How does informal employment impact population health? Lessons from the Chilean employment conditions survey

Safety Science xxx (2017) xxx–xxx

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How does informal employment impact population health? Lessons from the Chilean employment conditions survey Marisol E. Ruiz a,b,⇑, Alejandra Vives a,c, Èrica Martínez-Solanas d, Mireia Julià a,b, Joan Benach a,b,e a Health Inequalities Research Group - Employment Conditions Knowledge Network (GREDS-EMCONET), Department of Political and Social Sciences, Parc de Recerca, Universitat Pompeu Fabra, c/Ramon trias Fargas 25-27, 08005 Barcelona, Spain b Johns Hopkins University - Universitat Pompeu Fabra Public Policy Center, c/Ramon trias Fargas 25-27, 08005 Barcelona, Spain c Departamento de Salud Pública, Escuela de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 2° piso, 8330077 Santiago de Chile, Chile d ISGlobal, Doctor Aiguader 88, 08003 Barcelona, Spain e Transdisciplinary Research Group on Socioecological Transitions (GinTRANS2), Universidad Autónoma de Madrid, Madrid, Spain

a r t i c l e

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Article history: Received 26 July 2016 Received in revised form 27 December 2016 Accepted 15 February 2017 Available online xxxx Keywords: Informal employment Employment conditions Determinants on health Health inequalities Chilean labour market

a b s t r a c t Informal employment is an employment condition and a social determinant of health. Although it can represent a serious problem for public health, it is seldom studied as such. The aim of this study was to determine if there is a relationship between informal employment and health among different groups of workers in Chile. We used a cross-sectional study with data for 8357 workers from the first Chilean work, employment, health and quality of life survey (2009–2010). Workers were classified as formal or informal according to the contractual situation and workplace for dependent workers, educational level for the self-employed, and number of employees for employers. We then grouped these into Dependent formal, Non-dependent formal, Dependent informal and Non-dependent informal. Sex-stratified descriptive analyses and Poisson regression models with prevalence ratios (PR) adjusted for age were used to quantify the association between these four groups of employment and self-rated health and mental health (GHQ12). There was a positive and statistically significant association between informal employment and poor self-rated and mental health for men but not for women. Models for the interaction between informal employment and sex illustrated that it was statistically significant for both health outcomes. This study found a consistent relationship between informal employment and poor self-rated health and mental health. Further research is needed to better understand this association and the gender differences observed in this study. Ó 2017 Published by Elsevier Ltd.

1. Introduction For a long time public health research has highlighted the proximal psychosocial work environment determinants of health. Yet, this approach addresses only a portion of a complex system involving labour markets, employment and working conditions, psychosocial environments and health (Karasek and Theorell, 1990; Siegrist and Marmot, 2006). Against this background, work and employment are fundamental social determinants of health that have become an issue of growing scientific and social attention ⇑ Corresponding author at: Health Inequalities Research Group - Employment Conditions Knowledge Network (GREDS-EMCONET), Department of Political and Social Sciences, Parc de Recerca, Universitat Pompeu Fabra, c/Ramon trias Fargas 25-27, 08005 Barcelona, Spain. E-mail addresses: [email protected] (M.E. Ruiz), [email protected] (A. Vives), [email protected] (È. Martínez-Solanas), [email protected] (M. Julià), [email protected] (J. Benach).

in Public and Occupational Health over the last decades. Especially after the publication of the Report by the Commission on Social Determinants of Health (CSDH) in 2008, and the work conducted by the Emconet Knowledge network (EMCONET), ‘‘employment conditions” has emerged as an important social determinant of health (Commission on Social Determinants of Health, 2008) and there has been growing yet unbalanced knowledge regarding the different employment conditions (Benach et al., 2014). As mentioned above, an employment condition such as informal employment is considered a social determinant of health. Informality represents a serious problem for public health because of its unregulated and unregistered characteristics (Marmot et al., 2008). Nonetheless, the link between informal employment and health has not been thoroughly studied, especially in Chile. To study this relationship it is crucial to understand the labour market and the different employment agreements that could be impacting on informality. A recent study (Ruiz et al., forthcoming) allowed us

http://dx.doi.org/10.1016/j.ssci.2017.02.009 0925-7535/Ó 2017 Published by Elsevier Ltd.

Please cite this article in press as: Ruiz, M.E., et al. How does informal employment impact population health? Lessons from the Chilean employment conditions survey. Safety Sci. (2017), http://dx.doi.org/10.1016/j.ssci.2017.02.009

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M.E. Ruiz et al. / Safety Science xxx (2017) xxx–xxx

to better contextualise the Chilean labour market and advance towards the development of a categorisation of the working population. The national survey used to conduct this study has the advantage of providing substantial and high quality data about employment, working conditions, health and quality of life. Taking the above factors into account, studying informal employment and its consequences on health within the context provided by Chile is a unique opportunity. To better understand the impact of informal employment on population health, the aim of this research was to determine a relationship between informal employment and health among different groups of workers in the Chilean Labour Market. 1.1. Informality and precariousness As stated earlier, some employment conditions have been more studied than others. While unemployment can be considered as an extreme situation of deprivation and exclusion, with plenty of studies demonstrating its negative effects on health, from a quality of employment perspective, informality and precariousness are both emerging problems to be studied. In recent decades, as a result of an expansion of the neoliberal capitalist economy, new forms of non-standard employment have emerged around the world (Boyer, 1993; Monastiriotis, 2006). Precariousness and informal employment have become a global phenomena and growing issues of research interest (Van Aerden et al., 2014; Benach et al., 2014a). Despite emerging research on both informal and precarious employment conditions, many questions remain unanswered. Although there is a link between precarious and informal employment in that both cases deal with vulnerable and unprotected work, these two employment conditions have distinguishing characteristics and it is likely that different mechanisms link them to the population’s health (Benach et al., 2014b). On one hand, precariousness could be understood as a cross-cutting condition which combines different elements: employment instability; disempowerment (individualized bargaining); vulnerability (worker defenselessness to unacceptable workplace practices); low or insufficient wages; limited rights (suboptimal entitlement to social security benefits and worker rights); and incapacity to exercise rights (Benach et al., 2014b, pp. 238–239). On the other hand, informal employment is defined as a non-regulated placement in the labour market (International Labour Organization, 2002, 2012), that can take different forms. This non-regulated relationship usually involves an informal arrangement between employee and employer or self-employment (with an exchange of products or services but no exchange of labour force), and therefore does not have labour regulation and/or social protection (Ruiz et al., 2015). 1.2. Informal employment and health Among employment conditions, informal employment is one of the most extended forms of employment in the world, with special relevance to public health for at least three reasons. First, it constitutes a global phenomenon, mainly affecting low and middleincome regions. Global estimates show that more than half of non-agricultural employment in those countries is under informal employment arrangements (International Labour Organization, 2012). Second, informal workers are likely to work under worse working conditions than those in protected, higher quality and more secure jobs. Third, informal employment arrangements lacking social protection may produce a devastating ‘‘snow ball” effect that negatively impacts working life, housing quality and poverty, affecting not only the health of many workers but also the wellbeing and quality of life of their families and communities. However, little is known about informal employment and its association with health. First, the lack of a common definition of

