ORIGINAL RESEARCH published: 20 May 2021 doi: 10.3389/fpubh.2021.616191 Financial Strain and Health Status Among European Workers: Gender and Welfare State Inequalities Lucía Artazcoz 1,2,3,4*† , Imma Cortès-Franch 1,2,4,5† , Vicenta Escribà-Agüir 6 and Fernando G. Benavides 2,3† 1 Public Health Observatory, Agència de Salut Pública de Barcelona, Barcelona, Spain, 2 Ciberesp ISCIII, CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain, 3 Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain, 4 Institute for Research in Biomedicine, IIB-Sant Pau, Barcelona, Spain, 5 Department of Pediatrics, Obstetrics and Gynecology, and of Preventive Medicine, Faculty of Medicine, Autonomous University of Barcelona, Barcelona, Spain, 6 Health Inequalities Area, Centre for Public Health Research, Valencia, Spain Objectives: Although in-work poverty has been increasing, in Europe policy about Edited by: poverty and social exclusion tends to focus on labor market participation, independently Ulrich Laaser, Bielefeld University, Germany of the level of remuneration and the quality of work, and studies about financial strain Reviewed by: among workers, as well as on its relationship with health status, are still scarce. The Helmut Wenzel, objectives of this study were: (1) to compare the prevalence of financial strain among Independent Researcher, D-Konstanz, workers among different welfare state typologies, and (2) to examine whether the Germany Enver Envi Roshi, relationship between financial strain and health status differs by welfare state regime. University of Medicine, Tirana, Albania For both objectives we examined whether there were gender differences. Juergen Breckenkamp, Bielefeld University, Germany Methods: We conducted a cross-sectional study using data from the 6th European *Correspondence: Working Conditions Survey of 2015 and selected a subsample of all employees from the Lucía Artazcoz EU28 aged 16–64 years (13,156 men and 13,225 women). lartazco@aspb.cat † ORCID: Results: There were large differences in the prevalence of financial strain between Lucía Artazcoz welfare state typologies, which were not explained by individual factors. Additionally, orcid.org/0000-0002-6300-5111 differences across welfare regimes were greater among women. Nordic countries had Imma Cortès-Franch the lowest prevalence (12.1% among men and 12.3% among women) whereas Southern orcid.org/0000-0002-1244-9652 Fernando G. Benavides European countries had the highest (49.5% among men and 47.9% among women). orcid.org/0000-0003-0747-2660 In both sexes and in all welfare state typologies, financial strain was associated with poor self-perceived health status and poor psychological well-being. Whereas, Southern Specialty section: This article was submitted to European countries had the highest prevalence of financial strain, the magnitude of the Health Economics, association with health status was smaller than in other country typologies. a section of the journal Frontiers in Public Health Conclusion: In Europe, policies are needed to address the specific structural factors Received: 13 October 2020 leading to financial strain as well as its relationship with health status among workers. Accepted: 03 March 2021 Published: 20 May 2021 Keywords: financial strain, health’, economic hardship, socioeconomic factors, gender Citation: Artazcoz L, Cortès-Franch I, Escribà-Agüir V and Benavides FG INTRODUCTION (2021) Financial Strain and Health Status Among European Workers: Since the global economic crisis that started in 2007/2008, in-work poverty has been increasing (1). Gender and Welfare State Inequalities. However, despite this trend, in Europe there has been relatively little policy debate and research Front. Public Health 9:616191. about this topic (2), where policy about poverty and social exclusion tends to focus on labor market doi: 10.3389/fpubh.2021.616191 participation, independently of the level of remuneration and the quality of work (3). Frontiers in Public Health | www.frontiersin.org 1 May 2021 | Volume 9 | Article 616191 Artazcoz et al. Financial Strain and Health Status The EU Statistics on Income and Living Conditions (EU- by public bodies to those living in poverty or in risk of falling SILC) considers individuals to be at risk of in-work poverty if into poverty which can increase the incomes of households that they work for over half of the year and have an equivalized would otherwise be below the poverty threshold. Furthermore, yearly disposable household income below 60% of the median there are non-contributory benefits like family allowances which