How Did Employment and Financial Strain Affect the Self-rated Health of Lone Mothers Around the Time of the Economic Crisis? A Cross-sectional Comparison of the United Kingdom and Sweden

Abstract

Lone mothers face higher risk of poor self-rated health (SRH) than coupled mothers, partly explained by financial strain, non-employment, and welfare context. Comparing the United Kingdom and Sweden, we sought to determine how the economic crisis of 2008 affected the inequality in lone and coupled mothers SRH and what socioeconomic factors impacted this. Survey data was divided into periods corresponding to before, during, and after the economic crisis. Logistic regression was used to evaluate the impact of socioeconomic factors. Financial strain explained 70%–80% of the excess risk for poor health among Swedish lone mothers and 40% of those in the United Kingdom. Controlling for background and socioeconomic factors eliminated the health inequality among Swedish mothers. In the United Kingdom this inequality remained and may reflect the impact of social mechanisms such as stigma. Converse to what was expected, we did not observe significant variation over time in factors affecting SRH, nor did we find conclusive evidence of the impact of the economic crisis on the SRH of lone mothers. Factors that may account for these counterintuitive results, including retrenchment of the Swedish welfare state, economic lag, and reduction in overall inequality in health, are discussed.

Keywords

economic crisis financial strain lone mothers self-rated health unemployment

In recent times the nuclear family unit has lost its place as the major family arrangement, with a rise in lone parent structures, often headed by lone mothers.¹ It is well demonstrated that lone mothers suffer worse physical, mental, and self-rated health (SRH) when compared to coupled mothers, with risks of poor SRH up to 3 times that of coupled mothers.^2–7 Our previous research has shown that welfare context,⁸ financial strain,^9,10 and employment^4,11 are all important factors in explaining this inequality. Furthermore, SRH and contributing variables are not static and vary with time.^9,12 Many societal changes have taken place since these previous comparative studies were conducted, including the economic crisis of 2008 that has affected almost all European countries.¹³ To date, no studies have examined the impact of the economic crisis on lone mother’s health. The macroeconomic changes starting in 2008 provide a natural experiment where, drawing on our previous studies, we may analyze how the changing socioeconomic circumstances have affected the SRH of lone mothers.

Why Do Lone Mothers Have Poorer Health?

The relationship between social conditions, health, and policy has been conceptualized by Diderichsen and colleagues (Figure 1).¹⁴ In all societal groups there is a negative correlation between non-employment, poverty, and health, with those at the top of the social hierarchy reporting better health.^15,16 Social position influences material aspects such as physical environment and financial poverty as well as subjective experiences, the combination of which may contribute to chronic stress and difficulty coping with adverse life events.¹⁶ The interaction of factors affecting individuals, including their social environments, will determine the health effects of exposures. Due to socioeconomic pressures and the role of sole carer, relative living conditions for lone mothers are often poorer than those of coupled mothers, and they are likely to be exposed to health risks more frequently than coupled mothers (mechanism II). Individual factors such as lack of social support may increase the vulnerability and consequence of such risks (mechanisms III and IV). Factors further affecting vulnerability include the route into lone motherhood, which differs between contexts – with a tendency for British lone mothers to have never been coupled, whereas Swedish mothers enter via divorce or separation.⁸ Additionally, other selection into lone motherhood may affect health. British lone mothers tend to be younger, of lower educational status, and from working-class backgrounds, whereas Swedish lone mothers are more evenly distributed among socioeconomic groups.⁴ Despite contextual differences, lone mothers are at higher risk of poor health than coupled mothers, at a rate proportional to the amount of time spent alone.⁶

Figure 1.
A conceptual framework illustrating the links between social conditions, policy, and health (from Burstrom et al.⁸ adapted from Diderichsen et al.¹⁴).

The Role of Employment and Family Policy

Employment is the social determinant that has the largest potential influence on living conditions.¹⁷ It enhances health through income generation, social inclusion, and improved mental well-being.¹⁸ For lone mothers, however, the impact on health may differ. On the one hand, employment allows lone mothers who may be marginalized from society to integrate, build social support, and improve skills weakened from time out of work. On the other hand, combining full-time employment with responsibilities of a sole care provider may have a detrimental effect,¹⁹ making childcare policies and employment flexibility vital for engagement in the job market.²⁰ In the United Kingdom, lone mothers may attempt to secure informal childcare, without which they must find, and in some cases fund, formal childcare. This increases the risk of developing a care deficit, whereby resources do not meet the needs of either the mother or the child.^21,22 In Sweden childcare is comprehensive and heavily subsidized,²³ and flexible working policies are common. Employment rates for mothers are consequently the highest in Europe, standing at 73.1% in 2014,²⁴ and work is often described as a prerequisite to be included in society. The working imperative is strong and often embraced also by lone mothers themselves.²⁵ In the United Kingdom childcare costs are above average for countries in the OECD (Organization for Economic Cooperation and Development), and coverage is unpredictable.²³ Employment rates among lone mothers are therefore lower, and they may have greater difficulty securing financially viable employment.²³

Neoliberal policies in the United Kingdom have attempted to encourage lone mothers’ engagement with the job market. Successive U.K. governments devised policies, including Labour’s “New Deal for Lone Parent.s” and, from 2010, the Conservative’s “Make Work Pay” agenda.^26,27 Such policies tend to increase engagement with the job market, although financial returns are not guaranteed, particularly for lone mothers in settings such as the United Kingdom where they tend to be less educated and thus more likely to have low-paid and precarious employment.^4,26,28 Furthermore, U.K. welfare policies that restrict income support to lone mothers by requiring them to seek employment have been shown to be detrimental to their mental health.²⁹ Precarious employment contributes to stress and adverse health outcomes and increases in times of economic strain.³⁰ Policies encouraging employment have in some cases, however, been shown to increase self-reported life satisfaction for lone mothers, an effect which extends beyond simple financial gains.³¹

According to Korpi’s typology, there are 3 different family policy models: the main distinction is whether they favor traditional families, market reliance, or mother’s employment. The models vary in their support for traditional or dual-earner families.³² The United Kingdom is an example of a market-oriented family policy model that reinforces the traditional male-breadwinner role. Other examples of the market-oriented family policy model include Canada, Ireland, the United States, and Switzerland. Sweden is an example of a dual-earner model in which both parents’ right to employment is strengthened through flexible working policies, shared parental leave, and subsidized childcare. Other examples of this family policy include Norway, Finland, and Denmark. The U.K. model’s assumption that women act as the main caregiver is coupled with a means-tested benefit model. As societal norms shift from the traditional family unit and the workforce becomes increasingly feminized, this model disproportionately disadvantages women and produces the largest negative health effect when compared to other family policy models.^33–35 By contrast, during the 1990s recession the Nordic social-democratic system acted as a buffer to negative health consequences.³⁶ The extensive influences policy can have on health are shown in Figure 1 by entry points A–D.

