The impact of employment transitions on health in Germany. A difference-in-differences propensity score matching approach

Impact of early economic activity loss on all-cause mortality in gastric cancer survivors following curative treatment: a nationwide study in Korea

BACKGROUND

The impact of economic engagement on the health of cancer survivors is notable. Our study aims to explore the association between early loss of economic activity (EA) and the risk of all-cause mortality among gastric cancer survivors.

METHODS

This retrospective cohort study utilized data from Korea's National Health Insurance Service, focusing on 30-59-year-old gastric cancer patients who received either surgery or endoscopic procedures from January 2009 to December 2013. The primary outcome measure was all-cause mortality. Early loss of EA was identified when a patient's insurance status shifted to dependent within one year following treatment. Adjusted hazard ratios (HRs) and 95% confidence intervals (CI) for all-cause mortality were estimated using multivariable Cox proportional hazards models, conducting separate analyses for surgical and endoscopic groups.

RESULTS

Among 24,159 patients (median follow-up, 9.9 years), 2976 (12.3%) experienced all-cause mortality. Specifically, 2835 of these deaths occurred in patients who underwent surgery, while 141 were in the endoscopic procedure group. Early loss of EA was recorded in 14.4% of the surgery group and 7.7% of the endoscopic procedure group. Adjusted HRs (95% CI) for all-cause mortality associated with early loss of EA were 1.39 (1.27-1.54) for the surgery group and 2.27 (1.46-3.52) for the endoscopic procedure group.

CONCLUSIONS

This study highlights a significant association between the early loss of EA and an increased risk of all-cause mortality in those who have undergone curative treatments for gastric cancer. It underscores the crucial role of sustaining EA in enhancing the health outcomes of these survivors.

Job Loss Due to COVID-19: A Longitudinal Study of Mental Health, Protective and Risk Factors

The COVID-19 pandemic had a devastating impact on unemployment, which-compounded by the additional stressors associated with the pandemic-had considerable mental health impact. The current study examined the trajectory of mental health amongst those experiencing pandemic-related job loss, alongside the impact of risk and protective factors. Data were obtained from 374 Australian participants who were allocated to a waitlist control arm of a randomised control trial. The outcome variables assessed at baseline and six-month follow-up consisted of depression, anxiety, and suicidality. The assessed risk and protective factors were age, gender, relationship status, education, exercise frequency, COVID-related stress, dispositional resilience, and coping self-efficacy. Re-employment by follow-up was used as a covariate. Overall, there were decreases in depression and anxiety symptoms, and partial evidence of decreased suicidality, demonstrating an apparent capacity for individuals to better cope with their circumstances over time. Demographics and exercise had no effect on changes in mental health. Those with high COVID-related stress, low resilience, and low coping self-efficacy had worse mental health at baseline, although exhibited significantly greater improvements in mental health over time. Obtaining re-employment by follow-up did not predict changes in mental health. The present results offer an optimistic picture of recovery for those experiencing pandemic-related job loss, even for those with the most substantial risk and severity. The likely protective role played by Australian social welfare policies over the course of the study is explored. Stress around one's broader sociocultural or economic circumstances, perceived resilience, and coping self-efficacy are valuable targets for intervention.

Novel Internet Support for Neck-Specific Rehabilitation Improves Work-Related Outcomes to the Same Extent as Extensive Visits to a Physiotherapy Clinic in Individuals with Chronic Whiplash-Associated Disorders: A Prospective Randomised Study

PURPOSE

To address the current lack of information about work-related factors for individuals with whiplash-associated disorders (WAD) we investigated the effectiveness of 3 months of neck-specific rehabilitation with internet support in combination with four physiotherapy visits (NSEIT) compared to the same exercises performed twice a week (24 times) at a physiotherapy clinic (NSE).

METHODS

This is a prospective, multicentre, randomised controlled trial regarding secondary outcomes of work-related factors in 140 individuals with chronic moderate/severe WAD with 3- and 15-month follow-up.

RESULTS

There were no group differences between NSE and NSEIT in the Work Ability Scale or work subscales of the Neck Disability Index, Whiplash Disability Questionnaire or Fear Avoidance Beliefs Questionnaire (FABQ-work). Both groups improved in all work-related outcome measures, except for FABQ-work after the 3-month intervention and results were maintained at the 15-month follow-up.