national household income (4). However, several studies indicate also contribute to household income. Generally, higher levels of that objective measures of income do not capture the meaning decommodification are correlated with lower levels of financial of income adequacy to individuals, with people on low incomes strain (19). not always reporting financial strain, which indicates that these Defamilisation refers to the fact that welfare states, not two measures are different (5, 6). The concept of financial strain only influence the degree of an individual’s dependence on allows to understand the experience and meaning of poverty by markets, but also a person’s dependence on his or her own examining the extent to which families meet their basic needs (7). family. This concept is concerned with women’s dependence on the family due to care obligations and a male breadwinner Financial Strain and Health Status as well as the dependence status of young adults due to Financial strain is one of the greatest stressors encountered difficulties in labor market access and no access to transfers during adulthood, and has been shown to be related to poor in their own right, and on the dependence of the elderly due health status, independently of other measures of socio-economic to a lack of care options outside the family (20). Welfare position and demographic characteristics (8, 9). It can be linked state typologies with different defamilisation levels differ in to health because of inability to manage on the income which women’s participation in the labor markets and intergenerational involves stress, anxiety, and helplessness (10, 11). It has also been dependencies. Examples of defamilisation instruments include reported that people with financial strain are more likely to have free public childcare services, child benefit paid to families unhealthy behaviors (12). to cover some of the children’s material needs, and parental Most studies about financial strain and health status have leave to care for older or sick family members (17). Welfare focused on elderly people whereas studies about the working state measures which promote female employment are expected population are scarce (13). Moreover, low personal wages, that to reduce in-work poverty. Intergenerational dependency can are often the focus of studies on the working poor, are only have an ambiguous effect: while for young workers, living with one cause of financial strain, which depends on a household’s their parents will lower their risk of financial difficulties, the overall resources and needs, and includes individual factors financial strain for the working parents will rise. However, such as age, immigration status, employment and household the pooling of resources protects family members from characteristics (14). Additionally, due to the gender division of being poor. labor both the prevalence of financial strain and the relationship between financial strain and health status can differ by gender. Welfare State Regimes in Europe For example, a study about the impact of job loss and job Grouping EU countries according to their levels of recovery reported that for men, employment recovery was decommodification and defamilisation yields five country insufficient to alleviate financial strain and associated health groups: Nordic, Anglo-Saxon, Continental, Southern, and consequences, whereas in women regaining employment lead to Eastern European countries (21). Nordic countries are health recovery (15). characterized by high degrees of both decommodification and defamilisation. Macro and microeconomic policies stimulate Role of the Welfare State Regimes maximum employment participation on a basis of gender The prevalence of financial strain varies markedly between equality. Anglo-Saxon countries have the lowest levels of European countries (16) which can be explained, not only by decommodification of the five welfare state typologies, and differences in the individual factors associated with financial low levels of defamilisation, with family care considered to be strain, but also by contextual factors, primarily associated with a private responsibility. The lack of public childcare creates the levels of decommodification and defamilisation, which are a major barrier to female participation in the labor force. closely related to welfare state typologies (14, 17). On the other hand, the Anglo-Saxon countries have gone Decommodification refers to “the degree to which social the furthest in implementing in-work benefits (primarily tax policies permit people to make and maintain their