Relation between socioeconomic status, employment, and health during economic change, 1973-93

Social Inequalities in “Sickness”: Does Welfare State Regime Type Make a Difference? A Multilevel Analysis of Men and Women in 26 European Countries

In comparative studies of health inequalities, public health researchers have usually studied only disease and illness. Recent studies have also examined the sickness dimension of health, that is, the extent to which ill health is accompanied by joblessness, and how this association varies by education within different welfare contexts. This research has used either a limited number of countries or quantitative welfare state measures in studies of many countries. In this study, the authors expand on this knowledge by investigating whether a regime approach to the welfare state produces consistent results. They analyze data from the European Union Statistics on Income and Living Conditions (EU-SILC); health was measured by limiting longstanding illness (LLSI). Results show that for both men and women reporting LLSI in combination with low educational level, the probabilities of non-employment were particularly high in the Anglo-Saxon and Eastern welfare regimes, and lowest in the Scandinavian regime. For men, absolute and relative social inequalities in sickness were lowest in the Southern regime; for women, inequalities were lowest in the Scandinavian regime. The authors conclude that the Scandinavian welfare regime is more able than other regimes to protect against non-employment in the face of illness, especially for individuals with low educational level.

Comparing the socioeconomic status--health gradient among adults 50 and older across rural and urban areas of Thailand in 1994 and 2007

This paper examines associations between three indicators of socioeconomic status, education, income and bank savings, as well as one composite of these three measures, and self-assessed health for adults aged 50+ across rural and urban Thailand, comparing 1994 and 2007. Between 1994 and 2007 Thailand experienced rapid social changes that could impact on health overall and across groups, including population aging, socioeconomic development and changes in health policy. This led us to test whether overall health has improved as a result and whether the SES health gradient has changed. The data come from comparable survey sources from over seventy-thousand respondents, collected by Thailand's National Statistical Office. Generalized proportional ordered logit models were run that include up to three-way interactions of SES by year by rural versus urban location of residence are run. The three-way interactions allow for testing and of whether changes over time are due to complex intertwined effects. Results indicate that a) there has been improvement in health among the population aged 50 years and older in Thailand; b) there has been a flattening in the SES - health gradient in rural areas, and c) there has been little change in the gradient in urban areas, and if anything, there has been a widening of the relationship between income and health in urban Thailand. Divergence in the way the gradient has changed across rural and urban Thailand may point to the impact of social policy that has been aimed at poorer rural residents.

Employment status and the prevalence of poor self-rated health. Findings from UK individual-level repeated cross-sectional data from 1978 to 2004

OBJECTIVES

To assess, using individual level data, how the proportion of people in different employment statuses may have played a role in the prevalence of poor self-rated health from 1978 to 2004 as there have been major changes in employment patterns in advanced market democracies and employment is an important correlate of health.

DESIGN

Individual-level analysis of repeated cross-sectional surveys.

SETTING

UK.

PARTICIPANTS

125 125 men and 139 535 women of working age (25-59).

OUTCOME MEASURE

Self-rated general health.

RESULTS

Compared to 1978 there was evidence of higher levels of poor health in the subsequent years. For example, in 2004, the prevalence of poor health was 2.8 (95% CI 1.7 to 3.9) and 1.3 (0.1 to 2.5) percentage points higher than 1978 for men and women, respectively, after adjusting for age. After additional adjustment for socio-economic characteristics, annual differences compared to 1978 increased (5.4 (4.2 to 6.5) and 4.4 (3.2 to 5.6) for men and women in 2004). Further adjustment for employment status, however, attenuated the annual differences in poor health (0.7 (-0.3 to 1.7) for men and 1.5 (0.3 to 2.6) for women in 2004).

CONCLUSIONS

These results suggest that the proportion of people in different employment statuses, particularly the proportion in sickness- or disability-related economic inactivity, could play an important role in the prevalence of poor self-rated health in the UK. Whether decreasing economic inactivity would enhance population health is an open question that needs further investigation.

TRIAL REGISTRATION

This observational study was not registered.

Long-term effects of poor health on employment: the significance of life stage and educational level

Previous research has found the employment consequences of poor health to be of increased magnitude in low qualified groups. The purpose of this study is to investigate if this relationship varies within different stages of the life course when focusing on long term associations with non-employment. An expectation of the article is that stronger effects of poor health may be found in young adults compared to middle aged people. The article considers two possible explanations: normative change and life stage resources. Using three-wave panel data from the Norwegian county of Nord-Trøndelag, the HUNT study allows the study of respondents over two decades. Two narrow cohorts have been selected for comparison, and health was measured by self-reported longstanding limiting illness. For the analyses, cross tabulations, logistic regression, and fixed effects logistic regression techniques are used. The article concludes in favour of the resource explanation; young adulthood is a critical period in relation to long term employment consequences of poor health, and especially so among people with fewer educational resources. Cohort differences in the employment consequences of poor health are not likely to be caused by poorer work ethics among younger cohorts.

How Do Macro-Level Contexts and Policies Affect the Employment Chances of Chronically Ill and Disabled People? Part I: The Impact of Recession and Deindustrialization

Low employment rates of chronically ill and disabled people are of serious concern. Being out of work increases the risk of poverty and social exclusion, which may further damage the health of these groups, exacerbating health inequalities. Macro-level policies have a potentially tremendous impact on their employment chances, and these influences urgently need to be understood as the current economic crisis intensifies. In Part I of this two-part study, the authors examine employment trends for people who report a chronic illness or disability, by gender and educational level, in Canada, Denmark, Norway, Sweden, and the United Kingdom in the context of economic booms and busts and deindustrialization. People with the double burden of chronic illness and low education have become increasingly marginalized from the labor market. Deindustrialization may have played a part in this process. In addition, periods of high unemployment have sparked a downward trend in employment for already marginalized groups who did not feel the benefits when the economy improved. Norway and Sweden have been better able to protect the employment of these groups than the United Kingdom and Canada. These contextual differences suggest that other macro-level factors, such as active and passive labor market polices, may be important, as examined in Part II.

Losing life and livelihood: a systematic review and meta-analysis of unemployment and all-cause mortality

Unemployment rates in the United States remain near a 25-year high and global unemployment is rising. Previous studies have shown that unemployed persons have an increased risk of death, but the magnitude of the risk and moderating factors have not been explored. The study is a random effects meta-analysis and meta-regression designed to assess the association between unemployment and all-cause mortality among working-age persons. We extracted 235 mortality risk estimates from 42 studies, providing data on more than 20 million persons. The mean hazard ratio (HR) for mortality was 1.63 among HRs adjusted for age and additional covariates. The mean effect was higher for men than for women. Unemployment was associated with an increased mortality risk for those in their early and middle careers, but less for those in their late career. The risk of death was highest during the first 10 years of follow-up, but decreased subsequently. The mean HR was 24% lower among the subset of studies controlling for health-related behaviors. Public health initiatives could target unemployed persons for more aggressive cardiovascular screening and interventions aimed at reducing risk-taking behaviors.