CONCLUSIONS

Despite fewer physiotherapy visits for the NSEIT group, there were no group differences between NSEIT and NSE, with improvements in most work-related measures maintained at the 15-month follow-up. The results of the present study are promising for those with remaining work ability problems after a whiplash injury. Protocol registered before data collection started: clinicaltrials.gov NCT03022812.

Examination of the structural components of the Abilitator-A self-report questionnaire on work ability and functioning aimed at the population in a weak labour market position

OBJECTIVES

According to the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) panel, structural validity describes how well Patient-Reported Outcome Measures' (PROM) scores reflect the dimensions of the measured construct. The main purpose of this study was to examine the structural components of the Abilitator, a co-developed self-report questionnaire on work ability and functioning for the population in a weak labour market position.

METHODS

We examined to what extent the Abilitator has reflective and formative elements in its five summary scales: "C. Inclusion", "D. Mind", "E. Everyday life", "F. Skills", and "G. Body". The Abilitator data sample (n = 4555, men 51%, mean age 37 years) was collected in 2017-2022 by the Finnish Institute of Occupational Health in cooperation with the European Social Fund Priority 5 projects in which the participants have multiple challenges to gain employment. For the structural components and validity analysis we implemented both Confirmatory Factor Analysis (CFA) and Exploratory Factor Analysis (EFA).

RESULTS

Based on the COSMIN criteria for structural validity, the Abilitator reached approximate model fit with CFA when we analysed the different concepts of the questionnaire separately rather than in one unified model. An exception was "E. Everyday life" which was a formative summary scale, and it did not reach approximate fit. EFA showed that the items in the Abilitator's summary scales loaded on ten factors.

CONCLUSIONS

The Abilitator had both reflective and formative elements in its structure. It reached structural validity in those separate concepts that were based on a reflective model. This study revealed interesting connections between different aspects of the Abilitator and produced valuable information for further modification of the questionnaire.

Understanding the association between county-level unemployment and health stratified by education and income in the southwestern United States

Past research on the relationship between unemployment rates and population health has produced mixed findings. The relationship can be influenced by the kinds of health outcomes observed, time frame, level of geographic aggregation, and other factors. Given these mixed findings, there is a need to add to our knowledge about how unemployment rates and population health are related. There is limited research that examines the association of unemployment rates with both physical and mental health, while simultaneously stratifying populations by income and education levels. Using survey-based self-reported data, this first population-based study examined the association between unemployment rates and physically and mentally unhealthy days in the southwestern United States, by county-level stratification of income (high and low) as well as education (high and low), from 2015 to 2019. After controlling for covariates, associations were modelled using negative binomial regression, with autocorrelative residuals, and were reported as rate ratios (RR). Overall, we found that a 1% rise in unemployment rates was significantly associated with an increase in physically unhealthy days [adjusted RR 1.007; 95% CI, 1.004-1.011, P < 0.001] and mentally unhealthy days [RR 1.006; 95% CI, 1.003-1.009, P  < 0.001]. Upon stratification, a significant risk was found among the high education and high income category [RR 1.035; 95% CI, 1.021-1.049, P  < 0.001], as well as for the high education and low income category [RR 1.026; 95% CI, 1.013-1.040, P  < 0.001]. A better understanding of how unemployment is associated with the health of communities with different education and income levels could help reduce the burden on society through tailored interventions and social policies not only in the United States, but also in other developed nations.

Labour market status and depression in Russia: A longitudinal study, 2011-2017

AIMS

This is the first longitudinal study to examine the relationship between depression and the labour market in Russia. Using data from 2011 to 2017, we identify the impact that not being in employment has on mental distress, and we explore the mechanism underlying the observed association.

METHODS

Using data from the Russia Longitudinal Monitoring Survey - Higher School of Economics, we employ random-effects regression models to estimate the impact of employment conditions on the likelihood of reporting mental distress in Russia. This method allows us to distinguish between the selection effect associated with mental distress and direct causation.

RESULTS

Controlling for a range of socio-economic and demographic characteristics, we find that unemployment and labour market inactivity are strong predictors of the likelihood of reporting depression and serious nervous breakdown. However, we find that rather than negative labour market events giving rise to mental distress, the selection effect actually dominates, and the direction of causality therefore operates in reverse.