living at a credits) aimed at households with low earnings, specially single- socially acceptable level independent of market forces, without parent households (22). Continental European countries have having to sell their labor power on the labor market” (18). In considerable levels of decommodification and—although less trying to explain country-specific differences in financial strain so—defamilisation, with family policy models characterized among workers it is important to consider the level of earnings by high levels of traditional family support from the state, as well as the level and availability of other sources of income, and low levels of support for female participation in the particularly transfers, which typically include old-age pensions, labor force. Several Continental countries devote considerable sickness leave, and unemployment benefits. Welfare states are resources to family care provisions and active labor market related to labor market regulations which influence the level measures (19). Southern European countries are characterized of unemployment as well as precariousness and, consequently, by low levels of decommodification and of defamilisation wages and the risk of financial strain. It is also important to with low spending on family policies and lack of affordable consider in-work benefit programs with social transfers provided childcare services. Family and inter-generational solidarity play Frontiers in Public Health | www.frontiersin.org 2 May 2021 | Volume 9 | Article 616191 Artazcoz et al. Financial Strain and Health Status a strong role, not only reducing work/care conflicts but also in is closely related to material deprivation (29, 30). Therefore, providing protection against social risks (21). Finally, Eastern financial strain was assessed via the question “A household may European countries have low levels of decommodification, have different sources of income and more than one household and although women’s labor market participation is high in member may contribute to it. Thinking of your household’s total most cases, there has been a process of re-familisation in the monthly income, is your household able to make ends meet. . . ?”; post-communist era. Southern and Eastern European countries answers fell into six categories, from “very easily” to “with great have the highest level of precarious employment in the European difficulty.” The variable was dichotomized, and individuals who Union (23). answered “with some difficulty,” “with difficulty,” and “with great Welfare state typologies can also determine the relationship difficulty” were considered to suffer from financial strain. between financial strain and health status due to “health resilience” by which some areas exhibit better health outcomes Health Outcomes than would be expected given their level of deprivation. In Data on self-perceived health status were collected by asking these areas, health advantage is conferred by a complex range respondents to describe their general health as “very good,” of factors such as health-related behaviors, social, religious, or “good,” “fair,” “poor,” or “very poor” (31). This variable was ethnic support (11). dichotomized by combining “fair,” “poor,” and “very poor” to In summary, although poverty is one of the core objectives indicate poor self-perceived health, and “very good” and “good” of the European Union’s social inclusion strategy (24), policies to indicate good perceived health. Subjective well-being was are primarily focused on promoting labor force participation measured using the 5-item World Health Organization Well- and knowledge about financial strain and its relationship with Being Index (WHO-5) which is among the best and more health status among workers is still scarce. The objectives of this used questionnaires assessing subjective psychological well-being study were: (1) to compare the prevalence of financial strain (32). We created a dichotomous variable, where a score of ≤50 among workers among different welfare state typologies, and (2) indicated poor psychological well-being, though not necessarily to examine whether the relationship between financial strain and depression for which the usual score is ≤28 (33). This approach health status differs by welfare state regime. For both objectives has been used in many previous studies based on working we examined whether there were gender differences. conditions surveys (34, 35). It should be noted that the prevalence of depression among people currently working is very low due to METHODS the “healthy worker effect.” Study Design