Employment and Women's Health Effects of Paid Employment on Women's Mental and Physical Health

This article reviews empirical evidence concerning the effects of paid employment on women's mental and physical health, with special attention to variations in the effects of employment depending on the characteristics of women and their jobs. We highlight methodological issues and focus primarily on studies with longitudinal data for representative samples of women. We conclude that women's employment does not have a negative effect on their health, on the average. Indeed, employment appears to improve the health of unmarried women and married women who have positive attitudes toward employment. Possible mediators linking employment to health outcomes are discussed. Current evidence suggests that increased social support from co-workers and supervisors may be one important mediator of the beneficial health effects of employment. Given the paucity of available longitudinal studies, we encourage additional prospective research examining the mental and physical health consequences of employment according to job characteristics, personal characteristics, and disease outcome. We also recommend research on several promising mediators of employment-health relationships. Does paid employment increase a woman's risk for physical and mental health problems, or does paid employment improve a woman's health? On the one hand, some women are exposed to physical, chemical, and biological hazards on the job. Employed women may also suffer strain and exhaustion due to job stress and overload. On the other hand, employment generally results in increased income and better access tO health care, which should benefit women's health. Being an employee and co-worker may also increase a woman's contact with people who can provide social support, as well as opportunities for enhancing self-esteem and a sense of control. Because the relative importance of each of these effects varies, depending on the characteristics of a woman and her job, we would expect the net effect of employment on women's health to vary for different women. In this article, we review empirical findings on the net effect of employment on women's mental and physical health. We examine the health consequences of employment according to individual characteristics of women, their jobs, and their home lives. These may be considered moderators that shape the effect that employment has on health. Due to space limitations, we were forced to be extremely selective in our review. Accordingly, we have relied heavily on studies of longitudinal data for representative samples with appropriate methods of analysis (as discussed later). We also discuss underlying mechanisms or mediators that might account for the health effects of employment. We use the term mediator to refer to intervening variables through which employment influences health. Social support may be one important mediator, connecting paid employment to improved health for some women. Employment offers women an opportunity to increase the size of their social networks, which may, in turn, result in better health. Longitudinal studies have shown that social isolation and a lack of support predict early mortality (Berkman, 1984), depression (Aneshensel, 1985; Kaplan, Roberts, Camacho, & Coyne, 1987), and other indexes of physical and psychological dysfunction. (See Cohen & Wills, 1985, for a review.) Two groups that should benefit most from the protection offered by jobrelated social support are women under stress and those with limited sources of social support outside of work, such as unmarried women. Another mediator, which has been postulated to be an important link between employment and negative health consequences, is overload (Verbrugge, 1986). Multiple role strain is one type of overload. It includes role overload, which arises when women have too much to do as a result of their multiple roles, and role conflict, which arises when fulfillment of the demands of one role (e.g., employee) interferes with the fulfillment of the demands of another role (e.g., mother). Multiple role strain should be greatest for mothers of young children, fulltime workers, and married women whose husbands contribute relatively little to household labor and childcare. Heavy job demands constitute another type of overload that may have harmful effects on health. Theconsequences of overload may include fatigue, increased risk for coronary heart disease (Jenkins, 1982), and possibly a greater vulnerability to other physical and mental health risks associated with employment. M e t h o d o l o g i c a l I s s u e s Most studies concerning employment and women's health are based on cross-sectional data. Unfortunately, in most cases, cross-sectional data do not provide meaningful ev1394 November 1989 • American Psychologist Copyright 1989 by the American Psyciu31ogical Association, Inc. 0003-066X/89/$00.75 Vol. 44, No. 11, 1394-1401 idence concerning the effects of employment on women's health. For example, the finding that employed women are healthier than homemakers does not necessarily imply that employment has beneficial effects on women's health (Waldron, 1980). An alternative interpretation is that healthier women are more likely to become employed and to stay employed, and that is why employed women are healthier. This latter effect is called the healthy worker effect. Current research findings indicate that a woman's physical health influences whether she is employed, thus providing evidence for the healthy worker effect. Women who are not employed frequently report poor health as their reason for not having a job, and available evidence generally supports the validity of these self-reports (Kessler & McRae, 1982; Waldron, 1980; Waldron, Herold, & Dunn, 1982). In addition, analyses of longitudinal data have shown that women who were in better health initially were more likely to enter the labor force and less likely to leave the labor force during a subsequent follow-up interval (Waldron, Herold, Dunn, & Staum, 1982; Waldron & Jacobs, 1989a). Thus, good health increases the likelihood that a woman will be employed. One study (Jennings, Mazaik, & McKinlay, 