CONCLUSIONS

Knowledge of the underlying mechanism that links unfavourable labour market outcomes with mental distress is crucial for designing policies that can address this link. We argue that our findings provide grounds for the initiation of anti-stigma campaigns among employers, policymakers, health practitioners and politicians as well as the general population. Eradication of the perception that mental disorders are somehow different to 'real' illnesses will not only prevent Russians from self-selection into unemployment but may also transform outdated approaches to mental health care in Russia.

Health and inclusive labour force participation

The future of work is rapidly changing, with higher flexibility of the labour market and increasing informal employment in many countries worldwide. There is also an increased pressure to extend working careers until older age. We introduce the concept of working life expectancy as a useful metric, capturing the expected numer of years in paid employment across the working age individuals, in particular among different groups. We describe factors that determine working life expectancy. Macro-level factors focus on the socioeconomic and political context that influences labour force participation, primarily policies and legislation in specific countries. At the meso level, employment contracts and working conditions are important. The micro level shows that individual characteristics, such as education, gender, and age, influence working careers. There are three important groups with a disadvantaged position in the labour market-workers with chronic diseases, workers with impairing disabilities, and workers aged 50 years or more. Within each of these disadvantaged groups, macro-level, meso-level, and micro-level factors that influence entering and exiting paid employment are discussed. To assure that paid employment is available for everyone of working age and that work contributes to better health, specific challenges need to be addressed at the macro, meso, and micro levels. To reach inclusive labour force participation, national policies, company practices, and workplace improvements need to be aligned to ensure safe and healthy workplaces that contribute to the health and wellbeing of workers and their communities.

Gender differences in mental health following the transition into parenthood: Longitudinal evidence from the UK

Previous studies have largely omitted a dynamic analysis of how the transition into parenthood shapes gender differences in mental health trajectories. This study adopts a life course approach to examine how transitioning into parenthood affects men's and women's mental health across multiple domains over time, using large-scale panel data from the 'UK Household Longitudinal Study' (2009-2020). Results from fixed effects models with discrete-time trends show that: (1) women's mental health is more largely affected by parenthood than men's; (2) women's overall mental health shows stable improvements following childbirth, while men's shows mostly insignificant changes; (3) role and social functioning are largely improved among women following childbirth, but only marginally among men; (4) emotional functioning and vitality demonstrate the counteracting effects of parenthood for both genders, with increases in feeling happy but a deterioration in feeling calm and having energy, particularly during care-intensive years; (5) women show larger variations by socioeconomic characteristics than men, with women from higher socioeconomic backgrounds and working full-time experiencing smaller mental health benefits from parenthood compared to less privileged women or having lower paid work constraints. Overall, transitioning to parenthood leads to distinct changes in mental health domains with heterogeneous effects across genders and socioeconomic groups.

Do development zones increase carbon emission performance of China's cities?

As a special industrial cluster policy, "development zones" (DZs) represent the growth poles of the regions in which they are located; in China, they fulfill the dual tasks of industrial upgrading and green transformation. While the existing literature has paid close attention to the economic effects of development zones, few efforts have been made to examine their climate effects. Therefore, in the context of China's efforts to achieve "carbon peaking and carbon neutrality", this paper for the first time provides evidence of the effect of development zones on urban carbon emission performance; it does this by constructing a difference-in-difference (DID) model, which is based on panel data for Chinese cities in the period 1997-2017. The findings of the study indicate that the establishment of development zones had a positive influence on urban carbon emission performance without time lag effects. Our heterogeneity analysis of city groups indicated that development zones located in eastern region, or in large or coastal cities, exerted a more significant impact. The mechanism analysis that we conducted demonstrates that development zones promote carbon emissions performance by increasing GDP and reducing carbon emissions. Finally, this paper puts forward a series of policy measures, which are intended to strengthen the environmental benefit of development zones within the context of an urban green transition.

Does a working day keep the doctor away? A critical review of the impact of unemployment and job insecurity on health and social care utilisation

While the negative impact of unemployment on health is relatively well established, the extent to which that impact reflects on changes in health and social care utilisation is not well understood. This paper critically reviews the direction, magnitude and drivers of the impact of unemployment and job insecurity on health and social care utilisation across different care settings. We identified 28 relevant studies, which included 79 estimates of association between unemployment/job insecurity and healthcare utilisation. Positive associations dominated mental health services (N = 8 out of 11), but not necessarily primary care (N = 25 out of 43) or hospital care (N = 5 out of 22). We conducted a meta-analysis to summarise the magnitude of the impact and found that unemployed individuals were about 30% more likely to use health services compared to those employed, although this was largely driven by mental health service use. Key driving factors included financial pressure, health insurance, social network, disposable time and depression/anxiety. This review suggests that unemployment is likely to be associated with increased mental health service use, but there is considerable uncertainty around primary and hospital care utilisation. Future work to examine the impact across other settings, including community and social care, and further explore non-health determinants of utilisation is needed. The protocol was registered in PROSPERO (CRD42020177668).

