José Leopoldo Ferreira Antunes UNEMPLOYMENT AND HEALTH STATUS IN EUROPE The present study tries to shed some light on the understanding of factors associated with unemployment in the European context. During the last decades, Europe experienced intense geo-political transformations, with warfare and the emergence of newly independent states in its central and eastern portion, and the unification of richer western countries. The enlargement of the European Union is expected to promote development and improved social standings for candidate and future candidate countries. However, as the accession process requires adopting a common legislation, limited resources and significantly lower health status in central and eastern Europe challenge this expectation [11]. We aimed at documenting the recent evolution of unemployment in European countries during this complex process, by describing current levels and trends of unemployment ratios. The present study does not address direct causes or consequences of unemployment; we only aimed at exploring associations between trends of unemployment and the country-area profile of a broad set of factors related to collective health. Methods The World Health Organization – WHO Collaborating Centre for Health Statistics and Information in Lithuania in cooperation with the Health Information Unit of the WHO Regional Office for Europe in Denmark prepared a multipurpose data presentation system comprising the European health for all database (http://www.who.dk/hfadb), which provided primary information for the current study. Country-level figures for the unemployment ratio used the definition by the International Labour Organization. “Unemployed” comprise all persons above a specified age who during the reference period were without work, currently available for work or seeking work. The ratio was scaled as a percentage of the total labour force of each country in the period. We gathered yearly averages for the unemployment ratio in 47 European countries from 1990 to 2002. These countries were classified into six multiple-entry groups (fig. 1): European Union – EU (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden and United Kingdom), Nordic countries (Denmark, Finland, Iceland, Norway and Sweden), central and eastern Europe – CEE (Albania, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Hungary, Macedonia, Poland, Romania, Slovakia, Slovenia, Turkey and Yugoslavia); newly independent states – NIS – derived from the former Soviet Union (Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Russia, Tajikistan, Ukraine and Uzbekistan), central Asian republics – CAR (Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan), and acceding countries (Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia and Slovenia), referring to new member states joining the European Union on May 1, 2004. Although not integrated in any of these sets, San Marino and Switzerland were included in the appraisal of associations between variables. For methodological reasons (i.e. lack of sufficient information for the estimation of trends), Andorra, Cyprus, Monaco and Turkmenistan were not appraised in the study.    The estimation of unemployment trends (i.e. the annual percent increase of ratios) and current levels used the auto regression procedure of exact maximum-likelihood estimation for time-series analysis [8], observing methodological indications supplied by Antunes and Waldman [1]. In order to reduce random variation of estimates, current levels of unemployment refer to ex post forecasts for the year 2002 rather than the observed value for each country. The European health for all database also supplied current information for several indices of socio-economic and health status in each country: home connection to the water supply and access to hygienic sewage disposal (percentages), gross national product – GNP (in US$ thousands per capita), average calorie intake (per person, per day), life expectancy at birth (in years), and health expenditures in US$ thousands per capita and as a percentage of the gross domestic product. The under-5 mortality rate expresses the probability of dying between the birth and the exact age of five, by indicating the yearly number of child deaths per each 1,000 live births. Country-level information for the human development index was provided by the United Nations Development Programme [14]. This index is calculated as a composite figure assembling information on income, longevity and educational levels as informed by population data. The present study used space as an organizing frame to explore variations in unemployment trends in different European regions. The study of association between country-level figures of unemployment trends and covariates assessing socio-economic and health status used ordinary least squares regression analysis [4] for estimating the Pearson’s correlation coefficient. Statistical analyses used the SPSS software. Results Unemployment was on the rise in poorer European regions during the 1990s, while richer EU and Nordic countries experienced an overall decreasing trend concomitant with a lower average current level of unemployment (tab. I). Denmark, Ireland, Netherlands and San Marino presented decreasing trends of unemployment. Most EU countries (Austria, Belgium, Finland, France, Italy, Portugal, Spain, Sweden and United Kingdom) presented stationary trend for this outcome. Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Lithuania, Russia, Slovakia, Tajikistan, Ukraine and Uzbekistan were the countries presenting the higher increase of unemployment ratios during the 1990s. Table I. Average indices of unemployment, in groups of European countries, 1990–2002 Unemployment EU % Nordic countries % CEE % NIS % CAR % Acceding countries % Unemployment ratio, current level 7.80 5.62 17.94 20.29 8.08 15.69 Annual percent increase –1.02 –1.16 +5.77% +35.80 +43.58 +13.66 Source: European health for all database, World Health Organisation. Table II. Average indices of socio-economic and health status in groups of European countries, 1990–2002 Socio-economic and health status EU Nordic countries CEE NIS CAR Acceding countries 1 2 3 4 5 6 7 Percentage of population with home connection to water 95.83 96.53 77.80 63.36 66.63 91.69 Percentage population with access to hygienic sewage disposal 99.01 100.00 73.91 42.76 46.50 88.38 Gross national product (US$ thousands per capita) 22,573.25 29,308.00 3,467.50 1,336.43 644.00 5,020.00 Average number of calories per person per day (kcal) 3,472.92 3.268,06 3,060.19 2,653.49 2,511.42 3,192.67 Health expenditure (% of the Gross Domestic Product) 7.89 8.18 5.71 3.57 2.34 6.73 Health expenditure (US$ thousands per capita) 1,862.91 2.100,61 518.46 173.16 56.87 763.54                           cd. tab. II 1 2 3 4 5 6 7 Life expectance at birth (years) 77.80 78.24 72.62 69.22 67.04 73.27 Under-5 mortality rate (per 1,000 live births) 5.69 4.74 11.59 20.18 32.87 9.73 Human development index 0.921 0.935 0.804 0.754 0.719 0.838 Source: European health for all database, World Health Organisation. We also observed a remarkable contrast among European regions as regards a broad set of socio-economic and health related characteristics (tab. I). CEE and NIS countries presented lower GNP per capita, health expenditure, life expectancy, human development index, food intake, access to tap water and sewage, and higher child mortality than EU and Nordic countries. Figures for the CAR region indicated an even poorer profile of socio-economic and health status. Acceding countries presented slightly lower averages for unemployment current level and annual percent increase than the whole set of CEE countries indices, concurrent with better indices of socio-economic and health status. However, these figures are not equivalent to figures related to EU and Nordic countries, and an even poorer profile was observed for future candidates for accession (Bulgaria, Romania and Turkey). The country-area profile of unemployment trends presented a liner association with health-related conditions. This observation was confirmed by regression analysis, which showed high levels of correlation between the outcome variable of the study and covariates of socio-economic and health status (tab. III). Table III. Pearson’s r correlation coefficient between unemployment trends and health status related conditions in European countries, 1990–2002 Socio-economic and health status Pearson’s r correlation coefficient Percentage of population with home connection to water –0.519 Percentage population with access to hygienic sewage disposal –0.647 Gross national product (US$ thousands per capita) –0.522 Average number of calories per person per day (kcal) –0.521 Health expenditure (% of the Gross Domestic Product) –0.602 Health expenditure (US$ thousands per capita) –0.586 Life expectance at birth (years) –0.727 Under-5 mortality rate (per 1,000 live births) +0.693 Human development index –0.631 Source: European health for all database, World Health Organisation. European countries with higher annual percent increase of unemployment ratios tended to present higher under-5 mortality rates concurrent with lower life expectancy, human development, health expenditure, calorie intake, gross national product and access to tap water and sewage disposal. We also observed a significant association between unemployment current levels and trends, with a Pearson’s r correlation coefficient ranking 0.515. This observation indicates that the recent evolution of unemployment in Europe led to higher figures of unemployment in countries with a higher annual percent increase of ratios. Discussion Data presented here were submitted to the WHO Regional Office by European states or collected from other international organizations and sources. Since recording and handling population data systems vary between countries, so do the availability and accuracy of data reported to the WHO. Therefore, trend estimation and the appraisal of correlation are also limited, owing to differences in the definition of variables and in practices of data registering. The WHO Regional Office for Europe estimates that temporal and spatial irregularities in the report of events may have impaired the reliability of indices [18]. Aggravating this problem, the denominator for