differences in characteristics between the dropouts and the participants in a study may cause serious bias in an epidemiological study. To be a source of bias, differences in exposure conditions among participants and dropouts and such are often found must be related to the studied outcome (Criqui et al., 1978). Such a systematic bias may lead to under- or over-estimation of the ratio estimates found in epidemiological studies. When differences between participants and dropouts are found in, for example, educational levels, these may indicate differences in both exposure conditions and health status, thereby inuencing the results in the study. The eligible participants who did not participate in the follow-up in 1997 differed in a few respects from the participants, as has been presented in the result section, but we have no reason to believe that these differences have affected our results and conclusions. The difference between male participants and dropouts regarding the prevalence of sub-clinical depression might have been a contributing reason for women and men having very similar prevalence of sub-clinical depression in 1997. Sub-clinical depression was not related to unemployment, and therefore this difference is seen as being of minor importance in

our study. The REBUS participants in 1997 were also compared to the inhabitants of the Stockholm region regarding socio-economic conditions. The study group was very similar to the general population in occupation and level of income in 1993. Slightly fewer women in the study group had only nine years of compulsory school, slightly fewer participants of both genders in the study group had received social allowance (i.e. economic assistance from society), and slightly fewer had an ethnic origin other than Swedish. Also these results gave no reason to think that our results have been seriously inuenced by differences between participants and dropouts. The proportion of unemployment cases in the present paper agrees well with the unemployment rate in the general population in Sweden in 1997, approximately 12 per cent (Calmfors, 2001). Thus, the results from the cluster analysis revealed large differences between different clusters of individuals, where the level of unemployment in the clusters ranged from zero to 40 per cent. Conclusions As a general conclusion, the mental health indicators studied were of importance for unemployment, with reduced psychological well-being being identied as a risk indicator for unemployment in the analyses of association for both gender and for men in one of the clusters. Sub-clinical depression occurred to a high level in one of the female dominated clusters. In addition to those ndings, in this study, where a group of employed individuals from the general population was followed during four years, job insecurity was found to be a risk indicator for later unemployment among both genders, as were few opportunities for development at work among women. These factors predicted unemployment, also when age and other non-occupational factors were taken into consideration. Seven clusters were identied. One of them was male-dominated, where the individuals had a very high level of unemployment, reduced psychological well-being, insecure working conditions and demanding living conditions. A high level of unemployment, multi-demands at work and poor musculoskeletal health characterized the female equivalent. A moderate level of unemployment, high level of sub-clinical depression and a high level of high perceived physical load outside work characterized another femaledominated cluster. The results from the cluster

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analysis indicates that even though the main part of the study group has reasonable good mental health, occupational and non-occupational conditions, there are sub-groups who have a very demanding life situation, as a whole. There is a need for studies (with larger study groups than ours) on occupational risk indicators for unemployment with longitudinal design, and repeated examinations at rather short intervals, to conrm the results in the present paper. Appendix 1 Occupational factors Level within parentheses indicates cut-off points. 1. Heavy physical workload: Index on bent or twisted body postures, hands below knee levels, lifting/carrying loads between 5 and 15 kg and lifting/carrying loads exceeding 15 kg. (75% percentile). The ingoing questions were phrased the following way: How often do you work in bent or twisted body posture several times per hour? Five alternatives, from almost never to every work day ( one day per week) How often do you work with your hands below knee level exceeding 30 minutes per day? Five alternatives, from almost never to every work day ( one day per week) How often do you lift or carry loads between 5 and 15kg? Five alternatives, from almost never to every work day ( one day per week) How often do you lift or carry loads exceeding 15 kg? Five alternatives, from almost never to every work day ( one day per week) 2. Sedentary work: What proportion of the working day do you spend sitting down? Continuous scale from 0 to 100 percent (20%) 3. High perceived workload: 620 where 7 is very, very light and 19 very, very hard. (12) 4. Fulltime work: How many hours a week do you work? Four alternatives, from 119 to at least 35 hours (35 hours) 5. Overtime work: Do you work overtime? Three alternatives, from not at all to often (often) 6. Shift work: What working time do you have? Seven alternatives, from daytime to night work (all other working times than daytime) 7. Temporary employment: Permanent employment or various types of temporary employment (all other employment forms than permanent)