Health improvements of older adults based on benefit duration: Lessons from Korean social pension policies

The social pension, introduced in 2008 in Korea, has now become the most prominent old age income for most older adults. As of May 2022, it paid a monthly benefit of around USD 275 for 6.0 million older persons aged 65 and over who belong to the bottom 70% of the income and asset distribution. Although social pension's objectives focus on alleviating old age poverty and increasing income levels, it also encompasses a clear implication on health: social pension benefit can be spent on items or activities that improve the beneficiary's health. Using the Korean Longitudinal Study on Ageing data, between 2006 and 2018, and the Propensity Score Matching combined with Generalized Difference-In-Differences based on event study design, this study investigates the effects of receiving the social pension on objective measures of health that are representative of health and well-being in old age, by benefit duration. Study results showed that continually receiving social pension significantly improved beneficiaries' grip strength and cognitive ability. Grip strength was improved by 2.3-kg in the fifth year of receiving social pension. Additionally, the cognitive ability (K-MMSE score) was improved by 1.309 points in the first year. Results of descriptive analysis suggested that the social pension may have benefitted the health of the beneficiaries by improving their nutrition, health care utilization, and physical activities, and reducing financial strain and associated stress level. To the best of our knowledge, this is the first study to investigate the cumulative effects of nation-wide social pension programs on older adults' objective health measures by benefit duration up to five years, in a high-income country setting where old age income security systems are under-developed.

Work Ability After Anterior Cervical Decompression and Fusion Followed by a Structured Postoperative Rehabilitation: Secondary Outcomes of a Prospective Randomized Controlled Multi-Centre Trial with a 2-year Follow-up

Purpose Information on work ability after ACDF and postoperative rehabilitation is lacking. The aim of the present study is therefore to investigate the work ability benefits of a structured postoperative treatment (SPT) over a standard care approach (SA) in patients who underwent anterior cervical decompression and fusion (ACDF) for cervical radiculopathy and factors important to the 2-year outcome. Methods Secondary outcome and prediction model of a prospective randomized controlled multi-centre study with a 2-year follow-up (clinicaltrials.gov NCT01547611). The Work Ability Index (WAI) and Work Ability Score (WAS) were measured at baseline and up to 2 years after ACDF in 154 patients of working age who underwent SPT or SA after surgery. Predictive factors for the WAI at 2 years were analysed. Results Both WAI and WAS significantly improved with SPT and SA (p < 0.001), without any between-group differences. Thoughts of being able to work within the next 6 months, Neck Disability Index (NDI), and work-related neck load explained 59% of the variance in WAI at the 2-year follow-up after ACDF. Conclusions Patients improved over time without group differences, suggesting the improvement to be surgery related. Expectation to work within the next 6 months, self-reported neck functioning and work-related neck load were important to work ability and are central factors to ask early after ACDF, to identifying further interventions promoting return to work.

Job loss and psychological distress during the COVID-19 pandemic: Longitudinal Analysis from residents in nine predominantly African American low-income neighborhoods

While psychological distress is a common sequelae of job loss, how that relationship continued during the COVID-19 pandemic is unclear, for example, given higher health risk to working due to disease exposure. This paper examines changes in psychological distress depending on job loss among a cohort of randomly selected residents living in nine predominantly African American low-income neighborhoods in Pittsburgh PA across four waves between 2013 and 2020. Between 2013 and 2016, we found an increase in psychological distress after job loss in line with the literature. In contrast, between 2018 and 2020 we found change in psychological distress did not differ by employment loss. However, residents who had financial concerns and lost their jobs had the largest increases in psychological distress, while residents who did not have serious financial concerns-potentially due to public assistance-but experienced job loss had no increase in distress, a better outcome even than those that retained their jobs. Using partial identification, we find job loss during the pandemic decreased psychological distress for those without serious financial concerns. This has important policy implications for how high-risk persons within low-income communities are identified and supported, as well as what type of public assistance may help.