The negative health consequences of unemployment: the case of Poland

In the 1990s Poland began to make a transition to a free-market economy: a transition accompanied by a variety of negative socio-economic developments, most notably a rise in unemployment. The aim of this study is to shed light on the relationship between occupational status (including unemployment) and the risk of cardiovascular disease (CVD), by examining the experience of 542 men and 572 women between the ages of 40 and 50 of the town of Wroclaw in 2006. The Framingham Risk Score (FRS), which uses certain health and life-style parameters to predict the risk of major coronary problems over a 10-year period, was calculated, and the effect of occupational status on the FRS was assessed. The results showed that the FRS varied according to sex and to occupational status, with the highest FRS rating among unemployed men. Thus governmental policies to counter the adverse effects of unemployment should be developed to remedy the problem.

Burnout as a predictor of all-cause mortality among industrial employees: a 10-year prospective register-linkage study

OBJECTIVE

Burnout, a psychological consequence of prolonged work stress, has been shown to coexist with physical and mental disorders. The aim of this study was to investigate whether burnout is related to all-cause mortality among employees.

METHODS

In 1996, of 15,466 Finnish forest industry employees, 9705 participated in the 'Still Working' study and 8371 were subsequently identified from the National Population Register. Those who had been treated in a hospital for the most common causes of death prior to the assessment of burnout were excluded on the basis of the Hospital Discharge Register, resulting in a final study population of 7396 people. Burnout was measured using the Maslach Burnout Inventory-General Survey. Dates of death from 1996 to 2006 were extracted from the National Mortality Register. Mortality was predicted with Cox hazard regression models, controlling for baseline sociodemographic factors and register-based health status according to entitled medical reimbursement and prescribed medication for mental health problems, cardiac risk factors, and pain problems.

RESULTS

During the 10-year 10-month follow-up, a total of 199 employees had died. The risk of mortality per one-unit increase in burnout was 35% higher (95% CI 1.07-1.71) for total score and 26% higher (0.99-1.60) for exhaustion, 29% higher for cynicism (1.03-1.62), and 22% higher for diminished professional efficacy (0.96-1.55) in participants who had been under 45 at baseline. After adjustments, only the associations regarding burnout and exhaustion were statistically significant. Burnout was not related to mortality among the older employees.

CONCLUSION

Burnout, especially work-related exhaustion, may be a risk for overall survival.

Worklessness and regional differences in the social gradient in general health: Evidence from the 2001 English census

BACKGROUND

There has been much focus on separating contextual and compositional influences on social inequalities in health. However, there has been less focus on the important role of place in shaping the distribution of risk factors. Spatial variations in worklessness are one such factor. In this paper, then we examine the extent to which between and within regional differences in the social gradient in self-rated general health are associated with differences in rates of worklessness.

METHODS

Data were obtained for men and women of working age (25-59) who had ever worked from the Sample of Anonymised Records (Individual SAR)-a 3% representative sample of the 2001 English Census (349,699 women and 349,181 men). Generalised linear models were used to calculate region and age adjusted prevalence difference for not good health by education (as an indicator of socio-economic status) and employment status. The slope index of an inequality was also calculated for each region.

RESULTS

For both men and women, educational inequalities in worklessness and not good health are largest in those regions with the highest overall levels of worklessness. Adjusting for worklessness considerably attenuated the educational health gradient within all English regions (by over 60%) and virtually eliminated between region differences.

DISCUSSION

Macroeconomic policies, which influence the demand for labour, may have an important role in creating inequalities in general health of the working age population both within and between regions. Employment policy may therefore be one important approach to tackling spatial and socio-economic health inequalities.

Later-Life Career Disruption and Self-Rated Health: An Analysis of General Social Survey Data

The transition from employment to retirement is changing dramatically in Canada and other industrialized societies, with a decreasing proportion of working life being spent in stable career progression. This study used a sample of 2,592 subjects, aged 45 to 64, from the 1994 General Social Survey of Canada (GSS): Cycle 9, to describe situations of later-life career disruption (LLCD) in older workers in Canada and to investigate the association between LLCD and self-rated health. Results showed that a large proportion of older Canadian workers had experienced such LLCD as job interruption and job loss. Experience of job loss and job interruption over the prior 5-year period was found to be significantly associated with poor self-rated health, after controlling for age, education, body mass index, and activity limitation. However, after excluding respondents whose LLCD was known to be due to poor health, job interruption and job loss were separately found not to be significantly associated with poor health. The complexity of the findings and the direction of causation between LLCD and self-rated health, as well as some methodology issues, are discussed. Areas of future research are indicated.

Socioeconomic inequalities in the employment impact of ischaemic heart disease: a longitudinal record linkage study in Sweden

Aims: Low socioeconomic status is associated with increased risk of ischaemic heart disease (IHD) in many European and North American countries. We hypothesize that the adverse impact of having IHD may also be heavier in lower socioeconomic groups and may constitute a mechanism for generating or reinforcing social inequalities in health. Methods: Population registers of the 1.8 million residents of Stockholm County were used to assess the employment consequences over five years of having a diagnosis of IHD (600 cases) requiring hospital admission in 1996. We calculated annual age-standardized employment rates and age-adjusted odds of leaving employment during 1997—2001 by social class for in-patients and the general population. Results: Men and women who had an in-patient episode for IHD had lower age-standardized employment rates than the general population. Following hospital admission, the likelihood of patients with IHD leaving employment increased annually, and by 2001 their adjusted odds were almost four times greater (odds ratio 3.95, 95% confidence interval 3.23—4.83) than for the general population. The impact of IHD on employment was more severe with decreasing social class and patients employed in low-skilled manual occupations were significantly more likely to lose employment than professional workers with the same diagnosis. Within each social class patients had significantly higher odds of leaving employment than the general population. Conclusions: In spite of its progressive employment and rehabilitation policies, our study revealed considerable and socially differentiated employment consequences of IHD in Sweden. More account needs to be taken of such differential impact in health and social policy development.

Social mobility: evidence that it can widen health inequalities

Numerous studies consider the role of social, or occupational, mobility on health inequalities. A common conclusion is that social mobility constrains, rather than widens, social class health inequalities. It is argued that such 'gradient constraint' occurs because movers into higher social classes tend to have poorer health than those they join, while movers into lower social classes tend to have better health than those they join. This has led to the suggestion that increasing social mobility may be an effective policy to reduce health inequalities. However, this raises a paradox as many studies also show that health inequalities are widening. We compare class mobility and deprivation mobility between 1971 and 1991 with health in 1991 in England and Wales. In both cases, the health in 1991 of the 'mobile' tended to fall between that of those they left and those they joined. In comparison to the socially stable, the gradient was thus constrained. However, comparing the health in 1991 of everyone by their class/deprivation position in 1991 and 1971, the overall social class health gradient was little different, while the deprivation health gap was considerably wider in 1991. These results show that a reduction in inequalities is not a necessary consequence if the health of 'mobile' people falls between that of those they left and those they joined and this is particularly the case for deprivation mobility.