8. Low occupational pride (index on four questions): Are your current work tasks stimulating? Do you feel safe and condent in your work? Do you think your work is valuable? Do you think that your work is valued by others? Four alternatives from not at all to very much. The index was dichotomized at the 75th percentile. (75th) 9. Job strain: High values in both high demands and low control. High demands (index on ve questions): Does your work demand that you work very fast? Does your work demand that you work very hard? Does your work demand too great an effort? Do you have time enough to perform your work tasks? Are there any contradictory demands in your work? Four alternatives, from almost never to very often. The index was dichotomised at the 75th percentile. (75th) Low control (index on two questions): Do you have a possibility to inuence how your work should be done? Do you have a possibility to inuence what work that shall be done? Four alternatives from almost never to very often. The index was dichotomised at the 75th percentile. (75th) 10. Difcult decisions: Do you have to make difcult and independent decisions at work? Five alternatives, from yes often to almost never (yes) 11. Low exibility: It is possible for you to change the way you work or when you work, for example by changing shifts with a colleague or via job rotation? Four alternatives, from yes, to a high degree to no, not at all (no, not at all) 12. Few possibilities for on-the-job development (index on four questions): Can you learn new things at work? Does your work require skills? Does your work require creativity? Do you have to do the same task over and over again? Four alternatives, from almost never to very often. The index was dichotomised at the 75th percentile. (75th) 13. No education at employers expense: Have you during the last 12 months had education at your employers expense? Two alternatives, no or yes (no) 14. Threat of unemployment: How large do you think the risk is of your being made redundant within a year from now? Four alternatives, from no risk to large risk (large risk)

Risk indicators for unemployment among women and men

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Bolton W, Oatley K (1987) A longitudinal study of social support and depression in unemployed men. Psychol Med 17: 453 460. Broman C, Hamilton V, Hoffman W, Mavaddat R (1995) Race, gender, and the response to stress: Autoworkers vulnerability to long-term unemployment. Am J Commun Psychol 23: 235 255. Bygren L-O (1974) Met and unmet needs for medical and social services. Scand J Soc Med Suppl 8: 1134. Calmfors L (2001) Data about unemployment rates in Sweden published on the web site of Institute for International Economic Studies, Stockholm University, http:// www.iies.su.se/~lcalmfor/DanmarkOH.pdf. Criqui M, Barrett-Connor E, Austin M (1978) Differences between respondents and non-respondents in a populationbased cardiovascular disease study. Am J Epidemiol 108: 367 372. Dew M (1992) Mental health effects of job loss in women. Psychol Med 22: 751764. Dooly D, Fielding J, Levy L (1996) Health and unemployment. Annu Rev Publ Health 17: 449465. Frankenhauser M (1991) The psychophysiology of sex differences as related to occupational status. In: Frankenhauser M, Lundberg U, Chesney M (eds) Women, work and health. Stress and opportunities. Plenum Press, New York. Goldsmith A, Veum J, Darity W (1997) Unemployment, joblessness, psychological well-being and self-esteem: theory and evidence. J Sociol Econom 26: 133158. Hallsten L (1995) Psykisk ohlsa vid arbetslshet: Orsak eller effekt? Vlbennande bland anstllda vid Skolverstyrelsen och lnsskolenmnderna fre, under och ett r efter avvecklingen (Mental health among unemployed, result or effect? Well-being among employees at two governmental institutions before, during and one year after the closure of the institutions. Summary in English). Arbete och hlsa (1995) 15: 192. Hammarstrm A, Janlert U (1997) Nervous and depressive symptoms in a longitudinal study of youth unemployment selection or exposure? J Adolesc 20: 293305. Howard, A (1995) Rethinking the Psychol of work. In: Howard A (ed) The changing nature of work. Jossey-Bass Publishers, San Franciso: 513555. Jenkins R, Macdonald A, Murray J, Strathdee G (1982) Minor psychiatric morbidity and the threat of redundancy in a professional group. Psychol Med 12: 799807. Jin R, Chandrakant P, Svoboda T (1995) The impact of unemployment on health; a review of the evidence. Can Medical Assoc J 153: 529540. Josephson M (1999) Work factors and musculoskeletal disorders An epidemiological approach focusing on female nursing personnel. Thesis in Med, Karolinska Institutet, Stockholm, 1 150. Kilbom , Messing K (1998) Aches and pain an afiction of women. In: Kilbom , Messing K, Bildt Thorbjrnsson C (eds) Womens health at work. National Institute for Working Life, Solna. Korpi T (1998) The unemployment process. Studies of search, selection, and social mobility in the labour market. Stockholm, Stockholm, pp 1125. Leana C, Feldman D (1995) Finding new jobs after a plant closing: Antecedents and outcomes of the occurrence and quality of reemployment. Hum Relat 48: 13811401. Leino-Arjas P, Juha L, Mutanen P, Malmivaara A, Matikainen E (1999) Predictors and consequences of unemployment among construction workers; prospective cohort study. Br Med J 319: 600605.

Appendix 2 Non-occupational factors Level within parentheses indicates cut-off points. 15. Low frequency of social contacts (index on four questions): How often do you meet and spend time together with neighbours, colleagues, relatives and friends? Six alternatives, from almost never to several times a week (Once per month or less on all four questions) 16. Demanding life events: Loss of a partner/ relative/close friend or serious illness suffered by a partner/relative/close friend during the twelve months preceding the follow-up in 1993. Two alternatives, yes or no (yes) 17. High perceived load outside work: Continuous scale from 620 where 7 is very, very light and 19 very, very hard. (12) 18. Have you been unemployed once or several times since the the base-line study in 1969? Six alternatives, from no to 6 times or more (one time or more)

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