Self-employment,work and health: A critical narrative review

1 Introduction

Globally, self-employment (SE) has emerged as a key non-standard, precarious, and contingent work relationship [1, 2]. In the current digital age, SE appears in configurations and contours that differ from the labor market of 50 years ago and is part of a ‘paradigm shift’ from manufacturing/managerial capitalism to entrepreneurial capitalism [3, 4]. In Canada, for example, 2.9 million people were self-employed (SE’d) in 2018 and this is more than double those SE’d in 1976 [5]. Overall, SE’d workers account for 15%of employment in Canada [5]. Similarly, 10%of the Australian workforce is SE’d [6], and SE’d workers now comprise 15%of the workforce in Europe [7]. This SE trend is accelerating due to the rising ‘gig’ economy and the undermining of the former employment structures that provided secure, lifetime jobs with predictable advancement and stable pay [8–10].

In research literature, SE’d workers have been depicted as a special group of homogenous people [11, 12] who possess good health, enjoy the freedom of being their own boss and having flexible working hours, do not rely on the state (e.g., social security protection), and enjoy greater job satisfaction, quality of life, and opportunity to gain work-life balance than employees [7, 13]. They have a reputation for taking on a high level of personal risk to grow their businesses and also of creating employment opportunities for others [7, 15]. However, these depictions do not reflect the recent reality of SE [7, 16]. A murky, or dark side of the labor market, exists where a significant number of SE’d workers, both in high and low-income economies, are compelled to undertake this type of work due to unemployment, scarcity of alternatives, and other financial hardships [1, 17]. The diversity of SE’d workers is described by the Law Commission of Ontario (2012) who note that: “the experiences and vulnerabilities of this group range from billionaire entrepreneurs to taxi drivers working 90 hours a week simply to pay their bills and includes many people who are gaining income from SE activity alongside their main job” [1 p75]. Therefore, SE does not always mean self-sufficiency. Rather, some SE’d workers can be considered precariously employed as they earn low incomes and are at risk of poverty and social exclusion [1].

Mounting international evidence stresses that the changing nature of work is having profound adverse effects on workers’ safety, health, and wellbeing [4, 18–20]. For example, SE’d workers are at higher risk for certain diseases such as musculoskeletal disorders, joint pain, sleep disorders, and digestive complaints, compared to salaried workers [14, 22]. These risks stems from their job nature, for example, SE’d people encounter a higher level of job demands and workloads, self-exploition and absence of social protections, such as lack of health insurance, elevated anxiety about financial matters [14].

As well, SE’d workers are largely excluded from workers’ compensation coverage across jurisdictions [4, 23–25]. SE’d workers are often not eligible for sick pay, paid annual leave, or an old-age pension [25]. Without these safety nets, lower-income SE’d workers may unable to ensure their housing costs, medical expenses, food, and future security (e.g., retirement pension). They may encounter particular stressors due to work, or when out of work, as compared with employees in standard employment. In addition to income-based poverty, SE’d workers face particular challenges when they are unable to work due to illness or injury/disabilities, whether on a short- or long-term basis [4]. Surprisingly, very few attempts have been made to systematically investigate how these new forms of employment, including other forms of precarious employment, impact occupational injury and diseases.

Economically advanced countries that favor digital labor markets may be promoting the growth of a demographic of SE’d workers who are exposed to particular occupational diseases, sickness, and injury. Therefore, these jurisdictions may be considering the expansion of supports for sick and injured SE’d people and related changes in relation to labor laws, workers’ compensation policies, and social welfare policies. Despite the growth of SE in advanced economies, little is known how, and to what extent, social security systems support SE’d workers when they are away from work due to sickness and injury. Our overarching objective in this critical review was to understand how SE’d workers navigate, experience, or manage their injuries and illness when unable to work for health or impairment reasons.

2 Materials and methods

We conducted a critical interpretive review of peer-reviewed scientific literature [26]. Unlike a conventional systematic review, a critical interpretive review involves inductive interpretive synthesis that moves beyond aggregative summaries and enables reviews to build theory rooted in the empirical evidence under study [26]. This approach allowed us to appraise and critique a complex body of literature, irrespective of method, found by a systematic search. This method is particularly appropriate when there is a large body of diverse evidence on a subject [26, 27].

2.1 Searching the literature

Five databases were searched: Scopus, PsycINFO, CINAHL, PubMed, and ABI/INFO. The search was performed in January and February 2019. The choice of keywords and the search strategy were made in collaboration with a University of Waterloo librarian. Table 1 details the database search terms. To be included in this study, articles needed to focus on: 1) self-employment (either solo or with employees); 2) sickness, injury or disability; and 3) policy, insurance or other support systems relating to the inability to work or diminished capacity to work. As well, the articles had to focus on economically advanced economies as we sought comparable social security systems across the studies. Finally, articles had to be published in English in a peer-reviewed journal in 2001 or later.

