Report 3 - Exploring the Link Between Work-Life Conflict and Demands on Canada's Health Care System

Acknowledgements

This study was funded by Health Canada. Without its generous support, this research would not have been possible. The authors would like to acknowledge the efforts of the 100 employers who participated in this research and the 31,571 employees who filled out the survey. We would also like to thank our contact people at each of the participating organizations, as well as our research assistants Donna Coghill and Mark Julien for their efforts on our behalf. We are also grateful to the various individuals and groups at Health Canada who provided feedback on various aspects of the research. In particular, we would like to thank Jane Corville-Smith and Sophie Sommerer at Health Canada for their support and guidance throughout the long and arduous research process. Finally, we would like to acknowledge the support of our families throughout the data collection, data analysis and report-writing processes.

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Foreword

The issues associated with balancing work and family are of paramount importance to individuals, the organizations that employ them, the families that care for them, the unions that represent them and governments concerned with global competitiveness, citizen well-being and national health. Although much has been written about the topic, only a handful of "high-impact" studies have been conducted on this subject in Canada.¹ Despite the popular press fixation on the topic (reflecting reader interest) there is, at this time, little sound empirical data available to inform the debate. This is unfortunate as credible research in this area has the power to change how governments and employers think about the issue and how they formulate and implement human resource, social and labour policy.

A decade ago we, along with our colleagues Dr. Catherine Lee at the University of Ottawa and Dr. Shirley Mills at Carleton University, conducted a national study of work-life conflict in Canada to "explore how the changing relationship between family and work affects organizations, families and employers." ² In total, 14,549 employees from 37 medium and large private sector employment organizations and 5,921 employees from 7 federal public sector departments participated in this research.

A lot has happened in the 10 years since we conducted our first study on work-life balance. Academic research on the topic has burgeoned. Our personal understanding of the dynamics between work and family domains has also broadened as we have undertaken research with a number of companies in both the public and private sector.

Nationally, the 1990s was a decade of turbulence for working Canadians as companies downsized, rightsized, restructured and globalized. The recession of the early 1990s was followed by the "jobless recovery" of the mid-1990s, and job security was the issue that absorbed many working Canadians and their families. Organizations, faced with a glut of competent employees from which to choose, often paid little attention to becoming "best practice" with respect to human resource management. Paradoxically, as we enter the new millennium there has been a complete about-face with respect to this issue as employers, faced with impending labour shortages, have become preoccupied with recruiting and retaining "knowledge workers."³ Such employers have recognized that a focus on "human capital" is one key to increased productivity in the new millennium.

Throughout the 1990s, technological change and the need to be globally competitive increased the pressures on organizations and employees alike. Time in employment increased for many, as did the use of non-standard types of employment. Non-work demands also increased over the decade as family structures continued to change and the percentage of working Canadians with child care, elder care or both (the sandwich generation) continued to rise.

Taken together, these changes suggest it is time for another rigorous empirical look at the issue of work-life conflict.⁴ The research outlined in this report and others in the series was designed to provide business and labour leaders, policy makers and academics with an objective "big picture" view on what has happened in this area in Canada in the last decade and what the current situation is. As such, it will allow interested parties to separate the rhetoric from the reality with respect to work-life conflict.

The research study was undertaken with the following objectives in mind:

1. Quantify the issues associated with balancing work and life in the year 2001 and compare the situation today to that of 10 years earlier.
2. Quantify the benefits (to employees, employers, families and Canadian society) of work-life balance.⁵
3. Quantify the costs (to employees, employers, families and Canadian society) of work-life conflict.
4. Quantify the costs to the Canadian health care system of high levels of work-life conflict.
5. Help employees make the business case for change in this area in their organization.
6. Identify organizational best practices in terms of dealing with work and life issues.
7. Help organizations identify what they need to do to reduce work-life conflict in their organizations.
8. Help employees and families identify what they can do to reduce work-life conflict in their lives.
9. Empirically examine how public, private and not-for-profit (NFP) sector organizations differ from each other with respect to the work and lifestyle issues identified above.

In other words, this research examines the issues associated with work-life conflict, identifies who is at risk, articulates why key stakeholders (e.g. governments, employers, unions) should care and provides direction on ways to move forward. This research should:

• provide a clearer picture of the extent to which work-life conflict is affecting employees and employers in Canada,
• help organizations appreciate why they need to change how they manage their employees by linking conflict between work and life to the organization's "bottom line,"
• expand the overall knowledge base in this area, and
• suggest appropriate strategies that different types of organizations can implement to help their employees cope with multiple roles and responsibilities.

