The influence of the economic crisis on the association between unemployment and health:

an empirical analysis for Spain

Author(s): Rosa M. Urbanos-Garrido and Beatriz G. Lopez-Valcarcel
Source: The European Journal of Health Economics, Vol. 16, No. 2 (March 2015), pp. 175-
184
Published by: Springer
Stable URL: https://www.jstor.org/stable/24773852
Accessed: 27-05-2019 05:22 UTC

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Eur
Eur J
J Health
HealthEcon
Econ(2015)
(2015)16:175-184
16:175-184
DOI
DOI 10.1007/sl0198-014-0563-y
10.1007/sl0198-014-0563-y

ORIGINAL PAPER

The influence of the economic crisis on the association

between unemployment and health: an empirical analysis
for Spain
Rosa M. Urbanos-Garrido •

Beatriz G. Lopez-Valcarcel

Received: 22 July 2013/Accepted: 8 January 2014/Published online: 28 January 2014

© Springer-Verlag Berlin Heidelberg 2014

Abstract
Abstract Conclusions Anxiety andConclusions stress aboutAnxiety the
and stress
future
about the
associ
future associ
Objectives
Objectives To estimate
To estimate the impact ofthe impact
(particularly of
ated
long (particularly
with unemployment could long-
have ated
a large with unemp
impact on
term)
term) unemployment
unemployment on
on the overall andthe overall
mental health of and mental
individuals' health
health. It may of individuals'
be necessary to prevent health health
the
the Spanish
Spanish
working-age
working-age
population and
population
to check whether
and to check
deterioration whether
in vulnerable deterioration
groups such in vulne
as the unemployed,
the
the effects
effects of unemployment
of unemployment on and or also to have
health
on health have increased monitorincreased
specific health
orrisks
andthat arise to
also in moni
been
been tempered
tempered as a of
as a consequence consequence of
the economic crisis. the economic
recessions, crisis.
such as psychological recessions, such as
problems.
Methods
Methods We apply
We aapply
matching
a technique
matching to cross-sec
technique to cross-sec
tional
tional microdata
microdata fromHealth
from the Spanish the Survey
Spanish
for Keywords
Health
the Economic
Surveycrisisfor
• Unemployment
the Keywords Econom
years
years 2006
2006
and 2011-2012
and 2011-2012
to estimate the
to average Self-assessed
estimate
treat the health • Mental health
average •
treat- Self-assessed health
ment
ment effect
effect of unemployment
of unemployment on
on self-assessed health self-assessed
Matching health Matching technique
techniques • Spain
(SAH)
(SAH)in the
in last
the year,
lastmental
year,problems
mentalin theproblems
last year and in the last year and
on the
on the mental
mentalhealth
healthrisk
risk
in in the
the short
short term.
term. We We
also also
use ause a JEL
JEL Classification
Classification J64
J64 • •112
112■• 118
differences-in-differences estimation method between the