Exploring household income as a predictor of psychological well-being among long-term colorectal cancer survivors

PURPOSE

The purpose of this analysis was to determine the unique contribution of household income to the variance explained in psychological well-being (PWB) among a sample of colorectal cancer (CRC) survivors.

METHODS

This study is a secondary analysis of data collected as part of the Health-Related Quality of Life in Long-Term Colorectal Cancer Survivors Study, which included CRC survivors with (cases) and without (controls) ostomies. The dataset included socio-demographic, health status, and health-related quality of life (HRQOL) information. HRQOL was assessed with the modified City of Hope Quality of Life (mCOH-QOL)-Ostomy questionnaire and SF-36v2. To assess the relationship between income and PWB, a hierarchical linear regression model was constructed combining data from both cases and controls.

RESULTS

After accounting for the proportion of variance in PWB explained by the other independent variables in the model, the additional variance explained by income was significant (R (2) increased from 0.228 to 0.250; P = 0.006).

CONCLUSIONS

Although the study design does not allow causal inference, these results demonstrate a significant relationship between income and PWB in CRC survivors. The findings suggest that for non-randomized group comparisons of HRQOL, income should, at the very least, be included as a control variable in the analysis.

Mental health (GHQ12; CES-D) and attitudes towards the value of work among inmates of a semi-open prison and the long-term unemployed in Luxembourg

AIM

To analyse the relationships between mental health and employment commitment among prisoners and the long-term unemployed (LTU) trying to return to work.

METHOD

Fifty-two of 62 male inmates of a semi-open prison (Givenich Penitentiary Centre, the only such unit in Luxembourg), and 69 LTU registered at the Luxembourg Employment Administration completed a questionnaire exploring: 1) mental health (measured by means of scales GHQ12 and CES-D); 2) employment commitment; 3) availability of a support network, self-esteem, empowerment; and 4) socio-demographic characteristics.

RESULTS

Compared with LTU, inmates were younger, more had work experience (54.9% vs 26.1%), and more were educated to only a low level (71.1% vs 58.0%). The link between employment commitment and mental health in the LTU was the opposite of that seen among the prisoners: the more significant the perceived importance of employment, the worse the mental health (GHQ12 p = 0.003; CES-D p < 0.001) of the LTU; in contrast, among prisoners, the GHQ12 showed that the greater the perceived value of work, the lower the psychic distress (p = 0.012). Greater empowerment was associated with less depression in both populations. The education levels of people who did not reach the end of secondary school, whether inmates or LTU, were negatively linked with their mental equilibrium.

CONCLUSION

The two groups clearly need professional support. Future research should further investigate the link between different forms of professional help and mental health. Randomized controlled trials could be carried out in both groups, with interventions to improve work commitment for prisoners and to help with getting a job for LTU. For those LTU who value employment but cannot find it, the best help may be psychological support.

Contextual factors and social consequences of incident disease

BACKGROUND

Large geographical variations in the incidence of disability benefits have been reported, but it is unclear to what extent that is confounded by variations in disability rates and disease pattern in the population and whether local variations in rehabilitation and health insurance practice modify the employment effect of disease. We have studied risk of labour market exclusion following incident hospitalization for ischaemic heart disease (IHD), and whether this risk may be modified by contextual factors on the municipal level.

METHODS

A cohort design on a 10% random sample of the whole Danish population including individuals aged 43-60 years, (n = 516.454 person-years including 840 cases of IHD). The independent variable was incident hospitalization for IHD and outcome variable was defined as job loss 2 years after the event. Regional-level data included all the 275 Danish municipalities in 1996.

RESULTS

There was a strong association between incident IHD and labour market exclusion 2 years later, odds ratio (OR) = 2.8 (95% confidence intervals (CI) 2.4-3.4). Men had less risk of being excluded than women and immigrant status, low-educational attainment and co-morbidity were significantly associated with job loss. Also, regional characteristics did independently effect labour market exclusion. However, the individual relative risk of exclusion following incident IHD was not modified substantially when neither the fixed effects of the regional-level variables nor the random effect of municipality was included in the analyses.

CONCLUSION

Geographical variation in incidence of labour market exclusion following incident disease is not primarily an effect of differential social consequences across municipal variations in labour market and socio-economic conditions.

Occupational epidemiology and work related inequalities in health: a gender perspective for two complementary approaches to work and health research

OBJECTIVES

To provide a framework for epidemiological research on work and health that combines classic occupational epidemiology and the consideration of work in a structural perspective focused on gender inequalities in health.

METHODS

Gaps and limitations in classic occupational epidemiology, when considered from a gender perspective, are described. Limitations in research on work related gender inequalities in health are identified. Finally, some recommendations for future research are proposed.

RESULTS

Classic occupational epidemiology has paid less attention to women's problems than men's. Research into work related gender inequalities in health has rarely considered either social class or the impact of family demands on men's health. In addition, it has rarely taken into account the potential interactions between gender, social class, employment status and family roles and the differences in social determinants of health according to the health indicator analysed.

CONCLUSIONS

Occupational epidemiology should consider the role of sex and gender in examining exposures and associated health problems. Variables should be used that capture the specific work environments and health conditions of both sexes. The analysis of work and health from a gender perspective should take into account the complex interactions between gender, family roles, employment status and social class.

Economic consequences of incident disease: The effect on loss of annual income

Aims: To estimate the effect of incident disease on loss of annual income on an individual level, to analyse whether loss of job mediates the effect on loss of annual income, to analyse whether an association is modified by socioeconomic position, and to determine whether the effect on annual income is similar across three different diagnostic categories with different consequences in terms of functional limitations. Methods: This was a register-based study with a longitudinal design using a register of the Danish population covering 412,450 person years. Data on hospitalization are linked to information on income and employment. The setting was a 10% random sample of all individuals living in Denmark and aged 43—60 years in 1996—99. Results: Male cases of acute myocardial infarction (AMI), female cases of breast cancer and both male and female cases of intervertebral disease were associated with an increased and equally strong risk for experiencing a loss of annual income corresponding to one income decile (>25,000 DKK) in the year following disease (odds ratio (OR) from 1.37 (95% confidence interval (CI) 1.09—1.72) to 1.57 (95% CI 1.21—2.04)). No significant effect of female AMI was found. The effects of intervertebral disease and male AMI were mediated by loss of employment. This was not the case for breast cancer. No modifying effects of income level or occupational class were found. Conclusions: Despite different functional limitations, the three disorders have equally strong effects on annual income. This might be interpreted as a buffering effect of the welfare policies in relation to the more discriminating demands of the labour market.