Did the Integrated Urban and Rural Resident Basic Medical Insurance Improve Benefit Equity in China?

OBJECTIVES

The reform of merging 2 major health insurance schemes into Urban and Rural Resident Basic Medical Insurance (URRBMI) is recognized as a vital step to safeguard equal healthcare and benefit to each enrollee in China. Against this backdrop, this article aims to evaluate the impact of URRBMI integration on benefit and its contribution to benefit equity.

METHODS

The data of this study were derived from the China Health and Retirement Longitudinal Study 2011 and 2015. A total of 11 383 individuals were included in the final sample. Coarsened exact matching with difference-in-difference approach was firstly adopted to investigate the treatment effects of URRBMI on benefits. Next, the decomposition of concentration index (CI) was conducted to explore the contribution of URRBMI to benefit equity.

RESULTS

The coarsened exact matching with difference-in-difference results revealed that the consolidation of URRBMI has significantly improved outpatient benefit. The decomposition results showed that the contribution rates of URRBMI scheme to outpatient benefit rate (CI -0.0114), benefit probability (CI 0.0673), compensation fee (CI 0.0076), and reimbursement ratio (CI 0.0483) were 11.26%, -3.38%, -7.67%, and -0.81%, suggesting that this reform makes contribution to the propoor inequity in the outpatient benefit rate and relieves the prorich inequity in outpatient benefit probability and the degree of benefits.

CONCLUSIONS

The findings of this study provide novel evidence of enhanced benefits and benefit equity for outpatient care with the integration of URRBMI. Further efforts should be made to the expansion of URRBMI coverage and the elimination of income disparities that affecting benefit equity.

Moving Back to the Parental Home in Times of COVID-19: Consequences for Students' Life Satisfaction

Residential independence from parents is a key marker for young adults' transition to adulthood. Losing this independence by returning to the parental home marks a regression of adult development with negative implications for returnees' subjective wellbeing. This paper investigates how a return to the parental home during the COVID-19 pandemic affects the life satisfaction of university students. We used nationwide survey data from German university students (N = 913) to analyze differences in life satisfaction for those who did or did not return to their parental homes. Our results revealed two main findings. First, university students who moved back to their parental home reported significantly lower life satisfaction than those who remained living independently. Second, the association between moving back and life satisfaction varied by age. A return to the parental home was more detrimental to older students' life satisfaction, while students aged 24 or younger did not experience a significant decrease when moving back to the parental home. We discuss the implications of our findings in the context of young adults' subjective wellbeing during the COVID-19 pandemic.

Examining the impact of employment status on sleep quality during the COVID-19 pandemic in two low-income neighborhoods in Pittsburgh, PA

STUDY OBJECTIVES

African Americans have faced disproportionate socioeconomic and health consequences associated with the COVID-19 pandemic. The current study examines employment and its association with sleep quality during the initial months of the pandemic in a low-income, predominantly African American adult sample.

METHODS

In the early months of COVID-19 (March to May 2020), we administered a survey to an ongoing, longitudinal cohort of older adults to assess the impact of COVID-related changes in employment on self-reported sleep quality (N = 460; 93.9% African American). Participants had prior sleep quality assessed in 2018 and a subset also had sleep quality assessed in 2013 and 2016. Primary analyses focused on the prevalence of poor sleep quality and changes in sleep quality between 2018 and 2020, according to employment status. Financial strain and prior income were assessed as moderators of the association between employment status and sleep quality. We plotted trend lines showing sleep quality from 2013 to 2020 in a subset (n = 339) with all four waves of sleep data available.

RESULTS

All participants experienced increases in poor sleep quality between 2018 and 2020, with no statistical differences between the employment groups. However, we found some evidence of moderation by financial strain and income. The trend analysis demonstrated increases in poor sleep quality primarily between 2018 and 2020.

CONCLUSIONS

Sleep quality worsened during the pandemic among low-income African American adults. Policies to support the financially vulnerable and marginalized populations could benefit sleep quality.