two periods to check if the impact of unemployment on

healthdepends
health depends
on on
the the economic
economic Introduction
context. Introduction
context.
Results
Results Unemployment
Unemployment has
has
a significant
a significant
negative
negative
impact
impact
on both
on bothSAH
SAHandand mental
mental health.
health. This impact
This impact isThe impact of The
particularly
is particularly economic recessions
impact on health
of economic has been
recessions on health
high for
high forthe
the long-term
long-term unemployed.
unemployed. With With
respectrespect
the to the
topreviously previously
addressed. addressed.
Researchers Researchers
mainly focused onmainly
the focus
impact on
impact onmental
mental health,
health, negative
negative effects
effects significantly
role played role
significantly played by unemployment
by unemployment as a mediator
as a mediator agent [1-3], age
worsen with the economic crisis. For the full model,
worsen with the economic crisis. For the full model, the the because unemployment
because unemployment and working
and working conditions conditions
constitute
changesinineffects
changes effects
of of long-term
long-term unemployment
unemployment on mental
major
on mental major socialofdeterminants
social determinants of health
health [4], Beyond [4], Beyon
the influ
problems
problemsandandmental
mental health
healthrisk
risk
are,
are,
respectively,
respectively,ence
0.35 of the
0.35
(CI (CIinstitutional
ence of the context of the labour
institutional market and
context of the labour mark
0.19-0.50)and
0.19-0.50) and 0.20
0.20 (CI 0.07-0.34). social protection,
(CI 0.07-0.34). most
social attention
protection, hasattention
most been paid hastobeen
thepaid
study
to the study
of the risk factors linking
linking labour
labour status
status and
and health.
health. Several
Several
health economics papers
papers conclude
conclude that
that economic
economic down
down
Electronic
Electronic supplementary
supplementary material
material The version
The online online of this turns
version have
of this a counter-cyclical
turns role in terms
have a counter-cyclical of terms
role in health,of
and
health, and
article(doi:
article (doi: 10.1007/s
10.1007/s 10198-014-0563-y)
10198-014-0563-y) contains contains supplementary
supplementary that short-term
that short-term
unemployment
unemployment
improves population
improves health
population hea
material, which is available to authorized users.
material, which is available to authorized users. and mortality
and reduces re(juces in
mortality in developed
developed countries [5-9]. countries [5-
r, ,,, ~ ~ Moreover,
R. R. M.
public health literature
Urbanos-Garrido
M. Urbanos-Garrido
Moreover, publicprovides
healthr r
evidence
literature that
provides evidence that
Complutense
Complutense University of Madrid, Madrid, Spain being employed protects and promotes health [10-13],
University o
Previous
Previous
studies show that unemployment andstudi fall in
B. G. Lopez-Valcarcel (El)
B. G. Lopez-Valcarcel
income may lead to obesogenic diets [14] or be associated
Departamento
DepartamentodedeMétodos
MetodosCuantitativos
Cuantitativos
enenEconomfa
Economi'a
y Gestion,
y Gestion,
with health risk behaviours such as excessive alcohol
University
University of
ofLas
LasPalmas
PalmasdedeGran
GranCanaria,
Canaria,Campus
Campus
de de
Tafira,
Tafira,
35017
35017 Las Las Palmas
Palmas de Gran de Gran
Canaria, Canaria, Spain consumption
Spain consumption[15], [15], more
moresmoking
smoking [16] [16]
or decreased phys
or decreased
e-mail:
e-mail: bvalcarcel@dmc.ulpgc.es ical activity [17].
bvalcarcel@dmc.ulpgc.es Furthermore,
ical activity [17]. aFurthermore,
reduction in a
the level of in the level of
reduction

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 176 R. M. Urbanos-Garrido, B. G. Lopez-Valcarcel

