Misery loves company? A meta-regression examining aggregate unemployment rates and the unemployment-mortality association

Effectiveness of a three-component intervention supporting unemployed individuals with mental health issues in their job search and mental health recovery (3for1): study protocol of a non-randomized controlled study

BACKGROUND

There is a vicious cycle between unemployment and mental health issues. Unemployed individuals with mental health issues require individualized support at multiple levels in order to promote their mental health, and obtain and retain employment. The 3for1-intervention program aims to provide such support with three components (short-term psychotherapy, job coaching based on the Individual Placement and Support approach, and peer support). This study protocol outlines how the effectiveness of this three-component intervention program in terms of re-employment, mental health, and psychosocial outcomes will be evaluated.

METHODS

The 3for1-intervention program will be evaluated with a non-randomized controlled trial design in a multi-center study. 500 eligible participants aged between 18 and 60 years from six job centers in Southern Germany will be allocated to a control group or an intervention group. Allocation is time-based, with the control group being recruited first, followed by recruitment of the intervention group. The control group will receive treatment as usual, whereas the intervention group will receive treatment as usual as well as access to the three intervention components over a period of 12 months. Assessment will be conducted at baseline (t0), and 12 (t1) and 18 (t3) months later. The primary outcome will be the proportion of participants who are in employment subject to social insurance contributions at t1. Differences between control and intervention group will be tested with logistic regression analysis, controlling for relevant covariates. Analyses of secondary outcomes will relate to group differences regarding re-employment, health and well-being, social integration, help-seeking, and self-stigma at t1 and t2, applying logistic regression analysis or analysis of covariance. Additionally, usage of health services will be measured to evaluate the intervention program's cost effectiveness.

DISCUSSION

The 3for1-intervention aims to improve employability and mental health outcomes of a vulnerable population with high need for assistance. Improvements for this population would benefit the German welfare state as well. This study could provide valuable insights into the feasibility, implementation, and sustainability of this individualized, multi-level support program within German job centers.

TRIAL REGISTRATION

This trial is registered with the German Clinical Trials Register: DRKS00029002 (registered on 11 May 2022).

Labour market status and mortality risk: The Finnmark cohort study 1987-2017

AIMS

The aim of this study was to investigate the age-varying mortality risk associated with different labour market status categories.

METHODS

Data from a population-based survey carried out among adults aged 30-62 years in Finnmark in 1987/1988 were linked to the Norwegian Cause of Death Registry to identify all deaths occurring by December 2017. We used flexible parametric survival models to examine the age-varying associations between different labour market status categories (no paid work/homemaker, part-time work, full-time work, unemployment benefits, sick leave/rehabilitation allowance, and disability pension) and mortality.

RESULTS

Men with part-time work, unemployment benefits, sick leave/rehabilitation allowance, or disability pension had an increased mortality risk compared with men with full-time work; however, these findings were restricted to ages below 60-70 years, varying with labour market status category. For women, excess mortality was linked to disability pension in the younger age groups; in older age groups it was linked to the labour market status category no paid work/homemaker. Non-employment was associated with low education level compared with full-time employment.

CONCLUSIONS

The study showed increased mortality risk for some non-employment categories, with decreasing relative risk with age. Our findings suggest that the increased mortality risk is partly explained by health, pre-existing illnesses, and health-related behaviour and partly by other factors, such as social network and economic factors.

Financial Stress, Unemployment, and Suicide - A Meta-Analysis

Background: Socioeconomic factors such as financial stress and unemployment are known predictors of suicide. However, no large-scale meta-analyses exist. Aims: Determine the suicide risk following unemployment or financial stress. Method: Literature searched through July 31, 2021. Robust meta-analysis and metaregression of the risk of suicide following financial stress (23 studies) or unemployment (43 studies), from 20 nations. Subgroup meta-analyses by sex, age, year, country, and methodology. Results: The suicide risk following financial stress or unemployment was not significantly elevated among those with diagnosed mental illness. In the general population, we found significantly elevated suicide risks for financial stress (RR: 1.742; 95% CI: 1.339, -2.266) and unemployment (RR: 1.874; CI: 1.501, -2.341). However, neither was significant among studies controlling for physical/mental health (perhaps partially due to lower statistical power). We observed no significant differences by sex, age, or by GDP. We observed a higher suicide risk following unemployment in more recent years. Limitations: Publication bias was evident. We could not examine some individual-level characteristics, most notably the severity/duration of unemployment/financial stress. Heterogeneity was high for some meta-analyses. Studies from non-OECD countries are under-represented. Conclusion: After accounting for physical/mental health, financial stress and unemployment weakly associated with suicide, and the associations may be nonsignificant.