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Theoretical Framework

There is a vast academic literature dealing with the issue of work-life conflict. A complete review of this literature is beyond the purview of this series of reports and counter to our primary objective, which is to get easily understood and relevant information on work-life conflict to key stakeholders (governments, policy makers, employees, employers, unions). That being said, readers who are interested in the theoretical underpinnings of this research are referred to Figure 1. This theoretical framework incorporates both fundamental concepts from the research literature and the key insights we have gained from our 10 years of research in this area. This research is based on the premise that an individual's ability to balance work and life will be associated with both work and non-work demands (e.g. time in and responsibility for various work and non-work roles), as well as a number of key demographic characteristics (e.g. gender, job type, socio-economic status, area of residence, sector of employment). Further, it is hypothesized that an employee's ability to balance work and life demands will be associated with outcomes in the following areas:

• organizational (commitment, intent to turnover, absenteeism, job satisfaction, job stress, rating of the organization as a place to work);
• family (family life satisfaction, parental satisfaction, family adaptation, family integration, positive parenting);
• employee (perceived stress, depressed mood, perceived physical health, burnout, life satisfaction); and
• societal (use of the health care system).

  Figure 1: Theoretical Framework

Finally, it is postulated that the link between work-life conflict and these outcomes will be moderated by factors associated with both the organization in which the employee works (e.g. work arrangements used, perceived flexibility, work environment, management support, supports and services offered by the organization, ability to refuse overtime), as well as personal strategies that the employee and the employee's family use to cope (e.g. work different hours from spouse, delay having children, have a smaller family, the use of various family-based and individual coping strategies).

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The Report Series

This report is the third in a series of six. The series has been organized around the research framework shown in Figure 1 and includes the following:

Report One:	The 2001 National Work-Life Conflict Study put the series into context by describing the sample of employees who participated in the research and examining the various "risk factors" associated with work-life conflict.
Report Two:	Work-Life Conflict in Canada in the New Millennium: A Status Report made the business case for change by looking at how high levels of role overload, work to family interference, family to work interference, caregiver strain and work to family spillover) affect employers, employees and their families.
Report Three:	Exploring the Link Between Work-Life Conflict and Demands on Canada's Health Care System focuses on how work-life conflict affects Canada's health care system (i.e. quantifies the system demands associated with high work-life conflict and attempts to put some kind of dollar value on how much it costs Canada to treat the health consequences of such conflict).
Report Four:	Who Is at Risk? Predictors of High Work-Life Conflict will address who is at risk with respect to high levels of work-life conflict.
Report Five:	Reducing Work-Life Conflict: What Works? What Doesn't? will examine what employers, employees and their families can do to reduce work-life conflict.
Report Six:	Work-Life Conflict in Canada in the New Millennium: Key Findings and Recommendations from the 2001 National Work-Life Conflict Study will provide a summary of the key findings and recommendations from this research study.

It is hoped that the production of six specialized reports rather than one massive tome will make it easier for the reader to assimilate key findings from this rich and comprehensive research initiative. Each report will be written so that it can be read on its own. Each will begin with an introduction which includes the specific research questions to be answered in the report, a summary of relevant background information and an outline of how the report is organized. This will be followed by a brief outline of the research methodology employed. Key terms will be defined and relevant data presented and analyzed in the main body of the report. Where possible, national data will be referenced to allow the reader to put the findings from this research into context. Each report will end with a conclusion and recommendations chapter that will summarize the findings, outline the policy implications and offer recommendations.

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Organization of Report Three

Report Three is broken down into eight main chapters.

Chapter One includes an introduction in which key terms are defined and research objectives delineated.

Background information on Canada's health care system is provided in Chapter Two.

Details on the methodology used in the study are covered in Chapter Three. Included in this chapter is information on the sample, the measurement of use of the health care system and perceived health, the data analysis undertaken in this phase of the research, and the reporting protocols followed.

Chapter Four examines how Canadians view their health. Included in this chapter are answers to the following questions: How do Canadian employees see their health? What is the impact of gender, job type, sector of employment and dependent care status on perceptions of health? What is the link between work-life conflict and perceived health?

Chapter Five explores the link between work-life conflict and the use of Canada's health care system. The chapter starts by presenting benchmark data on how often in the last six months Canadian employees have sought care from a physician, sought care from other health care professionals (e.g. physiotherapist), sought care from mental health professionals, stayed overnight in the hospital (i.e. inpatient care), visited a hospital emergency department, and visited a hospital or clinic for treatment or tests (i.e. outpatient care). Data are then presented to answer the following two questions: What impact do gender, job type, dependent care status and sector of employment have on the use of different components of the health care system? What is the link between work-life conflict and use of various components of the health care system?

Chapter Six addresses how much health care costs could be reduced if Canadian employees were more able to balance work and life with respect to three sets of costs: physician visits, visits to a hospital emergency department and overnight hospital stays (i.e. inpatient care).

The link between prescription drug use and work-life conflict is drawn in Chapter Seven. Data are presented to address the following issues: How much money do Canadian employees spend on prescription drugs? What impact do gender, job type, dependent care status and sector of employment have on the amount spent on prescription medicine? What is the link between work-life conflict and the amount spent on prescription medicine?

Conclusions, policy implications and recommendations are presented in Chapter Eight.

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Executive Summary

There is a significant economic burden associated with keeping Canadians healthy. The health care sector is a large, resource-intensive industry employing more than 1.5 million Canadians. Canada spends more on health care in relation to the size of its economy (an estimated $122 billion in 2002: an average of $3,572 per Canadian) than every country in the world except the United States, France and Germany. In 2000, health care spending in Canada accounted for 32% of total government expenditures (including debt charges).