informal employment; secondly, the absence of a common method of measurement; and finally, the lack of data to measure this phenomenon and, consequently, the difficulty in measuring its impact on health (Ruiz et al., 2015). To date, the scarce available evidence shows that informal employment has negative consequences on well-being and health. Some studies have related informal jobs with poor mental health (Santana et al., 1997; Ludermir and Lewis, 2005; da Silva et al., 2006), while others have investigated specific health problems and their association with informality (Giatti et al., 2008b; Basu et al., 2016), associating informal work with worse health status (Alfers and Rogan, 2015; Giatti et al., 2008a; López-Ruiz et al., 2015; Ludermir and Lewis, 2003; Lund and Ardington, 2006), or have related informality with quality of life (Vélez Álvarez et al., 2015). Some studies have also included the absence of social security coverage in their analysis to describe the relationship between poor health and lack of labour and social protection (GarcíaUbaque et al., 2012). In most of this research the definition of informality is not clearly mentioned, although in some cases International Labour Organization parameters to classify informal employment is used. Only a few studies take their own definition of informality into account (Ludermir and Lewis, 2003; Lund and Ardington, 2006; Alfers and Rogan, 2015). As a social determinant of health, informal employment crosses the different axes of inequality, such as gender, age, social class, ethnicity and migrant status, contributing to health inequalities across those axes. Overall, men tend to have more formal contracts linked with full-time permanent jobs, whereas women are more likely to be affected by informal employment and job precariousness (Benach et al., 2010; Vanek et al., 2014). A simple examination of this indicator suggests that it is determined by gender patterns (Chen et al., 2006; Vosko et al., 2009). Furthermore, research has shown how employment conditions, and specifically informality, are affected by social constructs related to gender. Therefore, as expected, women are more affected by informal employment than men (Ludermir and Lewis, 2005; Artazcoz et al., 2007; Chen, 2012). 1.3. The Chilean case While informal employment can be observed on a large scale in some parts of the world such as South Asia (82%) or Sub-Saharan Africa (66%), impacting a large part of the population (Vanek et al., 2014), or even many countries in South America (ranging from 40% to 75%) (ILO and WIEGO, 2013), this information is not usually reported for Chile. The only available and updated official information is the number of employees without a contract, which stands at 18% (Instituto Nacional de Estadísticas, 2016) but this measurement is extremely limited and underrepresented. According to traditional measures, informality remains low in this country. Nonetheless, it is important to bear in mind that if an indicator based on absence of social security coverage is applied, informal employment tends to increase (Brega et al., 2016). The reason could be related to the rise of poor quality jobs created under the model of neoliberal policies (Portes and Roberts, 2005). Chile represents a paradigmatic country to study this issue because of the systematic introduction of these kinds of policies since a military coup overthrew President Allende’s government in 1973 (Fornazzari, 2013; Harvey, 2005) and since then, the presence of neoliberal perspectives have expanded in other countries. The implementation of neoliberal policies in Chile since the dictatorship has affected the labour market, increasing deregulation and flexibility and weakening trade unions (Riesco, 2009; Ocampo and Sehnbruch, 2015). New forms of employment, such as fee contracts or self-employment, have since emerged and increased in recent years (Brega et al., 2016). Ongoing research has shown that informality is a growing problem in this country,

Please cite this article in press as: Ruiz, M.E., et al. How does informal employment impact population health? Lessons from the Chilean employment conditions survey. Safety Sci. (2017), http://dx.doi.org/10.1016/j.ssci.2017.02.009

M.E. Ruiz et al. / Safety Science xxx (2017) xxx–xxx

as well as in Colombia or Mexico, which have similar macroeconomic policies (Portes and Roberts, 2005; Cota-Yañez and Navarro, 2015). As the complexity of the Chilean labour market has increased with the presence of new forms of employment, the critical element in assessing and understanding how informal employment could be affecting population health is a categorisation of the working population that properly accounts for the diversity of forms of informal employment (Braveman, 2003; Benach et al., 2012). Therefore, this study seeks to unravel informality in a context with consolidated neoliberal policies, such as the Chilean case. 2. Methods 2.1. Study design and data We performed a cross-sectional study using data from the ‘‘First Chilean work, employment, health and quality of life survey” (ENETS 2009–2010). The survey was conducted through multistage, stratified sampling to ensure representativeness at urban, rural areas and at the national level of the economically active population (Instituto de Seguridad Laboral, Dirección del Trabajo and Ministerio de Salud de Chile, 2009). The population sample included in the survey consisted of 9503 workers, aged 15 years or older, who declared in face-to-face interviews that they were working at that time or had worked in the last 12 months. Our sample was restricted to those who had worked during the week preceding the interview as well as workers who were absent at the time of the interview, whether due to illness or another justified reason. After applying the inclusion criteria, the sample included 8357 workers. 2.2. Study variables 2.2.1. Independent variable The independent variable consisted of four employment profiles, obtained by dividing the sample between dependent and non-dependent workers. We separated dependent workers according to contractual situation and place of work as formal or informal dependent workers. Lack of contract and fee contract were considered to be informal employment. These two modalities are not understood as labour contract, meaning workers have no protection in terms of labour regulation and are unable to exercise their rights. For place of work, we distinguished among three different types: domestic workers, homeworkers and employees working at employer’s premises or units. Non-dependent workers were split into self-employed and employers. We divided selfemployed according to educational level (informal: nonprofessional; formal: professional), and employers according to the number of workers (informal: fewer than 5; formal: 5 or more). This separation was according to the guidelines of the ILO (International Labour Organization, 2012) in order to generate classifications based on the productivity of enterprises, distinguishing smaller companies from larger ones. The enterprises with high productivity are more likely to be formal, and enterprises with low productivity could be considered informal. Therefore, it is presumed that informality is linked to enterprises with fewer workers. The resulting categories were: 1. Dependent formal workers (employees with contract, homeworkers with contract and domestic workers with contract); 2. Non-dependent formal workers (employers with 5 or more workers and self-employed professionals); 3. Dependent informal workers (employees with fee contract, homeworkers with fee contract, employees without contract, homeworkers without contract, domestic workers without con-