The Impact of the Economic Crisis

The global financial crisis of 2008 is widely recognized as the worst in recent history, causing widespread rises in unemployment rates, poverty, and debt.³⁷ In the United Kingdom, GDP fell by 4%, and the resulting recession was the worst since the second world war.³⁸ By contrast, Sweden suffered a 6% drop in GDP but recovered much quicker, particularly compared to the previous recession of the 1990s, which was less pronounced but more prolonged, resulting in greater socioeconomic effects.³⁹ In 2010, the change in U.K. government from the center-left Labour Party to a Conservative-led coalition marked the initiation of austerity, a fiscal policy not introduced in Sweden thus far. In the United Kingdom, austerity measures included tax increases and cuts to welfare, notably freezes in child and housing benefits. Historically, welfare cuts disproportionately affect those in greatest need, including lone mothers,^9,40 and spending on social welfare positively correlates to all-cause mortality.⁴¹

In Sweden and the United Kingdom, the situation for lone mothers was already poorer than before the crisis, with higher rates of unemployment, poverty, and rented accommodation compared to coupled mothers.⁸ Since lower resilience to the negative health effects of economic crises is linked to factors such as unemployment, female gender, and not being married,⁴² lone mothers are likely to fare worse than coupled mothers during the crisis period.

The Role of Financial Strain

Recent estimates suggest that up to 62% of lone mothers in the United Kingdom are at risk of poverty and social exclusion.^9,43 Ill health and financial strain are linked, whereby one increases the risk of the other.^44,45 SRH correlates with both actual income and subjective financial well-being, suggesting an effect beyond the material aspect.⁴⁶ Having a lack of resources leads to restricted participation in daily activities, thus contributing to social exclusion, which is both a cause and consequence of poverty.⁴⁷ Consequently lone mothers who are at higher risk of financial strain report greater levels of exclusion, depression, and stress compared to coupled mothers.^7,48,49

To tackle inequality, welfare states offer financial assistance to lone parents and those on low income. The redistributive effects of tax-benefit systems depend largely on the context, with both United Kingdom and Sweden having similar levels of tax-based work incentive but large differences in income inequality.⁵⁰ In the United Kingdom, benefits are modest and means-tested, catering mainly to the working class.⁵¹ On the other hand, Sweden’s social and economic policies are integrated, aiming to reduce inequality through generous monetary transfers and graduated yet universal policies. Given the relationship between income, both subjective and objective, and health,⁴⁵ we hypothesize that the economic crisis will result in a worsening of lone mothers SRH as financial strain increases. Considering previous findings regarding the health of general as well as vulnerable populations as a result of economic recessions,^13,52,53 we also predict a reduction in the inequality between lone and coupled mothers SRH during the crisis and an increase in the time period following the crisis.

Aim

The aim of the study was to explore how the economic crisis of 2008 affected the inequality in self-rated health between lone and couple mothers in the United Kingdom and Sweden and the extent to which non-employment and financial strain influence this inequality. The findings are discussed in the context of the changing welfare and family policy environments.

Methods

Study Design

This study uses survey data from the European Union Statistics on Income and Living Conditions (EU-SILC). This is a harmonized dataset compiled from national household surveys of EU member states. The national surveys are based on a representative random sample of the population, administered to all adults aged 16 and over. Legislation surrounding the surveys states that non-response rates should be no more than 40%.

The study population included mothers aged 20 to 59 years old with children aged up to 18 years living at home. Cross-sectional data from the United Kingdom and Sweden was used for years 2005–2012. The total sample size for the United Kingdom was 22,970, of which 4,294 were lone mothers. Corresponding numbers for Sweden were 9,328, of which 1,320 were lone mothers (Tables 1 and 2).

Table 1.
Sample Characteristics, UK.

2005–2007
2008–2009
2010–2012

Coupled
Lone
Coupled
Lone
Coupled
Lone

n % n % n % n % n % n %

Sample size 7,543 81.4 1,722 18.6 4,370 82.7 911 17.3 6,763 80.3 1,661 19.7

Age (years)

20–24 572 7.6 168 9.8 339 7.8 87 9.5 564 8.3 195 11.7

25–34 1,830 24.3 499 29.0 967 22.1 246 27.0 1,559 23.1 495 29.8

35–44 3,358 44.5 721 41.9 1,887 43.2 363 39.8 2,697 39.9 589 35.5

45–54 1,596 21.2 314 18.2 1,066 24.4 185 20.3 1,750 25.9 343 20.7

55–59 187 2.5 20 1.2 111 2.5 30 3.3 193 2.9 39 2.3

Employment^a

Employed 4,915 70.46 962 58.7 2,979 72.4 518 61.4 4,693 71.6 868 56.5

Non-employed 2,249 29.6 756 41.3.0 1,255 27.6 389 38.6 2,062 28.4 791 43.5.7

Highest level of education achieved

Low 824 11.4 348 20.4 378 9.4 172 19.7 607 9.6 305 19.4

Intermediate 3,871 53.8 902 52.8 2,094 51.9 509 58.2 3,010 47.8 909 57.7

High 2,502 34.8 457 26.8 1,562 38.7 194 22.2 2,679 42.6 362 23.0

Foreign born

UK born 6,486 86.0 1,524 88.5 3,759 86.8 828 91.1 5,619 83.8 1,428 86.1

Foreign born 1,056 14.0 198 11.5 573 13.2 81 8.9 1,085 16.2 231 13.9

Unmet need for health in last 12 months

No 6,874 95.8 1,597 93.1 3,912 96.9 835 92.9 6,060 97.1 1,555 94.6

Yes 298 4.2 119 6.9 126 3.1 64 7.1 181 2.9 89 5.4

Financial strain^a

No difficulty 4,383 59.7 468 28.2 2,266 53.4 232 26.1 3,385 51.7 349 22.0

Difficulty 3,126 40.3 1,250 71.8 2,089 46.6 677 73.9 3,329 48.3 1,307 78.0

At risk of poverty indicator

Not at risk of poverty 6,458 85.6 1,051 61.0 3,746 85.7 560 61.5 5,766 85.3 1,154 69.5

At risk of poverty 1,085 14.4 671 39.0 624 14.3 351 38.5 997 14.7 507 30.5

Self-rated health^a

Good 6,143 85.3 1,294 74.5 3,890 89.2 727 79.4 5,779 86.0 1,228 73.1

Poor 1,029 14.7 423 25.5 438 10.8 182 20.6 884 14.0 429 26.9

^aAge standardized.

Table 2.
Sample Characteristics, Sweden.

2005–2007
2008–2009
2010–2012

Coupled
Lone
Coupled
Lone
Coupled
Lone

n % n % n % n % n % n %

Sample size 2,918 85.5 493 14.5 2,093 85.6 352 14.4 2,997 86.3 475 13.7

Age (years)