Annual increases in health care costs have been the norm in Canada. Between 1997 and 2002, total health spending in Canada grew by almost $34 billion (an unprecedented rate of increase). It is currently at an all-time high, even after taking into account inflation and population growth. Overall, government spending on health care has increased significantly over the past several years, but the number of supported services has dropped.

The fastest growing component of health care expenditures, drug costs, have grown at an average rate of more than 11% over the past five years. In 1993, prescription and non-prescription medications were estimated to cost $9.884 billion and to account for 6.3% of the total economic burden of illness in Canada (Statistics Canada, 1999). This had risen to approximately $15.5 billion per year by 2001.

In Canada, many groups share the costs of health care. In 2001, about three quarters (73%) of total expenditures (i.e. approximately $2,400 per person) were provided by public sector sources (i.e. federal, provincial/territorial and municipal governments). The rest came from private sector sources (e.g. insurance) and individuals (e.g. out-of-pocket expenses). Government cutbacks and federal fiscal tightening have increased the need for the private sector to assume many of these costs through benefits programs. One of the main consequences of this set of strategies has been the growth of private health care expenditures from 25.5% of all health care funding in 1991 to 29.8% of spending in 1997. Individual Canadians pay for health care both directly (e.g. health insurance premiums and out-of-pocket health care expenses) and indirectly (i.e. the taxes Canadians pay contribute to public spending on health care).

The basic objective of this report is to increase awareness, at both the public policy and organizational level, that pressures on Canada's health care system could be reduced by focusing on workplace health issues. Specifically, this report uses hard data to draw the link between work-life conflict, health status and the use of Canada's health care system. It is hoped that the data contained in this report will motivate health care providers and institutions, governments and employers to work together to address workplace health and work-life issues of Canadians. Such a focus, we contend, will help reduce burdens on Canada's health care system.

This report uses data collected for part of the 2001 "National Study on Balancing Work, Family and Lifestyle" to answer the following questions:

1. How healthy are Canadian employees?
2. How much use do Canadian employees make of the health care system?
3. How much do Canadian employees spend on prescription medicine?
4. What impact do gender, job type, sector of employment and dependent care status have on perceived health? The use of Canada's health care system? The amount employees spend on prescription medicine?
5. How does work-life conflict (operationalized to include role overload, work to family interference, family to work interference and caregiver strain) affect perceived health? The use of Canada's health care system? The amount employees spend on prescription medicine?
6. What impact does high work-life conflict have on health care costs in Canada?

Key findings are summarized below.

Demographic Profile of Respondents

The sample consists of 31,571 Canadian employees who work for medium to large (i.e. 500 or more employees) organizations in three sectors of the economy: public (federal, provincial/territorial and municipal governments), private and not-for-profit (defined in this study to include organizations in the health care and educational sectors). In total, 100 companies participated in the study: 40 from the private sector, 22 from the public sector and 38 from the not-for-profit (NFP) sector. The sample is distributed as follows:

• 46% of the respondents work in the public sector, 33% work in the NFP sector, 21% are employed by a private sector company;
• 55% of the respondents are women;
• 46% of the respondents work in managerial and professional positions while 54% work in "other" positions (e.g. clerical, administrative, retail, production, technical); and
• Just over half (56%) of the respondents have dependent care responsibilities (i.e. spend an hour or more a week in child care, elder care or both).

The 2001 survey sample is well distributed with respect to age, region, community size, job type, education, personal income, family income and family's financial well-being. The mean age of the respondents is 42.8 years. Approximately half of the respondents are highly educated male and female knowledge workers (e.g. managers and professionals). One in three is a clerical or administrative employee; one in five holds a technical or production position. The majority of respondents are married or living with a partner (75%) and are part of a dual-income family (69%). Eleven percent are single parents. Twelve percent live in rural areas. One quarter of the respondents indicate that money is tight in their family; 29% of respondents earn less than $40,000 per year. One in three of the respondents has a high school education or less.

The majority of respondents have responsibilities outside of work. Seventy percent are parents (average number of children for parents in the sample is 2.1); 60% have elder care responsibilities (average number of elderly dependents is 2.3); 13% have responsibility for the care of a disabled relative; 13% have both child care and elder care demands (i.e. are part of the "sandwich generation"). The fact that the demographic characteristics of the sample correspond closely to national data provided by Statistics Canada suggests that the findings from this study can be generalized beyond this research.

Sample Profile: Levels of Work-Life Conflict

Role overload is having too much to do in a given amount of time. This form of work-life conflict occurs when the total demands on time and energy associated with the prescribed activities of multiple roles are too great to perform the roles adequately or comfortably. The majority of employees in our sample (58%) are currently experiencing high levels of role overload. Another 30% report moderate levels of role overload. Only 12% of the respondents in this sample report low levels of overload. Our research suggests that the proportion of the workforce experiencing high levels of role overload has increased substantially over time (i.e. by approximately 11%).