income may discourage between

seeking unemployment,
medical attention t
treatment costs [18]. ness,
This and is
effect health. Besides,
particularly stt
those countries where health
on this
coverage
subject is
forlinked
the Spa
to
status and/or the beginning
amount of the
of copayments is current
signific
Unemployment can also Benavides et al. health
impair mental [37], by
byus
v
psychological mechanisms,showed
loss of
a positive
self-esteem,
associatio
pes
health At
about the future, etc. [20-25]. andthe
more usetime,
same of hea
h
as the unemployed have association is less clear
a lower opportunity wh
cost o
time, they can
to be considered
may
invest a long-
choose
in health through
more,
lifestyles [26], or improve Tapia
their [38] found
mental healthab
volunteer work, although the psychological
unemployment ben
and mortal
volunteering depend on rates increase
factors such aswhen unem
reciprocity
nomic
time devoted to volunteer expansion
[27]. It is alsoperiods
expect
work-related diseases Rodriguez
will [39]when
be reduced showed that
unemp
increases [28, 29]. crisis tends to improve the
In this paper
providepeople living inabout
we
new evidence Catalonia
the
of ployment
unemployment (particularly on mental
long-term health
unempl
on overall health and economic
on crisis.
mental health by using m
for the Spanish adult population. But, beyond t
effect of unemployment on health, our main intere
analyse the differentialMaterials and methods
association between both v
in both pre-crisis and current-crisis periods. A pri
cannot expect an We use microdata from
unambiguous the Spanish national
effect. On health survey
the on
with the crisis the (SNHS) for two
situation of periods:
the 2006unemployed
(before the start of the crisis)
be
'normal', so the and that
stigma 2011-2012 (during
could the crisis)
harm [40, 41]. mental
Both surveys
disappears, whereas if which are comparable to other European
unemployment is rare,health databases,
the
tion of low self-esteeminclude
andvery similar questions. National
isolation may health
be surveys
am
[30]. This effect is supported by
employ a multistage, some studies
stratified-random s
design to identify
unemployment as a samples of risk
stronger adults. We have restricted
factor the selected
when itsample
is r
all-cause [31],tohospital-treated
the working-age population (16-65
mortality years old). As ou
non-fatal
behaviour [32, 33] or, main
more interestrecently,
focuses on the relationship
suicidesbetween long
[3
ever, the higher the unemployment, the worsea
term unemployment (over 1 year) and health, we use
restricted
spectives of getting a job and subsample
theonly composed precarious
more of employed and long
term unemployed
future as a worker. In this sense, (n = 13,663
we for 2006, and nexpect
would = 9,495 for
deterioration of 2011-2012).
jobless However, ashealth
people's a complementary analysis we
during
nomic recession also analyse
compared to the impact of unemployment
previous times on health
of from a
eco
upturn. This effect was wider perspective, thus
confirmed by using the sample
Preti andincluding
Mi
Italy. They find that a employed
rise in and all unemployed rates
suicide workers (nis
— 15,324
accom for
by a 2006 and n = 10,855 for
concurrent rise in unemployment rate percent2011-2012).
Finally, we With the
find in can aim of checking the
also
previous impact of unemployment
literature that
of unemployment seems on overall
to andhavemental health,
nowemajoremploy matching meth
influenc
mortality risk [35]. ods. Once this issue is addressed, we will test if there is an
Spain is experiencingincremental effect of unemployment
a lasting and onsevere
health as derived eco
crisis. The fall of GDP, from the rise
the economic recession.
of public In order to testdebt
this effect, and
we t
public deficit highlight will
theuse difference-in-difference
gravity of(DiD) the techniques. These
Spanish
situation. But the most methods have been previously feature
significant used to disentangle in
effectsthe
of unemployment on health [42]. rate, which r
crisis is the increasing unemployment
8.5 % in early 2007 to 27.2 % in the first quarter o
[36], exceeding the rateEstimation
of any of the impact
otherof unemployment
country on health in t
in 2006period,
pean Union. In the same and 2011-2012: matching
themethods percentage
ployed who have been looking for a job for ove
(long-term unemployed)We use matching
rose methods
from based on propensity
21.2 score to [43]56.3
These data widely justify addressing
separately for the relati
2006 and 2011-2012. Probit regressions are

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 An empirical analysis for Spain 177

used to estimate the ö and probability

y provide information on the effects
of of unemploy
being
more than 12 months ('treated') as a function of the ment on health before (6) and during (S + y) the economic
observable covariates vector X associated with unemploy crisis.

ment for each year. The parameter of interest to estimate is Alternatively, we estimate the model including all
the average treatment effect (ATT) of unemployment on unemployed, assuming that the impact on health of dif
unemployed. It is defined as ferent lengths of unemployment may be different:
4 4
ATT = E{Y\ - Y0\D = 1) = E(YX\D = 1) - E(Y0\D = 1),
(1) Yidt =
k= 1 k= 1

where Y represents health, subscripts 1 and 0 mean + Kßt + eidt

unemployed and employed, respectively, and D = 1 means (3)
unemployed. The second term on the right side of Eq. (1) is
where k = 1, 2, 3 and 4 stand, respectively, for unem
the counterfactual: what the health level of an unemployed
ployed who never worked, those who have been unem
person would be if he/she had a job. Several assumptions
ployed for less than 6 months, those who have been
need to be made in order to identify average unobserved
counterfactuals. It is assumed that all the relevant differ
unemployed for a period between 6 and 12 months and,
finally, for long-term unemployed.
ences between treated and non-treated are captured in the
X vector. A common support condition is also imposed on
Definition of variables
the treated units. Treated units whose probability of being
treated is larger than the largest p in the non-treated pool
Overall health is proxied by self-assessed health (SAH).
would be left unmatched. We use different matching
methods (^-nearest neighbours, with k from 1 to The
4— SAH question is formulated as follows in the SNHSs:
approximately the sample ratio between non-treated and
'During the last 12 months, would you say that your health
status
treated—within calipers equal to 0.05, and a kernel with a has been very good, good, fair, poor, very poor?'.
normal distribution) to check for robustness. We reportOur
thevariable which will take the value one if the individual
results for the kernel with a normal distribution. As a declares his/her health as fair, poor or very poor, and zero if
health is perceived as good or very good. This categori
complementary analysis we also estimate the matching
zation has been used in previous studies [44, 45],
models for the full sample of employed and unemployed
(both short- and long-term). We consider that mental health risks linked to unem