20–24 144 4.9 12 2.4 113 5.4 12 3.4 171 5.7 30 6.3

25–34 772 26.5 82 16.6 497 23.7 47 13.4 665 22.2 76 16.0

35–44 1,216 41.7 228 46.2 897 42.9 162 46.0 1,288 43.0 192 40.4

45–54 721 24.7 153 31.0 533 25.5 122 34.7 792 26.4 164 34.5

55–59 65 2.2 18 3.7 53 2.5 9 2.6 81 2.7 13 2.7

Employment^a

Employed 2,411 84.3 368 76.7 1,772 86.3 288 84.2 2,506 85.8 366 80.3

Non-employed 506 15.7 123 23.3 321 13.7 64 15.8 490 14.2 109 19.7

Highest level of education achieved

Low 224 7.7 64 13.1 151 7.2 44 12.5 151 5.1 46 9.8

Intermediate 1,543 53.1 275 56.1 1,051 50.4 200 56.8 1,438 48.2 247 52.4

High 140 39.2 151 30.8 884 42.4 108 30.7 1,397 46.8 178 37.8

Foreign born

Swedish born 2,490 85.4 398 80.7 1,758 84.4 283 80.4 2,480 83.1 372 78.5

Foreign born 424 14.6 95 19.3 324 15.6 69 19.6 506 16.9 102 21.5

Unmet need for health in the last 12 months

No 2,422 83.5 359 74.0 1,816 86.9 278 79.0 2,582 86.4 382 80.4

Yes 478 16.5 126 26.0 274 13.1 74 21.0 408 13.6 93 19.6

Financial strain^a

No difficulty 2,037 70.9 159 33.1 1,615 79.5 180 52.8 2,427 83.2 242 52.3

Difficulty 860 29.1 330 66.9 429 20.5 167 47.2 503 16.8 222 47.7

At risk of poverty indicator

Not at risk of poverty 2,763 94.7 387 78.5 1,958 93.5 256 72.7 2,742 91.5 312 65.7

At risk of poverty 155 5.3 106 21.5 135 6.5 96 27.3 255 8.5 163 34.3

Self-rated health^a

Good 2,359 81.7 350 71.7 1,789 85.2 271 76.8 2,614 86.9 374 78.9

Poor 505 18.3 137 28.9 304 14.8 81 23.2 369 13.1 98 21.1

^aAge standardized prevalence rates

Variables

Self-rated health (SRH): An individual’s overall self-assessment of health is a multidimensional overview bringing together aspects of physical, social, and emotional well-being. While this commonly used indicator is fundamentally a subjective measure, it has been shown to correlate with future mortality, morbidity, and general health conditions.^54–56 Since objective health measures are often calculated differently, SRH allows for cross-contextual comparisons, accounting for the influence of environment and society on one’s perception of health. Responses were dichotomized into less than good, referred to here as “poor” SRH, and “good” SRH. Due to possible cultural bias in how SRH is reported across countries,⁵⁵ we do not compare absolute levels but rather the relative differences in SRH.

Motherhood status: Lone mothers were defined as all households with 1 adult female and at least 1 dependent aged 18 or below. Coupled mothers were classified as households with 2 adult members and at least 1 dependent child.

Age: Age was used as a continuous variable. Respondents aged 20–59 years were included in the analysis to allow the youngest mothers to have completed at least a basic level of education.

Educational level: Education level was measured according to the International Classification of Education scale (ISCED). It was dichotomized into low level of education, corresponding to less than 10 years of schooling, and intermediate/high level.

Foreign born: Being foreign born may influence social and employment status as well as health.⁹ Here, it is dichotomized into whether the respondent was born in the country of residence or not.

Employment: Employment was defined as part- or full-time employment versus non-employment. Non-employment includes unemployed as well as economically inactive mothers not looking for work, such as homemakers, students, and those unable to work due to disability or illness.

Financial strain: The ability to make ends meet is frequently used in the existing literature to indicate financial, or economic, strain.^9,46 This is a subjective measure whereby participants are asked whether they had any difficulty making ends meet in the last 12 months.

At risk of poverty: This is an objective measurement of the risk of poverty calculated from the national equivalized disposable income after social transfers. If participant income falls below 60% of the national median disposable income, the participant is said to be at risk of poverty. It implicates a low relative income but not necessarily a low standard of living.⁵⁷

Unmet need for health: This self-reported variable indicates access to health care.⁵⁸ A positive response indicates at least 1 occasion when the respondent had a need for medical examination or treatment within the last 12 months but was not able to access it.

Time periods: To evaluate the impact of economic changes on the SRH, we stratified our analysis into 3 time periods, 2005–2007, 2008–2009, and 2010–2012. This allowed for a sufficient sample size within each category but also represented points at which events, such as the economic crisis (2008) and change in the U.K. government (2010), occurred, allowing us to examine the impact of subsequent sociopolitical changes on health.⁵²

Analyses

Population characteristics were calculated for lone and coupled mothers, stratified by country and time. Prevalence rates for SRH, non-employment, and financial strain were age standardized. We used Z-test to assess whether observed differences between groups were significant (results not shown). Statistical analyses were made using SPSS v23. Multivariate logistic regression was performed to assess the extent to which each background and socioeconomic variable affected the SRH of mothers. The proportion of excess risk of poor health among lone mothers that each variable accounted for was estimated by the explained fraction, using the formula:
$XF = [(OR - 1) - (OR * - 1)] / (OR - 1)$
where XF is explained fraction, OR is the odds ratio before adjusting for the variable, and OR* is the odds ratio after adjustment.⁵⁹

Multivariable regression models were constructed to determine the extent to which selected factors influenced the SRH of lone mothers. The first model was adjusted for potential confounders described above. The second model was also adjusted for non-employment, financial strain, and unmet health needs.

Results

Health and Social Profile of Lone and Coupled Mothers in the United Kingdom and Sweden

In Britain, lone mothers were more often in younger age ranges compared to the Swedish sample (Tables 1 and 2). In both contexts, lower levels of educational attainment were found among lone mothers compared to coupled mothers with British lone mothers approximately twice as likely to have attained a low level of education than British coupled mothers. Overall, Swedish mothers had a higher level of education than British mothers.

Prevalence of non-employment was greatest among lone mothers, with levels highest in the United Kingdom (Figure 2). In Sweden, a clear majority of lone and coupled mothers were employed. In both countries employment levels for all mothers peaked between 2008 and 2009, with 81.8% of lone mothers employed in Sweden and 57.1% in the United Kingdom.

Reporting of financial strain was higher among lone mothers than coupled mothers in both settings and all periods, and highest in the United Kingdom (Figure 3). Lone mothers in the United Kingdom were around twice as likely to report difficulty making ends meet than not when compared to coupled mothers. In Sweden, there was a downward trend in the prevalence of financial strain, which was lowest between 2010 and 2012. Rates among Swedish lone mothers were then even lower than coupled mothers in the United Kingdom. The risk of poverty measure did not correlate with reported financial strain. In the United Kingdom, where financial strain increased successively, the proportion of lone mothers at risk of poverty declined, falling by nearly 10 percentage points from 2005–2007 to 2010–2012, this may reflect falling national median income. In Sweden, despite decreasing reports of financial strain the proportion of mothers at risk of poverty increased.

In both countries, the prevalence of poor SRH was highest among lone mothers (Figure 4). Around a quarter of British lone mothers reported poor SRH. Levels of SRH among British lone and coupled mothers were significantly lower during the crisis period than before or after. In Sweden, prevalence of poor SRH among both lone and coupled mothers was highest in 2005–2007 and fell successively. Unmet needs for health were more prevalent among Swedish than British mothers. Lone mothers were more likely to report an unmet need for health or health care than coupled mothers in all time periods.

Figure 2.
Age standardized prevalence (%) of employment among lone and coupled mothers in the United Kingdom and Sweden.

What Is the Impact of Background Variables, Non-Employment, and Financial Strain on SRH of Lone Mothers?