and Population Welfare State Typologies We conducted a cross-sectional study using data from the Countries were grouped into five categories (21): Continental 6th European Working Conditions Survey (EWCS) of 2015. (Austria, Belgium, Germany, France, the Netherlands, and Details of the survey are reported elsewhere (25). For the Luxembourg), Anglo-Saxon (Ireland and the United Kingdom), purposes of this study, we selected a subsample of all employees Eastern European (Czech Republic, Estonia, Hungary, Lithuania, from the EU28 aged 16–64 years. We excluded self-employed Latvia, Poland, Croatia, Romania, Bulgaria, Slovenia, and workers because their employment and working conditions are Slovakia), Southern European (Cyprus, Greece, Spain, Italy, substantially different to those of salaried workers (26). Since Malta, and Portugal) and Nordic countries (Denmark, Finland, health problems may reduce the chance of having a good quality and Sweden). job, to avoid possible reverse causation, we excluded from our analysis all individuals who reported a limiting long-standing Adjusting Variables illness (LLI). The presence of LLI was assessed through two The analyses were adjusted for sociodemographic, employment questions: Do you have any illness or health problem which and household characteristics. Participants were grouped into has lasted, or is expected to last, for more than 6 months? three age categories, 16–24, 25–44, and 45–64 years, and This was a dichotomous question and those who answered immigration status was determined by country of birth, “yes” were further asked: “Are your daily activities limited with two categories, immigrants, and natives. Job category, because of this illness or health problem? Answers fell into which is a proxy for job qualification and socioeconomic three categories: workers who answered “yes, severely limited”, status (36), was coded according to the 2008 International and “yes, somewhat limited were considered to have LLI (n = Standard Classification of Occupations (37), and grouped 2,693). The final sample for analysis included 13,156 men and into three categories: upper (1 and 2), middle (3 to 5), 13,225 women. and lower (6 to 9). Type of contract had four categories: permanent, fixed-term temporary, no contract, and other. Variables Data on workers paid working hours were collected via Although many studies about material deprivation have focused the question: “How many hours do you usually work per on specific indicators of material hardship such as food week in your main paid job?” The responses for each insecurity, energy poverty or housing security, for example (7), question were summed and grouped into four categories: a single indicator of households’ ability to make ends meet <30 h [part-time employment (PTE)], 30–40 h (reference provides a valid subjective measure of overall financial strain (27, category), and >40 h a week [long working hours (LWH)]. 28). Moreover, previous studies have shown that this indicator We assessed household characteristics in terms of cohabitation Frontiers in Public Health | www.frontiersin.org 3 May 2021 | Volume 9 | Article 616191 Artazcoz et al. Financial Strain and Health Status with a partner, with parents, with other workers at home, country typologies were more pronounced among women. and with unemployed persons at home, all of which were On the other hand, gender differences within each country dichotomous variables, as well as the number of children (0, 1, typology were much smaller than those between welfare or >1). state typologies. Data Analysis Financial Strain and Health Status First, we conducted a bivariate analysis using the chi-square test Table 3 shows the association between financial strain and health to test for gender differences in all dependent and independent status. Among men, and for all welfare state typologies, financial variables, stratifying by welfare state typology. Second, to strain was related to poor self-perceived health status and poor compare the prevalence of financial strain between welfare psychological well-being, although in Nordic countries these state typologies, we fit logistic regression models, unadjusted differences were not statistically significant for poor health status. and adjusted for sociodemographic factors, employment, and The same pattern was observed among women, although the household characteristics. Finally, to test for association between differences were not statistically significant for self-perceived health outcomes and financial strain, we fit multiple logistic health status in Anglo-Saxon countries, or