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tract and family workers); 4. Non-dependent informal workers (employers with fewer than 5 workers and non-professional selfemployed). The first employment category, Dependent formal workers, is characterised by a relationship of dependence and subordination with a contract and social protection coverage. The second employment category, Non-dependent formal workers, is considered a financially sustainable employment situation given their higher level of education and presumable income situation. For this group, social protection coverage is subject to contract services independently. The category of Dependent informal workers is also characterized by a dependent and subordinate relationship, but without a contract and without social protection coverage, with the exception of workers with fee contract who can have social security so long as they pay for it themselves. Finally, the Non-dependent informal group has a lower level of education than non-dependent formal workers, so this group has higher probabilities of being lowincome. Although social protection coverage is subject to contract services independently, because of their low incomes, it is unlikely that they will pay for social security themselves.

2.2.2. Dependent variables The main outcome variables were self-rated health and mental health. Self-rated health was measured by asking the following question: ‘‘In general, how would you say is your health?” with 5 categories (very good, good, fair, bad, and very bad). This variable was dichotomized into good self-rated health (by combining the categories ‘‘very good” and ‘‘good”) and poor self-rated health (by combining the categories ‘‘fair”, ‘‘bad” and ‘‘very bad”). Mental health was measured with the 12 item version of the General Health Questionnaire (GHQ-12), which is a validated instrument used for the detection of multiple mental disorders, especially for common mental disorders (Ali et al., 2016; Araya et al., 1992). We dichotomized this variable into good mental health - scoring less than 5 - and poor mental health - 5 or more by combining suspicion and signs of psychopathology- (Ministerio de Salud, Chile, 2009). We included several socio-demographic characteristics: sex, age (under 35 years; between 35 and 64 years; more than 64 years), educational level (primary complete, secondary complete and higher education), occupation (manual, non-manual), and economic activity (agriculture, industry, construction, services, and public administration and other services).

2.3. Statistical analysis We performed Poisson regression models to study the relationship between the employment profiles and health outcomes. We calculated prevalence ratios (PR) with 95% confidence intervals (CI). All analyses were adjusted by age. In the first stage, we fit models stratified by sex using the dependent formal group as the reference category. Then, we tested an interaction term to observe if sex modified the effect of employment group on health (Adjusted Wald test with 95% CI). We estimated the size of the effects of the variables and the interaction between them considering the interaction term and using the male Dependent formal group as the reference category. We did another model within the previous model that was adjusted by occupation (Table A2, no significant differences were observed). Data were weighted using the probability weights provided by the ENETS 2009–2010. All analyses were performed using SPSS v.22 and STATA v.14.

Please cite this article in press as: Ruiz, M.E., et al. How does informal employment impact population health? Lessons from the Chilean employment conditions survey. Safety Sci. (2017), http://dx.doi.org/10.1016/j.ssci.2017.02.009

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3. Results Regarding socio-demographic characteristics, out of the total sample population of workers, 35.0% (2924) were women and 64.3% (5372) were men. Almost 46% of women and 38% of men are in informal employment according to this study. Table 1 shows that among women, Non-dependent informal workers were older (7.1%), while ageing male workers were concentrated in nondependent groups (more than 13.6%). Both men and women had lower educational level in informal groups of workers (more than 27% for Dependent informal and more than 39% for Non-dependent informal). About 86% of women in non-dependent groups had higher education (75% for men). Manual workers had more presence among informal groups (for Non-dependent informal workers: 61.7% of women and 85.6% of men; for Dependent informal group: 77.9% of women and 78% of men. It is however interesting to note that among men three quarters of the Dependent formal group performed manual jobs. Women were more present in jobs related to public administration and other services, with the exception of

Non-dependent informal workers, who had more presence in the service sector. Meanwhile, the distribution of the economic activity among men was similar in all groups of workers, with higher presence in the service sector (Table 1). Table 2 reports prevalences for both health outcomes and results of the model stratified by sex showing the prevalence of poor self-rated health and poor mental health. The prevalence of both health indicators was higher among women than men (35.5% v/s 20.1%, respectively, for general health, and 16.2% v/s 9.6% for mental health). The highest prevalence of poor self-rated health was observed in informal groups for both men and women. Nonetheless, among women these associations were nonsignificant. Regarding men, those performing activities in informal employment had a higher prevalence of poor self-rated health, especially among Dependent informal workers (PR: 1.73, CI95% 1.30–2.30). Informal workers had a somewhat higher prevalence of poor mental health, for both men and women. However, this was only significant among male Dependent informal workers (PR: 2.43, CI95% 1.59–3.70). Women and men working in

Table 1 Socio-demographic characteristics.

Women Total Age (years) <35 35–64 > 64 Total Educational level Primary school Secondary school Higher education Total Occupation Non-manual Manual Total Economic activity Agriculture Industry Construction Service Public administration and other services Total Men Total Age (years) <35 35–64 >64 Total Educational level Primary school Secondary school Higher education Total Occupation Non-manual Manual Total Economic activity Agriculture Industry Construction Service Public administration and other services Total