Disease severity, self-reported experience of workplace discrimination and employment loss during the course of chronic HIV disease: differences according to gender and education

OBJECTIVES

Evidence for the existence of a harmful effect of chronic disease on employment status has been provided. Although this effect of chronic illness on employment has been reported to be higher among the groups with the lowest position on the labour market, the mechanisms of such inequalities are poorly understood. The present study aimed at investigating social inequalities in the chances of maintaining employment during the course of HIV infection and at examining the correlates of such inequalities.

METHODS

The authors used data from a national representative sample of people living with HIV in France (ANRS-EN12-VESPA survey). Retrospective information on social trajectory and disease characteristics from the time of HIV diagnosis was available. The risk of employment loss associated with indicators of disease severity and HIV-related workplace discrimination was computed over time since HIV diagnosis according to sociodemographic and occupational factors, using Cox proportional hazards models.

RESULTS

Among the 478 working-age participants diagnosed as being HIV-infected in the era of multitherapies and employed at the time of HIV diagnosis, 149 experienced employment loss. After adjusting for sociodemographic and occupational factors, disease severity and self-reported HIV-related discrimination at work were significantly associated with the risk of employment loss in a socially-differentiated manner: advancement in HIV disease was associated with an increased risk of employment loss among women (HR 4.45, 95% CI 2.10 to 9.43) but not among men; self-reported experience of HIV-related discrimination at work was associated with an increased risk of employment loss among individuals with a primary/secondary educational level (HR 8.85, 95% CI 3.68 to 21.30) but not among those more educated.

CONCLUSIONS

Chronic HIV disease affects the chances of maintaining employment in a socially-differentiated manner, resulting in increasing inequalities regarding workforce participation. Disease severity and workplace HIV-related discrimination, particularly affecting the employment status of the most socioeconomically disadvantaged, may play a major role.

Biographical disruption associated with multiple sclerosis: Using propensity scoring to assess the impact

Chronic illness such as multiple sclerosis (MS) is often associated with 'biographical disruption', a concept that is derived from qualitative narrative analyses examining how people make sense of their illness in the context of their lives [Bury, M. (1982). Chronic illness as biographical disruption. Sociology of Health and Illness, 4, 167-182]. This paper attempts to operationalise the idea of disruption to one's life trajectory in quantitative analysis by examining the social, economic and emotional disruption associated with MS. A number of studies have suggested that it impacts negatively on employment, income and sexual relationships; however previous research has been based upon samples of people with MS (pwMS), with a dearth of studies comparing pwMS with the general population. This study reports a systematic comparison of MS and non-MS households to enable the impact of MS to be quantified in terms of household composition and marital status; household income; economic activity; and to determine whether biographical disruptions such as relationship breakdown or unemployment are more or less prevalent among those affected by MS compared to the general population. The MS sample came from randomly selected members of the UK MS Society (n=783) and those accessing the MS Society website (n=133). Data for the general population came from the 2001/02 British General Household Survey (GHS). Cases from the MS Society sample were matched using propensity scoring with cases from the GHS. The results of the matched analysis show that both men and women with MS are significantly less likely to be employed than those in the general population and are significantly more likely to have a 'below average' household income, despite the fact that they are in a higher social class and have higher educational levels than people in the general population. Differences between the MS and GHS samples in terms of marital status become non-significant when socio-demographic variables are controlled for using propensity scoring. This study provides robust evidence on how MS impacts on and disrupts the life of the person with MS and their household in terms of income and employment.

Socioeconomic differences in the impact of HIV infection on workforce participation in France in the era of highly active antiretroviral therapy

OBJECTIVES

We sought to measure the difference in employment rates between HIV-seropositive and HIV-seronegative persons and to establish whether this difference varied according to the HIV-infected persons' socioeconomic position as defined by education level.

METHODS

We used data from the VESPA (VIH: Enquête Sur les Personnes Atteintes) study, a large cross-sectional survey conducted among a nationally representative sample of 2932 HIV-infected patients in France. Age-, gender-, nationality-, and education-standardized employment rates were estimated with the French general population as the reference. The differences in employment rates with the general population were computed overall and according to education level.

RESULTS

Compared with that of the general population, the overall employment rate was 25% lower (95% confidence interval [CI]=16%, 32%) among HIV-infected patients diagnosed before 1994 and 9% lower (95% CI = 5%, 16%) among HIV-infected patients diagnosed from 1994 onward. The difference in employment rates with the general population was significantly higher among patients with a low education level. The employment rate of highly educated HIV-infected patients diagnosed from 1994 onward did not differ from that of the general population.

CONCLUSIONS

HIV infection was associated with decreased workforce participation among those with a low education level but not among highly educated individuals.

Is there a "Scottish effect" for self reports of health? Individual level analysis of the 2001 UK census

BACKGROUND

Scotland's overall health record is comparatively poor for a Western European country, particularly amongst people of working age. A number of previous studies have explored why this might be the case by comparing mortality in Scotland with England and Wales. A study in the 1980s showed that the higher prevalence of deprivation in Scotland accounted for Scotland's excess mortality risk. However, more recent studies suggest that deprivation now explains less of this excess. This has led to the suggestion that there is a yet unidentified "Scottish effect" contributing to Scotland's mortality excess. Recent research has also suggested that there could be an unidentified effect influencing Scotland's higher rate of heart disease. This paper explores whether there is also an unexplained Scottish excess, relative to England, in self reports of poor health.

METHODS

Data came from the individual Sample of Anonymised Records, a 3% random sample of the 2001 UK census. Using logistic regression models, self reports of health (limiting illness and general health) from the working age populations (aged 25 to 64) of Scotland and England were compared. Account was taken of people's country of birth. Stratified analysis by employment status allowed further exploration of Scotland's excess.

RESULTS

People born and living in Scotland reported higher levels of poor general health and limiting illness compared to people born and living in England. Adjustment for socioeconomic position and employment status largely explained the higher rates. In the stratified analysis a Scottish excess was seen only amongst the economically inactive born and living in Scotland. For those in employment, people born and living in Scotland actually had slightly lower odds of reporting poor general health and limiting illness than people born and living in England.

CONCLUSION

This analysis suggests that higher rates of poor self reported health in Scotland can be explained by differences in employment and socioeconomic position and so there is unlikely to be an unidentified "Scottish effect" for self reports of health. Scotland's excess of poor general health and limiting illness amongst the economically inactive is probably attributable to its economic and employment history.

Sickness absence as a risk factor for job termination, unemployment, and disability pension among temporary and permanent employees

OBJECTIVES

This study examined sickness absence as a risk factor for job termination, unemployment, and disability pension among temporary and permanent workers.

METHODS

Prospective cohort study with data on employment contract and sickness absence in 1996, job termination by 1997, and employment status in 1997 and 2000 for 19,093 temporary and 41,530 permanent public sector employees.