for psychological well- regression models adjusted for sociodemographic factors, being in Nordic countries. In both sexes, and for the two health employment, and household characteristics. Logistic regression indicators, the magnitude of the association was generally smaller models were stratified by gender and welfare state typologies and in Southern European countries. included weights derived from the complex sample design. DISCUSSION RESULTS This study has produced three main findings: (1) there were large Description of the Sample differences in the prevalence of financial strain between welfare Table 1 shows the general characteristics of the sample. Almost state typologies, which were not explained by sociodemographic half of workers from Eastern and Southern European countries factors, employment status, or household characteristics; (2) reported financial strain, whereas the lowest prevalence was differences across country typologies were more pronounced observed in Nordic countries. In Continental, Anglo-Saxon, and among women; and (3) in both sexes and in all welfare Eastern European countries, financial strain was significantly state typologies, financial strain was associated with poor higher among women. Eastern and Southern European countries self-perceived health status and poor psychological well-being had the highest prevalence of poor self-perceived health status, although the magnitude of the association differed by welfare with no gender differences; in contrast, in Anglo-Saxon and state typologies and gender. Nordic countries the prevalence was lower among women. The prevalence of poor psychological well-being was higher in Anglo- Prevalence of Financial Strain Saxon countries. After adjusting for sociodemographic, employment and The proportion of young employees was higher in Anglo- household characteristics, there were large differences in the Saxon countries and lower in Southern Europe; the proportion prevalence of financial strain between welfare state typologies of immigrants was larger in Anglo-Saxon countries but was <2% and they were greater among women. in Eastern European countries. As expected, the prevalence of financial strain was lower Regarding employment characteristics, in all country in Nordic countries, which are characterized by high levels of typologies, men were more likely to work in the lower both decommodification and defamilisation. However, Anglo- occupational category and to work long hours, whereas Saxon countries, ranked second, although they have the lowest women were more likely to work part-time. In both sexes, levels of decommodification of all typologies examined, and also fixed-term temporary contracts were more common in Southern have low levels of defamilisation. It should be noted that the and Eastern European countries, whereas working without a UK Working Tax Credit is the most important measure of its contract was more common in these latter typologies and in kind in Europe, both in terms of scope and budget (22). For Anglo-Saxon countries. working households receiving tax credits there is a reduction With regard to household characteristics, people from Eastern in the poverty gap of two-thirds. The Anglo-Saxon approach to and Southern European countries were more likely to live with reducing poverty emphasizes labor activation. In the UK, more parents. Living with unemployed persons at home was more than half of people who experienced in-work poverty in 1 year common among workers from Southern European countries. had exited by the following year, mostly by remaining in work but exiting poverty (38). The rather low levels of financial strain Prevalence of Financial Strain in Continental countries are likely due to their strongly regulated Table 2 shows differences in the prevalence of financial labor markets, together with traditional state economic support strain by gender and welfare state typology. The results for families, which assumes that women have most responsibility were almost unchanged after adjusting for sociodemographic for care at home (39). Eastern, and especially Southern European factors, employment, and household characteristics. Nordic countries, where almost half of workers suffer from financial countries had the most favorable profile, followed by Anglo- strain, had the highest prevalence of financial strain, which is Saxon countries, while Eastern and Southern European consistent with previous studies (40). Both country typologies are countries had the greatest financial strain. Differences between characterized by low levels of defamilisation