Dependent formal

Non dependent formal

Non dependent informal

Dependent informal

n

%

n

%

n

%

n

%

1576

49.9

58

3.4

624

20.8

666

24.9

588 967 21 1576

39.2 58.7 2.2 100.0

12 41 5 58

42.2 55.2 2.6 100.0

99 467 58 624

14.6 78.3 7.1 100.0

190 461 15 666

29.8 69.0 1.1 100.0

271 885 416 1572

14.4 55.6 30.0 100.0

3 5 50 58

4.9 8.3 86.8 100.0

252 363 9 624

39.6 57.8 2.6 100.0

232 366 68 666

27.9 59.7 12.4 100.0

707 782 1489

51.8 48.2 100.0

34 24 58

61.4 38.6 100.0

255 361 616

38.3 61.7 100.0

162 492 654

22.1 77.9 100.0

106 112 16 461 870 1565

7.7 6.7 1.4 29.9 54.3 100.0

5 5 0 18 28 56

10.9 5.1 0.0 25.0 59.0 100.0

59 61 3 377 116 616

5.7 9.4 0.3 58.3 26.3 100.0

50 22 3 126 463 664

6.6 3.6 0.3 22.4 67.1 100.0

3022

57.4

210

4.4

2136

24.8

1352

12.9

924 2019 79 3022

36.8 60.8 2.5 100.0

28 112 12 152

23.7 60.9 15.4 100.0

201 1099 212 1512

18.2 68.2 13.6 100.0

255 393 38 686

40.4 54.9 4.7 100.0

821 1822 371 3014

20.9 64.8 14.3 100.0

11 27 114 152

1.8 23.0 75.2 100.0

747 749 16 1512

47.3 51.4 1.3 100.0

285 347 54 686

31.9 55.9 12.2 100.0

698 2226 2924

28.9 71.1 100.0

94 56 150

66.8 33.2 100.0

226 1253 1479

14.4 85.6 100.0

115 562 677

22.0 78.0 100.0

485 646 432 754 683 3

13.6 21.8 12.8 27.6 24.3 100.0

18 25 21 60 26 150

19.0 12.0 18.6 30.0 20.4 100.0

423 146 239 562 121 1491

18.1 9.8 19.4 42.4 10.5 100.0

183 72 100 210 112 677

21.5 15.2 14.3 30.5 18.6 100.0

Please cite this article in press as: Ruiz, M.E., et al. How does informal employment impact population health? Lessons from the Chilean employment conditions survey. Safety Sci. (2017), http://dx.doi.org/10.1016/j.ssci.2017.02.009

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Table 2 Number (n), prevalence (%) and relationship between employment group and poor self-rated health and poor mental health: prevalence ratios (PR) and 95% confidence intervals. Women

Men

n

%

PR (95% CI)

n

%

PR (95% CI)

Poor Self-rated health Dependent formal Non-dependent formal Non-dependent informal Dependent informal Total

443 18 216 243 930

32.5 23.3 39.0 39.4 35.5

– 0.69 (0.29, 1.66) 1.06 (0.83, 1.36) 1.13 (0.85, 1.52)

505 23 423 182 1141

15.8 7.4 28.9 26.4 20.1

– 0.40 (0.18, 0.90) 1.54 (1.20, 1.96) 1.73 (1.30, 2.30)

Poor mental health Dependent formal Non-dependent formal Non-dependent informal Dependent informal Total

237 7 98 130 475

15.9 8.8 16.0 18.2 16.2

– 0.58 (0.22, 1.54) 0.95 (0.61, 1.49) 1.11 (0.71, 1.72)

210 10 135 91 448

8.5 3.0 8.5 19.3 9.6

– 0.36 (0.14, 0.98) 0.89 (0.60, 1.32) 2.43 (1.59, 3.70)

Reference category: Dependent formal.

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Poor self-rated health

3.5 3 2.5 2

2.35 2.13

2.10

1.5

1.58

1.44

1

1.73

1

0.5

0.42

0 Dependent Non Dependent Non formal dependent dependent informal informal formal

Dependent Dependent Non Non formal dependent dependent informal informal formal

Women

Men

4

Poor mental health

3.5 3 2.5 2

2.39 2.06 1.87

1.72

1.5 1

1.03

0.5

1

0.92 0.38

0 Dependent Non Dependent Non formal dependent dependent informal informal formal

Women

Dependent Non Dependent Non formal dependent dependent informal formal informal

Men

Fig. 1. Relationship between employment group and poor self-rated health and poor mental health: prevalence ratios (PR) and 95% confidence intervals: interaction effects model between sex and employment group.

Non-dependent formal jobs had a lower prevalence of both poor general and poor mental health than all other groups, although this only reached statistical significance among men. We then further tested if the relationship between health status (self-rated health and mental health) and employment profile was

modified by sex. The interaction was significant (Prob > F = 0.05 for mental health; Prob > F = 0.02 for self-rated health). The results of the interaction model (Fig. 1) allowed us to see more clearly that among women there was a higher risk of poor self-rated health in all groups of workers compared with Dependent

Please cite this article in press as: Ruiz, M.E., et al. How does informal employment impact population health? Lessons from the Chilean employment conditions survey. Safety Sci. (2017), http://dx.doi.org/10.1016/j.ssci.2017.02.009

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formal male workers. Although confidence intervals overlapped, the point estimate for both women and men suggest the same pattern and a positive gradient from formal to informal workers. The highest risk was observed among Dependent informal workers. Regarding poor mental health, all groups of workers tend to have lower prevalence ratios than those for poor self-rated health. The group of women with the highest risk of poor mental health compared to the reference category (Dependent formal male workers) is Dependent informal workers (PR: 2.06, CI95% 1.26–3.36), although differences across groups are small except for a markedly lower prevalence ratio for Non-dependent formal workers. Among groups of male workers, the pattern is different: only the Dependent informal group had a higher risk than the reference category (PR = 2.39, 95%CI: 1.55–3.68), an association that was stronger than for female workers. 4. Discussion We consider that our findings could represent a contribution to a better understanding of the impact of informal employment on the population’s health, considering differences between genders and within different groups of workers. Our study has produced four main findings: first, we found a relationship between informal employment and worse health. Second, we found a markedly lower prevalence of poor health among formal non-dependent workers than in all other groups. Third, the effects on health produced by informality are strongest among the male population. Fourth, for women, formal employment does not appear to have a protective effect when compared to informal employment. 4.1. Informal employment and health People working in informal employment may be exposed to a greater extent of suffering health consequences, because of the lack of protection and regulation of their jobs. Previous studies have indicated the same tendency observed in our research, that is, informal employment is related with poor health status and poor mental health (Santana et al., 1997; Ludermir and Lewis, 2003, 2005; da Silva et al., 2006; Lund and Ardington, 2006; Giatti et al., 2008a, 2008b; Alfers and Rogan, 2015; López-Ruiz et al., 2015). Although these studies come from different realities and approaches, they have found that informal employment could damage the health of the population. To our knowledge, only one study contradicts this trend stating that informality is a protective factor for health outcomes (Vélez Álvarez et al., 2015). Our findings suggest that informal work may be the greatest disadvantage in terms of health, especially for mental health among men. For the male population, considering both poor selfrated and poor mental health, the Dependent informal group experienced the worst health status followed by Non-dependent informal. With regard to formal employment, the Non-dependent formal group presented better health outcomes than Dependent formal. A very similar pattern was observed among women, although this population presented few differences between informal workers of both categories and Dependent formal workers. Comparing with the few studies taking into account the difference between self-employment and dependent employment, our results are consistent with Lund and Ardington 2006, but not with LópezRuiz et al. 2015, that have reported worse health indicators among non-dependent unprotected workers. For poor mental health, there was a significantly higher prevalence ratio among Dependent informal male workers, which may be due to the intrinsic features of these kinds of jobs (an example of male Dependent informal jobs could be truck drivers’ assistant to distribution). Ongoing research allowed us to investigate this