Dissolution of Non-cohabiting Relationships and Changes in Life Satisfaction and Mental Health

This study investigates how individuals' life satisfaction and depression are affected by the dissolution of a steady non-cohabiting intimate relationship. Previous studies have focused more on the consequences of divorce and less on the influence of non-cohabiting relationships on the well-being of the individual. The data for this study were taken from pairfam, a large-scale German panel survey, and were used to estimate fixed-effects panel regression models and impact functions to identify the overall effect of dissolution and trajectories after separation. The study sample comprised 2,631 individuals who were observed over the course of 11,219 partnership years. Based on the results of this study, three main findings were reported. First, the dissolution of a non-cohabiting relationship led to a significant decline in mental health and life satisfaction. Second, the trajectories after dissolution suggest that the decline was only temporary, showing readjustment after 1 year. Third, gender differences were identified, suggesting worse consequences for men who experienced a significant decline in both dimensions and did not readjust in life satisfaction until several years after the dissolution. For women, decreases were only found for life satisfaction, but quick readjustments were observed.

The Effect of China’s Two-Child Policy on the Child Sex Ratio: Evidence From Shanghai, China

Objective: The bias towards males at birth has resulted in a major imbalance in the Chinese sex ratio that is often attributed to China’s one-child policy. Relaxation of the one-child policy has the potential to reduce the imbalance in the sex ratio away from males. In this study, we assessed whether the bias towards males in the child sex ratio was reduced as a result of the two-child policy in China. Medical records data from one large municipal-level obstetrics hospital in Shanghai, East China. Design: Matching and difference-in-differences (MDID) techniques were used to investigate the effect of the two-child policy on the imbalance in the sex ratio at birth after matching for pregnancy status and socioeconomic factors. Results: Analyzing 133,358 live births suggest that the relaxation of the one-child policy had a small, but statistically significant effect in reducing the imbalance in the male to female sex ratio at birth. Conclusion: The results demonstrate that relaxation of the one-child policy reduced the imbalance in the male to female sex ratio at birth from 1.10 to 1.05 over the study period at one of the major obstetrics and gynecology hospitals in China.

The association between unemployment trajectories and alcohol consumption patterns. Evidence from a large prospective cohort in The Netherlands

Unemployment is expected to influence alcohol consumption, but studies show mixed results, partly because most studies concentrate on current employment status. However, unemployment could be particularly consequential if it is part of a trajectory of employment precariousness. Moreover, the association between unemployment and alcohol consumption may not be homogeneous across the population, but differ by subgroups (e.g. socioeconomic status). This study longitudinally analyses the association between different employment trajectories and alcohol consumption, and examines if the association is moderated by socioeconomic status (SES), partner status, age and gender. Four waves of data of the Lifelines Cohort study are used. Sample consists of individuals from 18-50 years old, active in the labor market (n = 104,766) from the northern provinces of the Netherlands. Employment trajectories are defined by employment status in each wave, duration of unemployment, and number of exposures to unemployment. Drinking patterns are divided into "abstainers", "moderate drinking" (<1.5 drinks/day), "heavy drinking" (≥1.5 drinks/day) and "binge drinking" (≥5 drinks/occasion; 4 for women). The associations are estimated with multinomial logistic regression models. Results show that recent, long-term unemployment (≥ 6 months) is associated with higher rates of heavy drinking (RRR = 1.26 [95 % CI 1.03-1.54]), whereas short-term unemployment does not show any association with the outcome. Being continuously unemployed throughout the observation period shows a strong association with binge drinking (RRR = 1.43 [95 % CI 1.06-1.93]), as well as reporting 2 or more long unemployment spells (RRR = 1.49 [95 % CI 1.21-1.83]). The group of abstainers (77.95 % women) have significantly lower SES, and poorer health than their peers. For some individuals, recent unemployment increases the likelihood for abstinence (RRR = 1.23 [95 % CI 1.00-1.51]). Evidence suggests that length of unemployment is key in order to grasp its effects in terms of changing drinking patterns.

Payment mechanism and hospital admission: New evidence from Thailand healthcare reform

In 2007, Thailand's Civil Servant Medical Benefit Scheme (CSMBS), one of the three main public health insurers, adopted a new payment mechanism for hospital admission. There has been a shift from fee-for-service toward Diagnostic Related Group (DRG)-based payment that transfers financial risk from the government to health care providers. This study investigates the effects of this policy change on hospital admission, frequency of admission, length of stay (LOS), type of hospital admitted, and out-of-pocket (OOP) inpatient medical expenditure. By employing nationally representative micro-level data (Health and Welfare surveys) and difference-in-difference approach, this study finds a 1 percentage point decline in hospitalization, a 10% higher chance of admission at community hospitals (the lowest level inpatient public health care facility), and a 7% less chance of admission at higher level public health care facilities like general hospitals. No significant change was observed in LOS, frequency of admission, or OOP inpatient medical expenditure associated with the post-2007 payment mechanism change. Our results emphasize the effectiveness of a close-ended payment mechanism for health care in developing countries. This study also adds to the limited literature on using micro-level data to investigate payment mechanism change in the context of low- and middle-income countries.

