Introduction

Life expectancy continues to increase and will ensure that the old-age dependency ratio, the number of elderly people as a share of those of working age, will rise steadily from 29.4 in 2016 to 50.3 by 2050 in Europe.1 2 In response, many countries have raised the statutory retirement age.3 The challenge is ensuring that those of working age are actually participating in the labour force.4 Health-related exclusion from the labour market is present in many countries,5 6 whereby workers with a chronic illness are at increased risk of becoming disabled or unemployed. Leaving paid employment may further impact health negatively.7

Studies have shown that the presence of a chronic disease is an important barrier for entering and maintaining paid employment.5 Educational inequalities in morbidity, such as chronic health conditions, are well documented across European countries.8 Some studies have suggested that the effect of chronic illness on maintaining paid employment differs by socioeconomic position. Bartley and Owen reported that workers with a chronic disease in lower socioeconomic position had more difficulties staying in paid employment than those with a higher socioeconomic position during times of economic crisis.9 In Sweden and the UK, labour market attachment for those with a chronic illness is reduced, with the effect being substantially stronger in the UK than in Sweden.10 11

The differential effect of socioeconomic position on the association between chronic illness and paid employment may be modified by national social and economic conditions, such as labour market policies.12 European countries can be categorised in five regions: the Nordic, Continental, Anglo-Saxon, Southern and Eastern regions.13 14 This typology reflects general differences in employment protection and income security. Non-employment rates for persons with a longstanding illness as well as a low educational level were found particularly high in the Anglo-Saxon and Eastern regions, compared with the Nordic region.15 The poor position of disabled people was suggested to be partly counteracted by employment protection,16 although inequalities in health in itself were not consistently smaller in the Nordic region.17

Few studies have documented the trends over time in socioeconomic differences in labour force participation between persons with and without a chronic illness. A repeated cross-sectional study over 25 years in Britain showed that within the lower occupational class, persons with a limiting illness had greater and more rapidly widening gaps in labour force participation than in the higher occupational class.18 A comparison between the Nordic countries and the UK showed that, since the mid-1990s, there has been a deterioration in paid employment among persons with limiting longstanding illness with a low education, even when the economy was doing well.19

Limited information exists on trends in health-related educational inequalities in paid employment among persons in different European regions, since most studies have focused on a single country or compared a selected group of countries. Therefore, the aims of this paper are (1) to examine absolute and relative differences in paid employment between persons with and without a chronic illness within each educational group in five European regions and (2) to describe trends in socioeconomic differences in paid employment between people with and without a chronic illness within European countries.

Methods

Results

The study population consisted of 179 724 participants of whom half were women, the largest group was intermediately educated, 75% were employed and 27% had a chronic illness. The Eastern region had a large intermediate educated group (64%), whereas the Southern and Anglo-Saxon regions had a relatively large low-educated group (28% and 38%, respectively) (table 1). The Southern region had the lowest labour force participation, and the lowest percentage of people with a chronic illness. The Nordic region had the highest employment but also the highest prevalence of people with a chronic illness.

Labour force participation over the period 2005–2014 among men without a chronic illness remained stable for intermediate and high-educated persons but decreased by about 5% among those with lower education (figure 1A). Within each educational group, labour force participation among men with a chronic illness was substantially lower than among men without illness, with the largest difference among the lowest educated persons. For women, the labour force participation increased slightly for most groups over the period 2005–2014 (figure 1B). Women had a consistently lower labour force participation than men with increasing differences by lower educational level. Women with a chronic disease had substantially lower labour force participation than women without a chronic illness.

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Figure 1

Proportion in paid employment with and without chronic illness by educational level—men (above) and women (below) in 26 European countries (2005–2014).

The absolute differences in labour force participation between persons with and without a chronic illness increased with lower educational level among men and women (table 2). The absolute differences were larger for men than for women. For low-educated persons, the absolute differences in labour force participation between men with and without a chronic illness were higher in the Nordic, Anglo-Saxon and Eastern region (32.9%–35.3%) than in the Continental and Southern region (21.5%–26.1%). Among women a comparable pattern was observed.

A similar pattern was found for relative differences in health-related labour force participation (table 3). Overall, low-educated men with a chronic illness were 1.4 to 1.9 times more likely to be outside of paid employment than low-educated men without a chronic illness, whereas this was 1.1 to 1.2 times within the high educational group. Relative differences in labour force participation among low-educated men without and with a chronic illness were the highest in the Anglo-Saxon and Eastern region (1.79–1.94). For men with high education, modest regional differences were found in labour force participation between those without and with a chronic illness. Comparable patterns were observed for women.

Trends in absolute differences in labour force participation showed stable inequalities for men in all educational groups in most regions (table 4, see online supplementary tables 1 and 2). Among men, significant narrowing of absolute health-related inequalities in paid employment was observed for low and high-educated persons in the Southern region over the period 2005–2014. For women, significant widening of absolute health-related inequalities in paid employment were observed for low and intermediate-educated women in the Continental and Anglo-Saxon region. In the Eastern region, significant widening in inequalities was observed for low-educated women, while narrowing inequalities were observed for high-educated women.

Trends in relative differences in labour force participation were constant among high-educated men and widened in low-educated men (table 5, see online supplementary tables 3 and 4). Among men, significant widening of relative differences were observed for lower educated persons in the Nordic and Continental region of respectively 1% and 2.6% over the period 2005–2014. Significant narrowing of relative health-related inequalities in paid employment was observed among higher educated men in the Continental and Southern region (−0.3% and −0.6%). Trends for women were similar. In most regions, relative health-related inequalities in paid employment were widening for low-educated women (between 1.0% and 3.7%), although in the Southern region, there was a small narrowing (−0.7%). For high-educated women there was no clear trend.

