Is the association between precarious employment and mental health mediated by economic difficulties in males? Results from two Italian studies

Since the late 80’s in Europe precarious employment has increased steadily [1], following major legislative and economic changes in the organization of the labour market introduced in most European Union countries. In particular, in Italy, the «Treu law», enacted in 1997, promoted work flexibility allowing temporary contracts and redesigning the apprenticeship, but with the result of increasing the possibility of job insecurity [2]. Later in 2003, the «Biagi law» introduced additional forms of precarious employment, such as project-based and occasional contracts [2]. Due to these reforms, many permanent full-time jobs have been replaced by forms of precarious work with the consequence that in the last years among newly hired flexible contracts are almost the double of the permanent ones [3].

Early research on precarious work suggested that flexible employment could have positive effects for workers, allowing higher salaries, more prestigious positions and increased opportunities for professional experiences [4, 5]. However, this would apply only to high-skilled workers, whereas, in all other cases, it seems that flexible employment has rather negative consequences on both professional and private life as well as on health, due to structural uncertainty resulting from contractual uncertainty, income instability, and worse working conditions [6, 7]. Furthermore, more and more studies have documented, also in Italy [8], the health consequences of precarious employment, and most of these researches agree in attributing to job insecurity adverse effects on workers’ health, particularly mental health [6, 9, 10]. More generally, researchers agree that job insecurity has positive effects only if it is a voluntary choice and not a constraint [4].

It is also well-recognized that economic difficulties are an important determinant of health, especially mental health [11, 12]. During the 2008 global financial recession, that is known to have increased workers’ economic difficulties and reduced the possibility of finding a new job in case of dismissal, negative effects of the economic crisis on workers’ mental health and stress were observed [13]. Based on a review of 350 studies, a consensus paper of the European Psychiatric Association has recognized the deleterious consequences of the economic crises on mental health, particularly on psychological well-being, depression, anxiety, insomnia, alcohol abuse, and suicidal behavior. Unemployment, indebtedness, precarious working conditions, inequalities, lack of social connectedness, and housing instability emerge as main risk factors, especially for men of working age with a more disadvantaged socioeconomic position [14].

As mentioned above, many studies have explored the mental health effect of precarious work and economic strain separately, but the mediating role of economic strain still remains unclear.

Aims of this paper are to evaluate whether an association exists in the Italian population between precarious employment and mental health, as well as to assess the role of economic conditions as mediators of this relationship.

To test our hypotheses, we used the data from two different national sources: a) the National Health Interview Survey (HIS), conducted by the Italian National Institute of Statistics; b) the Italian behavioural risk factor surveillance system “Progressi delle Aziende Sanitarie per la Salute in Italia” (PASSI), conducted by the Italian National Institute of Health.

The final analysis was performed on 31,948 subjects (51.8% males) in PASSI and on 21,894 subjects (53.9% males) in HIS. Differences among employment categories are presented in Table 1. As expected, in both studies, precarious workers were younger and showed higher prevalence of females, singles and subjects without children, compared to permanent workers. Interestingly, precarious workers also showed higher prevalence of subjects with higher occupational social class and with tertiary education. No differences among categories of employment were found regarding the prevalence of at least one chronic condition.

Table 2 shows the association between categories of employment and mental health status, separately by gender. Among men, in both surveys the likelihood of experiencing poor mental health was almost doubled in precarious compared to permanent workers, when the model was set with minimal adjustment. In the fully adjusted model, this association was slightly weaker but still significant in PASSI study (PR 1.90, 95% CI 1.08–3.34), while it lost statistical significance in HIS study (PR 1.69, 95% CI 0.91–3.16). However, no heterogeneity was found between the two surveys. In contrast, no difference in mental health was found for temporary male workers and for both temporary and precarious female workers, compared to permanent workers. Results did not change considering the subsample of single females, or that of single females with children (data not shown). Due to this lack of association in females, the mediation analysis was performed only in males.

The proposed mediation model is shown in Fig. 2. Its aim is to decompose the TCE between categories of employment and mental health into the PDE and the TIE through the mediation of the variable “lack of financial resources”. A strong TIE of financial strain was observed in PASSI (PR 1.49, 95% CI 1.31–1.72) and a weaker, although statistically significant, in HIS (PR 1.12, 95% CI 1.01–1.28), whereas PDE for precarious work was not anymore significant taking into account the presence of the mediator. Also, a statistically significant TIE was found for temporary work, limited to the PASSI sample (Table 3).

The results of our analyses showed that Italian male workers with precarious employment are more likely to have mental health problems than those with permanent employment, while this phenomenon is not observed among temporary workers. Furthermore, we found that precarious job is not directly associated with poor mental health, but rather it is related with economic problems, possibly caused by job instability. The results described above only apply to males and were not observed in females.