RESULTS

For women aged 40 years or less and for women over 40, a high sickness absence increased the risk of job termination among temporary employees (OR 1.52 (95% CI 1.36 to 1.71) and OR 1.70 (95% CI 1.36 to 2.13) respectively). High absence was not associated with job termination among men in temporary employment. Among permanent employees, high sickness absence predicted job termination among older, but not among younger employees. Temporary employees with high sickness absence were at the highest risk of immediate unemployment and unemployment three years later. Among older permanent employees, high sickness absence was associated with subsequent work disability pension.

CONCLUSIONS

A high rate of sickness absenteeism increases the risk of job termination and unemployment among women in temporary public sector jobs. For permanent employees, secure employment provides protection against unemployment even in the case of high sickness absence.

Mental health and hostility as predictors of temporary employment: evidence from two prospective studies

We used two studies to examine whether mental health and hostility predicted temporary employment. Study 1 involved a cohort of 970 Finnish hospital employees (102 men, 868 women) who had temporary job contracts at baseline. After adjustment for demographics, organisational tenure and part-time work status, doctor-diagnosed psychiatric disorder predicted continuing in temporary employment instead of receiving a permanent job by the end of the 2-year follow-up. A higher level of hostility was also associated with temporary employment, but only among employees in low socioeconomic positions. In Study 2, anxiety and aggressive behaviour were measured in a cohort of 226 Finnish school children (116 boys, 110 girls) at 8 years of age. Anxiety in childhood predicted temporary employment at age 42. Aggressive behaviour in childhood was related to ongoing temporary employment status in adulthood among individuals in low socioeconomic positions. Our findings suggest that selection by individual characteristics operates between the temporary and permanent workforces. Mental health problems, a part of which are already seen in childhood, seem to restrict individuals' possibilities to gain secure labour market positions. Hostility and aggressiveness seem to be related to labour market prospects only among individuals in low socioeconomic positions.

[The individual's status in the labor market and health inequity in Brazil]

OBJECTIVE

To investigate inequalities in personal health conditions and in the utilization of healthcare services according in relation to the individual's status in the labor market.

METHODS

This study was based on 39,925 males aged 15 to 64 years living in 10 Brazilian metropolitan regions, who took part in the 1998 National Household Survey. They were classified as formal labor, informal labor, unemployed or outside of the labor market. Each category was compared with formal labor regarding sociodemographic characteristics, health status indicators and healthcare utilization. This analysis was by means of Pearson's Chi-square test. Multinomial logistic regression was used to investigate independent associations between labor market status, health status indicators and healthcare utilization.

RESULTS

The classification of the participants' status was that 52.2% were formal labor, 27.7% informal labor, 10% unemployed and 10.2% were outside of the labor market. There were significant differences between these categories with respect to age, schooling, household income, household status and region of residence. Independent of the sociodemographic characteristics, unemployment, informal labor status and, especially, exclusion from the labor market remained associated with poor health status.

CONCLUSIONS

The individual's status in the labor market is expressed through a gradient of inequality in health conditions. These findings reinforce the need to also consider the individual's status in the labor market in studies on healthcare inequalities.

Burnout in the general population. Results from the Finnish Health 2000 Study

BACKGROUND

Burnout is a chronic stress syndrome which develops gradually as a consequence of prolonged stress situation. Socio-demographic factors related to job-related burnout have not been studied in the whole population. We investigated the relative differences in the level of burnout between groups based on various socio-demographic factors in the population-based Finnish sample.

METHODS

The nationally representative sample comprised 3,424 employees aged 30-64 years. Burnout was assessed with the Maslach Burnout Inventory-General Survey. The socio-demographic factors of interest were gender, age, education, type of employment, work experience, socio-economic status (SES), working time, and marital status.

RESULTS

Only small differences in burnout were found between the different population groups. As a three-dimensional syndrome, burnout was associated with age. In contrast to what has been consistently reported so far, mostly among human service work and in non-representative studies, burnout seemed to increase somewhat with age. Among women, burnout was also related to education, SES, and work experience, and among men, to marital status.

CONCLUSIONS

Burnout can evolve in all kinds of vocational groups. It seems that age does not generally protect against burnout. A low education level and low social status carry a possible risk of burnout for women, and being single, divorced, or widowed carry a possible risk of burnout for men.

Self-rated health in relation to employment status during periods of high and of low levels of unemployment

BACKGROUND

There is a need for more research on the health impact of changes in the national unemployment rate. Therefore, the present study was carried out to compare levels of self-rated health during periods of high and low levels of unemployment.

METHODS

Data included cross-sectional interviews from the Swedish Survey of Living Conditions, which were based on random samples of inhabitants between 16 and 64 years of age living in Sweden. Data were collected for the period 1983-89, when unemployment levels were low (n = 35 562; 2.5%) and for the period 1992-97 when unemployment was high (n = 24 019; 7.1%).

RESULTS

After adjusting for sociodemographic variables as well as long-term disease or handicap, the differences in self-rated health between the unemployed and employed were larger when unemployment levels were high in the 1990s, than when they were low in the 1980s. More groups of the unemployed were afflicted with poor health when unemployment was high, compared with when it was low. In 1992-97, being married, living in larger cities, or not having a long-term disease or handicap no longer buffered the negative effects on health among the unemployed.

CONCLUSIONS

Poorer self-rated health among the unemployed seems to be an increasing public health problem during high levels of unemployment.

Employment loss following HIV infection in the era of highly active antiretroviral therapies

BACKGROUND

Employment is a major factor in maintaining living conditions of patients with chronic diseases. This study aimed to quantify the frequency and to identify the determinants of employment loss during the first years of HIV disease in the era of highly active antiretroviral therapies (HAART).

METHODS

The French PRIMO multicentre prospective cohort of 319 patients enrolled during primary HIV-1 infection between 1996 and 2002. Employment loss was defined as moving from employment to inactivity between two visits. Characteristics associated with employment loss were assessed using generalized estimating equations.

RESULTS

During a median follow-up time of 2.5 years, 56 employment losses occurred among 51 patients (18.0%). In multivariate analysis, female gender (adjusted odds ratio 3.1; 95% confidence interval 1.1-8.5), non-permanent job (3.8; 1.5-9.3) and poor accommodation (4.2; 1.6-11.2) constituted independent risk factors for employment loss; subjects with a high occupational position had a decreased risk of job loss. Moreover, an updated HIV viral load above 10 000 copies/ml either persistent (2.4; 1.1-5.0) or incident (3.7; 1.0-13.9) and hospitalization in the preceding 6 months (3.9; 1.6-9.7) constituted independent risk factors for employment loss, as tended to be a baseline CD4 cell count <350/mm(3) (1.9; 0.9-4.3) and chronic comorbidity (1.8; 0.9-3.6).

CONCLUSIONS

In the HAART era, employment loss is frequent from the first months of HIV infection. Employment loss occurs especially in women and in patients with adverse socioeconomic conditions, severe HIV infection and/or comorbidity. Social interventions should seek to prevent HIV-infected patients from leaving their job from the earliest times of the disease.

