Poor health as cause and consequenceof unemployment:

mechanisms and interventions

Alex Burdorf

Department of Public Health

Erasmus Medical Centre in Rotterdam

Erasmus himself

Erasmus himself

People who use their erudition to write for a learned minority don’t seem to me favoured by fortune but rather to be pitied for their continuous self-torture...for they continuously add, change, delete, and rewrite their treatis, only to be read and critised by colleagues.

Praise of Folly 1511

Schuring et. al. Int Arch Occup Environ Health 2009;82:1023-30.

1. Role of employment in health inequalities

Roelfs et al. Soc Sci Med 2011;72:840-54

1. Role of employment in health inequalities

Meta-analysis on unemployment and mortality

Two well-established mechanisms

Selection process:

Health problems are a barrier to enter paid employment AND

health problems may cause loss of paid employment

Causation process:

Unemployment may cause health problems AND

re-employment will decrease health problems

(paid employment as health intervention)

1. How does health influences paid employment ?

Burdorf et. al. Rotterdam, 2008

1. Role of work in health inequalities

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percentage unemployed

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regression line w omen

Unemployment in the neighbourhood and life expectancy in Rotterdam

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Neighbourhood effect on all cause mortality, men(upper quartile % unemployment)

ARIC (US) Eindhoven London Helsinki Turin Madrid

Model 1: adjusted for age Model 2: adjusted for age, education and occupation

Van Lenthe et al., JECH 2005;59:231-7

1. Role of work in health inequalities

Conclusions part I:

1. Profound differences in health status across employment status:

men: disabled > unemployed / retired > employed

women: disabled > unemployed / retired / homemaker > employed

2. Unemployment is associated with substantially higher mortality

3. Living in a neighbourhood with high unemployment is associated

with higher mortality

Unemployment affects individuals and groups

1. Role of work in health inequalities

2. What are potential benefits of interventions ?

2. What are potential benefits of interventions ?

Relevant questions:

- what is the relative contribution of working conditions and

lifestyle factors to the occurrence of poor health?

- how large is the direct effect of poor health on labour force

displacement?

- how large is the direct effects of determinants of poor health on

labour force displacement?

- what are the potential benefits of interventions on (determinants

of ) poor health for labour force participation?

Relative probability of displacement from the labour market during 2 year follow-up 2004 to 2006 in the SHARE study

[Van den Berg et al. Occup Environ Med 2010;67:845-52]

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unemployed retired homemaker disabled

Work status

Od

ds

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io less than good health

chronic disease

depressive symptoms

mobility problems

2. What are potential benefits of interventions ?

Persons 50 - 65 y, employed at wave 1 (n=4797), prospective analysis

of SHARE study

Early retirement Unemployment

(n = 631) (n=130)

OR OR

Less than good health 1.65* 2.25*

Overweight 1.12

Obesitas 1.75*

Alcohol (> 2 units/day) 1.25*

Lack of job control 1.11 2.22*

Effort-reward imbalance 1.54* 1.11

(adjusted for age, sex, education, and country)

2. What are potential benefits of interventions ?

Persons 50 - 65 y, unemployed at wave 1 (n=386), prospective analysis

Entering paid employment

(n=110)

OR

Poor health vs excellent 0.23

Fair health vs excellent 0.28

Overweight vs normal 0.72

Obesitas vs normal 0.43

(adjusted for age, sex, education, and country)

2. What are potential benefits of interventions ?

Van den Berg et al. J Occup Environ Med 2010;52:576-83.

2. What are potential benefits of interventions ?

Life table analysis 2004 based on associations between self-assessed health and exit from paid employment (longitudinal analysis of SHARE)

Effect of interventions on labour participation among men aged 50 and older

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age

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art

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current participation

prevention of poor health

2. What are potential benefits of interventions ?

Life table analysis 2004 based on associations between self-assessed health and exit from paid employment (longitudinal analysis of SHARE)

Effect of interventions on labour participation among women aged 50 and older

0102030405060708090

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age

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pa

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current participation

prevention of poor health

2. What are potential benefits of interventions ?

Theoretical effects on work life expectancy through eliminationof ill health and work-related determinants

Men Women

Improved job control & 0.4 yr 0.5 yr

better effort-reward balance

Reduced physical load at work 0.3 yr 0.4 yr

Self-rated good health 0.4 yr 0.5 yr

2. What are potential benefits of interventions ?

Conclusions part III:

Prevention of poor health will have a noticeable influence on labour

force participation, especially among older workers

ill health matters ! Working conditions and lifestyle matter !

This provides important entry-points for policies aimed at increasing

labour force participation.

2. What are potential benefits of interventions ?

3. What are the challenges in the near future?

3. What are the challenges in the near future?

Working longer, but how ?

3. What are the challenges in the near future?

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What to do ?

Health promotion among unemployed persons: consider carefully !

3. What are the challenges in the near future?

Many studies suffer from selection bias: more work-ready claimants

Financial incentives often too low or too short

Personal advisors and individual case management helped some

persons

3. What are the challenges in the near future?

Need for a tailored

approach ?

3. What are the challenges in the near future?

3. What are the challenges in the near future?

Essential components in re-employment interventions ?

* Combined approach of employment, health, and other problems

* Integrated support

* Create realistic perspective (what can you do, you can do it)

* Health as a resource, but not as independent goal

3. What are the challenges in the near future?

3. What are the challenges in the near future?

Research questions:

1. What are effective interventions that prevent long-term displacement

from the labour force?

[health, working conditions, lifestyle, work ability]

2. What are effects of social and physical environment on health and

lifestyle behaviours of workers and those unemployed?

3. How do we support workers with chronic diseases?

4. What is the cost-effectiveness of re-employment programmes?

5. How to communicate the importance of health at work?

[work life expectancy]

…and then life after work…

“The health gap between the lowest and highest paid

occupational groups widens in retirement.

A lifetime on a low wage physically ages a person eight years

earlier than high earners.

Retirement does not level the playing field. These health

inequalities actually increase.”

Chandola, Whitehall study, BBC News May 18, 2009

…and then life after work…

a.burdorf@erasmusmc.nl

www.erasmusmc.nl/mgz

www.nihes.nl