and, additionally, Frontiers in Public Health | www.frontiersin.org 4 May 2021 | Volume 9 | Article 616191 Frontiers in Public Health | www.frontiersin.org Artazcoz et al. TABLE 1 | General description of the population by sex and welfare state typology. Continental Anglo-Saxon Eastern Europe Southern Europe Nordic Men Women Men Women Men Women Men Women Men Women N = 5,142 N = 5,109 N = 1,995 N = 1,919 N = 2,592 N = 2,871 N = 2,800 N = 2,746 N = 627 N = 580 Financial strain 27.6 31.0c 17.8 24.4c 41.4 44.3a 49.5 47.9 12.1 12.3 Poor self-perceived 12.7 12.9 12.9 8.7c 18.1 18.2 19.7 20.3 14.0 9.1b health Poor psychological 10.5 14.4a 18.9 22.8b 14.2 15.2 11.9 14.0a 12.0 14.0 well-being Sociodemographic characteristics Age 10.5 9.5 14.0 12.6 8.4 6.7a 5.9 5.9 9.8 9.4 16–24 25–44 47.0 49.0 47.7 47.7 51.9 55.5 51.2 51.2 48.4 44.6 45–64 42.5 41.5 38.3 39.7 39.7 37.8 42.9 42.9 41.8 46.0 Immigrant 8.8 9.5 17.7 17.4 1.4 1.4 8.0 8.2 9.4 10.0 Employment characteristics Job category Upper 20.7 20.7c 34.7 36.2c 16.7 28.0c 17.0 22.9c 29.9 37.9c Middle 38.6 62.4 33.1 53.7 30.8 50.3 39.8 56.6 38.3 52.1 Lower 40.7 16.9 32.2 10.1 52.5 21.7 43.2 20.5 31.7 10.0 5 Working time <30 h 9.1 38.8c 10.7 38.4c 7.4 13.2c 11.8 31.6c 10.4 15.3c 30–40 h (standard) 71.9 52.8 51.5 47.6 57.9 65.9 64.7 58.5 64.3 71.8 >40 h 19.0 8.4 37.8 14.0 34.7 20.9 23.5 9.9 25.3 12.9 Type of contract Permanent 84.6 81.2c 85.6 85.9 78.4 78.1c 74.4 68.6c 86.1 82.4 Fixed-term temporary 9.7 12.5 5.0 5.0 14.0 14.5 17.1 18.5 9.9 13.1 No contract 1.6 2.4 4.6 4.6 4.7 3.0 6.0 9.2 1.6 1.2 Other 4.1 3.8 4.8 4.8 2.9 4.3 2.5 3.7 2.4 3.3 Household characteristics Living with a partner 70.3 67.2b 67.3 67.1 66.2 70.3b 65.9 66.7 66.8 61.6 Living with parents 8.6 7.4 16.3 12.0 25.3 17.6 20.0 16.9 5.9 5.3 May 2021 | Volume 9 | Article 616191 Number of children Financial Strain and Health Status 0 57.6 48.2c 59.7 53.7b 60.3 47.0c 54.4 45.7c 54.9 54.0 1 16.9 22.7 16.0 18.5 20.7 28.2 23.1 25.9 16.1 17.2 ≥2 25.5 29.1 24.3 27.8 19.1 24.8 22.4 28.4 29.0 28.8 Other workers at home 62.8 67.4c 68.0 74.9c 61.8 70.6c 61.7 59.1c 58.9 58.3 c Unemployed at home 6.3 6.0 8.0 8.5 12.4 8.7 18.9 14.1c 5.9 6.0 Employees aged 16–64 years (%). P-values compare men and women in each country typology. 6th European Working Conditions Survey, 2015. a P < 0.05, b P < 0.01, c P < 0.001. Artazcoz et al. Financial Strain and Health Status they have the highest labor market precariousness and lowest 2.39–4.08a 2.05–3.62a 4.76–8.23a 4.69–8.10a incomes (23, 41). 95% CI Differences in the prevalence of financial strain across welfare state regimes were larger among women which may be explained by a greater effect of differences in defamilisation levels among them. However, this is a speculation which deserves further research. aOR 3.12 2.72 6.26 6.16 1 Financial Strain and Health Status Financial strain was related to poor self-perceived health status and poor psychological well-being in both sexes and in all b 2.49–4.15a a 5.08–8.54a country typologies, even after adjusting for age, immigrant 1.76–3.02 4.38–7.36 95% CI % refers to the prevalence of financial strain in each category. a P < 0.05; b P < 0.01. Odds ratios are adjusted for sociodemographic factors, employment, and household characteristics. status, occupational, and household characteristics. This finding is consistent with those of other studies, which report that current financial strain is strongly and independently associated with depression, even more than other traditional measures of socio-economic position (27, 42). However, it should be cOR 3.21 2.30 5.67 6.58 noted that in both sexes the magnitude of the association was 1 generally smaller in Southern European countries. This finding is consistent with previous comparative studies reporting the greater health resilience of Mediterranean countries which could be related to a several factors (11) such as family solidarity, 12.3 31.0 24.4 44.3 47.9 % social support or diet, among others. A study carried out among African American families with incomes below 250% of the federal poverty level also found a positive relationship Crude (cOR) and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). 6th European Working Conditions Survey, 2015. between social support and resilience to urban poverty (43). b 2.15–3.59a a 4.49–7.61a 1.17–2.05 3.71–6.31 Studies carried out in Europe have shown that the magnitudes 95% CI of health inequalities vary by welfare state regime but that this variation is not always in the direction expected as the Scandinavian countries do not exhibit the smallest health inequalities (44, 45). aOR 2.78 1.55 4.84 5.84 Strengths and Limitations 1 To our knowledge, this is the first study about financial strain and health status in a large and representative sample of employees from the EU28 countries. Unlike other studies based on the EU- SILC, in which only the head of the household was asked about b 2.15–3.54a a 5.52–9.14a 1.20–2.05 3.98–6.60 TABLE 2 | Association between financial strain and country group by gender. 