All variables analyzed, except being foreign born in the United Kingdom setting, were associated with poor SRH, and further explained part of the excess risk of poor SRH among lone mothers (Tables 3 and 4). The explained fraction for non-employment was similar in both countries and all time periods. Unmet health needs had a greater impact on poor SRH in Sweden than they did in the United Kingdom for the first 2 time periods, the difference diminished following the crisis period, when 10% of the excess risk can be explained by this variable for both countries.

Table 3.
Odds Ratios With 95% Confidence Intervals for Poor Self-Rated Health Among Lone Mothers in UK, Adjusted for Age and Each Variable in Turn, Stratified by Time Period.

2005–2007 Age 1.0 (1.01–1.03) 1.0 (1.01–1.03) 1.0 (1.01–1.02) 1.0 (1.02–1.04) 1.0 (1.02–1.03) 1.0 (1.01–1.03) 1.0 (1.01–1.03)

Lone mothers 2.0 (1.77–2.29) 2.0 (1.77–2.29) 1.9 (1.68–2.18) 1.9 (1.06–2.11) 1.6 (1.41–1.84) 1.8 (1.53–2.00) 1.9 (1.70–2.21)

Foreign born 1.1 (0.93–1.29)

Education 1.8 (1.59–2.14)

Employment 2.4 (2.15–2.72)

Financial strain 2.2 (1.97–2.51)

At risk of poverty 1.8 (1.53–2.01)

Unmet health needs 3.9 (3.17–4.79)

Explained fraction 0.0 0.1 0.2 0.4 0.3 0.1

2008–2009 Age 1.0 (1.03–1.05) 1.0 (1.02–1.04) 1.0 (1.02–1.04) 1.1 (1.04–1.06) 1.0 (1.03–1.05) 1.0 (1.03–1.05) 1.0 (1.02–1.05)

Lone mothers 2.3 (1.93–2.83) 2.3 (1.93–2.84) 2.1 (1.74–2.60) 2.1 (1.71–2.54) 1.9 (1.58–2.35) 2.0 (1.62–2.41) 2.1 (1.72–2.55)

Foreign born 1.1 (0.86–1.42)

Education 2.2 (1.78–2.81)

Employment 3.3 (2.74–3.93)

Financial strain 2.2 (1.78–2.60)

At risk of poverty 2.0 (1.65–2.45)

Unmet health needs 4.2 (3.07–5.79)

Explained fraction 0.0 0.2 0.2 0.3 0.3 0.2

2010–2012 Age 1.0 (1.02–1.04) 1.0 (1.02–1.04) 1.0 (1.02–1.04) 1.0 (1.04–1.05) 1.0 (1.03–1.04) 1.0 (1.03–1.04) 1.0 (1.02–1.04)

Lone mothers 2.4 (2.13–2.78) 2.4 (2.13–2.78) 2.2 (1.92–2.54) 2.1 (1.87–2.46) 1.9 (1.67–2.20) 2.2 (1.91–2.51) 2.3 (2.03–2.66)

Foreign born 1.1 (0.89–1.24)

Education 2.5 (2.14–2.94)

Employment 3.2 (2.79–3.60)

Financial strain 2.9 (2.48–3.29)

At risk of poverty 2.1 (1.78–2.36)

Unmet health needs 3.9 (3.02–5.04)

Explained fraction 0.0 0.2 0.2 0.4 0.2 0.1

Note. Bold face values highlight the odd ratios for poor SRH of lone mothers.

Table 4.
Odds Ratios With 95% Confidence Intervals for Poor Self-Rated Health Among Lone Mothers in Sweden, Adjusted for Age and Each Variable in Turn, Stratified by Time Period.

2005–2007 Age 1.0 (1.01–1.03) 1.0 (1.01–1.03) 1.0 (1.01–1.04) 1.0 (1.02–1.05) 1.0 (1.02–1.04) 1.0 (1.01–1.03) 1.0 (1.01–1.04)

Lone mothers 1.8 (1.40–2.18) 1.7 (1.36–2.13) 1.7 (1.32–2.07) 1.6 (1.25–1.98) 1.2 (0.94–1.51) 1.7 (1.33–2.09) 1.6 (1.27–2.00)

Foreign born 1.8 (1.46–2.28)

Education 2.5 (1.94–3.33)

Employment 3.2 (2.60–3.94)

Financial strain 2.9 (2.41–3.49)

At risk of poverty 1.4 (0.99–1.85)

Unmet health needs 3.2 (2.58–3.84)

Explained fraction 0.1 0.1 0.2 0.7 0.2 0.2

2008–2009 Age 1.0 (1.00–1.03) 1.0 (1.00–1.03) 1.0 (1.00–1.03) 1.0 (1.02–1.04) 1.0 (1.00–1.03) 1.0 (1.00–1.03) 1.0 (1.01–1.03)

Lone mothers 1.7 (1.29–2.26) 1.7 (1.26–2.21) 1.6 (1.22–2.14) 1.6 (1.22–2.16) 1.2 (0.90–1.63) 1.5 (1.14–2.03) 1.5 (1.14–2.02)

Foreign born 2.2 (1.70–2.85)

Education 2.6 (1.84–3.56

Employment 3.8 (2.92–4.96)

Financial strain 3.4 (2.69–4.32)

At risk of poverty 1.7 (1.18–2.33)

Unmet health needs 3.9 (3.02–5.06)

Explained fraction 0.1 0.1 0.1 0.7 0.3 0.3

2010–2012 Age 1.0 (1.02–1.05) 1.0 (1.02–1.05) 1.0 (1.03–1.05) 1.1 (1.04–1.06) 1.0 (1.03–1.05) 1.0 (1.03–1.05) 1.0 (1.02–1.05)

Lone mothers 1.8 (1.40–2.31) 1.8 (1.37–2.26) 1.7 (1.34–2.21) 1.7 (1.30–2.15) 1.2 (0.89–1.53) 1.4 (1.06–1.80) 1.7 (1.31–2.20)

Foreign born 1.6 (1.27–2.04)

Education 2.8 (1.99–3.96)

Employment 3.0 (2.38–3.85)

Financial strain 4.0 (3.19–4.94)

At risk of poverty 2.6 (1.97–3.36)

Unmet health needs 4.7 (3.75–5.86)

Explained fraction 0.1 0.1 0.2 0.8 0.1 0.1

Note. Bold face values highlight the odd ratios for poor SRH of lone mothers.

In Sweden, financial strain was the most important explanatory factor throughout, accounting for 70%–80% of the excess risk of poor SRH among lone mothers. Following adjustment for financial strain, the excess risk of poor SRH for lone mothers was no longer significant. While financial strain was the most influential variable in Britain, accounting for 30%–40% of the excess risk, the impact was not as pronounced as in Sweden.

Do Non-Employment and Financial Strain Explain the Inequalities in SRH between Lone and Coupled Mothers?

When adjusting for background variables, the risk of poor SRH for British lone mothers was nearly double than for coupled mothers (model 1, Table 5). Unlike the United Kingdom, which showed a gradual increase in the excess risk of poor SRH in each subsequent period, the odds ratio for Sweden increased by 10% in the latter period only (Table 6).

Table 5.
Odds Ratios With 95% Confidence Intervals of Poor Self-Rated Health for UK Lone Mothers Compared to Coupled Mothers, Stratified by Year Category and Adjusted for Age and Background Factors Alone (Model 1), Then by Age, Background Factors, Non-Employment, Financial Strain, and Unmet Health Needs (Model 2).