Work to family interference occurs when work demands and responsibilities make it more difficult for an employee to fulfil family role responsibilities. One in four of the Canadians in this sample report that their work responsibilities interfere with their ability to fulfil their responsibilities at home. Almost 40% of the respondents report moderate levels of interference. The proportion of the Canadian workforce with high levels of work to family interference has not changed over the past decade.

Family to work interference occurs when family demands and responsibilities make it more difficult for an employee to fulfil work role responsibilities. Only 10% of the Canadians in this sample reported high levels of family to work interference. Another third reported moderate levels of family to work interference. Our data suggest that the percentage of working Canadians who give priority to family rather than work has doubled over the past decade.

Approximately one in four of the individuals in this sample experiences what can be considered to be high levels of caregiver strain: physical, financial or mental stress that comes from looking after an elderly or disabled dependent. While the majority of the respondents to this survey (74%) rarely experience this form of work-life conflict, 26% report high levels of caregiver strain.

Who, in this sample, has more problems balancing work and family responsibilities? The evidence is quite clear-employed Canadians with dependent care responsibilities. Employees who have child and/or elder care responsibilities report higher role overload, work to family interference, family to work interference and caregiver strain than their counterparts without dependent care. The fact that employed parents and elder caregivers have greater difficulties balancing work and family is consistent with the research done in this area and can be attributed to two factors: greater non-work demands and lower levels of control over their time.

Job type is associated with all but one of the measures of work-life conflict. On the one hand, employees with higher demands at work (e.g. managers and professionals) are more likely than those in "other" jobs to experience high levels of overload and work to family interference. Those in "other" jobs, on the other hand, are more likely to report higher levels of caregiver strain due to the financial stresses associated with elder care.

Women are more likely than men to report high levels of role overload and high caregiver strain. This is consistent with the fact that the women in this sample devote more hours per week than men to non-work activities such as child care and elder care, and are more likely to have primary responsibility for non-work tasks.

How healthy are Canadian employees?

How do Canadian employees view their physical health? While just under half of the respondents to this survey (48.4%) indicate that their health was very good or excellent, almost one in five (16.7%) perceives his or her health to be fair or poor. This is a significantly lower proportion of respondents perceiving that they are in very good to excellent health (and not surprisingly a higher proportion reporting that they are in fair to poor health) than reported by Statistics Canada (1999) for Canadians aged 12 or older. While some of this difference might be explained by the age differences in the two samples (younger Canadians can be expected to enjoy better health than older Canadians), it is also likely that working conditions and job-related stress are taking their toll on Canadian employees' health status.

How much use do Canadian employees make of Canada's health care system?

Employed Canadians routinely seek medical care from their physician and other health care professionals. In the six months prior to this study:

• Just over half (54%) of the respondents sought care from their physician for reasons other than a routine check-up or maternity follow-up. These employees made an average of 5.8 physician visits per year.
• One in three (29.3%) visited a hospital or clinic on an outpatient or day-use basis for medical tests or procedures. These employees made an average of 3.8 outpatient visits per year.
• One in three (31.8%) of the respondents sought medical care from a health care professional other than a physician. These employees made an average of 10 visits per year to other health care professionals.
• Just over one in ten of the employees in the sample (13.1%) sought medical care at a hospital's emergency department for a personal health problem. These employees made an average of 3.2 visits per year to an emergency department.
• Just over one in ten (10.6%) of the respondents sought help from a mental health professional. These individuals made an average of 8.2 visits per year to a mental health professional.
• Almost six percent of the respondents required inpatient hospital care (i.e. stayed overnight in the hospital). These employees stayed in hospital for an average of 4.6 nights per year.

These data also allow us to estimate the average use that Canadians employed in larger organizations make of the different facets of Canada's health care system. Such employees make approximately:

• 3.2 visits per year to a physician,
• 3.0 visits per year to other health care professionals (e.g. physiotherapist, chiropractor),
• 1.0 outpatient visit per year to a hospital or clinic for medical tests or procedures,
• 0.9 visits per year to a mental health professional,
• 0.4 visits per year to a hospital emergency department, and
• 0.3 overnight stays per year in a hospital.

How much do Canadian employees spend on prescription medicine?

The typical Canadian who works for the country's larger employers spent approximately $164 per year on prescription medicine for personal use. While 44% of employees did not purchase any prescription drugs, one in five (19%) spent more than $300 per year on prescription medicines for their own personal use.⁶ Eighty percent of the respondents noted that their employer paid for 100% of their drug costs. Virtually all of the other employees indicated that they and their employer shared the costs of prescription drugs. The high degree of correspondence between the data on prescription drug expenditures and perceived health (the one in five respondents who spent $300 or more a year on prescription medication also rated their health as fair or poor) increases our confidence in these findings.

Impact of key contextual variables

This research initiative has culminated in the collection of a large, rich, comprehensive data set with which to examine perceived health and the use of Canada's health care system by employed Canadians. One of the strengths of this research is that the capacity of this large data set allows us to examine how key factors-such as the gender of the employee, the type of job he or she holds, the sector in which he or she works and the dependent care responsibilities he or she assumes-affect perceived health, spending on prescription medication and use of various facets of the health care system. Key differences are noted below.

