Exploring the relationship between self-employment and cardiovascular health in women | BMC Women’s Health


We performed a weighted cross-sectional analysis to examine the relationship between self-employment and cardiovascular health in women. We ran additional models to assess the impact of health care access on this relationship. As predicted, our results showed that self-employed women had significantly better outcomes for multiple risk factors for cardiovascular disease (obesity, hypertension, diabetes, participation in physical activity at least twice a week, and BMI) than women who were employed for wages. It was found that these results were not influenced by access to health care, consistent with our other hypothesis suggesting that factors outside of access to health care underlie these observed associations. Notably, there was a large difference in reported involvement in regular physical activity between the two groups. A possible explanation for this observed connection could be the increased flexibility associated with self-employment. Reducing stress along with consistent physical activity may also contribute to the observed improvements in obesity, high blood pressure, diabetes and BMI in self-employed women.

We found no significant association between self-employment and mental health interventions. This could be a consequence of the sensitive but non-specific nature of our mental health interventions (history of emotional, nervous or psychiatric problems and history of depression). Studies using mental health interventions assessed over a time frame of days or weeks can provide more information [20]. Narain and Jeffers found positive mental health outcomes among self-employed black women when they used “number of days of poor mental health in the past 30 days” as a measure of mental health [12].

To our knowledge, this is the first study to examine the association between self-employment and a broad range of risk factors for cardiovascular disease, health outcomes and health behaviors in women. It is also the only study on the subject that controls weekly working hours and perceived neighborhood safety, and one of the few studies to examine the role of health care access. Our results are largely consistent with those of Yoon and Bernell, who also found that the self-employed are more likely to be physically active and of normal weight, and less likely to report hypertension and diabetes [11]. However, unlike Yoon and Bernell, we find only an insignificant negative trend between independence and hyperlipidemia [11]. Our results are also consistent with the work of Narain and Jeffers, who found an association between self-employment and reduced reports of high blood pressure and “not exercising” in black women [12].

Although this study makes several contributions to the literature, it has some important limitations. First, we could not account for selection bias and reverse causality with this particular study design. It may be the case that self-employed women are healthier than paid women when they start college and may choose non-traditional employment structures themselves [21]. However, we attempt to mitigate the impact of selection bias by controlling for different proxies of socioeconomic status (education, neighborhood quality, and access to health care).

Also, due to the nature of our data set, we could not account for some potential confounding variables. Race was not controlled for within the survey due to the high prevalence of non-responders to the race demographic question. However, perceived safety in the neighborhood served as a reasonable indicator of race because perceptions of neighborhood safety tended to vary significantly between racial groups [22]. Furthermore, our results are consistent with similar research conducted in Black women, so excluding race as a covariate is unlikely to have significantly altered our results [12]. The association between self-employment and health outcomes may also have been influenced by household income, another covariate that we did not include in our study due to a high proportion of missing data. However, we controlled for several proxies for income, e.g. B. Level of education, perceived safety in the neighborhood and access to health care. Like many other studies examining the relationship between self-employment and health, we could not control for the employment branch, which may vary by employment structure and be related to our results. However, given the high level of gender segregation in the industries, this issue may not be as problematic in the context of this particular study.

Nor could we distinguish between women who chose self-employment out of business interest (“casual self-employment”) and women who may have been pushed into self-employment due to unemployment or other more unfavorable factors (“necessary self-employment”). The factors driving women to become self-employed can have a significant impact on health outcomes. Studies have shown that both the physical and psychological benefits of self-employment extend to opportunity entrepreneurs, while necessity entrepreneurs may only benefit from mental health benefits [20]. In addition, we could not control the job description, but the educational status can partly serve as an indicator.

Finally, our dataset required the use of self-reported health outcomes instead of measured outcomes. Controlling access to healthcare has been our main approach to minimizing bias arising from the use of self-reported measures, which have been shown to be most reliable among those with regular access to healthcare [12].

Our results suggest that employment structure may have an important impact on cardiovascular disease risk factors in women. Consequently, empowering women’s entrepreneurship can be a health issue as well as a step towards gender equity. In 2019, there were more than two million more self-employed men than self-employed women [23]. Much of the explanation for this disparity has been attributed to personality differences; namely that women are less likely to engage in “entrepreneurial behavior” than men [24]. However, studies have also found that women, regardless of their employment structure, are more likely to work part-time due to domestic constraints; This can make it difficult to sustain a small business and push women towards wage work [25]. Women are also more likely to pursue careers in service industries (e.g. healthcare and education), which may be less easily adapted to self-employment [25, 26]. Finally, women generally have less social capital and fewer business connections than men, which can make self-employment a riskier option than wage labor [26]. Given these factors, encouraging women to be self-employed may require advocating for more progressive gender attitudes, recruiting more women into business education, and government-sponsored economic development [27]. Additionally, supporting women-owned businesses is essential. Recent literature has shown that self-employed women have been disproportionately affected by the COVID-19 pandemic [28]. Ensuring these companies have equitable access to resources to keep them afloat during the pandemic and subsequent recovery can be a matter of both economic security and health in the short and long term.

While it is not realistic to expect that all women will become self-employed, it might be worth considering how some of the positive characteristics of self-employment, such as greater autonomy and flexibility and reduced vulnerability to discrimination, can be imported into the context of wage work . Notably, the disruption to workplace norms caused by the COVID-19 pandemic presents a unique opportunity to rethink workplace culture. Flextime is used by some employers to encourage employee autonomy and allows employees a degree of control over their work schedule [29]. Flextime is generally viewed positively by employees and is associated with increased motivation, productivity, job satisfaction, health and well-being [29, 30]. However, a survey conducted by the Society for Human Resource Management found that only 57% of companies offered flexible schedules in 2019 [31]. Implementing a well-structured flextime policy could ultimately lead to improvements in both mental and physical health. To make flextime more widely available, employers would need to use technology that facilitates communication between employees, makes their specific policies transparent, and allows for increased cross-departmental coordination [31]. There is also a need to implement effective practices to reduce gender discrimination in the workplace. Strategies to reduce discrimination can include consciously designing mixed-gender work environments, formalizing decision-making, networking and mentoring programs, more democracy in the workplace, and tougher consequences for acts of discrimination [19, 32].

Increasing women’s empowerment can be more than an issue of economics or gender equality. This study and other early research suggest that self-employment may be a consequential factor in women’s cardiovascular health. Ultimately, given the high burden of cardiovascular disease in women, it may be necessary to define enhanced autonomy, flexibility and inclusivity in the workplace as strategies for workplace wellbeing rather than recruitment or retention tactics.


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