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Table 1

Details the database search terms.

Search terms
Category	Keywords used in the search
Self-employment	“Self employ*” OR “Self-employ*” OR “Independent Operator ” OR “Gig Work*” OR “Gig Employ*” OR Entrepreneur OR “Employment Without Employ*” OR “Independent Contract*” OR “Dependent Contract*” OR “Disguised Work*” OR “Bogus Work*” OR “False Work*” OR “Own Account Self-employ*” OR “Solo Self employ*” OR “Solo Self-employ*” OR “Stable Own Account Self-employ*” OR “Own Boss Employ*” OR “Own Boss Work*” OR “Unincorporated Self employ*” OR “Dependent Self Employ*” OR “Economically Dependent Self-employ*”
Health status	Health OR Injury OR Disability OR Impairment OR Stress OR “Well-being*” OR Wellness OR “Long and Irregular Working*” OR “Flexible Working Schedule*” OR “Work-life Balance” OR “Access to Care” OR “Access to Health Care” OR “Body Mass Index” OR “Physical Health” OR “Mental Health” OR Diabetes OR “High Blood Pressure” OR “High Cholesterol” OR Arthritis
Support systems	“Return to Work” OR RTW OR “Work Reintegration” OR “Sick Leave*” OR Pension* OR Insurance OR “Vocational Rehabilitation” OR “Disability Insurance” OR “Sickness Absence” OR “Retirement Disability Pension” OR “Public Health Insurance”

The database search yielded 1623 articles (See Fig. 1). After removing duplicates (642), 981 articles were screened by examining titles and abstracts. Inter-rater reliability among the three reviewers (the lead author and two colleagues) was established through a series of trials until 95%agreement was reached. A total of 766 articles were excluded after reading titles and abstracts and a further 197 articles after reading the full-texts. Thus, our final sample included 18 relevant articles.

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Fig. 1

Flowchart of the literature search.

Of the final sample of 18, more than half of the articles [11] were published between 2015 and 2019, as presented in Fig. 2.

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Fig. 2

Distribution of articles by year.

Half of the articles focused on the United States of America, while the remaining articles focused fairly evenly on the Netherlands, Australia, Canada, Germany, and France. Two articles focused jointly on European countries, as shown in Table 3. Thus, the issues of health (e.g., sickness and physical impairments) and health management among SE’d working populations appear to be under-researched in advanced economies. More than half (10/18) of the articles were based on quantitative analysis, and only four articles focused on qualitative data, while the rest of the articles were mixed method, commentary, discussion paper, and a policy paper, as shown in Table 4, which shows the substatuve foci of the sample articles.

Five themes and twenty-one subthemes emerged through an iterative process of data extraction and synthetization from 18 articles. The themes were (i) conceptualizing SE; (ii) double-edged sword; (iii) dynamics of illness, injury, and disability; (iv) formal and informal health management support systems; and, (v) occupational health services and rehabilitation. These are summarized in Table 5.

5 Discussion

The 18 articles included in this review covered diverse aspects of how self-employed are supported when they are unable to work due to illness, injury, and disability. In our view, one of the challenges of providing supports to SE’d people is derived from unclear definitions of who is SE’d. Three articles in our review attempted to demystify the conceptualization of SE [30, 38]. Key to this perspective is Gevaert et al.’s analysis that pull factors, such as flexibility, draw people to enter into SE [31]. We question if this explanation is broadly applicable to SE’d workers. It has become common to promote pull factors by highlighting that people opt for SE, both as an alternative to unemployment and a good fit for persons with a disability. This latter view downplays the context of underlying social and economic conditions [7, 31], and is inconsistent with an OECD cross-national study asserting that there is a causal relationship between unemployment and SE [3].