2005–2007
2008–2009
2010–2012

Model 1 Model 2 Model 1 Model 2 Model 1 Model 2

Age 1.0 (1.01–1.02) 1.0 (1.02–1.04) 1.0 (1.02–1.04) 1.1 (1.04–1.06) 1.0 (1.02–1.04) 1.0 (1.04–1.05)

Lone mothers 1.9 (1.68–2.18) 1.5 (1.27–1.68) 2.1 (1.73–2.58) 1.6 (1.29–1.98) 2.2 (1.91–2.53) 1.6 (1.36–1.83)

Foreign born 1.0 (0.88–1.23) 0.9 (0.74–1.05) 0.9 (0.66–1.19) 0.8 (0.57–1.07) 0.9 (0.74–1.07) 0.7 (0.60–0.89)

Low education 1.8 (1.59–2.13) 1.4 (1.16–1.59) 2.3 (1.81–2.86) 1.5 (1.20–1.97) 2.6 (2.17–3.00) 1.6 (1.36–1.94)

Non-employment 2.1 (1.89–2.43) 3.0 (2.49–3.69) 2.7 (2.32–3.07)

Financial strain 2.0 (1.72–2.22) 1.8 (1.49–2.23) 2.5 (2.15–2.92)

Unmet health needs 3.8 (3.07–4.71) 3.8 (2.72–5.41) 3.4 (2.55–4.45)

Note. Bold face values highlight the odd ratios for poor SRH of lone mothers.

Table 6.
Odds Ratios With 95% Confidence Intervals of Poor Self-Rated Health for Swedish Lone Mothers Compared to Coupled Mothers, Stratified by Year Category and Adjusted for Age and Background Factors Alone (Model 1), Then Adjusted by Age, Background Factors, Nonemployment, Financial Strain, and Unmet Health Needs (Model 2).

2005–2007
2008–2009
2010–2012

Model 1 Model 2 Model 1 Model 2 Model 1 Model 2

Age 1.0 (1.01–1.04) 1.0 (1.03–1.05) 1.0 (1.00–1.03) 1.0 (1.02–1.05) 1.0 (1.03–1.05) 1.0 (1.04–1.06)

Lone mothers 1.6 (1.30–2.04) 1.1 (0.82–1.35) 1.6 (1.20–2.12) 1.1 (0.80–1.49) 1.7 (1.32–2.19) 1.1 (0.83–1.47)

Foreign born 1.6 (1.29–2.04) 1.2 (0.95–1.57) 2.0 (1.54–2.62) 1.4 (1.08–1.95) 1.5 (1.18–1.91) 1.1 (0.87–1.49)

Low education 2.3 (1.76–3.04) 1.8 (1.32–2.41) 2.2 (1.54–3.04) 1.6 (1.09–2.31) 2.6 (1.82–3.64) 1.9 (1.25–2.81)

Non-employment 2.5 (2.02–3.18) 3.0 (2.25–4.03) 2.0 (1.53–2.65)

Financial strain 2.2 (1.83–2.72) 2.4 (1.86–3.10) 3.0 (2.39–3.84)

Unmet health needs 2.8 (2.29–3.48) 3.6 (2.74–4.77) 4.3 (3.43–5.50)

Note. Bold face values highlight the odd ratios for poor SRH of lone mothers.

In Sweden, the excess risk of poor SRH became statistically insignificant when adjusting for background and social variables, suggesting that these variables help explain the inequality in SRH between motherhood status. In contrast, when adjusting the British data, the inequality remained, suggesting other factors at play that have not been investigated here.

What Effect Did the Economic Crisis Have on the SRH of Lone Mothers?

In Britain, prevalence of poor SRH for both lone and coupled mothers was lowest during the crisis period of 2008–2009. Additionally, at the time of the crisis financial strain had the least impact on SRH of British lone mothers, which may reflect reduced financial inequality. In Sweden, the crude excess risk of poor SRH was lowest at the time of the recession (Table 4); however, following adjustment for background variables (Table 6), the odds ratio for poor SRH among lone mothers was highest post-recession.

Overall, we did not observe significant variation over time in the factors explaining poor SRH among lone mothers nor did we observe a worsening of SRH in relation to the economic crisis.

Discussion

Lone mothers in both contexts are at greater risk of poor SRH than coupled mothers, with mothers in the United Kingdom facing the highest relative risks. The trends in inequality persisted throughout the time periods and, converse to what was expected, we did not find that the economic crisis had a significant impact on the SRH of lone mothers. There was no longer excess risk among Swedish lone mothers when controlling for background factors and socioeconomic variables, whereas the risk remained for British lone mothers. It should be noted that the development over time in the United Kingdom for lone mothers seems to follow that of coupled mothers, with a negative trend for all in terms of financial situation and health. In Sweden, however, the situation picked up for lone and couple mothers alike following the crisis.

The only background variable that was not associated with poorer SRH was being foreign born in the United Kingdom. This may be due to the “healthy migrant effect” whereby migrants, coupled with immigration policies, positively self-select in terms of health status.^60,61 This effect is supported in working-age European populations,⁶² such as our sample. In Sweden, however, immigrant status is a marker of socioeconomic disadvantage and is associated with poorer SRH among mothers.⁹ The interplay of immigration policies, integration, and social welfare state may account for the minimal health effects observed in the United Kingdom compared to Sweden.⁶³

Figure 3.
Age standardized prevalence (%) of financial strain among lone and coupled mothers in the United Kingdom and Sweden.

Figure 4.
Age standardized prevalence (%) of poor SRH among lone and coupled mothers in the United Kingdom and Sweden.

The most striking finding was the difference in explanatory variables between contexts, with financial strain explaining a large proportion of the excess risk in Sweden but no single factor having an overall impact in Britain. This contradicts previous findings from 1984 to 1995 that financial strain and employment explained around half of the excess risk in Britain but only 3%–13% in Sweden.¹¹ Since this original study, alterations to data collection methods as well as the manner in which questions are posed could contribute to variations in the findings. Furthermore, the U.K. government has changed several times since this study, with each government bringing changes in health and family policies.⁴³ Sweden underwent large-scale economic liberalization during the 1980s and 1990s,⁶⁴ including changes to benefits entitlements and tax reforms. Such situations have been shown to increase income inequality⁶⁵ and may be a contributing factor to this change in results. In an analysis of the development of family policy in Sweden (including both universal and, perhaps most importantly, the needs-tested benefits), the Swedish Social Insurance Agency shows that the redistributive power of the Swedish family policy has declined during our study period.⁶⁶ This has resulted in high levels of relative poverty among lone mothers in particular and increased differentials due to family type, as the same trend has not been seen among couple mothers. Lastly, our sample did not include lone mothers below the age of 20 who may be more susceptible to financial difficulties and non-employment and constitute a large proportion of British lone mothers. The later cutoff age for our sample may account for some differences observed between previous studies.