issue more in depth. A qualitative approach enabled us to suggest that both lack of regulation and coverage, along with the uncertainty of the employment relationship could be affecting the mental health status of this group. It should also be noted that jobs performed by men yield more exposure to suffering accidents at work (Biddle and Blanciforti, 1999). Therefore, because of the increased hazards, Chilean male workers admitted to experiencing more physical and sensory demands (Rocha et al., 2014). Furthermore, the evidence shows an increase in injuries and occupational illness for informal workers (Santana, 2004; Ostry, 2009; GarcíaUbaque et al., 2012). As stated earlier, the theoretical models developed consider psychosocial factors as key elements affecting work environment and having an impact on health. The lack of control at work could be an important mechanism that might explain poor mental health for the Dependent informal group of male workers. 4.2. Non-dependent formal work and health The lowest prevalence ratios of poor health status were observed among Non-dependent formal workers. Among women, the pattern observed was similar to that for men, even though there was insufficient statistical power to establish that female workers of this group had better health outcomes. As stated earlier, the difference between the group composed of Non-dependent formal and the group of Non-dependent informal is the educational level for self-employed and the amount of employees for employers. It is important to bear in mind that the Non-dependent formal group of workers is the highest educated population with better personal income (results not shown). These two related elements could explain the conformation of a highly select group of workers, which has a catalyzing effect on the inequality observed among the Chilean population (Lopez et al., 2013). Furthermore, the health outcomes obtained may be due to the effect produced by the combination of determinants such as education and income (Bourdieu, 1973; Regidor, 2001). Although some articles have studied self-employment and health, to our knowledge, there is no previous research that considers and studies this particular group (Non-dependent formal workers), which means we have no reference with which to compare our results. To cite just a few examples of what has been studied in this field, a study focused on Central America found that selfemployed men with social security coverage (meaning formal workers under that criteria) had worse mental health than formal employees. There were no differences found among women (López-Ruiz et al., 2015). On the other hand, a study using European data found that self-employed workers had better subjective well-being than employees (Sevä et al., 2016). The difference between our results and theirs could be determined by the composition of this particular group of workers in Chile. Therefore, more research is needed to investigate this subject and the association with health status. 4.3. Formality versus informality according to gender Even though the results of our study are consistent with previous research, there is an important difference among some of them regarding gender effects on health outcomes. Specifically, our findings show an association between worse health and men working informally, despite the point estimate showing the same trend for female workers (with overlapped confidence intervals). Previous research reports the strongest association between poor health and informal employment in female workers. Considering the empirical studies taking gender differences into account, the data analysed in most of them did not provide information at the national level, because they only covered a particular region

Please cite this article in press as: Ruiz, M.E., et al. How does informal employment impact population health? Lessons from the Chilean employment conditions survey. Safety Sci. (2017), http://dx.doi.org/10.1016/j.ssci.2017.02.009

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(Santana et al., 1997; Ludermir and Lewis, 2003, 2005; da Silva et al., 2006; Giatti et al., 2008a). Concerning studies with samples at the national level (Alfers and Rogan, 2015; López-Ruiz et al. 2015), we could observe a similar pattern as in our study. Regarding the differences found in health status among men and women, as stated earlier, gender is an important axis of inequality. Within the context of a patriarchal system based on hierarchical and asymmetrical relations between genders, society gives greater recognition and social value to traditionally male roles and behaviours (de Beauvoir, 1953; Bourdieu, 2000). This system of asymmetric relations damages the basic access to social determinants of health, affecting population health through a gender-pattern-system. Therefore, from a gender perspective, while women have longer life expectancies, they are also subject to experiencing worse health and quality of life (Verbrugge, 1985; Connell, 2012). This aspect would most likely be determined by gender patterns and gender inequalities in health (Malmusi et al., 2012). The double burden of paid and unpaid work could be a key mechanism in explaining this issue (Artazcoz et al., 2004). Furthermore, the greater domestic workload carried by women, the lack of family policies that could enable a better work-life balance (Artazcoz et al., 2014), and the little male contribution to housework could explain the low female participation in the Chilean labour market, which is barely 43.4% (Piras and Rucci, 2014). In this sample and concerning the double burden of paid and unpaid work, while 44.8% of women were exposed to high double burden, only 7.9% of men experienced the same situation (Table A1). The unpaid reproductive work may be regarded as a key element for women in understanding the higher levels of worse health status. Taking health status into account, specifically for women, formality does not seem to be a protective factor in the Chilean labour market. This does not mean that employment formalisation is unnecessary or important for them, as there are several factors to be considered. Firstly, this may be due in part to the fact that, as stated earlier, women have worse health than men. If we consider the total population, (not only workers) even though the indicators of poor self-rated health are worse for both sexes, the largest increase was observed in women. While women reached 48.5% of prevalence, men had 32.6% (Ministerio de Salud, Chile, Pontificia Universidad Católica de Chile & Universidad Alberto Hurtado, 2009). Secondly, due to the implementation of neoliberal policies, poor labour conditions have been expanded for the working population as a whole (Ruiz-Tagle and Sehnbruch, 2015), which affect women to a higher extent (Durán and Kremerman, 2015). An example of this matter is the increase in inequality (Lopez et al., 2013) and, strongly linked to this issue, low wages, which particularly affect women because of the gender pay gap that rises to 21.4% (Brega et al., 2015). Therefore, if informal employment could be related with the increasing risk of poor health status for men, for women, formal employment may not have reached the standards that make it a protective determinant of health. 4.4. Strengths and limitations To our knowledge, this is one of the first studies conducted in a country as a whole that analyses the relationship between different groups of workers in formal and informal employment and health status, using a large and representative sample of the working population. Furthermore, such a study is the first that has been done within the Chilean labour market. Second, we had to conduct an in-depth analysis of the Chilean labour market through the categorisation of the working population in different groups to ensure that all types of informality would be considered. The classification of workers proposed was established using a qualitative approach

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for a better understanding of the several forms from which informality can evolve under neoliberal public policies (Ruiz et al., forthcoming). The assumptions made were supported by theoretical and previous empirical findings, along with un-published research. Third, using a representative survey of all workers provided us with great data to achieve the aim of this study. Therefore, our findings enable us to have a better insight of the relationship between informal employment and poor health, encouraging further research in other similar contexts. On the other hand, the use of cross-sectional data represents a clear limitation in making statements about causality. However, the results are consistent with previous research. Second, the analyses of this study were only adjusted by age. Although occupation could be understood as a proxy of social class, our position considers this axis of inequality to engage a high level of complexity, including different social determinants of health such as educational level, education security, childhood, environment and surrounding neighbourhood.