Original approach to the individual characteristics associated with forgone healthcare: a study in underprivileged areas, Paris region, France, 2001-2003

BACKGROUND

The social inequalities in health have endured or even worsened comparatively throughout different social groups since the 1990s. Our objective was to identify the individual characteristics (socio-economic status, living conditions, individuals' social integration, health beliefs, expectations and representation and psychological characteristics) statistically associated with the fact of stating (or not) that healthcare had been forgone because of cost.

METHODS

In this cross-sectional, multi-centre study we randomly selected a study sample from five underprivileged areas in the Paris region. A multiple logistic regression model was used to calculate the odds ratios (OR) and 95% confidence interval (CI). The validity of the model was assessed by goodness-of-fit tests (Pearson and deviance) and by the study of 100 bootstrap samples.

RESULTS

After making adjustments for numerous individual socio-economic and health characteristics, we observed a higher occurrence of reported forgone healthcare among people who have had financial worries during adulthood [ORyes/no=5.47 (1.44-20.75)], a life-course experience of physical, sexual or psychological abuse [ORyes/no=2.86 (1.40-5.84)]; who have experienced childhood difficulties [OR1/never difficulties=5.28 (1.81-15.39), OR2-4/never=7.62 (2.69-21.57), OR>4/never=8.57 (2.39-30.80)]; who have expressed a low degree of sickness orientation [OR(low/high)=2.62 (1.33-5.14)], a high worry/concern about health [ORhigh/low=2.71 (1.33-5.50)] and a low self-esteem [ORmedium/high=8.28 (1.44-47.64), ORlow/high=16.44 (2.81-96.24)].

CONCLUSION

Aside from purely financial hurdles, other factors play a role in the non-use of healthcare services. Health policies mainly promoting equal financial access to healthcare have little chance of abating health inequalities.

Associations between socio-economic circumstances at two stages of life and adolescents' oral health status

There is a consistent association between unfavourable socio-economic circumstances and oral health. Although the effects of poor social circumstances in childhood are known to have lasting influences on general health, there is little information on their effects regarding chronic oral diseases.

OBJECTIVE

To assess the relationship between oral health status and socio-economic circumstances at two different periods of adolescents' life.

METHODS

A two-phase cross sectional study was carried out in Brazil. In Phase I, 652 13-year-olds were clinically examined and interviewed. In the second phase, 311 families were randomly selected for in-depth interviews. Information was collected on several indicators of socio-economic circumstances, family related variables, school grade level, and oral health behaviour, at two different life stages, at birth and at 13 years of age. The outcome variable was oral health status at the age of 13. It was constructed by counting the worst scores of DMFT, gingival bleeding, calculus and dental plaque. The data analysis used stepwise logistic regression.

RESULTS

The response rates for phases I and II were 85% and 94%. Boys, those at a lower grade level at school for their age, and those who experienced high levels of material deprivation at birth and at the age of 13 were more likely to have high levels of oral diseases; the odds ratios were 4.12 (1.86-9.16), 2.41 (1.01-5.76) and 4.61 (1.30-16.3), respectively.

CONCLUSION

Brazilian adolescents experiencing adverse socio-economic circumstances at birth and at the age of 13 had high levels of oral diseases.

How do persons with intellectual disability manage in the open labour markets? A follow-up of the Northern Finland 1966 Birth Cohort

BACKGROUND

The aim was to study how many of the individuals with intellectual disability (ID; IQ < or = 70) in an age cohort were not receiving a disability pension by the age of 34 years and what their life situation was like in terms of employment, education and morbidity. In 2000, the Northern Finland 1966 Birth Cohort (n=12,058 live-born) included 129 individuals with ID.

METHOD

The outcome data on employment, education, pensions and morbidity were obtained from national registers.

RESULTS

A total of 85.3% (n=110) of all the individuals with ID were on pension, and 66 of them had severe ID (IQ <50) and 44 had mild ID (IQ 50-70). Altogether 99 were drawing a pension because of ID, and 11 had a main diagnosis other than ID in the register of Social Insurance Institution. Nineteen individuals with mild ID were not on disability pension. The educational level of those without pension was low, and all whose occupation was known worked in low-level manual trades in the open labour market. During the past 8 years (1993-2000), their employment rate had been lower and unemployment rate correspondingly higher and unemployment periods longer than those of the reference group (IQ >85 or not measured). As to the morbidity, they had been hospitalized twice more often than those in the reference group and the mean of their hospitalization days was over fourfold.

CONCLUSION

More attention should be paid to the vocational education and supported employment services of individuals with ID to help them to manage as independently as possible.

Social capital in working life and the health of employees

It is commonly assumed that social capital influences health, but only few studies have examined this hypothesis in the context of the workplace. The present prospective cohort study of 6028 public sector employees in Finland investigated social capital as a workplace characteristic which potentially affects employee health. The two indicators of social capital were trust in the labour market, measured by security of the employment contract, and trust in co-worker support. Self-rated health status and psychological distress were used as indicators of health. The combination of subsidised job contract and low co-worker support (i.e. the lowest category of social capital) was associated with poorer health prospects than the combination of permanent employment and high support (the highest social capital category) in an age-adjusted model, but this association disappeared in logistic regression analysis adjusted by sociodemographic background factors and baseline health. Fixed-term employment predicted better self-rated health and less psychological distress when compared with permanent employment. Co-worker support was most common in permanent and least common in subsidised employees and it was associated with better self-rated health in women. Our findings suggest only partial support for the hypothesis of work-related social capital as a health resource.

Unemployment and early cause-specific mortality: a study based on the Swedish twin registry

OBJECTIVES

We investigated the association between unemployment and early cause-specific mortality to determine whether the relationship was modified by other risk indicators.

METHODS

Female and male twins (n=20632) were followed with regard to mortality from 1973 through 1996. Questionnaire data from 1973 were used to obtain information on experience of unemployment and on social, behavioral, health, and personality characteristics.

RESULTS

Unemployment was associated with an increased risk of suicide and death from undetermined causes. Low education, personality characteristics, use of sleeping pills or tranquilizers, and serious or long-lasting illness tended to strengthen the association between unemployment and early mortality.

CONCLUSIONS

An increased risk of death from external causes implies a need for support for those experiencing unemployment, particularly susceptible individuals.

Trends in socioeconomic inequalities in self-assessed health in 10 European countries

BACKGROUND

Changes over time in inequalities in self-reported health are studied for increasingly more countries, but a comprehensive overview encompassing several countries is still lacking. The general aim of this article is to determine whether inequalities in self-assessed health in 10 European countries showed a general tendency either to increase or to decrease between the 1980s and the 1990s and whether trends varied among countries.

METHODS

Data were obtained from nationally representative interview surveys held in Finland, Sweden, Norway, Denmark, England, The Netherlands, West Germany, Austria, Italy, and Spain. The proportion of respondents with self-assessed health less than 'good' was measured in relation to educational level and income level. Inequalities were measured by means of age-standardized prevalence rates and odds ratios (ORs).