The long-term impact of the COVID-19 unemployment shock on life expectancy and mortality rates

We adopt a time series approach to investigate the historical relation between unemployment, life expectancy, and mortality rates. We fit Vector-autoregressions for the overall US population and for groups identified based on gender and race. We use our results to assess the long-run effects of the COVID-19 economic recession on mortality and life expectancy. We estimate the size of the COVID-19-related unemployment shock to be between 2 and 5 times larger than the typical unemployment shock, depending on race and gender, resulting in a significant increase in mortality rates and drop in life expectancy. We also predict that the shock will disproportionately affect African-Americans and women, over a short horizon, while the effects for white men will unfold over longer horizons. These figures translate in more than 0.8 million additional deaths over the next 15 years.

Health Equity and Its Economic Determinants (HEED): protocol for a pan-European microsimulation model for health impacts of income and social security policies

Introduction

Government policies on taxation and social security are important determinants of population health outcomes and health inequalities. However, there is a shortage of evidence to inform policymakers of the health consequences of such policies. The Health Equity and Its Economic Determinants project aims to assess the potential impacts of different taxation and social security policies across Europe on population health and health inequalities using a computer-based simulation that provides projections over multiple health domains.

Methods and analysis

In the first phase, key input parameters for the model will be estimated using estimation techniques that control for the effects of prior exposure on time-varying confounders and mediators (g-methods). The second phase will involve developing and validating the microsimulation model for the UK. Policy proposals, developed with policymakers, will be simulated in the third phase to investigate the impacts of income tax and social security changes on population health and health inequalities. In the final phase, the microsimulation model will be extended across other European countries.

Ethics and dissemination

This project will use deidentified secondary data for which ethical approval and consents were received by the original data collectors. No further ethical approval will be required for our main analytical datasets. Dissemination plans include academic publications, conference presentations, accessible policy briefings, mass media engagement and a project website. Both the syntax and the underlying synthetic data for the HEED microsimulation model will be made freely available through GitHub and the project website.

Unemployment and COVID-19-related mortality: a historical cohort study of 50,000 COVID-19 patients in Fars, Iran

OBJECTIVES

Previous studies have estimated the risk of death associated with unemployment in the coronavirus disease 2019 (COVID-19) pandemic, but no studies have examined unemployment before COVID-19 infection as a risk factor for COVID-19-related mortality. Thus, this study aimed to investigate COVID-19 mortality among this population.

METHODS

Data on 50,038 people aged 25-59 years were collected from 38 agencies in Fars Province, Iran, from February 2020 to July 2021. Follow-up lasted from participants' diagnosis with COVID-19 based on the results of a reverse transcription-polymerase chain reaction test to participants' death or the end of the study period. The association between unemployment and COVID-19-related mortality was estimated using the Poisson regression method, and a sensitivity analysis was conducted to calculate the E-value.

RESULTS

Unemployment was associated with a 2.41-fold (95% confidence interval [CI], 2.01 to 2.90) higher age-adjusted and sex-adjusted risk of COVID-19-related mortality. The adjusted Poisson regression analysis showed 8.82 (95% CI, 6.42 to 12.11), 2.84 (95% CI, 1.90 to 4.24), and 1.58 (95% CI, 1.24 to 2.01) times higher risks of COVID-19-related mortality among unemployed people aged 25-39 years, 40-49 years, and 50-59 years, respectively, than among their employed counterparts. Unemployment increased the risk of COVID-19 mortality by 3.31 (95% CI, 2.31 to 4.74) and 2.30 (95% CI, 1.86 to 2.84) times in female and male, respectively. The E-value was 3.43, reflecting the minimum strength of confounding required to shift the association between unemployment and COVID-19-related mortality toward the null.