Figure 2 presents the inequalities between low and high-educated persons for the influence of a chronic illness on being in paid employment within each educational group. The excess relative difference among low-educated persons across 26 European countries varied between 50% and 100% among men and between 58% and 100% among women when compared with high-educated persons. The variation in educational inequalities in labour market position of those with a chronic disease was larger within European regions than between European regions, indicating substantial differences between countries with supposedly similar welfare regimes.

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Figure 2

Relative inequality in paid employment among persons with a chronic illness comparing low-educated persons with high-educated persons.

Discussion

Within Europe, persons with a chronic disease were less often in paid employment than persons without a chronic disease in the period 2005–2014. The low education group had the largest absolute and relative differences in paid employment between persons with and without a chronic illness. For men these differences were more pronounced than for women. The Nordic, Anglo-Saxon and Eastern regions had substantially higher relative and absolute differences in paid employment than in the Continental and Southern region. The relative position on the labour market for persons with a chronic illness worsened in the past 10 years among low-educated persons and remained fairly stable for high-educated persons.

The risk of being outside of paid employment with a chronic illness is higher for persons with a low education than those with a high education. Previous studies have shown comparable results in specific countries9 11 16 18 or across Europe in one particular year.27 28 Our study expands this knowledge by demonstrating that these patterns are consistent over time and European countries and by illustrating that health-related educational inequalities in paid employment have widened rather than narrowed in the past decade.

Men and women with a chronic illness had less access to the labour market than their healthy colleagues, especially among lower educated persons. Possible explanations for the observed educational inequality relate to severity of chronic illnesses and quality of jobs. In this study, chronic illness could not be differentiated by diagnosis and severity. It may be hypothesised that lower educated workers more often suffer from chronic diseases with functional limitations than high-educated workers.29 30 Having a chronic illness and functional limitations follows a social gradient in our data (high educated 49%, low educated 73%). The education inequality may also be explained by differences in strenuous work and other job characteristics that may interfere with health problems.31 32

A few studies have demonstrated that strenuous work conditions hamper workers with a chronic illness to remain in paid employment. Among Finnish workers, physical work load strongly mediated the association between musculoskeletal disorders and exit from paid employment.33 A Dutch study attributed 12% of educational differences in disability benefits to work characteristics.34 Another Dutch study showed that high autonomy, high social support and low psychosocial job demands strongly moderated the association between chronic health conditions and exit through disability benefits.35 Lower socioeconomic jobs more often have unfavourable work characteristics.36 Therefore, the ability to remain in paid employment is reduced for low-educated persons with a chronic illness.

Health-related absolute and relative differences in paid employment across educational groups were consistently lower in the Southern region than in other European regions. A few studies12 18 27 have noted larger absolute and relative differences in labour force participation between persons with and without a chronic illness in regions with low employment protection compared with regions with high employment protection. Our results in the Southern region, which is characterised by high employment protection, corroborates these previous studies. However, the educational inequalities in paid employment depicted in figure 2 showed a larger variation between countries in the same region than between different regions. This suggests that other social, legal and economic conditions, such as availability of social benefits, also play a role in being in paid employment of people with a chronic illness. More studies are necessary to evaluate the influence of various national indicators of social, cultural and economic conditions on the variation in health-related educational inequalities in paid employment.

The absolute and relative disadvantages in labour force participation among those with a chronic disease were more pronounced for men than for women in most welfare states. In the Southern welfare state regime, the absolute and relative differences were smaller for women, but in the Nordic welfare state regime, the two groups showed similar patterns. These regional differences may partly be explained by institutional support, that is, the full-employment policies of the Nordic region, facilitating the integration of women into the labour force by providing for example child care, although often the decision to be active or not is strongly affected by education and fertility choices.37 38 The high labour force participation of women in Nordic welfare states can contribute to higher relative differences between those with and without a chronic illness compared with the Southern region. This is in line with previous studies stating that in terms of socioeconomic inequalities, the relative inequalities do not appear to be smallest in more redistributive countries such as the Scandinavian welfare state, but that the absolute health of all social classes is often better.39

The trends observed in this study showed that over the period 2005 to 2014, educational inequalities in paid employment of persons with a chronic illness have widened among low-educated persons. In the recent decades, precarious employment, such as temporary contracts and part-time work, have become more common in Europe.40 41 Further research is necessary to evaluate whether the increase in precarious employment could be an explanation for increasing educational inequalities in paid employment.

The trend analysis might be influenced by the differential effect of the economic crisis across regions. The Continental and Eastern region have had an increase in persons in paid employment over the period 2005–2014, while the Southern region had a decrease of persons in paid employment due to the economic crisis. In periods of high and rapid increase in unemployment rates, workers in good health will also lose their jobs and, thus, the influence of ill health on paid employment will attenuate.42 This mechanism may explain why we found a decreasing trend in the Southern region. Furthermore, health may have worsened during the economic crisis. For persons with existing health issues, this could have led to more difficulties maintaining paid employment. A recent study found an increase in absolute inequalities in health between educational groups after the recent economic crisis in the Continental and Anglo-Saxon region.43 This may explain the increasing trends we found in these regions.