In the age of post-industrial labor markets, entrepreneurial capitalism [3], and fissured workplaces [4], SE as a category of work continuously “receives fresh blood and loses old blood through underground mobility” [3 p131], that is to say, SE is incessantly being reshaped in form and fashion, and it has become common for some wage-earning workers to also work as a SE in some sectors part-time. For example, conventional ideas of SE do not capture the working life of Uber drivers and Airbnb hosts, most of whom have another main job [48]. Conventional discourses defining SE have not acknowledged the heterogeneity of the new modes of SE work, despite several hybrid forms of SE [3, 16]. Weil [4] raised a very timely and crucial question, with respect to “fissured workplaces” about the restructuring of work arrangements in American society. This is now here clearer than between regular employees and those in alternative work arrangements, such as limited-term contracts, work with staffing agencies, and SE [4]. New forms of work, including freelancing, micro-farming, Uber driving, and Airbnb hosting, challenge the traditional understanding and conceptualization of SE. Despite this complexity, employment statistics, such as American household (e.g. Current Population Survey, Contingent Worker Supplement) and employer-based surveys (e.g. current employment statistics or Quarterly Census of Employment and Wages) do not sufficiently capture all relevant features of SE. As a result, existing estimations and definitions related to SE, for instance, in the USA, are insufficient and contradictory [4].

In this review, surprisingly, we found very few articles that exactly focused on our research question. Of the three components of our research question –SE status, issues around health and sickness, and state support systems, few explored all three components in depth. For example, Beattie et al. mainly discussed the experiences of Australian SE’d farmers after a serious farm injury [33], but barely addressed the experiences of how the injured farmers were supported during their sickness or when they were away from work. Similarly, Ashley et al. focused on people with congenital disabilities who are SE’d, and on available support systems to manage and grow their business, but not on work-induced injury or disabilities [41]. Yoon and Bernell placed more importance on the health issues (prevalence of health conditions) than health management issues (what happens when injured or ill) [18] and the Sharp’s article is a commentary, with an overall focus on the three components [7]. As such, there is a clear-cut knowledge gap in understanding the experiences of SE’d workers in relation to their health, illness, and work injury, and how they manage their illness and livelihood when they are unable to work.

It is unclear how the gig economy impacts occupational health and health-related services and social securities of SE’d workers. In our view, SE is inevitable in the age of flexible capital accumulation but needs proper supports to grow and be sustained [25]. However, globally several intermediate classes, such as temporary staffing agencies, are exempted from accountabilities in terms of providing legal and social security protections [49]. These gaps raise ethical and philosophical questions about working relations, in relation to neoliberal and capital market demands that provide value to consumers and investors, but fail workers. What is particularly interesting is that SE’d workers in complex supply chains are sometimes not aware of who funds their positions. Some employers intentionally set up workers as SE to evade or reduce tax liabilities or employers’ responsibilities –are called false (bogus) SE [50, 51]. Essentially, this neoliberal approach makes workers responsible for their own social protection.

Our review reveals that there is an ongoing debate around whether SE’d workers are healthier than wage earners. There is a hegemonic and popular discourse about positive experiences of SE’d people, with several articles promoting the view that SE’d workers are healthy because of the flexibility in SE’d work, [7, 42] and can, therefore, take care of their health (e.g., buying private health insurance and medical care) with their savings, enjoy better quality of life and health status, greater job satisfaction, and many more advantages compared to salaried workers [29]. In our view, however, these assertions are outdated. In practice, with diverse type of SE, including digital platform gigs, it is likely that many SE’d workers are earning low wages [52].

With few exceptions [53–55], we know very little from the existing literature on how contemporary SE’d people experience their work and health. As such, it is necessary to explore empirically how sector-specific SE’d people survive with low incomes, especially when injured or ill. Currently, statistical analyses do not accurately reflect the situation of SE’d people in economically advanced countries in the case of SE, and may not be applicable for other countries. It is noteworthy that most of the articles in our sample are based on quantitative analysis, national surveys and concentrated in the USA [18, 29]. Ultimately, what is at stake is a nuanced understanding of experiences of health, sickness and injury experiences of SE’d people. Research, based on quality or mixed-method approaches is needed, and more quantitative research is needed to explore the prevalence and role of SE. As well, because SE in the gig economy often involves workers doing multiple jobs (e.g., Uber drivers), possible negative health repercussion needs to be explored.

Class and SE is a topic that requires attention. For instance, in economically advanced welfare state countries, research studies often present SE’d farmers as healthy, but it is historically evident that SE’d farmers are rich through inter-generational inheritance, and thus have a certain amount of land and housing, and annual farm production and profit. Therefore, their health status must be framed according to their privileged position and the cannot be compared with other SE’d workers, such as those in the gig economy. Interestingly, some researchers expressed their concern about farmers because ‘aging’ is undermining their health status, and aging is connected to a variety of diseases [33]. Farmers are forced to work before complete recovery from hospital and rehabilitation because of workload and lack of help [33]. They are also vulnerable in terms of mental health, as they are socially isolated. While salaried workers are mentally supported by their coworkers, SE’d people work alone; thus, they are more vulnerable in terms of mental health and illness than salaried workers [7, 22]. A timely concern of consequence is that the next generation is not willing to continue with farming,[33] and this situation is aggravating the health of aging farmers.