CONCLUSIONS

Unemployment prior to COVID-19 infection increased the risk of COVID-19-related mortality. COVID-19-related mortality disproportionately impacted unemployed women and younger unemployed people.

A Global Meta-analysis of the Immigrant Mortality Advantage

A large body of research on the “Healthy Immigrant Effect” (or “Paradox”) has reported an immigrant mortality advantage. However, other studies do not find such significant effects, and some even present contradictory evidence. This article is the first systematic meta-analysis that investigates the immigration-mortality relationship from a global perspective, examining 1,933 all-cause and cardiovascular mortality risk estimates from 103 publications. Our comprehensive analysis allows us to assess interactions between origin and destination regions and to reexamine, on a global scale, some of the most notable explanations for the immigrant mortality advantage, including suggestions that this paradox may be primarily the result of selection effects. We find evidence for the existence of a mild immigrant mortality advantage for working-age individuals. However, the relationship holds only for immigrants who moved between certain world regions, particularly those who immigrated from Northern Africa, Asia, and Southern Europe to richer countries. The results highlight the need in the broader migration literature for an increased focus on selection effects and on outcomes for people who chose not to migrate or who were denied entry into their planned destination country.

Projected All-Cause Deaths Attributable to COVID-19-Related Unemployment in the United States

Objectives. To project the range of excess deaths potentially associated with COVID-19-related unemployment in the United States and quantify inequities in these estimates by age, race/ethnicity, gender, and education.Methods. We used previously published meta-analyzed hazard ratios (HRs) for the unemployment-mortality association, unemployment data from the Bureau of Labor Statistics, and mortality data from the National Center for Health Statistics to estimate 1-year age-standardized deaths attributable to COVID-19-related unemployment for US workers aged 25 to 64 years. To accommodate uncertainty, we tested ranges of unemployment and HR scenarios.Results. Our best estimate is that there will be 30 231 excess deaths attributable to COVID-19-related unemployment between April 2020 and March 2021. Across scenarios, attributable deaths ranged from 8315 to 201 968. Attributable deaths were disproportionately high among Blacks, men, and those with low education.Conclusions. Deaths attributable to COVID-19-related unemployment will add to those directly associated with the virus and will disproportionately burden groups already experiencing incommensurate COVID-19 mortality.Public Health Implications. Supportive economic policies and interventions addressing long-standing harmful social structures are essential to mitigate the unequal health harms of COVID-19.

Impact of Political Economy on Population Health: A Systematic Review of Reviews

Background. Although there is a large literature examining the relationship between a wide range of political economy exposures and health outcomes, the extent to which the different aspects of political economy influence health, and through which mechanisms and in what contexts, is only partially understood. The areas in which there are few high-quality studies are also unclear. Objectives. To systematically review the literature describing the impact of political economy on population health. Search Methods. We undertook a systematic review of reviews, searching MEDLINE, Embase, International Bibliography of the Social Sciences, ProQuest Public Health, Sociological Abstracts, Applied Social Sciences Index and Abstracts, EconLit, SocINDEX, Web of Science, and the gray literature via Google Scholar. Selection Criteria. We included studies that were a review of the literature. Relevant exposures were differences or changes in policy, law, or rules; economic conditions; institutions or social structures; or politics, power, or conflict. Relevant outcomes were any overall measure of population health such as self-assessed health, mortality, life expectancy, survival, morbidity, well-being, illness, ill health, and life span. Two authors independently reviewed all citations for relevance. Data Collection and Analysis. We undertook critical appraisal of all included reviews by using modified Assessing the Methodological Quality of Systematic Reviews (AMSTAR) criteria and then synthesized narratively giving greater weight to the higher-quality reviews. Main Results. From 4912 citations, we included 58 reviews. Both the quality of the reviews and the underlying studies within the reviews were variable. Social democratic welfare states, higher public spending, fair trade policies, extensions to compulsory education provision, microfinance initiatives in low-income countries, health and safety policy, improved access to health care, and high-quality affordable housing have positive impacts on population health. Neoliberal restructuring seems to be associated with increased health inequalities and higher income inequality with lower self-rated health and higher mortality. Authors' Conclusions. Politics, economics, and public policy are important determinants of population health. Countries with social democratic regimes, higher public spending, and lower income inequalities have populations with better health. There are substantial gaps in the synthesized evidence on the relationship between political economy and health, and there is a need for higher-quality reviews and empirical studies in this area. However, there is sufficient evidence in this review, if applied through policy and practice, to have marked beneficial health impacts. Public Health Implications. Policymakers should be aware that social democratic welfare state types, countries that spend more on public services, and countries with lower income inequalities have better self-rated health and lower mortality. Research funders and researchers should be aware that there remain substantial gaps in the available evidence base. One such area concerns the interrelationship between governance, polities, power, macroeconomic policy, public policy, and population health, including how these aspects of political economy generate social class processes and forms of discrimination that have a differential impact across social groups. This includes the influence of patterns of ownership (of land and capital) and tax policies. For some areas, there are many lower-quality reviews, which leave uncertainties in the relationship between political economy and population health, and a high-quality review is needed. There are also areas in which the available reviews have identified primary research gaps such as the impact of changes to housing policy, availability, and tenure.

