Background
Health equity has gradually become a research hotspot in the field of health system reform [
1,
2]. Achieving health equity has been a source of concern with a strong degree of support and response from all countries of the world [
3]. China also regards the realization of health equity as the key issue of health reform and development in the current context. Specifically, the planning outline of “Healthy China 2030” has proposed that we should focus on the health problems of vulnerable groups of people to achieve health equity [
4]. As an important economic and material basis for people, economic status is an important factor affecting health and health inequity. The widening of the income gap in China has also aroused widespread public concern. Empirical studies about health inequality have commonly used economic status to analyse health inequalities and inequities [
5‐
7]. As Wagstaff suggested, in order to analyse socioeconomic health inequities, health-related information must be supplemented by data on socioeconomic status. There are many approaches to measuring socioeconomic status such as income, expenditure, or consumption [
8]. Health inequalities are not only affected by physiological conditions but also widely determined by socioeconomic characteristics and inequalities may be further widened by unemployment [
9]. The World Health Organization proposed that each country should set up health equity monitoring systems to reduce health inequalities by collecting data on key indicators such as employment status, which can be determined by the labour market [
10]. Unlike retired people, most unemployed people quit the labour force for non-physiological reasons and cannot sell their labour at a balanced price in the market [
11]. In addition, some articles have examined the impact of unemployment and income inequalities on the degree of criminality and mental health [
12], as well as the associations between unemployment, income inequality and suicide mortality [
13]. It is of great practical significance to compare and measure the income-related health inequality between unemployed and employed individuals in China.
There is a body of literature that has explored the association between unemployment and lifestyle behaviours (e.g., alcohol consumption and smoking) [
14,
15], the effects of unemployment on mental health (e.g., depression, mental disorder and suicide thoughts) [
16‐
19], and the effects of unemployment on physical health outcomes (e.g., mortality) and subjective health outcomes (e.g., self-reported health) [
20‐
22]. Empirical evidence has demonstrated that unemployment has a severely negative effect on health and that unemployment also significantly raises the risk of mental disorders and suicide [
23,
24]. In addition, some international studies have revealed that unemployed people were significantly more likely to have poor self-reported health than employed people [
20‐
22]. Unemployment may lead households into a cycle of poverty [
25] and households may be disadvantaged in terms of health and access to health care services, which leads to changes in health equity. Therefore, it is logical to start from the key groups and to carry out research on inequity in health-related quality of life among the unemployed. It is highly important to prevent unemployed individuals from falling into long-term health problems and poverty, to improve the precision of poverty alleviation policies and to promote the construction of “Healthy China 2030”.
Despite many health indicators being used to assess the effect of unemployment on health, health-related quality of life remained remarkably absent from health measurement [
26]. Health-related quality of life (HRQOL) is generally considered a key measurement indicator of health care outcomes and is constructed multidimensionally in relation to a person’s self-perceived health [
27]. The EuroQol 5 dimensions (EQ-5D) is a standardized instrument, and is most commonly used for measuring the quality of life in public health research [
28,
29]. Some recent studies have examined the correlates of unemployment and HRQOL by using the MOS 8-item short-form health survey instrument, SF-12 instrument and SF-36 instrument [
30‐
33], but studies that used the EQ-5D instrument to explore the relation of unemployment and HRQOL are relatively few in number. The EQ-5D instrument is easy to operate and has high applicability, as it has been tested in a large-sample and large-scale Chinese National Health Services Survey. Most importantly, the EQ-5D has time trade-off values based on a conversion of Chinese preferences for EQ-5D health states, which can more accurately reflect the HRQOL of Chinese residents [
34].
Despite the importance of unemployment in models of social and ecological determinants of health, we know very little about the relationship of unemployment and health inequities in HRQOL. Leaving unemployment and employment out of public health inequity research creates a blind spot. This paper thus contributes to two strands of literature on the empirical evaluation of HRQOL for unemployed individuals and health inequities in China. First, the existing literature on the relation of unemployment and health has focused on mental health and self-assessed health [
16‐
22], but the literature on the association of unemployment and HRQOL is scarce. In addition, the inequity in HRQOL for the unemployed and employed has not yet been evaluated using the CI and HI. Second, with the instruments for measuring quality of life, studies attempt to investigate the relationship between unemployment and HRQOL by using the EQ-5D instrument are very limited [
30‐
32]. Third, in terms of methods, researchers often analysed HRQOL and inequities in HRQOL by using descriptive statistical analysis and linear regression, lacking a scientific method to balance the comparison groups; thus, such approaches cannot reflect the ceiling effect of EQ-5D and measure the inequity of HRQOL quantitatively [
33]. In this article, we make an initial contribution to filling what is a rather large gap in the public health inequity research by investigating the relationship between unemployment and health inequities in HRQOL.
Based on the abovementioned background, we have attempted to answer three main questions: (1) What is the health utility of the employed and the unemployed in China? Is the health utility value of the unemployed higher than that of the employed? (2) What are the levels of inequality and inequity in HRQOL between the employed and unemployed? Are the concentration index and horizontal equity index of the unemployed higher than those of the employed? (3) How do relevant factors contribute to the health inequalities in HRQOL between the employed and unemployed? In this paper, we have calculated and compared the health utility between the employed and unemployed in China. In addition, we decomposed the inequality and analysed the inequity in HRQOL between the employed and unemployed in China. Careful consideration of unemployment in public health research can allow us to make better progress towards achieving health equity.
Discussion
In the present research, we have assessed the long-studied topic of HRQOL in the research area of health care and economics. Based on the matched data, our results demonstrated that unemployed people reported lower HRQOL than employed people. In addition, unemployed people had higher levels of pro-rich inequality and horizontal inequity in HRQOL, which was mainly related to factors of economic status, educational status, age, smoking and health insurance. Therefore, there are three aspects of this study that should be discussed.
