By using longitudinal data, this study explored the changes in income following the uptake of OPMH treatment, a proxy for mental disorder, by migrant background and income level among women aged 23–40 years in Norway. To the best of our knowledge, this is the first study to examine the effect of OPMH treatment on income in migrant-, descendant- and majority women. We found that OPMH treatment had a significantly negative impact on work-related income, which supports the social selection perspective. Adjustment for several time-varying background variables such as educational level, marital status and motherhood did not alter this. Our results are in accordance with previous research showing that mental disorders are associated with subsequent income loss (23–26). Furthermore, we also found the effect of mental disorders, defined by OPMH treatment, to vary by income level, with greater adverse effects among women in the low-income group. This finding confirms previous research (23, 26). However, our hypothesis regarding a greater loss of income among migrant women, when compared to majority and descendant women, was mostly rejected. We found that the change in income following the uptake of OPMH treatment was negative for all groups, except for EU Eastern European women in the high-income group who actually experienced no significant change in income. Only descendant and migrant women from non-EU Eastern Europe with low income, and women from Middle East and North Africa with high income, experienced a greater loss of income when compared to majority women. All the other groups either did not differ significantly from majority women or experienced a smaller loss in income following the uptake of OPMH treatment. When accounting for several background variables, only a minor part of the income loss following the uptake of OPMH treatment was explained. However, education level, motherhood and marital status did explain the difference in income between majority and descendant women and migrant women from Nordic countries and South Asia with a high income.
The larger loss of income among users of OMPH with low income can be a result of the greater severity of experienced disorders when compared to women with high income. Luciano and Meara (34) found that the proportion of unemployed and individuals with low income increased with severity of mental disorder. However, this explanation cannot be confirmed or rejected by the data used in this study. Furthermore, women with low income may suffer greater loss of income following mental disorder as they are more likely to experience financial difficulties which can again affect recovery. For some groups of women, the income loss following the uptake of OPMH treatment seems to be temporary, while for others the effect may be more long-lasting, as indicated in Fig. 1. Another potential explanation is that the larger loss of income in the low-income group may be a result of poorer labour market attachment among these women, e.g. they could work part-time or work on short-term contracts. Additionally, high-income women may have better coping and negotiation skills that allow them to keep functioning in their work roles better, even if they have a mental disorder. They may be more able to negotiate a temporary deal to combine their illness and work with their employer or have a more flexible type of job.
Despite the higher likelihood of migrant women being in precarious employment and low-skilled jobs than majority population (13), mental disorders seem to have a less adverse, though still negative, effect on their income compared to majority women. This may be a result of postponement of help seeking among some migrant women, especially those with low income. A reason for that could be that in order to provide financial support for themselves and their families, migrant women with a low income stay at work while ill, despite reduced productivity. In Norway, the social benefit is calculated based on the income from the last few years prior to becoming ill or injured (35). Thus, as many migrant women have more precarious labour market attachment, it is possible that the financial compensation that migrants get when they become ill or lose their job is lower than that for the majority group.
Among those with high income, migrant women from the three European groups experienced a smaller income reduction compared to the majority. Women from Western- and EU Eastern Europe, in both income groups, are largely labour migrants (36), who may only have short-term plans of remaining in the country. Thus, their motivation for staying in work despite mental health difficulties can result in a smaller income reduction than for other groups. In addition, these European women may have better protection than some other migrant groups because they are more likely to enter the Norwegian labour market with valuable skills that are in demand. Other migrant- and descendant women with high income experienced a larger income loss due to mental disorders, measured by OPMH treatment, than majority women did. It is possible that because women in these groups are more often in precarious employment (such as short-term contracts) (13), and compared to European migrants, less likely to enter Norway as labour migrants, they are more likely to fall out of the labour market when their work ability and productivity declines. Thus, income in this migrant group may decrease more than for labour migrants or majority women. Helgesson, Tinghög (28) found that labour market marginalization of migrants can mainly be explained by poor labour market attachment of migrants prior to experiencing a mental disorder when compared to non-migrants. The authors found migrants experiencing mental disorders were at increased risk of unemployment.
The type of mental disorder individuals in the studied groups are treated for could also explain some of the differences in income loss. Studies investigating the association between mental disorders and income found for instance, that the effect was stronger for anxiety disorders than for personality disorders or dysthymia (26). Previous research found migrant women, mainly from low-income countries, had higher levels of common mental disorders such as anxiety (37). Thus, selection of migrant women with, for instance, anxiety into the high-income group could explain the larger loss of income among non-Western migrant women. However, in this study, we were unable to investigate the differences by the type of mental disorder.
This study has several strengths. Use of a dynamic sample allowed us to follow women entering the study sample later than at the study start in 2006, due to immigration or reaching the adequate age, and to include women who died or emigrated during the study period as long as they had at least three consecutive years in the study. Furthermore, we only included potentially healthy women, since we applied a two-year wash-out period to ensure that we measured the change in income due to use of such services. However, to access OPMH services, the referral from a general practitioner or psychologist is required and it may take a long time before an appointment is made. Thus, even before entering OPMH treatment, individuals may have been affected by mental disorders for a significant amount of time and their income may have already started to decrease or stagnate by the time we considered them as exposed, as suggested by Fig. 1.
By using information on OPMH treatment from national registers, we rule out any self-reported bias. Migrants might not only participate in surveys to a lesser extent due to language difficulties but also, when participating, give biased answers due to the experienced discrimination and negative perceptions about migrants (38). However, it is important to bear in mind that many migrants may face linguistic or cultural barriers when seeking healthcare (39). Therefore, using OPMH treatment as a proxy for mental disorders represents a selected group of individuals. There are several steps that need to be undertaken before entering OPMH services and individuals in OPMH treatment have actively sought help (40). Thus, migrants in the OPMH treatment group may be among the most resourceful. Use of OPMH treatment only detects those who entered the treatment and not all women experiencing mental disorders. We also lack information on those using private healthcare services or inpatient services. However, inpatient treatment accounts for only about five percent of all contacts with mental healthcare services (41). The operationalization of mental disorder is therefore the main limitation of this study.
Despite this limitation, utilization of a more detailed grouping of migrants is novel with regard to studying this association. Further, use of register data to gain information on income is an advantage due to no missing income data, as all individuals with paid employment in Norway are registered in the database. Self-reported income is a sensitive topic, and often suffers from large numbers of missing values (42).