indices calculation used population estimates, which also reflect heterogeneous levels of accuracy. During the 1990s, these problems were intensified by severe socio-economic difficulties and armed conflicts in some countries, mainly in the former republics of Yugoslavia and Soviet Union. These considerations must be borne in mind when making comparisons at the country level. Notwithstanding these demands for caution, we argue that WHO data system is the best and most reliable if not the only source of information available for international comparisons and the planning of health services. These observations motivated the present spatial data analysis, which indicated factors associated with inequalities in the European profile of unemployment trends. Unemployment has been associated with increased risk for a wide set of health damage and mortality [6,15], even after adjusting for socio-economic standings of individuals, their age and pre-existing diseases. The unemployed have been reported as susceptible to a higher risk of mental health disorders, suicide, smoking and lung cancer, poor diet and obesity [2,10,13,17]. A recent review of literature [16] indicated negative effects of unemployment for the following somatic conditions: arterial hypertension, coronary heart disease; disturbances in the metabolism of lipids; suppression of immunity; gastro-intestinal problems; respiratory diseases; liver disorders as a result of increased alcohol consumption; and the formation of new malignant tumours. Unemployment can per se increase the risk of several diseases, and the long-term unemployed may present a more adverse risk factor profile as regards diet, smoking and alcohol consumption [7,9], besides having lower access to health care facilities. Moreover, recent research [5] showed that the loss of job security is already a risk factor for worsening health, which indicates that the persistence of high levels of unemployment in a rotatory labour market can subject an even larger number of individuals to the prejudicial effects of unemployment on health. Even before people become unemployed, adverse health effects can increase owing to chronic exposure to the stress associated with the announcement of redundancies and worries about the future. The observed correlation between unemployment and health status involves complex pathways and suggests different possibilities. Studies addressing these conditions should not only consider the unemployed as subjected to health problems, but also remember that diminished strength and physical disadvantage of individuals suffering illnesses or disabilities can reduce their capacity of achieving a regular job. Unemployment can thus be thought of not only as a cause or contributing factor, but also as a consequence of disease and bad health. The potential linkage between unemployment and health has two concurrent directions. Furthermore, the relationship connecting unemployment and health disadvantage does not exclusively reflect causes and consequences appraised at an individual basis, and several studies assessed the association between both phenomena at a collective level [3,12]. High unemployment levels is indicative of reduced social capital of a community (i.e. weakened social cohesion resulting in reduced social support to those in need), which might induce a contextual effect on the health status of populations. It is illustrative that a negative correlation between the average number of calories per person per day and unemployment trend is found. Calorie intake is a broad indication of food consumption, and is expected to reflect some linear relationship with indices of socio-economic status. Better fed, enjoying higher country-level welfare and health-related conditions, as indicated in the present study, richer western nations in Europe experienced a better evolution of unemployment during the last years. This observation indicates a progress that, regrettably, did not hold for CEE and NIS regions. Poorer European countries had increasing trends of unemployment concurrent with worse indications of socio-economic and health status.This is a major feature of social injustice imbricated in health inequalities, which must be taken into account during the enlargement process of the European Union. Unemployment trends reflect a long standing process, which cannot be easily modified in the short run. The present study showed that this process is rooted in socio-economic standings, and has important consequences for the health status of populations. In especial, acceding countries and future candidates for accession could be indicated as having a poorer unemployment profile than countries already integrated in the European Union. This discrepancy challenges expectations of improving overall health status and promoting development in Europe; and overcoming it must remain a focus of international public health concern and policies. 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To cite this article: Jose Leopoldo Ferreira Antunes, Unemployment and health status in Europe, [in:] Niebrój L., Kosińska M., Unemployment and Health Care, Katowice: Wyd. SAM 2004, p. 23-29