A large body of evidence published in the literature in recent years demonstrates a link between job insecurity and mental health, which has been observed also in longitudinal studies [6, 8, 25, 26]. Strong associations have been found between job insecurity and minor psychiatric morbidity [27], mental distress [28] and poor mental health [29, 30], while other studies have shown the role of job instability in anxiety disorders [31] and in depression [26]. Many of these studies did not explore the results separately by gender, but where the outcomes are reported distinctly for males and females, some of them do not find gender differences [27, 32]. This could be due to the fact that these studies were conducted in Northern Europe countries, where the contribution of males and females to the family economic income is much more balanced than in Italy [33], where the male breadwinner model probably still stands as the most diffuse in society. In such a cultural context, it is plausible to assume that men perceive more strongly the problem of job insecurity or unemployment compared to women. In support of this hypothesis, a study conducted in another Southern Europe country (Spain) showed no effect of job insecurity on mental health in women, while an association was found in men [30]. Moreover, even restricting the analysis to single women, or to single women with children, where the breadwinner model might be expected, we did not find any association between type of employment and poor mental health. Interaction between biological and social factors could be an alternative explanation for the observed gender differences in Italy, but the literature evidence on this last hypothesis is divergent and non-final. It would be appropriate to further investigate the phenomenon through more suitable tools than those available to us.

Considering the role of financial strain in the relationship between precarious work and mental health, we found that the latter is not directly associated with poor mental health but there is a mediating factor, namely financial strain, which explains this relationship in men.

Actually, the association between scarcity of economic resources and poor mental health or poor perceived health status is not new information. Many publications have been produced on the subject, especially during the years of the global economic crisis: two systematic review on mental health outcomes show that economic recession is possibly associated with negative effects on psychological wellbeing, common mental disorders, substance disorders and suicidal behaviour [13, 34]. Bacci et al. demonstrated that indicators of economic deprivation are strong predictors of negative self-perceived health status [35].

With this study we add a further piece of knowledge showing that work precariousness is not directly associated with poor mental health, but it seems to act through financial strain.

The same mediation analysis conducted in the two surveys gave consistent results, but in PASSI the mediated effect of the economic difficulties was much stronger than in HIS. This difference could be due to the different mental health detection tools used in the two surveys. In fact, PASSI uses the PHQ-2, which is a depression-screening tool investigating symptoms of depressed mood and anhedonia. It has good reliability, validity, and sensitivity [18] and it was found to effectively rule out depression [36]. The MCS-12 was designed for use in the general population as a multi-factorial measure of health-related quality of life experienced over the past 4 weeks. The MCS-12 does not specifically assess depressive symptoms and, although related to depressive symptoms or diagnosed depression, is a measure less accurate of depression compared to PHQ-2 (e.g.: anhedonia is not investigated by the SF-12). The MCS-12 score does not target a specific psychiatric condition, but it is a more general indicator of mental well-being.

However, having obtained similar results in two large surveys regarding the effect of financial strain mediation in the association between precarious work and poor mental health can be considered a strong point in support of our conclusions. Furthermore, as far as we know, this is the first time that the role of financial strain in this association has been studied through a formal mediation analysis. This technique allows not only to evaluate the risk attenuation produced by the inclusion of the candidate mediator in a regression model, but also to quantify the component of the association mediated by the mediator.

The main limitation of our research is that data used for the analysis came from cross-sectional studies, whose design does not allow to infer a causal relationship between job insecurity and mental health. It is possible, in fact, that part of the association identified is due to reverse causality, as subjects with poor mental health could have been more likely to obtain a precarious work. However, in this case, the gender differences in this association would not be easily explainable. In addition, the cross-sectional design does not guarantee the assumption of temporality necessary to perform an unbiased mediation analysis. However, the relationship between exposure and outcome, exposure and mediator, and mediator and outcome have been already observed in longitudinal studies [37‐39], making plausible our assumptions. Another limitation is that our results are based on self-reported data. In fact, the information collected by both PASSI and HIS is not based on objective measurements, but on answers provided by respondents. Therefore, the information collected can be influenced by various biases, especially when the topic of investigation is mental health, because of the social stigma surrounding this subject, leading to an underestimation of the prevalence. However, this bias may probably be a non-differential one and could lead at most to an attenuation of the strength of the association.

Economic uncertainty is a factor strongly associated with poor mental health. Precarious employment with fixed-term contracts and low wages contributes to the economic strain, which in turn has consequences on mental health related quality of life and on the risk of symptoms of depression or dysthymia. These results have also some implications for employment and labour market policies: when job stability cannot be guaranteed for economic, political and market reasons, active labour market policies should be strengthened (by increasing their effectiveness, targeting, coverage) and their interaction with passive measures encouraged. Concerning passive policies, beside more traditional policies such as economic support for unemployment (subsides) and minimum salary set for precarious workers (currently under discussion in Italy), additional services such as access to mental health supporting cares should be guaranteed.