Impact of gender

What impact does gender have on perceived health and use of the health care system? First, and perhaps most importantly, when job type and dependent care status are taken into account, there were no differences in perceived health that could be associated with gender. This is a very important finding as it runs counter to much of what has been reported in the literature (e.g. women report poorer health, albeit only at younger ages). This would suggest that it is life circumstances (e.g. being compressed into lower level jobs within organizations, lower levels of perceived control) rather than gender itself which is associated with the lower levels of perceived health often reported by women. In other words, it is the work environment and demands at work and home that contribute to gender differences in health rather than some inherent characteristic of women that makes them more vulnerable to disease and/or stress.

Despite the fact that there were no gender differences in perceived health, the women in the sample made substantively more use of Canada's health care system than the men. The data in this regard are unequivocal. Visits to a physician, other health care professionals and mental health professionals, as well as treatment on an outpatient basis and spending on prescription drugs, were all strongly associated with gender-with women making more use of these facets of the health care system and spending more on prescription drugs than men even when job type, dependent care responsibilities and sector of employment were taken into account. How can one reconcile these two facts (i.e. women make more use of the health care system even though there are no substantive gender difference in perceived health)? Three explanations are plausible:

• Women are more likely than men to seek care when they are not well (e.g. women are making appropriate use of physician services and men are not seeking treatment for illness).
• Women are more likely to see their physician for non-physical concerns (e.g. counselling).
• Women are more likely to seek treatment for "female" health issues such as menopause care, menstrual issues and breast screening than men are to seek care for "male" health issues.

Further study is needed to determine the etiology of these results.

Impact of job type

What impact does job type have on perceived health and the use of the health care system? While the conclusions one draws with respect to the link between job type and health depend very much on the measure being used, the majority of the findings from this study support the idea that managers and professionals are in better health than their counterparts in non-professional positions.

Respondents in managerial and professional positions, regardless of their gender, were more likely than their counterparts in "other" non-professional jobs, to describe their health as being very good or excellent. Respondents in "other" positions were more likely to describe their health as fair or poor. These findings are consistent with the research in the area which links lower socio-economic status with poorer physical health.

Curiously enough, given the above findings with respect to perceived health, use of the health care system is not strongly associated with job type. When gender is taken into account, job type is not associated with visits to other health care professionals, visits to mental health professionals, inpatient use of hospitals and the likelihood of seeking outpatient treatment. The results are even stronger for the male sample where there were no job-type differences in visits to a physician and the amount spent on prescription drugs.

Examination of the data on use of the emergency department helps us to reconcile these two sets of data. Job type is strongly associated with use of Canada's emergency department with those in "other" positions being more likely to seek care from an emergency department than their counterparts in managerial and professional positions. There are several possible explanations why employees in "other" positions are more likely to use this form of health care. First, it may be that employees in this group are less likely to have a family physician and more likely to rely on emergency room physicians for medical problems and emergencies. This explanation of the data appears to apply to men in "other" positions in particular (i.e. they are more likely than their male counterparts in managerial and professional positions to say their health is fair/poor but no more likely to have visited a physician). Second, it may be that employees in "other" positions find it more difficult to get time off work to seek care from a physician and are required to go to the emergency department for care outside of regular hours. Finally, the fact that women in "other" positions are more likely than any other group of employees in this sample to say their health is fair/poor, to have visited a physician, and to have visited other health professionals suggests that, in this case, the higher number of visits to the emergency department reflects the fact that this group of women is in poorer health.

Finally, it is important to note that when gender is taken into account there is no association between job type and visits to a mental health professional. This is an important finding given the fact that many other studies have talked about the stresses associated with working in clerical and administrative positions within the organization (i.e. low-control jobs). The data from this study suggest that the disappearance in job-type differences in stress levels can be attributed to the fact that the stresses and demands associated with being a manager or a professional have increased over time while the amount of control such individuals wield has declined. There is no evidence that the converse has occurred (i.e. that the stresses associated with pink and blue collar work has diminished over time).

Impact of gender and job type

It is interesting to note that while job type is associated with physician visits and prescription drug use for the women in the sample (females in "other" positions are more likely to visit the physician and spend more money on prescription medication than female managers and professionals), no such difference was noticed for the men in the sample. There are several plausible explanations for this finding. First, it may be that managerial and professional jobs offer a health advantage to women. Alternatively, it may be that clerical and administrative jobs (e.g. pink collar jobs) have a more deleterious impact on the health of women than blue collar jobs do on the health of men. Finally, it is also possible that women in clerical and administrative positions who make the most visits to the physician have long-standing health issues which reduce their ability to advance in the organization. Further study is needed to determine the etiology of these results.

Impact of dependent care

Having dependent care responsibilities (i.e. children at home and/or elder care) is negatively associated with perceived health for both men and women. Employees without dependent care responsibilities, regardless of gender, were more likely to rate their health as very good or excellent while those with child and/or elder care responsibilities were more likely to say their health was good or fair/poor. These data suggest that combining work and family responsibilities takes its toll on the health of employed men and women. Furthermore, the fact that dependent care responsibilities (i.e. parenthood, elder care responsibilities) appear to impair the health of both men and women suggests that it is the challenges of combining work with parenting/caregiving that impair health, not being a working mother or caregiver.