5. Conclusions Within the expansion of neoliberal policies, new forms of employment have emerged and an updated conceptualisation of the working population under these new circumstances remains to be developed (Scott-Marshall, 2010). Particularly in Chile, even though this reality has taken over the labour market for decades, from an official point of view the analysis of employment conditions has not changed. Because of the emergence of new forms of employment, the classification of employment status has become increasingly complex (Lund and Ardington, 2006), which is the main reason that new forms of employment require renewal and better categorisations (Van Aerden et al., 2014). Our findings show that there are important differences between forms of employment, allowing us to sustain the importance of making an effort to improve a conceptualisation taking this complex and changing reality into account. In order to investigate the health consequences that different groups of workers could be exposed to, rethinking a classification is an essential matter (Scott-Marshall, 2010). Even though informal employment seems to be a small obstacle in the Chilean labour market, this study has shown that despite the fact that this country does not have high levels of informality compared with the rest of the American continent, it still represents a substantial problem. Achieving this was essential to being able to analyse how population health is affected by informal employment and Chile seems to provide a unique context. As stated earlier, with an under-regulated labour market, informality may be a growing reality in countries with neoliberal policies especially because of the increase of self employment (non-dependent and informal) (Ruiz-Tagle and Sehnbruch, 2015; Brega et al., 2016). This fact could affect a greater number of workers, damaging their health. Finally, it is important to bear in mind that there could be other mechanisms affecting the link between informal employment and adverse health status, such as the interaction with axes of inequality or other determinants of health that have been stated above. This study is part of a larger and ongoing research project which will allow us to have a comprehensive approach and understanding of informal employment and how this important determinant of health could be impacting population health. This kind of research is required to encourage the development of relevant public policies in order to ensure protection and regulation for all workers, improving their health and reducing health inequalities. Nevertheless, in order to continue studying and better understanding this problem, our findings highlight that further studies are

Please cite this article in press as: Ruiz, M.E., et al. How does informal employment impact population health? Lessons from the Chilean employment conditions survey. Safety Sci. (2017), http://dx.doi.org/10.1016/j.ssci.2017.02.009

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M.E. Ruiz et al. / Safety Science xxx (2017) xxx–xxx

Table A1 Double burden of paid and unpaid work by employment group.

Women Total Double burden High Low Total Men Total Double burden High Low Total

Dependent formal

Non dependent formal

Non dependent informal

Dependent informal

n

%

n

%

n

%

n

%

1576

49.9

58

3.4

624

20.8

666

24.9

697 878 1575

40.3 59.7 100.0

24 34 58

38.7 61.3 100.0

312 308 620

51.0 49.0 100.0

361 304 665

49.5 50.5 100.0

3022

57.4

210

4.4

2136

24.8

1352

12.9

274 2745 3019

7.7 92.3 100.0

13 137 150

8.5 91.5 100.0

160 1346 1506

7.3 92.7 100.0

82 601 683

9.1 90.9 100.0

Table A2 Prevalence ratios (PR) and 95% confidence intervals in two models: relationship between employment group and poor self-rated health and poor mental health. Model 1a

Model 2b

Women PR (95%CI)

Men PR (95%CI)

Women PR (95%CI)

Men PR (95%CI)

Poor Self-rated health Dependent formal Non-dependent formal Non-dependent informal Dependent informal

2.10 1.44 2.13 2.35

(1.69. (0.62. (1.65. (1.71.

2.62) 3.34) 2.76) 3.22)

– 0.42 (0.19. 0.91) 1.58 (1.24. 2.00) 1.73 (1.31. 2.30)

2.24 1.55 2.24 2.34

(1.80–2.80) (0.70–3.43) (1.75–2.87) (1.72–3.17)

– 0.46 (0.21–1.02) 1.49 (1.17–1.89) 1.69 (1.27–2.24)

Poor mental health Dependent formal Non-dependent formal Non-dependent informal Dependent informal

1.87 1.03 1.72 2.06

(1.28. (0.38. (1.06. (1.26.

2.72) 2.81) 2.79) 3.36)

– 0.38 (0.14. 1.00) 0.92 (0.62. 1.37) 2.39 (1.55. 3.68)

1.89 1.08 1.77 1.82

(1.30–2.76) (0.40–2.91) (1.09–2.88) (1.11–2.98)

– 0.40 (0.15–1.06) 0.90 (0.60–1.34) 2.33 (1.50–3.61)

Reference category: Male dependent formal. a Adjusted by age. b Adjusted by age and occupation.

needed to improve the knowledge of the impact of informal employment on population health. Conflicts of interest The authors declare no potential conflicts of interest with respect to the research, authorship and publication of this article. Acknowledgements This study was partially supported by a grant from the Comisión Nacional de Investigación Científica y Tecnológica de Chile, as part of ME Ruiz doctoral thesis. The authors would like to thank Albert Navarro for his comments and statistical review, and Kayla Smith for her contribution in reviewing the language and discourse of this paper. Appendix A See Tables A1 and A2. References Alfers, L., Rogan, M., 2015. Health risks and informal employment in South Africa: does formality protect health? Int. J. Occup. Environ. Health 21 (3), 207–215. http://dx.doi.org/10.1179/2049396714Y.0000000066. Ali, G.-C., Ryan, G., De Silva, M.J., 2016. Validated screening tools for common mental disorders in low and middle income countries: a systematic review. PloS One 11 (6), e0156939. http://dx.doi.org/10.1371/journal.pone.0156939.