ployment may operate in both the short and long term. As

Estimates of the incremental crisis effect: DiD shown by Lucas et al. [46], the effect of unemployment on
life satisfaction lasts for some time, but the unemployed
An estimate of the effect of the economic crisis on the
quickly seem to be mentally adapted to their new status.
Furthermore, as was mentioned above, in the context of
health impact of long-term unemployment may be obtained
by using a DiD technique. We estimate a regression model
economic crisis the social stigma of unemployment that
could
with the pooled data of both health surveys. Controlling by harm mental health tends to fade away. Thus, mental
X covariates, the model includes two main fixed effects,
health is represented by two variables: first, a dummy
variable which indicates the presence of chronic depres
one for the crisis (/I) and another for the employment status
(<5), as well as the interaction between them (7): sion, anxiety or other mental problems during the previous
year, which is used as a proxy of permanent mental health
Yidt = a + <5Unemp/f + h + y(Unempl7 * t) + X'itßt + sidh
(Pmhealth); second, we use the Goldberg index [47], which
represents short-term mental health risk and is frequently
where t = 0 means 2006, t = 1 means 2011-2012, and used in clinical medicine. This variable (Rmhealth) is
computed by using the answers to a 12-item set of ques
subscript d stands for the employment status. The effect of
X variables is assumed to be different in both years. Thetions (see Table Al, Supplementary Material). Each
unbiasedness of the structural estimators depends on thequestion has four possible answers, which are recoded as
parallel paths assumption. In order to make that assumption 0 = 'no problem' or 1 = 'with problems'. The final
dummy takes the value 1 if the person has three or more
as plausible as possible, we included in X all the covariates
that could have an influence on health and could be related positive answers to the Goldberg 12-item scale question
to the employment status before the crisis and during the naire (which is shown in Table Al, Supplementary Mate
crisis. Under the usual hypothesis on the stochastic e term rial). This categorization has been previously used in
(mean zero, independent of the regressors), the parameters related literature [21].

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 178 R. M. Urbanos-Garrido, B. G. Lopez-Valcarcel

Table 1 Definition of variables and descriptive statistics

Variable Definition 2006 2011-2012

(n = 15,324) (n = 10,855)
Mean3 Mean3

Labour status Employed 1 if the person declares to be employed 88.4 % 75.9 %

Unem_never 1 if the person declares to be unemployed and he/she has 0.6 %

never 1.0 %
worked

Unem_6 5.1 %
1 if the person declares to be unemployed for 6 months or less 7.0 %

Unem_6_12 1.7 %
1 if the person declares to be unemployed for a period between 3.8 %
6 months and 1 year
Unem_12 1 if the person declares to have been unemployed for 1 year4.2or% 12.1 %
more

Overall health SAH 24.9or

Self-assessed health: 1 if fair, poor or very poor; 0 if good % 19.2 %

very good
Mental health Pmhealth 11.4 %
1 if the person declares chronic depression, anxiety or other 7.6 %

mental problems during the previous year

Short-term mental health risk Rmhealth 1 if the person has three or more positive answers to the 18.3 % 19.3 %