What impact does having responsibility for the care of dependents have on employees' use of the health care system? Surprisingly, when gender is taken into account, dependent care status is not associated with the use of physician services, other health care professionals, inpatient visits to hospitals, outpatient visits to hospitals and the use of emergency departments. It is, however, associated with visits to mental health professionals. When gender is taken into account, employees with dependent care responsibilities were more likely than their counterparts without such responsibilities to seek care from a mental health professional. They also made more visits to these professionals. These data are very interesting as they indicate that combining work and caregiving responsibilities has a negative impact on the mental (rather than the physical) health of employees. This interpretation of the data is consistent with the fact that the employees in this sample who have dependent care responsibilities reported higher levels of stress, burnout and depressed mood than their counterparts without dependent care.

When these results are looked at through the lens of two of the most common workplace health models (Karesek and Theorell's [1990] Job Strain Model and Siegrist's [1996] High Effort/Low Reward Model), it seems appropriate to label the job of employed parent/elder caregiver as either a high-demand/low-control and/or high-effort/low-reward pursuit. This classification would allow researchers to apply the vast research literature in these areas to the field of work-life conflict.

Impact of sector of employment

Sector of employment is associated in a systematic manner with all but two of the measures of perceived health and health care system use included in the study. When gender is taken into account (e.g. males compared to males, females to females), it can be seen that public sector employees were more likely to have visited a physician than their counterparts in the private and NFP sectors. They also made more visits per year than employees in the other sectors. This finding is consistent with the fact that this group of employees was more likely to rate their health as poor. The relationships observed with respect to the use of other health care professionals, visits to a mental health professional, outpatient treatment and spending on prescription medication is also very consistent. In all cases, men working in the private sector made significantly less use of the health care system than any other group in the sample while females working in the public sector made significantly greater use. While some of the sectoral differences in health can likely be attributed to either age (private sector younger), policies within the sector (public sector employees have more generous health benefits) or socio-economic status (those in the NFP sector are highly educated and well paid), it is likely that the issue is much more complex than this. Future research in this area is needed to determine the reasons behind these sectoral differences.

The link between role overload and health⁷

What implications does high role overload have on the health of Canada's employees and the burdens placed on Canada's health care system? The findings from these data are unequivocal: employees with high levels of role overload are in poorer physical and mental health and make greater use of Canada's health care system than those with low levels of role overload. Consider the following. Compared to their counterparts with low levels of role overload, employees with high role overload are:

• 2.9 times more likely to say their health is fair/poor,
• 2.6 times more likely to have sought care from a mental health professional,
• 2.4 times more likely to have received care on an outpatient basis,
• 1.9 times more likely to have spent more than $300 per year on prescription medicine for their personal use,
• 1.8 times more likely to have made 6 or more visits per year to a physician,
• 1.6 times more likely to have made 8 or more visits per year to another health care professional,
• 1.5 times more likely to have required inpatient hospital care, and
• 1.4 times more likely to have visited a hospital emergency room.

What do these data mean in terms of the health care system? Higher work-life conflict is associated with increased health care costs. For example, we calculated the direct cost of:

• physician visits due to high role overload to be approximately $1.8 billion per year,
• inpatient hospital stays due to high role overload to be approximately $3.8 billion per year, and
• visits to the hospital emergency department due to high role overload to be approximately one quarter of a billion dollars per year.

These data also indicate that employers who overwork their employees (i.e. place a high reliance on unpaid overtime) will pay a price in terms of increased benefit expenditures. Companies that focus on reducing role overload should reap a number of benefits to their bottom line, including reduced absenteeism (see Duxbury & Higgins [2003]) and lower benefit costs.

The link between work to family interference and health

What implications does high work to family interference have on the health of Canada's employees and the burdens placed on Canada's health care system? From the analysis presented in this report, we conclude that employees with high levels of work to family interference are in poorer physical and mental health and make greater use of Canada's health care system than those with low levels of work to family interference. Compared to their counterparts with low levels of work to family interference, employees with high levels of interference are:

• 2.4 times more likely to say their health is fair/poor,
• 1.7 times more likely to have sought care from a mental health professional,
• 1.7 times more likely to have received care on an outpatient basis,
• 1.6 times more likely to have made 6 or more visits per year to a physician,
• 1.5 times more likely to have visited a hospital emergency room,
• 1.4 times more likely to have required inpatient hospital care, and
• 1.3 times more likely to have spent more than $300 in the past year on prescription medicine for their personal use.

Not surprisingly, given the above data, higher levels of this form of work-life conflict are also associated with increased health care costs. For example, we calculated the direct health costs of high levels of work to family interference to be approximately $2.8 billion per year (two thirds of a billion dollars per year in physician visits, $2 billion per year in inpatient hospital stays and just over $100 million per year in visits to the hospital emergency department).