Araya, R., Wynn, R., Lewis, G., 1992. Comparison of two self administered psychiatric questionnaires (GHQ-12 and SRQ-20) in primary care in Chile. Social Psych. Psych. Epidemiol. 27 (4), 168–173. Artazcoz, L., Artieda, L., Borrell, C., Cortès, I., et al., 2004. Combining job and family demands and being healthy: what are the differences between men and women? Eur. J. Public Health 14 (1), 43–48. Artazcoz, L., Borrell, C., Cortàs, I., Escribà-Agüir, V., et al., 2007. Occupational epidemiology and work related inequalities in health: a gender perspective for two complementary approaches to work and health research. J. Epidemiol. Commun. Health 61 (Suppl. 2), ii39–ii45. http://dx.doi.org/ 10.1136/jech.2007.059774. Artazcoz, L., Cortès, I., Puig-Barrachina, V., Benavides, F.G., et al., 2014. Combining employment and family in Europe: the role of family policies in health. Eur. J. Public Health 24 (4), 649–655. http://dx.doi.org/10.1093/eurpub/ckt170. Basu, N., Ayelo, P.A., Djogbénou, L.S., Kedoté, M., et al., 2016. Occupational and Environmental Health Risks Associated with Informal Sector Activities— selected case studies from West Africa. New Solutions: J. Environ. Occup. Health Policy 26 (2), 253–270. http://dx.doi.org/10.1177/1048291116651726. Benach, J., Solar, O., Vergara, M., Vanroelen, C., et al., 2010. Six employment conditions and health inequalities: a descriptive overview. Int. J. Health Services: Plan., Admin., Eval. 40 (2), 269–280. Benach, J., Puig-Barrachina, V., Vives, A., Tarafa, G., et al., 2012. The challenge of monitoring employment-related health inequalities. J. Epidemiol. Commun. Health 66 (12), 1085–1087. http://dx.doi.org/10.1136/jech-2012-201103. Benach, J., Muntaner, C., Solar, O., Santana, V., et al., 2014. Employment, Work and Health Inequalities: A Global Perspective. E-book edition. Barcelona, Icaria. Available from: (accessed: 22 June 2016). Benach, J., Vives, A., Amable, M., Vanroelen, C., et al., 2014b. Precarious employment: understanding an emerging social determinant of health. Annu. Rev. Public Health, 35229–35253. http://dx.doi.org/10.1146/annurevpublhealth-032013-182500. Biddle, E.A., Blanciforti, L.A., 1999. Impact of a changing U.S. workforce on the occupational injury and illness experience. Am. J. Indust. Med. Suppl 17–10. Bourdieu, P., 1973. Cultural reproduction and social reproduction. In: Richard Brown (Ed.). Knowledge, education and cultural change. Papers in sociology of education]. Great Britain, Tavistock Publications. Available from: (accessed: 12 January 2016).

Please cite this article in press as: Ruiz, M.E., et al. How does informal employment impact population health? Lessons from the Chilean employment conditions survey. Safety Sci. (2017), http://dx.doi.org/10.1016/j.ssci.2017.02.009

M.E. Ruiz et al. / Safety Science xxx (2017) xxx–xxx Bourdieu, P., 2000. La Dominación Masculina. Editorial Anagrama, Barcelona. Boyer, R., 1993. The Convergence Hypothesis Revisited: Globalization but Still the Century of Nations? CEPREMAP, Paris. Braveman, P.A., 2003. Monitoring equity in health and healthcare: a conceptual framework. J. Health Popul., Nutr. 21 (3), 181–192. Brega, C., Durán, G., Sáez, B., 2015. Mujeres Trabajando. Una exploración al valor del trabajo y la calidad del empleo en Chile. Santiago, Chile, Fundación SOL. Brega, C., Páez, A., Sáez, B., Durán, G., 2016. Informe Mensual de Calidad del Empleo (IMCE) Febrero - Abril 2016. Available from: (accessed: 29 January 2016). Chen, M., 2012. The Informal Economy: Definitions, Theories and Policies. (accessed: 24 May 2016). Chen, M., Vanek, J., Heintz, J., 2006. Informality, gender and poverty: a global picture. Econ. Political Weekly 41 (21), 2131–2139. Commission on Social Determinants of Health, 2008. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health: Commission on Social Determinants of Health Final Report. World Health Organization. Connell, R., 2012. Gender, health and theory: conceptualizing the issue, in local and world perspective. Social Sci. Med. 74 (11), 1675–1683. http://dx.doi.org/ 10.1016/j.socscimed.2011.06.006. Cota-Yañez, R., Navarro, A., 2015. Análisis del mercado laboral y el empleo informal mexicano. Papeles de población 21(85), 2. da Silva, M.C., Fassa, A.G., Kriebel, D., 2006. Minor psychiatric disorders among Brazilian ragpickers: a cross-sectional study. Environ. Health: Global Access Sci. Source 5. de Beauvoir, S., 1953. The Second Sex. Knopf, New York. Durán, G., Kremerman, M., 2015. Los verdaderos sueldos en Chile. Panorama actual del valor del trabajo usando la Encuesta NESI 2014. Santiago, Chile, Fundación SOL. Fornazzari, A., 2013. Speculative fictions Chilean culture, economics, and the neoliberal transition. Pittsburgh, PA, University of Pittsburgh Press. Available from: . García-Ubaque, J.C., Riaño-Casallas, M.I., Benavides-Piracón, J.A., 2012. Informalidad, desempleo y subempleo: Un problema de salud pública. Rev Salud Publica (Bogota), 138–150. Giatti, L., Barreto, S.M., César, C.C., 2008a. Household context and self-rated health: the effect of unemployment and informal work. J. Epidemiol. Commun. Health 62 (12), 1079–1085. http://dx.doi.org/10.1136/jech.2007.069740. Giatti, L., Barreto, S.M., César, C.C., 2008b. Informal work, unemployment and health in Brazilian metropolitan areas, 1998 and 2003. Cadernos de Saúde Pública24 (10), 2396–2406, doi:http://dx.doi.org/10.1590/S0102-311X2008001000020. Harvey, D., 2005. A Brief History of Neoliberalism. Oxford University Press, Oxford; New York. ILO & WIEGO, 2013. Women and Men in the Informal Economy: A Statistical Picture, second ed. p. 205. Available from: (accessed: 20 June 2016). Instituto de Seguridad Laboral, Dirección del Trabajo & Ministerio de Salud de Chile, 2009. Primera Encuesta Nacional de Empleo, Trabajo y Salud: ENETS 2009– 2010. Diseño conceptual y metodológico. Instituto Nacional de Estadísticas, 2016. Boletines de prensa, Empleo. Available from: (accessed: 29 February 2016). International Labour Organization, 2002. El trabajo decente y la economía informal. International Labour Organization. International Labour Organization, 2012. Measuring informality: A Statistical Manual. International Labour Organization. Karasek, R., Theorell, T., 1990. Healthy Work: Stress, Productivity, and the Reconstruction of Working Life. Basic Books, New York. Lopez, R., Figueroa, E., Gutierrez, P., 2013. La ‘parte del león’: Nuevas estimaciones de la participación de los súper ricos en el ingreso de Chile. Available from: (accessed: 11 January 2016). López-Ruiz, M., Artazcoz, L., Martínez, J.M., Rojas, M., et al., 2015. Informal employment and health status in Central America. BMC Public Health 15698, doi:http://dx.doi.org/10.1186/s12889-015-2030-9. Ludermir, A.B., Lewis, G., 2003. Informal work and common mental disorders. Social Psych. Psych. Epidemiol. 38 (9), 485–489. http://dx.doi.org/10.1007/s00127003-0658-8. Ludermir, A.B., Lewis, G., 2005. Is there a gender difference on the association between informal work and common mental disorders? Social Psych. Psych. Epidemiol. 40 (8), 622–627. http://dx.doi.org/10.1007/s00127-005-0938-6.