First, the most fascinating finding was that there was statistically higher EQ-5D utility for employed individuals compared with unemployed individuals, and this study was the first to assess HRQOL among the employed and unemployed individuals by using the EQ-5D-3L instrument in China. This indicated that unemployment was associated with poor HRQOL. This result is consistent with several reports that unemployed people are likely to have poorer HRQOL than employed people [
26,
31,
47]. Specifically, this may be because people who experience unemployment are deprived of these benefits (e.g., income, social contact, status and activity), face greater financial and mental stress, and have lower health care utilization.
Second, the present study verified that the CI of HRQOL between the employed and the unemployed were both positive values, suggesting that the higher HRQOL was concentrated among rich men between the employed and unemployed people in Shaanxi. Additionally, the CI of the EQ-5D utility values among the unemployed was higher than that among the employed, which suggested that the unemployed had a higher pro-rich inequality in HRQOL than the employed. This study fills the gap in the literature by the comparing socioeconomic-related inequality between employed and unemployed individuals. Since previous research has not primarily focused on health inequality between employed and unemployed people in China, we can only compare this estimation with previous research on different kinds of people. Consistent with several previous reports of the different insured populations [
5], findings from the marginal effect estimates among employed and unemployed individuals indicated that an advanced level of education was connected to better HRQOL. This might be because highly educated people have a stronger health awareness and better ability to cope with diseases. Moreover, as expected, age had a negative marginal effect, signifying that elderly people tend to have lower health outcomes. Furthermore, our findings indicate that the economic level intensified the pro-rich inequality in HRQOL and that the gap between the rich and poor people remains the key factor influencing inequality in HRQOL between the employed and unemployed, which was in agreement with previous studies of the different populations [
5,
34,
42]. Apart from the economic level, age, educational status, health insurance and health behaviour also contributed to inequality in HRQOL. From the government point of view, this research demonstrated that basic health insurance schemes and educational level would reduce the pro-rich inequity in HRQOL for unemployed people. Ensuring basic medical insurance and enhancing education remain important health policies to reduce the inequity in HRQOL [
33]. In contrast, commercial insurance and other insurance also increased the pro-rich inequity of HRQOL in unemployed individuals. It seems that commercial insurance has focused on efficiency due to market competition and most of the beneficiaries have been high-income groups. Smoking and drinking also contributed to increasing the pro-rich inequity of HRQOL, which is consistent with several reports that tobacco use and alcohol consumption were adverse health consequences and significant causes of health inequity worldwide [
48]. This is because those who experienced social disadvantage, with low incomes or unemployment, were more likely to become regular smokers [
49]. The purchase of tobacco products by households of tobacco users with lower socioeconomic status exacerbates poverty and social inequities by reducing the funds available for basic expenditures such as housing, clothing and food [
50].
Third, our results regarding the inequity in HRQOL may be attractive to policy makers in regions where unemployment has increased significantly due to the financial crisis. In our research, after subtracting the contribution of the need variables, we found that the horizontal inequity index illustrated not only that there was pro-rich inequity in HRQOL between the two groups but also that this inequity for unemployed individuals was still higher than that for employed individuals, which may be explained by the reduction in income associated with unemployment [
25,
33]. People have unequal access to social resources, including health resource, resulting in an increase in horizontal inequity in HRQOL. Specifically, unemployment had a negative effect on health equity and increased the pro-rich inequity in HRQOL. Therefore, when promoting a “Healthy China 2030” to achieve health equity among different groups, such as the unemployed and employed groups, the government should consider the contribution of education and basic health insurance schemes to reduce pro-rich inequity.
Strengths and limitations
The current investigation has three key strengths. First, it is the first to compare the HRQOL of unemployed and employed individuals by using the EQ-5D-3L based on a conversion for Chinese preferences. Furthermore, we offer well-informed estimates of the associations between unemployment and socioeconomic-related inequality and inequity in Chinese HRQOL. The third key strength is that the findings of this investigation were based on a stronger balance between the unemployed and the employed groups by using the coarsened exact matching method.
At the same time, we acknowledge that the present study also has some limitations. First, in the data material, self-reported information regarding socioeconomic variables and EQ-5D scores may contain measurement errors and possibly introduce recall bias. Second, the data derived from Shaanxi Province and our conclusion may not be generalizable to all of China. Third, we must indicate that without valid instrumental variables, causal interpretations are hazardous, and possible endogenous problems could not be omitted in these cross-sectional data. Therefore, we refer to associations between unemployment and HRQOL. Fourth, the present study was subject to possibly unobserved confounding factors, such as disability status, access to healthy food, and social interaction. Finally, in the analytical techniques, the coarsened exact matching may exclude some observations that are very dissimilar in observable characteristics to obtain two groups that are as similar as possible.
Conclusions
In conclusion, the unemployed had poorer HRQOL than the employed in this study in China, and the unemployed had higher pro-rich inequity in HRQOL than the employed. Unemployment is linked with health-related quality of life and inequality in HRQOL. It appeared that unemployment intensified the inequality and inequity in HRQOL. The major contributors to inequality in HRQOL were economic status, education status, age, smoking and health insurance for employed and unemployed residents. Education status and basic health insurance have positive effects on decreasing inequity in HRQOL among the unemployed. Intervention initiatives aiming to tackle long-term unemployment through active labour market programmes, narrow economic gaps, improve educational equity and improve the health status of the unemployed should be considered by the government to achieve greater health equity. Additionally, the socialization of health insurance for the unemployed should be improved.
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