(Goldberg index) Goldberg 12-item scale questionnaire

Age Age in years 40.49 (10.91) 42.02 (10.78)
Female 1 if female 52.3 % 45.5 %

Education Edlb Primary education or below (reference category) 29.0 % 10.0 %

Ed2b Compulsory secondary education 22.0 % 45.0 %

Ed3b Non-compulsory and pre-university secondary education 16.1 % 13.7 %

Ed4b Specific labour training 9.3 % 9.0 %

Ed5b University graduate 23.0 % 22.3 %

Region (autonomous Regl Andalucia (reference category) 7.9 % 12.5 %

communities) Reg2 Aragon 9.0 % 4.0 %

Reg3 Asturias 2.8 % 3.5 %

Reg4 Baleares 6.9 % 3.9 %

Reg5 Canarias 4.2 % 5.5 %

Reg6 Cantabria 5.5 % 3.1 %

Reg7 Castilla y Leon 3.8 % 5.6 %

Reg8 Castilla-La Mancha 3.3 % 3.8 %

Reg9 Cataluna 9.2 % 10.7 %

Reg 10 Comunidad Valenciana 6.3 % 8.8 %

Regl 1 Extremadura 2.8 % 4.4 %

Reg 12 Galicia 10.2 % 5.4 %

Reg 13 Madrid 8.0 % 10.2 %

Reg 14 Murcia 6.3 % 4.1 %

Reg 15 Navarra 5.9 % 3.0 %

Reg 16 Pais Vasco 4.0 % 5.9 %

Reg 17 La Rioja 2.5 % 3.4 %

Reg 18 Ceuta and Melilla 1.7 % 2.2 %

Chronic conditions Chronic 1 if the person suffers from any chronic illness from a list of 12 56.4 % 48.2 %
conditions

Sample of employed and unemployed people aged 16-65

a For the categorical variables, data are % in the category; for continuous variables, data include standard deviation in brackets
b The categories do not add up to one because there are some persons with missing education level

In both models (matching and DiD regression) the women and zero for men, represents sex. Educational level
X vector of covariates includes age, sex, education and
is categorized by means of five dummies: primary educa
region. The variable Female, taking the value one fortion or below (Edl, reference category), compulsory

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 An empirical analysis for Spain 179

secondary education (Ed2),

of Spaniards non-compulso
participating in the labour market, employed
versity secondary or unemployed, is better
education in 2011-2012 specific
(Ed3), than in 2006,
despite the severity of
requiring non-compulsory the Spanish economic recession.
secondary educa The
university graduatepercentage
(Ed5). of people
Household
declaring bad health drops incom
from 24.9
to 19.2 %. Also the
considered as a regressor percentage of people
because itdeclaring
is to have
not a
SNHS 2011-2012. We also include a set of dummies suffered depression, anxiety or mental problems in the last
12 months
representing the region of residence, with Andalusia acting is lower in 2011-2012 than in 2006. These
as the reference category. Regional dummies mayresults,
act as a which may seem paradoxical, have also been
observed
proxy of the availability of re-employment opportunities in with survey data from Catalonia [39]. They may
reflect
the geographical area [48]. Furthermore, the regional that health is being assessed in relative terms. Thus
factor
may be relevant as regional public authorities can imple
in the context of economic problems and high unemploy
ment,of
ment social policies aimed at moderating adverse effects health would rank lower among individuals' co
cerns. For the short-term mental health risk variable,
unemployment and precarious work on health [49].
however, the total percentage of individuals at risk in
Finally, in the matching probit equation for propensity
of unemployment we control for 'permanent' health-rela
2011-2012 is slightly higher than in 2006, mostly due to
ted conditions. As has been discussed in previous deterioration
studies of this health proxy for workers who have
[42, 50, 51], the causal relationship between unemploy
recently lost their job (unemployment duration shorter than
6 months), and for unemployed persons who have been
ment and health is, a priori, bidirectional, as remaining
jobless may increase the risk of illness, but also some
looking for a job for more than 1 year, as suggested by
Table 2.
conditions may affect the probability of being unemployed.
Therefore, we include a dummy equal to one if the According
person to Table 2, SAH and mental health seem to
declares that he/she suffers at least one of twelve chronicbe worse among unemployed people (except for those who
diseases: osteoarthritis, arthritis or rheumatism, chronic have never worked) than among employed people. The
allergy, asthma, thyroid problems, heart disease, cervical longer the unemployment period, the wider the gap.
hernia, lower back hernia, stomach ulcer, skin diseases, However, descriptive results shown in Table 2 could be
constipation, headache and haemorrhoids. As a robustness biased estimators of group differences because of compo
check, we also estimate the models excluding chronic sitional effects. The groups of employed and unemployed
conditions. by duration differ significantly by sex, age, educational
Definitions of all the variables are shown in Table 1. level, region of residence and health conditions.
The results are detailed in the following section. AllTable
cal 3 renorts the ATT estimates for 2006 and
culations were made with Statal2 software [52]. 2011-2012 by using kernel estimates with a
kernel, for the subsample of employed people ('u
and unemployed people ('treated'). No individ
Results excluded because of common support require
2006 and only one is excluded in 2011-2012. W
show the results for the impact of long-term un
Table 1 shows descriptive statistics for all the variables for
the whole sample of people aged 16-65, employed and
ment on health. The estimated probit equation
unemployed, for 2006 and 2011-2012. It is worth notingpensity score are displayed in Table A2 (Suppl
that the composition of both samples by education level
Material). The results obtained from alternative
and geographical location differs. As the samples areapproaches are shown in Table A3 (Supplementary
truncated at 65 years of age, a substantially higher Material).
pro All results are very robust to the matching
method. The second column of Table 3 contains the
portion had attained the compulsory educational level in
2011-2012 than in 2006. Besides that, a number of people
sample data corresponding to the unemployed. The thir
with very low education, who had been working in
column shows the estimated health of the unemployed
they had been working (counterfactual). The fourth
unskilled jobs in the building sector during the economic
umn is the difference between the two previous colum
boom, might have left the labour market during the crisis.
These changes in the composition of the active population
and it estimates the impact of unemployment on health
after the crisis aftermath would induce some changes in This
the estimate is called the average treatment effect (AT
regional composition of the sample, too. as it measures the loss in health that may be attributable
Table 2 shows basic descriptive statistics of health unemployment. Finally, the fifth column shows the st
tistical significance of the ATT estimates. The left a
indicators by labour status before and during the crisis. The
unemployed are classified in five categories according to
right sides of the table show, respectively, results for 2
the duration of unemployment. As may be observed, SAH and 2011-2012.