The link between family to work interference and health

This form of work-life conflict is not as strongly associated with perceived health and use of the health care system as the other forms of work-life conflict examined in this study. While family to work interference is negatively associated with perceived health (employees with high family to work interference are almost twice as likely to say their health is fair/poor than employees with low family to work interference), and positively associated with use of Canada's health care system and prescription drug use, the magnitude of these relationships are (with one exception) lower than can be observed with the other three forms of work-life conflict. The extent to which this form of work-life conflict increases health costs and demands is also lower than can be observed with respect to role overload and caregiver strain. These data would suggest that Canadian society will benefit (though employers may not) if more Canadians place a higher priority on family than on work.

That being said, the data indicate that there are health consequences associated with giving family roles a higher priority than work roles-poorer mental health. Employees with high family to work interference are almost twice as likely to seek care from mental health professionals than their counterparts with low levels of this form of interference. What causes the increased incidence of mental health problems in this group (e.g. increased stress and depression) is hard to determine from the cross-sectional data collected for this analysis. Future research should seek to determine the direction of causality with respect to these findings (i.e. does putting family first cause increased stress or does an individual who is suffering from poorer mental health place an increased importance on his or her family?).

The link between caregiver strain and health

This form of strain appears to be more closely linked to physical health problems and less strongly associated with mental health concerns than the other three forms of work-life conflict. Employees with high levels of caregiver strain make the greatest use of physician services and are the most likely to have spent time in hospital on both an inpatient and an outpatient basis. They also make the highest use of the emergency room and spend the greatest amount on prescription medication. Compared to their counterparts with low levels of caregiver strain, employees with high levels of caregiver strain are:

• 1.8 times more likely to have received care on an outpatient basis,
• 1.7 times more likely to say their health is fair/poor,
• 1.6 times more likely to have spent $300 in the last year for prescription medicine for their personal use,
• 1.5 times more likely to have sought care from a mental health professional,
• 1.5 times more likely to have required inpatient hospital care,
• 1.5 times more likely to have visited a hospital emergency room, and
• 1.4 times more likely to have made 6 or more visits per year to a physician.

It would appear from these data that caregiver strain is associated with an increased incidence of illness that requires treatment and prescription drugs.

Data on caregiver strain provide further support for our conclusion that work-life conflict is associated with increased health care demands and costs. For example, we calculated the direct costs of inpatient hospital stays due to high caregiver strain to be approximately $4 billion per year, of physician visits due to high caregiver strain to be over $500 million per year and of visits to a hospital emergency department due to high caregiver strain to be over $100 million per year.

These data also point to a significant costs savings for employers who address the issues associated with elder care. Companies could save about $128 per employee per year in prescription costs alone if they could reduce caregiver strain.

Conclusions and Recommendations

In this report, we established that:

• Work-life conflict in its various forms is a problem for many Canadian employees.
• High work-life conflict is associated with lower levels of perceived health for working Canadians, regardless of how we conceptualize work-life conflict.
• High levels of work-life conflict have a negative impact on employers' bottom line and increase demands on Canada's health care system.
• The health care-related costs of high work-life conflict are staggering-approximately $6 billion a year attributable to high role overload, $5 billion a year to high caregiver strain, $2.8 billion to high work to family interference and half a billion dollars for high family to work interference.⁸
• Two forms of work-life conflict are particularly costly (both in terms of increased demands on the health care system, and increased health care and benefits costs): high role overload and high caregiver strain.

Role overload appears to be the greatest culprit: we estimate that physician visits would be 25% lower, inpatient hospital stays would be reduced by 17% and use of Canada's emergency rooms would be cut by 23% if high levels of this form of work-life conflict could be eliminated. These findings suggest that the downsizing strategies implemented by many employers throughout the 1980s and 1990s and the concomitant increase in employee workloads (see Higgins and Duxbury, 2002) have backfired and the savings in payroll (i.e. salary and benefit dollars) realized by corporations and public sector employers through downsizing may be offset by substantial increases in costs to the health care system. It would appear that work-life conflict is not only a moral issue-it is a productivity and economic issue, a workplace issue and a social issue, and needs to be addressed as such.

Caregiver strain is also problematic. Analysis of our data suggests that physician visits could be reduced by 8%, inpatient hospital stays lowered by 18% and use of Canada's emergency rooms cut by 14% if high levels of this form of work-life conflict could be eliminated. These findings suggest that the aging of the Canadian workforce and the greater need to provide elder care is overwhelming employees' ability to cope with both work and life demands. The lack of social and governmental support for elder care, as well as inflexible work schedules, mean that employees with elder care commitments often have no choice but to miss work and/or take an unpaid leave of absence. If nothing is done to alleviate the demands placed on these workers, ill health due to this form of work-life conflict is likely to increase dramatically in the next decade as more baby boomers assume responsibility for the care of their parents. These findings indicate that if business does not take strategic action with respect to this issue soon (e.g. implement family-friendly work arrangements and benefits), the government should step in and take action to help employees deal with elder care issues. The country cannot afford to pay the health care costs incurred by organizational inaction in this area.