RESULTS

Socioeconomic inequalities in self-assessed health showed a high degree of stability in European countries. For all countries together, the ORs comparing low with high educational levels remained stable for men (2.61 in the 1980s and 2.54 in the 1990s) but increased slightly for women (from 2.48 to 2.70). The ORs comparing extreme income quintiles increased from 3.13 to 3.37 for men and from 2.43 to 2.86 for women. Increases could be demonstrated most clearly for Italian and Spanish men and women, and for Dutch women, whereas inequalities in health in the Nordic countries showed no tendency to increase.

CONCLUSIONS

The results underscore the persistent nature of socioeconomic inequalities in health in modern societies. The relatively favourable trends in the Nordic countries suggest that these countries' welfare states were able to buffer many of the adverse effects of economic crises on the health of disadvantaged groups.

Systematic review of the role of gender as a health determinant of hospitalization for depression

Objectives:To conduct a systematic review of selected health determinants, including gender, and their impact on hospitalization rates for depression. Depression includes both depressive and bipolar disorders. Selected health determinants were gender, age, sex, family structure, education, and socioeconomic status.

Methods:Systematic search of conventional and fugitive literature sources. All reports of primary data, systematic reviews, and meta-analysis of primary data were included if they focused on hospitalization for depression and reported data by one or more of the selected health determinants. Two researchers independently evaluated each citation for inclusion and extracted data from the included studies.

Results:There is an important underreporting of health determinants data in studies of hospitalization for depression. No studies examined the role of gender. Age and sex were reported in 83 percent and 80 percent of the 110 included studies. Women showed a higher rate of hospitalization for depression than men (p<.05). Age and diagnosis had different effects in men and women. Adult women were significantly more likely than men to report a depressive disorder, whereas men were more likely to report a bipolar disorder (p<.05). Little can be concluded on the other health determinants.

Conclusions:The importance of reporting hospitalization data and conducting hospital utilization analysis by sex and health determinants, including gender, must be emphasized.

Unemployment and mental health: understanding the interactions among gender, family roles, and social class

OBJECTIVES

We examined gender differences in the effects of unemployment on mental health and assessed whether such effects are associated with interactions among gender, family roles, and social class.

METHODS

Our analysis included 3881 employed and 638 unemployed workers, aged 25 to 64 years, interviewed in the 1994 Catalonian Health Survey.

RESULTS

Unemployment had more of an effect on the mental health of men (age-adjusted odds ratio [OR] = 2.98; 95% confidence interval [CI] = 2.30, 3.87) than on that of women (age-adjusted OR = 1.51; 95% CI = 1.11, 2.06). Gender differences in effects were related to family responsibilities and social class.

CONCLUSIONS

Understanding the effects of unemployment on mental health requires consideration of the interactions among gender, family responsibilities, and social class.

Unemployment and suicide. Evidence for a causal association?

OBJECTIVES

To determine the independent associations of labour force status and socioeconomic position with death by suicide.

DESIGN

Cohort study assembled by anonymous and probabilistic record linkage of census and mortality records.

PARTICIPANTS

2.04 million respondents to the New Zealand 1991 census aged 18-64 years.

MAIN OUTCOME MEASURE

Suicide in the three years after census night.

RESULTS

The age adjusted odds ratios (95% confidence intervals) of death by suicide among 25 to 64 year olds who were unemployed compared with employed were 2.46 (1.10 to 5.49) for women and 2.63 (1.87 to 3.70) for men. Similarly increased odds ratios were observed for the non-active labour force compared with the employed. Strong age only adjusted associations of suicide death with the socioeconomic factors of education (men only), car access, and household income were observed. Compared with those who were married on census night, the non-married had odds ratios of suicide of 1.81 (1.22 to 2.69) for women and 2.08 (1.66 to 2.61) for men. In a multivariable model the association of socioeconomic factors with suicide reduced to the null. However, marital status and labour force status remained strong predictors of suicide death. Unemployment was also strongly associated with suicide death among 18-24 year old men. Sensitivity analyses suggested that confounding by mental illness might explain about half, but not all, of the association between unemployment and suicide.

CONCLUSIONS

Being unemployed was associated with a twofold to threefold increased relative risk of death by suicide, compared with being employed. About half of this association might be attributable to confounding by mental illness.

The relationship between job stress, burnout and clinical depression

The definition and phenomenological features of 'burnout' and its eventual relationship with depression and other clinical conditions are reviewed. Work is an indispensable way to make a decent and meaningful way of living, but can also be a source of stress for a variety of reasons. Feelings of inadequate control over one's work, frustrated hopes and expectations and the feeling of losing of life's meaning, seem to be independent causes of burnout, a term that describes a condition of professional exhaustion. It is not synonymous with 'job stress', 'fatigue', 'alienation' or 'depression'. Burnout is more common than generally believed and may affect every aspect of the individual's functioning, have a deleterious effect on interpersonal and family relationships and lead to a negative attitude towards life in general. Empirical research suggests that burnout and depression are separate entities, although they may share several 'qualitative' characteristics, especially in the more severe forms of burnout, and in vulnerable individuals, low levels of satisfaction derived from their everyday work. These final issues need further clarification and should be the focus of future clinical research.

Health selection in the Whitehall II study, UK

There has been considerable debate over the importance of the health selection hypothesis for explaining social gradients in health. Although studies have argued that it may not be an important explanation of social gradients in health, previous analyses have not estimated, simultaneously, the relative effect of health on changes in social position and of social position on changes in health (social causation). Cross-lagged longitudinal analyses using structural equation models enable the estimation of the relative size of these pathways which would be useful in determining the relative importance of the health selection hypothesis over the social causation hypothesis. Data from four phases of the Whitehall II study (initially consisting of 10,308 men and women aged 35-55 in the British civil service) were collected over a 10 year period. There was no evidence for an effect of mental (GHQ-30 and SF36) or physical health (SF-36) on changes in employment grade. When financial deprivation was used as a measure of social position, there was a significant effect of mental health on changes in social position among men although this health selection effect was over two and a half times smaller than the effect of social position on changes in health. The results suggest that the development of social gradients in health in the Whitehall II study may not be primarily explained in terms of a health selection effect.

Trends in socioeconomic health inequalities in the Netherlands, 1981-1999

STUDY OBJECTIVE

To determine changes in socioeconomic inequalities in self reported health in both the 1980s and the 1990s in the Netherlands.

DESIGN

Analysis of trends in socioeconomic health inequalities during the last decades of the 20th century were made using data from the Health Interview Survey (Nethhis) and the subsequent Permanent Survey on Living Conditions (POLS) from Statistics Netherlands. Socioeconomic inequalities in self assessed health, short-term disabilities during the past 14 days, long term health problems and chronic diseases were studied in relation to both educational level and household income. Trends from 1981 to 1999 were studied using summary indices for both the relative and absolute size of socioeconomic inequalities in health.