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 180 R. M. Urbanos-Garrido, B. G. Lopez-Valcarcel

Table 2 Health indicators by labour status before and during

Health outcome Bad health (%)a Mental problems in last 12 months (%)b Mental health risk in the short-term (%)c

Year 2006 2011-2012 2006 2011-2012 2006 2011-2012

Employed 23.8 17.2 10.7 5.9 17.1 15.9

Unem_never 17.7 15.8 7.4 3.5 19.2 12.3

Unem_6 29.0 18.2 17.1 8.5 25.9 28.1

Unem_6_12 34.1 21.3 17.3 12.7 32.3 25.6

Unem„12 42.1 31.8 19.4 16.8 30.0 33.4

Total 24.9 19.2 11.4 7.7 18.3 19.3

All the reductions of the percentages between 2006 and 2011

Percentage declaring that their self-assessed health in the last
b Percentage declaring that they have had chronic depression
Percentage declaring three or more positive answers to the

Table 3 Impact estimates of unemployment on health 2006

Long-term unemployment

Dependent variable3 Pre-crisis (2006) Crisis (2011-2012)

Unemployed Counterfactual Impact f Unemployed Coun

E(Yi\D = 1) E(Yq\D = 1) (ATT) E(Y,\D = 1) E(Y0\D = 1) (ATT)
(%)b (%)c (pp)d (%) (%) (PP)
(SAH) % bad health 41.7 29.9 11.8 5.8*** 31.7 21.0 10.7
(Pmhealth) % mental health 19.5 13.9 5.6 3.4*** 16.7 7.0 9.7
problems
(Rmhealth) % mental health risk in 30.0 19.6 10.4 5.5*** 33.4 17.4 16.0 11.5*
the short term (Goldberg)

Total unemployment (short- and long-term)

Dependent variable Pre-crisis (2006) Crisis (2011-2012)

Unemployed Counterfactual Impact t Unemployed Counterfactual Impact t

E(Y\ \D = 1) E(Yq\D = 1) (ATT) E(YX\D = 1) E{Y0\D = 1) (ATT)
(%) (%) (pp) (%) (%)

(SAH) % bad health 33.6 26.7 6.9 5.6*** 25.3 18.6 6.7
(Pmhealth) % mental 17.2 12.5 4.7 4 9*** 13.0 6.3 6.7
health problems
(Rmhealth) % mental health risk 27.9 19.2 8.7 7.6*** 29.7 16.6 13.1
in the short term (Goldberg)

Matching methods. Propensity score with Gaussian kernel

: p < 0.01. Control variables are age, sex, education, region and chronic conditions
a Matching models to estimate the effect of long-term unemployment on overall health
mental health risk in the short term (Rmhealth)

b Sample data corresponding to unemployed

Estimated data for unemployed if they had been working (counterfactual)
d Average treatment effect (ATT) = column 2 — column 3. It measures the loss in healt
between 2 %, it is expressed as percentage points
e Ratio to determine statistical significance of the ATT estimates