How can Canada afford not to address the issue of work-life conflict?

These numbers offer a wake-up call to employers and governments for a number of reasons. First, they suggest that a substantive proportion of their workforce (almost one in five) is more likely to engage in behaviours (e.g. purchase prescription medicine, be absent from work) that can negatively impact the bottom line. This may affect Canada's ability to compete globally. Second, they indicate that combining work and family responsibilities takes its toll on the health of employed Canadians, regardless of their gender (i.e. this is no longer a women's issue). Finally, these findings support the population health model which links lower socio-economic status and ill health, and suggest that workplace health efforts and interventions such as paid personal leave and health promotion activities need to be targeted to this level of the organization.

After examining the data in this report, the relevant question changes from "how much will it cost Canada to deal with the issue of work-life conflict" to "how can the nation afford not to address the issue of work-life conflict?" Why should employers and governments promote and practise healthy workplaces that allow employees to balance work and life? Simply put-Canada's ability to be globally competitive in the future depends on our ability to address this issue. The data presented in this report paint a frightening picture of how inattention to workplace health and work-life issues is impacting Canada's health care system. Health issues that arise due to heavy workloads at home and at work and an inability to balance conflicting demands not only cost the employer money in increased absenteeism and health benefit costs, but sick employees also have a negative impact on the health care system. As the Canadian Council on Integrated Health Care (CCIH) (2002, p. 22) notes:

"The boundaries of the workplace are permeable and costs are easily transferred to other facets of society. It is for these reasons that workplace health must become a priority for governments and not just for employees, employers and unions."

The first priority for both employers and governments is to reduce the demands on working Canadians

The data suggest that employers and governments who wish to improve the health of their workforce, reduce the tax burdens on their citizens, and positively influence the health care system need to pay attention to role overload. This form of work-life conflict is strongly associated with heavy work demands, longer hours at work, high amounts of unpaid overtime, greater amounts of work-related travel and a culture of face time (i.e. emphasis is on "presenteeism" as opposed to outputs and deliverables). It also represents the highest levels of relative and absolute risk with respect to poorer physical and mental health and all measures of use of Canada's health care system included in this study.

The main predictor of high role overload is time spent in paid employment. This research project has determined that time in work has increased dramatically over the past decade. Whereas one in ten respondents in 1991 worked 50 or more hours per week, one in four does so now; during this same time period, the proportion of employees working between 35 and 39 hours per week declined from 48% of the sample to 27%. This increase in time in work was observed for all job groups and all sectors of employment. Further work is needed to determine exactly why work demands have increased over the decade. Possible explanations drawn from the data collected for this research initiative include organizational anorexia (downsizing-especially of the middle manager cadre-has meant that there are not enough employees to do the work and managers to strategize and plan); corporate culture (if you do not work long hours and take work home, you will not advance in your career, not keep your job during downsizing); increased use of technology (technology such as e-mail has added the expectation of immediate response to the workplace); global competition (work hours have been extended to allow work across time zones, increased competition and a desire to keep costs down has limited the number of employees it is deemed feasible to hire); the speed of change has increased to the point that many organizations have lost their ability to plan and prioritize; and the fact that employees are worried about the consequences of "not being seen to be a contributor" (e.g. downsized out of a job, inability to advance).

The link between hours in work and role overload, burnout, and physical and mental health problems (see Duxbury and Higgins, 2003) suggests that these work loads are not sustainable over the long term. The data from this study reinforce this conclusion. Canadians are subsidizing, through their tax dollars and financial support of the health care system, organizational practices such as "doing more with less," downsizing, basing promotions on hours at work, setting unrealistic work expectations, managing by crisis, etc. Organizations that employ such strategies need to bear the financial costs of such strategies-not Canadian taxpayers.

The second priority for both employers and governments is to reduce caregiver strain

As noted above, this form of work-life conflict appears to be closely linked to physical health problems and higher use of medical care services and prescription medications. The percentage of the workforce experiencing high levels of caregiver strain is also expected to increase dramatically in the next decade as first the parents of the baby boomers, and then the baby boomers themselves, require care. If steps are not taken now to put policies, procedures and institutions into place to help employees care for their aging parents, the health care demands and costs associated with this kind of strain can be expected to increase dramatically in the near future.

Looking at the issue through a workplace health lens

This study has established the need for governments and organizations to take more responsibility for workplace health issues such as work-life conflict-to look at these issues through a population health lens. How can this best be done? Nineteen recommendations are given in this report: 13 addressed to governments, six to employers. The recommendations to government suggest changes to how the health care system is structured, deal with ways to make the idea of change in this area attractive to employers (e.g. financial investments and penalties), outline how they can create a public push for change in this area (e.g. social marketing campaign, a Web site communicating the costs of poor workplace practices to Canadians, forming partnerships with key stakeholders and community groups), address the issue of elder care, and call for additional funding for empirically sound research and data collection in the area. Recommendations to employers include suggestions on how to better track the costs to their bottom line of their various workplace practices, ones dealing with horizontal management of the issue, and recommendations dealing with leadership and accountability for workplace health.

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