There are several possible explanations why we found little difference in inequalities between lone and couple mothers following the economic crisis. First, government spending on social protection can act as a buffer to short-term health effects during economic downturns, as shown previously in Sweden where such spending is relatively high.⁶⁷ Second, health inequalities may actually decrease as the crisis affects the income of usually healthy and well-protected members of society.⁶⁸ Finally, since austerity measures only began to be introduced around 2010, the limited effect on our results could be due to an economic lag,⁶⁹ whereby the knock-on effects of financial and social changes on health are yet to be realized. Indeed, general trends in SRH show steeper decline in the latter phase of the economic crisis across Europe, from 2010 onwards.⁷⁰ Overall however, there has been a failure of consensus for the effect of the crisis on SRH.⁷¹

How Did Employment Relate to SRH?

Non-employment was higher among lone mothers than coupled mothers in both contexts. While it was associated with poorer SRH, it did not entirely explain the excess risk among lone mothers in either setting. A synergy effect has been shown to exist between non-employment and health whereby a larger effect is observed than suggested by excess risk alone.⁴ Non-employment may have a greater impact on the health of lone mothers than coupled mothers through interactions in social position, vulnerability, and exposures (Figure 1).

Lone mothers in our sample, and indeed in other research,⁴ were more likely to have a lower level of education, increasing susceptibility to precarious or low-paid employment. Higher educated mothers enjoy greater financial returns from employment, allowing them to fund help in caring for dependents and thus benefit more.⁷² While we find an association between non-employment and poor SRH, previous research also finds full-time employment can be detrimental to health.^19,72 Depending on the welfare context, financial gains from employment will not always compensate for the loss of benefits and added physical strain.^23,28 In 2010 the British coalition government introduced policies aimed at incentivizing full-time employment for lone parents; however, on an average wage, lone mothers working more than 6 hours per week were worse off financially than those not working.²⁶ In Nordic countries policies targeting lone mothers to encourage labor force participation effectively engaged them with work, but this, as in the United Kingdom, had polarizing financial effects depending on the wage earned.⁷³ Sensitivity analysis on our results revealed no difference between part- and full-time employment on the impact of SRH. However, it should be noted that the higher employment rates in Sweden among lone mothers leads to relatively lower levels of financial strain.

How Did Financial Strain Relate to SRH?

In the United Kingdom, the explained fraction for financial strain fell slightly in the time period corresponding to the financial crisis of 2008. This is consistent with reports that income inequality fell during these years and reflects general financial constraints experienced at all societal levels as a consequence of the recession.⁵⁰ Additionally, the increase in prevalence of families at risk of poverty in Sweden and the increasing effect this had on SRH over time may reflect rising average incomes alongside increasing financial hardship for those already at a lower socioeconomic position. Financial strain and at risk of poverty measure 2 different aspects of the financial situation, and it is worth noting that the association between SRH and subjective financial strain is stronger than the association between SRH and at risk of poverty. While the Swedish welfare system may afford lone mothers more protection from financial strain than the U.K. mothers, the provision of financial assistance does not necessarily protect against ill health. It has been previously shown that receipt of social assistance in Sweden leads to feelings of powerlessness and dependency, which have long-term negative consequences on perceived well-being.⁷⁴

It may be the case that financial strain explains more of the risk in Sweden due to the difference in social composition of lone motherhood,⁸ leaving financial variables as the main divider. In Sweden shared parental responsibility levels, where children divide their time equally between each parent, are rising; this may contribute to lessening the health damaging effects of time strain and feelings of being alone in responsibility for children.⁷⁵ Swedish lone mothers face less stigma attached to their status, whereas the U.K. lone mothers report high levels of stigma and social exclusion.⁴⁸ These social aspects may impart a greater impact on the health of lone mothers in the United Kingdom than Sweden and could account for observed differences in explanatory variables, leaving financial strain as the main divider in this study. From Diderichsen’s model we can deduce that lone mothers are already at a different social position and more vulnerable to ill health when exposed to financial strain than coupled mothers.¹⁴ The adverse health effect of financial strain is therefore likely due to bio-psycho-social mechanisms whereby financial strain and perceptions of inadequacy lead to stress and long-term negative health effects.^44,46

Methodological Considerations

Strengths of this study include the large sample size taken from the EU-SILC database and harmonized for cross-contextual comparisons. Additionally, analyzing the data in context with family policy helps identify entry points specific to lone mothers at which to tackle health inequalities. Where subjective measures are used, such as self-rated health or difficulty making ends meet, cultural differences between countries may be reflected in responses. Therefore, we do not compare absolute prevalence of these across countries but rather the relative numbers. Limitations of the study include the use of cross-sectional data, which does not permit us to infer causality but rather that an association exists between the variables and outcome under investigation. Further studies should investigate this association using longitudinal cohort data. In Sweden between 2005 and 2006, the primary data collection method changed from face-to-face to telephone interviews. Following this change, the prevalence of poor SRH decreased and could reflect selection bias where fewer of the most disadvantaged are reached, causing an underestimation of the risks of poor health among lone mothers.

This study focused on a selected number of health determinants previously demonstrated to impact the health of lone mothers. No single factor stood out as contributing to poor SRH in the United Kingdom as in Sweden, and indeed when controlling for the dependent variables, the excess risk remained, suggesting that other important variables have not been controlled for in our analysis. Another explanation is that the ability to make ends meet does not reflect the complex and dynamic disadvantages that lone mothers face in the United Kingdom. British lone mothers report high levels of stigma and social exclusion.⁴⁸ Considering such social aspects may help delineate the individual and societal differences in SRH. Finally, the role of unmet health needs is unclear from our analysis, and future studies should investigate this further in relation to the differing health systems found in the United Kingdom and Sweden.

Conclusion

There was a striking inequality in SRH between lone and coupled mothers in both contexts, with lone mothers at higher risk of poor SRH than coupled mothers across all time periods. Non-employment was associated with poor SRH and more common among lone mothers, reflecting the difficulties lone mothers face balancing employment and the role of sole carer.

In Sweden, financial strain had the greatest impact on SRH, explaining up to 80% of the excess risk that faced lone mothers. In the United Kingdom, we found no single explanatory factor but rather a combination of factors which potentially interact to influence lone mother’s SRH. It is likely that there are further social mechanisms that affect the health of lone mothers that have not been investigated here. Finally, we found no conclusive evidence of the impact of the economic crisis on the SRH of lone mothers in either context. Further research is needed to explore the long-term effects of the crisis and resultant policy changes as well as the influence of social mechanisms on lone mother’s health.