1984) has addressed the question: To what extent is the relationship between employment status and health observed in cross-sectional data influenced by the effects of health on employment status? Jennings et al. first showed that in their sample, as in other samples, employed women were healthier than homemakers. Specifically, employed women were less likely to report that their health was worse than the health of other women their age, and this was true even in analyses that controlled for number of chronic conditions and restricted activity days. The relationship between health and employment status was then tested again, this time excluding women who reported that their health influenced their employment status. Specifically, the second analysis excluded those homemakers who reported that poor health was a highly or moderately important reason for not being employed. In this analysis, the relationship between employment status and health was reversed, with homemakers reporting better health than employed women. These findings suggest that the healthy worker effect has a major influence on relationships observed in cross-sectional data, and thus cross-sectional data generally do not provide an adequate basis for assessing the effects of employment on women's physical health. Research concerning mental health and the healthy worker effect has evaluated the extent to which mental health influences women's employment status. This reThis research was supported by funds from the John D. and Catherine T. MacArthur Network on the Determinants and Consequences of Health-Promoting and Health-Damaging Behavior. We are grateful to Michael Frese, Kathleen McCartney, and Deborah Phillips for their comments on an earfier draft of this article. Correspondence concerning this article should be addressed to Rena L. Repetlg who is now at Department of Psychology, New York University, 6 Washington Place, 4th Floor, New York, NY 10003. search evidence is more limited and appears inconsistent (Kessler & McRae, 1982). One analysis has found that women who reported "nervousness, tension, anxiety or depression" were less likely to join the labor force and more likely to leave the labor force, but in another analysis the balance between negative and positive affect did not predict whether a woman would leave employment (unpublished results from Waldron, Herold, Dunn, & Staum, 1982; Waldron & Jacobs, 1989a). This evidence indicates that it is important to use longitudinal data in order to distinguish between the effects of health on employment and the effects of employment on health. In analyzing longitudinal data, it is important to use appropriate methods of analysis in order to assess the effects of employment on health. For example, it is not possible to distinguish between effects of employment on health and effects of health on employment on the basis of an analysis that assesses the relationship between employment status and health at the time of follow-up, with controls for initial employment status and health. In our summary of research findings, we refer to this type of analysis as concurrent. Unless otherwise described, all findings cited in our review of empirical evidence are based on appropriately analyzed longitudinal data for women, with controls for initial health status either in the analysis or through other means (e.g., elimination of individuals who had the dis. ease under investigation at the beginning of the followup period) (Waldron & Jacobs, 1989b). Because there is strong evidence for a healthy worker effect with regard to physical health, the employment and physical health findings we cite are almost exclusively from longitudinal studies. We focus on studies that have representative samples, containing substantial numbers of women. In addition, age, education, race, and marital status can influence both employment status and health, confounding the obtained relationships. Almost all findings cited here were derived from analyses that controlled for age and education or were based on a sample with a restricted range of age and education. In addition, we discuss findings regarding the health effects of employment within different race and marital status subgroups. Physical and mental health have been measured in diverse ways in the studies we review. Indexes of physical health have ranged from mortality verified by death certificates to physician-diagnosed chronic health conditions to self-reported general health or physical symptoms. Several longitudinal studies have demonstrated that selfreport measures of general health are related to all-cause mortality, even when statistical adjustments have been introduced for the standard risk factors for survival (Kaplan & Camacho, 1983; Waldron, Herold, & Dunn, 1982). So we have considered self-report measures of health as valid, if imprecise, measures of health status. We also report results for several biological variables that result in increased risk of coronary heart disease. These include elevated blood pressures, elevated levels of serum cholesterol or low density lipoprotein (LDL) cholesterol, and low levels of high density lipoprotein (HDL) tholesNovember 1989 • American Psychologist 1395 terol. Indexes of mental health included in the studies reviewed here are self-report scales of anxiety and depression and general scales of psychological symptoms. Almost all of the studies used validated measures of mental health or scales derived from these validated measures. Different definitions of employment status have been used in the literature. We use the term employed women to refer to women currently employed in either part-time or full-time jobs. The one exception to this rule is the Framingham Heart Study data, in which any woman who was employed outside the home for over half of her adult years is included in the employed group. Labor force participants are those women who are currently employed or are not employed, but are looking for a job, that is, unemployed. Nonemployed women are women who are not in the labor force. Although this group has been defined in different ways in the research literature, it usually includes homemakers, students, and disabled and retired