A growing concern world-wide is that SE’d people working alone at home experience different physical and mental health hazards due to isolation; for example, 40%of SE’d people in the UK say they have felt lonely since becoming their own boss, which has profound impact related to depression, heart disease [35]. Ultimately, the work and health of SE’d workers is unclear and requires analysis taking into account the nature and sector of jobs and income level. Though many governments are encouraging SE, Gevaert et al. [31] acknowledged that the work-related mental well-being of SE’d people remains understudied and unexplored. In our view, mental and physical health issues of SE’d people need to be addressed in legislation and policies related to workers’ compensation and labor standards, and more research addressing this lacuna is needed. Although SE’d workers make significant contributions to economies [4], the discourse of providing social security system support them is surprisingly ignored globally despite their similar life needs in relation to wage earners in terms of foods, housing, and health care [25].

Our review suggests that government and statuary supports to SE’d people in economically developed countries are limited (e.g., Canada, Australia, and France) compared to salaried workers, although some countries have statuary policy, such as health insurance, sick leave claim, to support SE’d workers (e.g., USA), as described in several articles in our sample [7, 30].

Our review also finds the existence of informal supports to help to grow an independent business [42]. However, as Beattie et al. stressed, without compelling government-sponsored social protection and support systems, there is no sustainable solution for the growing SE’d population [33]. In this context, we examine the situation of SE’d workers using a lens of social justice. Whether someone is working for wage or profit, under a contract, or providing gig services, their employment status should not be a determining factor or cornerstone to determine their eligibility for social protections, social insurance or tax legislations. All are workers with their only asset of human capital; thus, all workers who depend on the sale of their capacity to work and survive should be covered and protected by labor protections and social supports [20]. In this sense, there is a knowledge gap in understanding how SE’d workers are ensured social justice. In Australia, there is an assumption that SE’d are less likely to make compensation claims, compared to regular employees [37]. SE is one of the four categories of employment with the highest underreporting of compensation claims [23]. So, in Australia, similar to Canada, [42] SE’d workers are excluded from worker’s compensation claims, and even those covered do not lodge claims because of lack of knowledge of their entitlement [4].

The essence of the authors’ [19, 42] arguments draws attention to a recent debate in Canada about whether SE’d workers need government supports or whether these external supports should be approached in a sector-specific manner. In 2013, the Ontario workers’ compensation board imposed mandatory insurance on SE’d construction workers [56]. This decision prompted large protests from the SE’d independent contractors, who resisted the policy, which required them to pay six to seven times more than their ongoing personal insurance policies. They saw this as unfair and discriminatory to SE’d workers because the workers’ compensation insurance only covered work-related injury, while their private insurance covered all health conditions, regardless of the source of the injury or illness [56]. In our view, this debate calls for further study to understand the nuanced motives of SE’d workers behind acceptance or rejection of the government support and what kinds of programs would provide the kinds of support needed by SE’d people.

In our review, sick leave claim, aging, and musculoskeletal disorders are found to be intimately connected, because sick leave rates increase with age and older claimants seek more sick leave, predominately due to musculoskeletal disorders [32, 33]. In a similar vein, we argue that researchers should investigate how age along with gender, race, or ethnicity may influence SE’s health and return to work. Though several articles in our review addressed the role of health insurance and state subsidies or support systems, it remains unclear whether SE’d people who are subsidized by the government will take on the expense of health insurance [29, 33]. We suggest that state-sponsored and subsidized health insurance can play a pivotal role in growing SE. However, there are job lock effects counteracting this, as more incentives or subsidies on health insurance do not guarantee that more wage earners enter into SE due to other drivers, such as payroll taxes, capital investment, and capital gain, which underpin the barriers to entry to SE [46].

6 Conclusion

Results from this critical interpretive review of SE in economically advanced countries draw attention to controversies over conceptualizing SE status, why people choose SE, merits, and demerits of SE, and how SE’d people are supported by formal and informal health systems. A common issue was a lack of eligibility among SE’d workers for social protections, and almost no studies addressed how SE’d workers manage when they are unable to work due to sickness and injury. Through this synthesis, we have provided a clearer picture of SE labor conditions, elucidating how the discourses of SE’d workers’ health, sickness, and return to work are under-researched in academia and public policies. Under the circumstances, we believe that creating necessary support systems for sick and injured SE’d workers to support their return to work is of paramount importance and that future research should consider the broad diversity among SE’d workers and their contexts.