	2005–2007	2008–2009	2010–2012
Age (years)
20–24	572	7.6	168	9.8	339	7.8	87	9.5	564	8.3	195	11.7
25–34	1,830	24.3	499	29.0	967	22.1	246	27.0	1,559	23.1	495	29.8
35–44	3,358	44.5	721	41.9	1,887	43.2	363	39.8	2,697	39.9	589	35.5
45–54	1,596	21.2	314	18.2	1,066	24.4	185	20.3	1,750	25.9	343	20.7
55–59	187	2.5	20	1.2	111	2.5	30	3.3	193	2.9	39	2.3
Employment^a
Employed	4,915	70.46	962	58.7	2,979	72.4	518	61.4	4,693	71.6	868	56.5
Non-employed	2,249	29.6	756	41.3.0	1,255	27.6	389	38.6	2,062	28.4	791	43.5.7
Highest level of education achieved
Low	824	11.4	348	20.4	378	9.4	172	19.7	607	9.6	305	19.4
Intermediate	3,871	53.8	902	52.8	2,094	51.9	509	58.2	3,010	47.8	909	57.7
High	2,502	34.8	457	26.8	1,562	38.7	194	22.2	2,679	42.6	362	23.0
Foreign born
UK born	6,486	86.0	1,524	88.5	3,759	86.8	828	91.1	5,619	83.8	1,428	86.1
Foreign born	1,056	14.0	198	11.5	573	13.2	81	8.9	1,085	16.2	231	13.9
Unmet need for health in last 12 months
No	6,874	95.8	1,597	93.1	3,912	96.9	835	92.9	6,060	97.1	1,555	94.6
Yes	298	4.2	119	6.9	126	3.1	64	7.1	181	2.9	89	5.4
Financial strain^a
No difficulty	4,383	59.7	468	28.2	2,266	53.4	232	26.1	3,385	51.7	349	22.0
Difficulty	3,126	40.3	1,250	71.8	2,089	46.6	677	73.9	3,329	48.3	1,307	78.0
At risk of poverty indicator
Not at risk of poverty	6,458	85.6	1,051	61.0	3,746	85.7	560	61.5	5,766	85.3	1,154	69.5
At risk of poverty	1,085	14.4	671	39.0	624	14.3	351	38.5	997	14.7	507	30.5
Self-rated health^a
Good	6,143	85.3	1,294	74.5	3,890	89.2	727	79.4	5,779	86.0	1,228	73.1
Poor	1,029	14.7	423	25.5	438	10.8	182	20.6	884	14.0	429	26.9

	2005–2007	2008–2009	2010–2012
Sample size	2,918	85.5	493	14.5	2,093	85.6	352	14.4	2,997	86.3	475	13.7
Age (years)
20–24	144	4.9	12	2.4	113	5.4	12	3.4	171	5.7	30	6.3
25–34	772	26.5	82	16.6	497	23.7	47	13.4	665	22.2	76	16.0
35–44	1,216	41.7	228	46.2	897	42.9	162	46.0	1,288	43.0	192	40.4
45–54	721	24.7	153	31.0	533	25.5	122	34.7	792	26.4	164	34.5
55–59	65	2.2	18	3.7	53	2.5	9	2.6	81	2.7	13	2.7
Employment^a
Employed	2,411	84.3	368	76.7	1,772	86.3	288	84.2	2,506	85.8	366	80.3
Non-employed	506	15.7	123	23.3	321	13.7	64	15.8	490	14.2	109	19.7
Highest level of education achieved
Low	224	7.7	64	13.1	151	7.2	44	12.5	151	5.1	46	9.8
Intermediate	1,543	53.1	275	56.1	1,051	50.4	200	56.8	1,438	48.2	247	52.4
High	140	39.2	151	30.8	884	42.4	108	30.7	1,397	46.8	178	37.8
Foreign born
Swedish born	2,490	85.4	398	80.7	1,758	84.4	283	80.4	2,480	83.1	372	78.5
Foreign born	424	14.6	95	19.3	324	15.6	69	19.6	506	16.9	102	21.5
Unmet need for health in the last 12 months
No	2,422	83.5	359	74.0	1,816	86.9	278	79.0	2,582	86.4	382	80.4
Yes	478	16.5	126	26.0	274	13.1	74	21.0	408	13.6	93	19.6
Financial strain^a
No difficulty	2,037	70.9	159	33.1	1,615	79.5	180	52.8	2,427	83.2	242	52.3
Difficulty	860	29.1	330	66.9	429	20.5	167	47.2	503	16.8	222	47.7
At risk of poverty indicator
Not at risk of poverty	2,763	94.7	387	78.5	1,958	93.5	256	72.7	2,742	91.5	312	65.7
At risk of poverty	155	5.3	106	21.5	135	6.5	96	27.3	255	8.5	163	34.3
Self-rated health^a
Good	2,359	81.7	350	71.7	1,789	85.2	271	76.8	2,614	86.9	374	78.9
Poor	505	18.3	137	28.9	304	14.8	81	23.2	369	13.1	98	21.1

	2005–2007	2008–2009	2010–2012
Age	1.0	(1.01–1.02)	1.0	(1.02–1.04)	1.0	(1.02–1.04)	1.1	(1.04–1.06)	1.0	(1.02–1.04)	1.0	(1.04–1.05)
Lone mothers	1.9	(1.68–2.18)	1.5	(1.27–1.68)	2.1	(1.73–2.58)	1.6	(1.29–1.98)	2.2	(1.91–2.53)	1.6	(1.36–1.83)
Foreign born	1.0	(0.88–1.23)	0.9	(0.74–1.05)	0.9	(0.66–1.19)	0.8	(0.57–1.07)	0.9	(0.74–1.07)	0.7	(0.60–0.89)
Low education	1.8	(1.59–2.13)	1.4	(1.16–1.59)	2.3	(1.81–2.86)	1.5	(1.20–1.97)	2.6	(2.17–3.00)	1.6	(1.36–1.94)
Non-employment			2.1	(1.89–2.43)			3.0	(2.49–3.69)			2.7	(2.32–3.07)
Financial strain			2.0	(1.72–2.22)			1.8	(1.49–2.23)			2.5	(2.15–2.92)
Unmet health needs			3.8	(3.07–4.71)			3.8	(2.72–5.41)			3.4	(2.55–4.45)

	2005–2007	2008–2009	2010–2012
Age	1.0	(1.01–1.04)	1.0	(1.03–1.05)	1.0	(1.00–1.03)	1.0	(1.02–1.05)	1.0	(1.03–1.05)	1.0	(1.04–1.06)
Lone mothers	1.6	(1.30–2.04)	1.1	(0.82–1.35)	1.6	(1.20–2.12)	1.1	(0.80–1.49)	1.7	(1.32–2.19)	1.1	(0.83–1.47)
Foreign born	1.6	(1.29–2.04)	1.2	(0.95–1.57)	2.0	(1.54–2.62)	1.4	(1.08–1.95)	1.5	(1.18–1.91)	1.1	(0.87–1.49)
Low education	2.3	(1.76–3.04)	1.8	(1.32–2.41)	2.2	(1.54–3.04)	1.6	(1.09–2.31)	2.6	(1.82–3.64)	1.9	(1.25–2.81)
Non-employment			2.5	(2.02–3.18)			3.0	(2.25–4.03)			2.0	(1.53–2.65)
Financial strain			2.2	(1.83–2.72)			2.4	(1.86–3.10)			3.0	(2.39–3.84)
Unmet health needs			2.8	(2.29–3.48)			3.6	(2.74–4.77)			4.3	(3.43–5.50)

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Nina Kirk, BMBS, MSc, is a trainee obstetric and gynecologic doctor currently working in the United Kingdom. She completed her medical degree at the University of Nottingham and a master’s degree in Global Health at Karolinska Institutet, Sweden. Her research interests include maternal and global health and health inequalities.

Sara Fritzell, PhD, is affiliated with the Department of Public Health Sciences at Karolinska Institutet and employed at the Public Health Agency of Sweden. Her main research interests include health inequalities and social determinants of health, especially related to single parenthood, including health of parents with shared custody, in different welfare contexts. She has previously published in Health and Place, Social Science and Medicine, Health Policy, International Journal of Health Services, and Reproductive Health.