The estimates show that one or long-term

more years
unemployment
of unem increases the probability o
showing mental
ployment tend to significantly deteriorate the health risk and
overall by 10.4 percentage points (p
mental health before the economic recession and also before the crisis, and by 16 pp for the period 2011-2012
during the crisis. Once we account for the X covariates,
The ATT for mental health problems in the last year ris

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 An empirical analysis for Spain 181

Table 4 DiD estimates of the health impact of lon

Dependent variable Effect Coefficients (95 % CI)a Pseudo Pseudo n

(R2)b {R2)c
Model without controls Full model0

(SAH) % bad health (A) Change in SAH after the -0.28 (-0.45;-0.12) -0.19 (-0.42;+0.04) 0.044 0.070 23,754
crisis

(5) Effect of unemployment 0.40 (0.30; 0.50)*** 0.32 (0.22; 0.42)***

in the base year (2006)
(y) Change in the effect of 0.06 (-0.07;+0.18) 0.04 (-0.09;+0.17)
unemployment on SAH
after the crisis aftermath

(Pmhealth) % mental health (/) Change in Pmhealth -0.20 (-0.42;+0.01) -0.22 (-0.52;+0.08) 0.06 0.079 23,711
problems after the crisis
(5) Effect of unemployment 0.25 (0.14; 0.37)*** 0.21 (0.09; 0.32)*
in the base year (2006)
(y) Change in the effect of 0.34 (0.19; 0.49)*** 0.35 (0.19; 0.50)***
unemployment on
Pmhealth after the crisis
aftermath

(Rmhealth) % mental health risk (A) Change in Rmhealth -0.02 (-0.18;-0.15) 0.0073 (-0.23;+0.25) 0.025 0.054 23,162
in the short term (Goldberg) after the crisis
(<5) Effect of unemployment 0.36 (0.25; 0.47)*** 0.3476 (0.24; 0.46)***
in 2006

(y) Change in the effect of 0.20 (0.07; 0.34)*** 0.2027 (0.07; 0.34)***
unemployment on
Rmhealth after the crisis
aftermath

Differences-in-differences model to estimate the effect of long-term unemployment on overall health (SAH), on mental health (Pmhealth)
problems and on mental health risk in the short term (Rmhealth). The three dependent variables are defined in the "Materials and methods"
section

*** Significant at 1 % (p < 0.01)

Estimated effects correspond to Eq. (2). The parameter of highest interest is y. It measures the change in the effect of unempl
after the crisis compared to the effect in 2006. Point estimates and 95
b Model controlling only for age and sex
Full model that adjusts for age, sex, education and region allowing different effects in each year (2006 and 2011)

from 5.5 pp in 2006 to 9.7 pp in 2011-2012. The ATT in Table A4 (Supplementary Material), which ar
reported
when SAH is considered was 11.8 in 2006 and 10.7 in similar to those shown in Table 3.

The bottom part of Table 3 collects the results from

2011-2012. Thus, the effects of long-term unemployment
matching models estimated for the full sample of
on mental health seem to be larger in times of economic
downturn, whereas this association is not found inemployees
SAH. It and unemployed, both short- and long-term (the
is plausible that self-reported health is not capturing so
corresponding probit estimates are reported in Table A5 of
much real changes in health but changes in the perceived
the Supplementary Material). It shows also the significant
level of health, which could be affected by the fact men
effects of unemployment on SAH and both dimensions of
tioned above that health is being assessed in relative terms.
mental health, although these are much lower with regard
As mentioned in the previous section, we initially conlinked to long-term joblessness. Furthermore, the
to those
sider in the X vector of covariates the presence ofresults
chronicagain suggest that the negative impact of unem
conditions, as poor health may increase the risk of on mental health may be higher during economic
ployment
becoming unemployed. However, this variable recessions.
could be
endogenous as some chronic diseases could also worsen
The DiD estimates mostly confirm these results. Table 4
when a worker loses his/her job. To deal with thisshows
problem
the estimates corresponding to the health impact of
we did some robustness checks by excluding the dummy
long-term unemployment. Therefore, the estimated effects
correspond
chronic from the model. The results, which are fully to Eq. (2) in the "Materials and methods"