95% CI financial strain, this study included all workers. The perceptions of the head household may differ from those of other household members (41). In contrast to many previous studies, we assessed and identified gender differences in the prevalence of financial strain across welfare state typologies. The study also has some limitations. It has a cross-sectional Women cOR study, so we cannot entirely rule out the possibility that poor 2.76 1.57 5.12 7.11 1 health causes financial strain. However, we reduced this potential reverse causation bias by excluding individuals who reported LLI in the previous 6 months. Therefore, we have focused on a relatively healthy and homogeneous population and adjusted for Men 12.1 27.6 17.8 41.4 49.5 % a broad range of individual factors of financial strain and still we have found a consistent relationship between financial strain and health status. Southern European Eastern European CONCLUSION Anglo-Saxon Continental There are large differences in the prevalence of financial Nordic strain between welfare state typologies, which are independent of individual factors and more pronounced among women. Frontiers in Public Health | www.frontiersin.org 6 May 2021 | Volume 9 | Article 616191 TABLE 3 | Association between family financial strain and health by welfare state typology and gender. Frontiers in Public Health | www.frontiersin.org Artazcoz et al. Men Continental N = 5,142 Anglo-Saxon N = 1,995 Eastern Europe N = 2,592 Southern Europe N = 2,800 Nordic N = 627 % aOR 95% CI % aOR 95% CI % aOR 95% CI % aOR 95% CI % aOR 95% CI Poor self-perceived health status No financial strain 10.3 1 11.6 1 13.8 1 16.8 1 13.2 1 Financial strain 19.1 2.22 1.82–2.70c 19.8 1.79 1.27–2.52b 24.3 1.80 1.42–2.28c 22.8 1.28 1.02–1.60a 18.7 1.28 0.64–2.54 Poor psychological well-being No financial strain 7.1 1 17.8 1 10.9 1 8.9 1 10.4 1 Financial strain 19.3 3.05 2.49–3.74c 25.1 1.57 1.17–2.11b 18.6 1.77 1.38–2.26c 14.9 1.85 1.41–2.41c 24.0 3.56 1.84–6.88c Women Continental N = 5,109 Anglo-Saxon N = 1,919 Eastern Europe N = 2,871 Southern Europe N = 2,746 Nordic N = 580 % aOR 95% CI % aOR 95% CI % aOR 95% CI % aOR 95% CI % aOR 95% CI Poor self-perceived health status No financial strain 9.0 1 7.6 1 13.6 1 19.2 1 7.9 1 Financial strain 21.8 2.97 2.45–3.61c 9.6 1.38 0.91–2.10 24.2 1.86 1.51–2.31c 21.6 1.24 1.00–1.53a 17.1 2.61 1.19–5.72a Poor psychological well-being No financial strain 10.5 1 19.5 1 10.5 1 10.4 1 13.0 1 2.30–3.28c 1.94–3.37c 1.60–2.51a 1.37–2.22c 7 Financial strain 23.5 2.75 31.7 2.56 21.1 2.01 17.7 1.74 18.3 1.36 0.66–2.79 Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). 6th European Working Conditions Survey, 2015. Note: % refers to the prevalence of in each category. a P < 0.05; b P < 0.01; c P < 0.001; odds ratios are adjusted for sociodemographic factors, employment and household characteristics. May 2021 | Volume 9 | Article 616191 Financial Strain and Health Status Artazcoz et al. Financial Strain and Health Status Whereas, the levels of decommodification and defamilisation can DATA AVAILABILITY STATEMENT explain to a great extent these cross-country differences, they are not correlated to the differences in the magnitude of the Publicly available datasets were analyzed in this study. This associations between financial strain and health status. Among data can be found here: Data come from the 6th European employees of the EU28, financial strain is related to poor health working conditions survey (https://www.eurofound.europa.eu/ status and poor psychological well-being in both sexes and in all surveys/european-working-conditions-surveys/sixth-european- welfare state typologies, independently of age, immigrant status, working-conditions-survey-2015). employment, and household characteristics. However, whereas Southern European countries have the highest prevalence of AUTHOR CONTRIBUTIONS financial strain, the magnitude of the association with health status was smaller than in other country typologies. LA and IC-F contributed in the conceptualization and design The differences between welfare state typologies in the of the study. 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