Bo Burström, MD, PhD, is a professor in social medicine at the Department of Public Health Sciences, Karolinska Institutet, and senior consultant to Stockholm County Council, Sweden. His research interests are mainly in inequalities in health, access to health care and social consequences of disease, and health and living conditions of socially and economically disadvantaged groups. He has also done international comparative studies on the impact of policy on inequalities in health.

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	2005–2007				2008–2009				2010–2012
	Coupled		Lone		Coupled		Lone		Coupled		Lone
	n	%	n	%	n	%	n	%	n	%	n	%
Sample size	7,543	81.4	1,722	18.6	4,370	82.7	911	17.3	6,763	80.3	1,661	19.7
Age (years)
20–24	572	7.6	168	9.8	339	7.8	87	9.5	564	8.3	195	11.7
25–34	1,830	24.3	499	29.0	967	22.1	246	27.0	1,559	23.1	495	29.8
35–44	3,358	44.5	721	41.9	1,887	43.2	363	39.8	2,697	39.9	589	35.5
45–54	1,596	21.2	314	18.2	1,066	24.4	185	20.3	1,750	25.9	343	20.7
55–59	187	2.5	20	1.2	111	2.5	30	3.3	193	2.9	39	2.3
Employment^a
Employed	4,915	70.46	962	58.7	2,979	72.4	518	61.4	4,693	71.6	868	56.5
Non-employed	2,249	29.6	756	41.3.0	1,255	27.6	389	38.6	2,062	28.4	791	43.5.7
Highest level of education achieved
Low	824	11.4	348	20.4	378	9.4	172	19.7	607	9.6	305	19.4
Intermediate	3,871	53.8	902	52.8	2,094	51.9	509	58.2	3,010	47.8	909	57.7
High	2,502	34.8	457	26.8	1,562	38.7	194	22.2	2,679	42.6	362	23.0
Foreign born
UK born	6,486	86.0	1,524	88.5	3,759	86.8	828	91.1	5,619	83.8	1,428	86.1
Foreign born	1,056	14.0	198	11.5	573	13.2	81	8.9	1,085	16.2	231	13.9
Unmet need for health in last 12 months
No	6,874	95.8	1,597	93.1	3,912	96.9	835	92.9	6,060	97.1	1,555	94.6
Yes	298	4.2	119	6.9	126	3.1	64	7.1	181	2.9	89	5.4
Financial strain^a
No difficulty	4,383	59.7	468	28.2	2,266	53.4	232	26.1	3,385	51.7	349	22.0
Difficulty	3,126	40.3	1,250	71.8	2,089	46.6	677	73.9	3,329	48.3	1,307	78.0
At risk of poverty indicator
Not at risk of poverty	6,458	85.6	1,051	61.0	3,746	85.7	560	61.5	5,766	85.3	1,154	69.5
At risk of poverty	1,085	14.4	671	39.0	624	14.3	351	38.5	997	14.7	507	30.5
Self-rated health^a
Good	6,143	85.3	1,294	74.5	3,890	89.2	727	79.4	5,779	86.0	1,228	73.1
Poor	1,029	14.7	423	25.5	438	10.8	182	20.6	884	14.0	429	26.9

2005–2007	Age	1.0	(1.01–1.03)	1.0	(1.01–1.03)	1.0	(1.01–1.02)	1.0	(1.02–1.04)	1.0	(1.02–1.03)	1.0	(1.01–1.03)	1.0	(1.01–1.03)
	Lone mothers	2.0	(1.77–2.29)	2.0	(1.77–2.29)	1.9	(1.68–2.18)	1.9	(1.06–2.11)	1.6	(1.41–1.84)	1.8	(1.53–2.00)	1.9	(1.70–2.21)
	Foreign born			1.1	(0.93–1.29)
	Education					1.8	(1.59–2.14)
	Employment							2.4	(2.15–2.72)
	Financial strain									2.2	(1.97–2.51)
	At risk of poverty											1.8	(1.53–2.01)
	Unmet health needs													3.9	(3.17–4.79)
	Explained fraction			0.0		0.1		0.2		0.4		0.3		0.1
2008–2009	Age	1.0	(1.03–1.05)	1.0	(1.02–1.04)	1.0	(1.02–1.04)	1.1	(1.04–1.06)	1.0	(1.03–1.05)	1.0	(1.03–1.05)	1.0	(1.02–1.05)
	Lone mothers	2.3	(1.93–2.83)	2.3	(1.93–2.84)	2.1	(1.74–2.60)	2.1	(1.71–2.54)	1.9	(1.58–2.35)	2.0	(1.62–2.41)	2.1	(1.72–2.55)
	Foreign born			1.1	(0.86–1.42)
	Education					2.2	(1.78–2.81)
	Employment							3.3	(2.74–3.93)
	Financial strain									2.2	(1.78–2.60)
	At risk of poverty											2.0	(1.65–2.45)
	Unmet health needs													4.2	(3.07–5.79)
	Explained fraction			0.0		0.2		0.2		0.3		0.3		0.2
2010–2012	Age	1.0	(1.02–1.04)	1.0	(1.02–1.04)	1.0	(1.02–1.04)	1.0	(1.04–1.05)	1.0	(1.03–1.04)	1.0	(1.03–1.04)	1.0	(1.02–1.04)
	Lone mothers	2.4	(2.13–2.78)	2.4	(2.13–2.78)	2.2	(1.92–2.54)	2.1	(1.87–2.46)	1.9	(1.67–2.20)	2.2	(1.91–2.51)	2.3	(2.03–2.66)
	Foreign born			1.1	(0.89–1.24)
	Education					2.5	(2.14–2.94)
	Employment							3.2	(2.79–3.60)
	Financial strain									2.9	(2.48–3.29)
	At risk of poverty											2.1	(1.78–2.36)
	Unmet health needs													3.9	(3.02–5.04)
	Explained fraction			0.0		0.2		0.2		0.4		0.2		0.1

	2005–2007				2008–2009				2010–2012
	Model 1		Model 2		Model 1		Model 2		Model 1		Model 2
Age	1.0	(1.01–1.02)	1.0	(1.02–1.04)	1.0	(1.02–1.04)	1.1	(1.04–1.06)	1.0	(1.02–1.04)	1.0	(1.04–1.05)
Lone mothers	1.9	(1.68–2.18)	1.5	(1.27–1.68)	2.1	(1.73–2.58)	1.6	(1.29–1.98)	2.2	(1.91–2.53)	1.6	(1.36–1.83)
Foreign born	1.0	(0.88–1.23)	0.9	(0.74–1.05)	0.9	(0.66–1.19)	0.8	(0.57–1.07)	0.9	(0.74–1.07)	0.7	(0.60–0.89)
Low education	1.8	(1.59–2.13)	1.4	(1.16–1.59)	2.3	(1.81–2.86)	1.5	(1.20–1.97)	2.6	(2.17–3.00)	1.6	(1.36–1.94)
Non-employment			2.1	(1.89–2.43)			3.0	(2.49–3.69)			2.7	(2.32–3.07)
Financial strain			2.0	(1.72–2.22)			1.8	(1.49–2.23)			2.5	(2.15–2.92)
Unmet health needs			3.8	(3.07–4.71)			3.8	(2.72–5.41)			3.4	(2.55–4.45)