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 182 R. M. Urbanos-Garrido, B. G. Lopez-Valcarcel

section. The parameter X shows

However, the
the results change
here reported in
differ from each
those found o
health measures that occurred during
by previous Spanish studies the
that check how crisis
the impact of
parameter ô accounts for the effects
unemployment on health variesof long-term
depending on the economic u
ployment on health. context [37-39],
Finally, which could
the be partially explained
parameter of by h
interest is y, which differences in the
measures thedefinition of health variables.
change in the effe
unemployment on health Our
after
study has the
a numbercrisis
of limitations.
compared
First, cross-sec t
effect in 2006. We estimate two alternative models in order tional data do not allow for exploration of causal relation
to check how the X vector of covariates may alter the
ships between unemployment and health as longitudinal
results. databases do. Previous research with panel data from the
As shown in Table 4, long-term unemployment hasSpanish a sample of the EU-SILC did not confirm the sig
significant impact on both overall and mental health. nificant effect of unemployment on SAH for the period
2007-2010 [55]. A similar result is found by Böckerman
Moreover, the interaction term y is positive and significant
and Ilmakunnas [42], who use panel data from the European
for mental health models, suggesting that negative effects
of unemployment on people's psychological health are Community Household Panel for Finland. They show that
intensified because of the economic crisis. That intensifi the event of unemployment does not matter as such for SAH
cation is higher for mental problems—e.g. depression and
andconclude that the cross-sectional negative relationship
between unemployment and SAH is related to the fact that
anxiety—in the last year than for the short-term mental
health risk (Goldberg index). However, SAH does not seem
persons who have poor SAH are being selected for the pool
of the unemployed. Nevertheless, the EU-SILC waves do
to worsen more with unemployment in times of economic
crisis than before the crisis aftermath. It may also benot
verinclude specific information about mental health—
although it may be assumed that SAH also includes the
ified that estimates barely depend on the vector of covari
ates. Our results are consistent with the hypothesis individuals' rating of their mental health—so the impact of
unemployment on Spaniards' psychological health with
suggested by Karasek and Theorell [53], in the sense that
economic recessions may encourage individuals to antici
longitudinal microdata cannot be verified.
pate stressful situations, including job loss and difficultySecond,
in it has to be noted that some relevant determi
dealing with financial obligations. nants of unemployment may be excluded from the X vector
We have also estimated alternative DiD models that of covariates, such as the occupational sector or the eligi
bility
include all unemployed and the corresponding dummies for for public subsidies, and thus our estimates may be
different periods of unemployment (Table A7, Supple biased. The omission of other relevant variables may also
mentary Material). The obtained results are similar tobias the estimates. This is the case of household income,
those
which is not available in the SNHS for 2001-2012. The
shown in Table 4. Except for those who have never
effects of unemployment on health could in fact be
worked, unemployment negatively influences overall
health and mental health. The impact on overall health
reflecting the impact of the lack of income. However, this
increases with the length of unemployment. Like problem
in our will be mitigated as long as omitted variables
operate similarly in both periods. In addition, the dummy
base model, which was restricted to long-term unemploy
for chronic conditions included in the X vector could be
ment, the impact on overall health does not seem to change
in times of crisis. Moreover, the impact on mental condi endogenous, and the results consequently would be biased.
To deal
tions is larger after the crisis, as in the base model, only for with this problem we did some robustness checks,
the long-term unemployed. The effects on the Goldberg with satisfactory results.
index become more serious after the crisis for those who Third, the proxies for overall health and permanent mental
health are constructed from survey questions, which refer to
are unemployed for less than 6 months and also for those
who are unemployed for more than 12 months. the last 12 months. Therefore, when we use the full sample of
unemployed (including short- and long-term jobless people),
we are searching for associations between variables which are
Discussion defined for different reference periods. However, this prob
lem disappears when the analysis focuses on the impact of
Our results are in line with previous work showing a
long-term unemployment on health.
positive relationship between unemployment rates andFourth, the self-reported definition of unemployed could
mental health risks [34], and are also consistent with those
bias the estimation results owing to self-selection, if those
who have been unemployed for a long time tend to classify
found by Gili et al. [54], who show how the economic
themselves as inactive.
crisis has significantly increased the frequency of mental
health disorders among primary care users in Spain, par Fifth, although in the DiD estimation we adjusted for all
the measured covariates that might be correlated to labour
ticularly among families experiencing unemployment.

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 An empirical analysis for Spain 183

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