The "Hispanic mortality paradox" revisited: Meta-analysis and meta-regression of life-course differentials in Latin American and Caribbean immigrants' mortality

The literature on immigrant health has repeatedly reported the paradoxical finding, where immigrants from Latin American countries to OECD countries appear to enjoy better health and greater longevity, compared with the local population in the host country. However, no previous meta-analysis has examined this effect focusing specifically on immigrants from Latin America (rather than Hispanic ethnicity) and we still do not know enough about the factors that may moderate the relationship between immigration and mortality. We conducted meta-analyses and meta-regressions to examine 123 all-cause mortality risk estimates and 54 cardiovascular mortality risk estimates from 28 publications, providing data on almost 800 million people. The overall results showed that the mean rate ratio (RR) for immigrants vs. controls was 0.92 (95% CI, 0.84-1.01) for all-cause mortality and 0.73 (CI, 0.67-0.80) for cardiovascular mortality. While the overall results suggest no immigrant mortality advantage, studies that used only native born persons as controls did find a significant all-cause mortality advantage (RR, 0.86; 95% CI, 0.76-0.97). Furthermore, we found that the relative risk of mortality largely depends on life course stages. While the mortality advantage is apparent for working-age immigrants, it is not significant for older-age immigrants and the effect is reversed for children and adolescents.

Unemployment is associated with lower cortisol awakening and blunted dehydroepiandrosterone responses

Previous research has investigated the endocrinological consequences of unemployment as a likely pathway behind chronic stress and negative health outcomes. Despite these early attempts at delineating the neuroendocrine consequences of the chronic stress experienced by the unemployed, identifying a consistent and stable effect has remained elusive. Here we sought to strengthen existing knowledge into the effect of the stress of employment status on cortisol by improving on the methodological weaknesses of earlier studies and extend this line of enquiry by measuring the steroid hormone Dehydroepiandrosterone-Sulfate (DHEAS). Saliva samples were collected from unemployed and employed participants at four time points across two days. As expected, unemployed people reported higher stress, lower social support and lower self-esteem. Unexpectedly, the unemployed showed lower overall cortisol output, a likely consequence of a higher cortisol awakening response (CAR) in the employed. However, they also had a higher DHEA output across the day, albeit the diurnal pattern across the day was more dysregulated compared to that seen in those employed with a blunted response evident in the evening; the cortisol:DHEAS ratio was also lower in the unemployed group. Further, these hormone differences were correlated with self-esteem and stress. Taken together these results suggest that the relationship between employment status and endocrine responses is far more complicated than previously thought. We have shown for the first time that unemployed people have a lower CAR, but also show a blunted DHEA response relative to those employed and we suggest that this may be a feature of chronic stress exposure or perhaps dependent on the prevailing socio-economic context.