9

Lund, F., Ardington, C., 2006. Employment status, security, and the management of risk: a study of workers in Kwamsane, KwaZulu-Natal. Available from: (accessed: 28 June 2016). Malmusi, D., Artazcoz, L., Benach, J., Borrell, C., 2012. Perception or real illness? How chronic conditions contribute to gender inequalities in self-rated health. Eur. J. Public Health 22 (6), 781–786. http://dx.doi.org/10.1093/eurpub/ckr184. Marmot, M., Friel, S., Bell, R., Houweling, T.A.J., et al., 2008. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet 372 (9650), 1661–1669. http://dx.doi.org/10.1016/S0140-6736(08) 61690-6. Ministerio de Salud, Chile, 2009. Guía clínica Tratamiento de personas con depresión. Ministerio de Salud, Chile, Pontificia Universidad Católica de Chile & Universidad Alberto Hurtado, 2009. Encuesta Nacional de Salud ENS Chile 2009–2010. Monastiriotis, V., 2006. Employment flexibility and UK regional unemployment: persistence and macroeconomic shocks. Dept. of Trade and Industry, London. Ocampo, J.A., Sehnbruch, K., 2015. Introduction: Quality of employment in Latin America. Int. Labour Rev. 154 (2), 165–170. http://dx.doi.org/10.1111/j.1564913X.2015.00237.x. Ostry, A.S., 2009. Globalization and the marginalization of unskilled labor: potential impacts on health in developed nations. Int. J. Health Serv.: Plan. Admin., Eval. 39 (1), 45–57. Piras, C., Rucci, G., 2014. Chile: Participación laboral femenina y calidad del empleo. Available from: (accessed: 14 June 2016). Portes, A., Roberts, B.R., 2005. The free-market city: Latin American urbanization in the years of the neoliberal experiment. Stud. Comp. Int. Develop. 40 (1), 43–82. Regidor, E., 2001. La clasificación de clase social de Goldthorpe: marco de referencia para la propuesta de medición de la clase social del grupo de trabajo de la Sociedad Española de Epidemiología. Revista Española de Salud Pública 75 (1). Riesco, M., 2009. Change in the Chilean social model. Int. Labour Rev. 148 (3), 283– 300. http://dx.doi.org/10.1111/j.1564-913X.2009.00063.x. Rocha, K.B., Muntaner, C., Solar, O., Borrell, C., et al. (2014) Social class, psychosocial occupational risk factors, and the association with self-rated health and mental health in Chile. Cadernos de Saúde Pública. [Online] 30 (10), 2219–2234. Available from: doi:10.1590/0102-311X00176213. Ruiz, M.E., Tarafa, G., Jódar, P., Benach, J., 2015. ¿Es posible comparar el empleo informal en los países de América del Sur?: análisis de su definición, clasificación y medición. Gaceta Sanitaria 29 (1), 65–71. http://dx.doi.org/ 10.1016/j.gaceta.2014.07.015. Ruiz-Tagle, J., Sehnbruch, K., 2015. More but not better jobs in Chile? The fundamental importance of open-ended contracts. International Labour Review. 154 (2), 227–252. http://dx.doi.org/10.1111/j.1564-913X.2015.00240. x. Santana, V.S., 2004. Informal jobs and non-fatal occupational injuries. Annal. Occup. Hyg. Ann. Occup. Hyg. 48 (2), 147–157. Santana, V., Loomis, D., Newman, B., Harlow, S., 1997. Informal jobs: another occupational hazard for women’s mental health? Int. J. Epidemiol. 26 (6), 1236– 1242. Scott-Marshall, H., 2010. The social patterning of work-related insecurity and its health consequences. Soc. Indic. Res. 96 (2), 313–337. Sevä, I.J., Vinberg, S., Nordenmark, M., Strandh, M., 2016. Subjective well-being among the self-employed in Europe: macroeconomy, gender and immigrant status. Small Business Economics. 46 (2), 239–253. http://dx.doi.org/10.1007/ s11187-015-9682-9. Siegrist, J., Marmot, M.G., 2006. Social Inequalities in Health: New Evidence and Policy Implications. Oxford University Press, Oxford; New York. Van Aerden, K.V., Moors, G., Levecque, K., Vanroelen, C., 2014. Measuring employment arrangements in the European labour force: a typological approach. Soc. Indic. Res. 116 (3), 771–791. http://dx.doi.org/10.1007/s11205013-0312-0. Joann Vanek, Chen, M., Carré, F., Heintz, J., et al., 2014. Statistics on the Informal Economy: Definitions, Regional Estimates & Challenges]. Available from: (accessed: 24 May 2016). Vélez Álvarez, C., Pico Merchán, M.E., Escobar Potes, M. del P., 2015. Determinantes sociales de la salud y calidad de vida en trabajadores informales. Manizales, Colombia. Salud de los Trabajadores. 23 (2). Available from: (Accessed: 14 June 2016). Verbrugge, L.M., 1985. Gender and health: an update on hypotheses and evidence. J. Health Soc. Behav. 26 (3), 156–182. Vosko, L.F., MacDonald, M., Campbell, I., 2009. Gender and the Contours of Precarious Employment. Routledge, London; New York.

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