Elucidating the role of unemployment in complex social inequalities in mental health: An intersectional mediation analysis of the cross-sectional Spanish National Health Surveys

Women, migrants and those in manual occupations face barriers in the labor market and are more vulnerable to unemployment, which in turn may impact mental health and contributes to inequalities. Previous research has not considered the intertwinement of multiple inequalities. This study examined intersectional inequalities (intersecting gender, social class, and migration status) in poor mental health and the mediation role of unemployment in the Spanish adult population, using the 2012 and 2017 cross-sectional Spanish National Health Surveys (n = 22,383, 18-64 years, response rates: 89.6 % and 74.0 %). Mental health was measured using the GHQ-12 and classified into good and poor. Unemployment was classified as employed or unemployed. Gender (men or women), social class (manual or non-manual) and migration status (born in Spain or migrant) were cross-classified in eight intersectional strata. Intersectional mediation analysis showed that, compared to non-manual native men, poorer mental health was found in women, migrants and manual occupations (total effect). Unemployment completely mediates mental health inequalities in strata of men with manual occupations but partially in strata of women. Moreover, mental health inequality was explained by both higher unemployment prevalence (pure indirect effect) and by greater vulnerability to unemployment (mediated interaction effect) among native men and women in manual occupations and immigrant women in non-manual occupations compared to non-manual native men. In conclusion, complex mental health inequalities seem to be underpinned by the dual processes of higher risks and worse consequences of unemployment. Health policies should target strata of manual occupations since they were more likely to be unemployed.