SETTING

The Netherlands.

PARTICIPANTS

For the period 1981-1999 per year a random sample of about 7000 respondents of 18 years and older from the non-institutionalised population.

MAIN RESULTS

Socioeconomic inequalities in self assessed health showed a fairly consistent increase over time. Socioeconomic inequalities in the other health indicators were more or less stable over time. In no case did socioeconomic inequalities in health seemed to have decreased over time. Socioeconomic inequalities in self assessed health increased both in the 1980s and the 1990s. This increase was more pronounced for income (as compared with education) and for women (as compared with men).

CONCLUSION

There are several possible explanations for the fact that, in addition to stable health inequalities in general, income related inequalities in some health indicators increased in the Netherlands, especially in the early 1990s. Most influential were perhaps selection effects, related to changing labour market policies in the Netherlands. The fact that the health inequalities did not decrease over recent years underscores the necessity of policies that explicitly aim to tackle these inequalities.

Selection from fixed term to permanent employment: prospective study on health, job satisfaction, and behavioural risks

STUDY OBJECTIVE

To examine health, job satisfaction, and behavioural risks as antecedents of selection from fixed term to permanent employment.

DESIGN

Prospective cohort study of change in employment contract during a two year period. Self reported health, recorded sickness absence, job satisfaction, behavioural risks, demographics, and occupational characteristics were assessed at baseline.

SETTING

Hospital staff in two Finnish hospital districts.

PARTICIPANTS

A cohort of 526 hospital employees (54 men, 472 women) aged 20 to 58 years with a fixed term job contract at baseline.

MAIN RESULTS

During the follow up period, 137 became permanently employed. Men, employees in higher positions, full time workers, and those with five to eight years in the employ of the hospital were more likely to become permanently employed. After adjusting for these factors, obtaining a permanent job contract was predicted by self rated good health (odds ratio (OR) 3.90; 95% confidence intervals (CI) 1.34 to 11.36), non-caseness of psychological distress (OR 1.80; 95% CI 1.01 to 3.20), high job satisfaction (OR 1.86; CI 1.17 to 2.94), and non-sedentary life style (OR 2.64; CI 1.29 to 5.41), compared with the rest of the cohort.

CONCLUSIONS

Investigation of fixed term employees yields new information about selective mechanisms in employment mobility. Good health seems to promote the chances for a fixed term employee to reach a better labour market status. These results correspond to earlier research on selective mechanisms in other forms of employment mobility and provide a partial explanation for the socioeconomic gradient of health.

Analysing changes of health inequalities in the Nordic welfare states

This study examined changes over time in relative health inequalities among men and women in four Nordic countries, Denmark, Finland, Norway and Sweden. A serious economic recession burst out in the early 1990s particularly in Finland and Sweden. We ask whether this adverse social structural'development influenced health inequalities by employment status and educational attainment, i.e. whether the trends in health inequalities were similar or dissimilar between the Nordic countries. The data derived from comparable interview surveys carried out in 1986/87 and 1994/95 in the four countries. Limiting long-standing illness and perceived health were analysed by age, gender, employment status and educational attainment. First, age-adjusted overall prevalence percentages were calculated. Second, changes in the magnitude of relative health inequalities were studied using logistic regression analysis. Within each country the prevalence of ill-health remained at a similar level, with Finns having the poorest health. Analysing all countries together health inequalities by employment status and education showed no major changes. There were slightly different tendencies among men and women in inequalities by both health indicators, although these did not reach statistical significance. Among men there was a suggestion of narrowing health inequalities, whereas among women such a suggestion could not be discerned. Looking at particular countries some small changes in men's as well as women's health inequalities could be found. Over a period of deep economic recession and a large increase in unemployment, particularly in Finland and Sweden, health inequalities by employment status and education remained broadly unchanged in all Nordic countries. Thus, during this fairly short period health inequalities in these countries were not strongly influenced by changes in other structural inequalities, in particular labour market inequalities. Institutional arrangements in the Nordic welfare states, including social benefits and services, were cut during the recession but nevertheless broadly remained, and are likely to have buffered against the structural pressures towards widening health inequalities.

Socio-economic outcome of paraplegia compared to lower limb amputation

STUDY DESIGN

The socio-economic outcome was retrospectively compared between patients with traumatic lower limb amputation and those with paraplegia due to a spinal cord injury (SCI).

OBJECTIVE

To evaluate the effect of specific rehabilitative procedures on the socio-economic outcome.

SETTING

Paraplegic Centre at the University Hospital in Zurich, Switzerland.

METHODS

Accidents occurring in a collective of 1.9 million persons in Switzerland over 3 years were included in the study. Fifty-six persons with unilateral amputation of lower limbs were compared with 54 persons with paraplegia. The follow-up was assessed over 5 years.

RESULTS

The following data was obtained in patients with amputations compared to those with SCI (median values): (1) hospital stay: 150 versus 164 days; (2) the work was taken up after 689 versus 616 days; (3) the global average case costs amounted to SFr. 491.000 versus SFr. 606.000 during the first 5 years after injury; (4) the permanent degree of disability was determined to 40% versus 42%. Except for the global costs, all differences were not significant.

CONCLUSIONS

There are only a few differences between the socio-economic outcomes between patients with lower limb amputations and those with paraplegia. It remains unclear if the highly specialised rehabilitation services provided for patients with SCI accounts for the similarity since individuals with SCI have additional neurogenic dysfunction of the bladder and bowel. Alternatively, the data may suggest a need for greater rehabilitation services for amputees or may reflect a threshold effect in rehabilitation outcomes.

Class differences in the social consequences of illness?

STUDY OBJECTIVE

To investigate adverse social consequences of limiting longstanding illness and the modifying effect of socioeconomic position on these consequences.

DESIGN

Cohort study on the panel within the annual Swedish Survey of Living Conditions where participants were interviewed twice with eight years interval 1979-89 and 1986-97. Sociodemographic characteristics, self reported longstanding illness, employment situation and financial conditions were measured at baseline. Social consequences (economic inactivity, unemployment, financial difficulties) of limiting longstanding illness were measured at follow up eight years later.

SETTING

National sample for Sweden during a period that partly was characterised by high unemployment and reduction in insurance benefits.

PARTICIPANTS

PARTICIPANTS were 13 855 men and women, economically active, not unemployed, without financial difficulties at the first interview and aged 25-64 years at the follow up.

MAIN RESULTS

Persons with limiting longstanding illness had a higher risk of adverse social consequences than persons without illness. The effect was modified by socioeconomic position only for labour market exclusion while the effects on unemployment and financial difficulties were equal across socioeconomic groups.

CONCLUSIONS

Labour market policies as well as income maintenance policies that deal with social and economical consequences of longstanding illness are important elements of programmes to tackle inequalities in health. Rehabilitation within health care has a similar important part to play in this.