The mark of mental health problems. A field experiment on hiring discrimination before and during COVID-19

Mental health problems are associated with poor labour market outcomes. Based on data from a field experiment, this article investigates the extent to which hiring discrimination limits the job opportunities of young applicants who disclose a history of mental health problems. From September 2019 to December 2020, 1398 job applications were sent in pairs to 699 employers with job openings in a broad selection of occupations in the Norwegian labour market. The applicants were equally qualified except that, in each pair, one applicant informed about mental health problems as an explanation for a past employment break. The results show that applicants who disclose mental health problems are discriminated against in hiring processes. Applicants with mental health problems have about 27% lower probability of receiving an invitation to a job interview and about 22% lower probability of receiving any positive employer response. These results do not seem to have been driven by the COVID-19 crisis that unfolded during the course of the study. As such, the study provides suggestive evidence that uncertain economic times might not necessarily increase the level of discrimination against applicants with mental health problems.

Evaluation of a health-related intervention to reduce overweight, obesity and increase employment in France and the United Kingdom: a mixed-methods realist evaluation protocol

Background

Obesity, overweight and unemployment are interlinked, with debilitating effects on mortality, health, wellbeing and quality of life. Existing interventions to reduce overweight, obesity and unemployment have addressed these challenges independent of each other with limited success. The Adding to Social capital and individual Potential In disadvantaged REgions (ASPIRE) project will develop an innovative model using a combination of skills training and health and wellbeing interventions to improve health, wellbeing, quality of life and reduce overweight, obesity and unemployment in England and France. The aim of this paper is to outline the protocol for evaluating the ASPIRE project to examine the effectiveness of the intervention and clarify the mechanisms and contextual factors which interact to achieve outcomes.

Methods

A mixed-method realist evaluation using a single-group before-and-after design will be used. The evaluation will consist of development of an initial programme theory, theory validation and refinement using quantitative and qualitative data to understand the causal mechanisms, contexts of implementation and their interactions that result in outcomes observed in ASPIRE. Primary outcomes that will be assessed are change in body weight and body mass index, reemployment and a rise on the ASPIRE participation ladder. The ASPIRE participation ladders consists of a series of 5 steps to engage participants in the project. The first step on the ladder is joining an ASPIRE hub with paid employment as the final step on the ladder. Secondary outcomes will be physical activity, diet quality, self-efficacy and health-related quality of life. Both quantitative and qualitative approaches are appropriate in this study because the use of validated questionnaires and objective measures will demonstrate how much the intervention addressed outcomes related to weight loss and reemployment and the qualitative data (photovoice) will provide insights into the contexts and experiences that are unique to participants in the project.

Discussion

The results from this evaluation will provide an understanding of how a model of health-related interventions which improve health, wellbeing and maintenance of a healthy lifestyle could reduce overweight, obesity and unemployment. The findings will enable the adaptation of this model for effective implementation in different contexts and circumstances.

Trial registration

ISRCTN registry: Study ID: ISRCTN17609001, 24th February 2021 (Retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10523-3.

Billing system and health care utilization: Evidence from Thailand

We examined the role of billing processes in health care utilization by exploiting a shift in provider payment from fee-for-service reimbursement towards fee-for-service direct disbursement for outpatient services in Thailand. Specifically, prior to October 2006, affected patients had to pay the full cost of outpatient treatment and subsequently received reimbursement; thereafter, these payments can be sent directly to the providers, without patients having to pay anything upfront. By using nationally representative micro-data and a difference-in-difference methodology, we show that the direct disbursement policy leads to an increase in outpatient utilization among the sick. This non-price change has long-lasting impacts and particularly increases the health care utilization of sick individuals who are living in rural areas, are less educated and earn low incomes. These findings suggest that direct disbursement helps to increase liquidity constraint individuals' health care utilization. The results emphasize the effectiveness of behavioural interventions in health policy making.

The effect of tobacco- and alcohol-control policies on household spending patterns in Kenya: An approach using matched difference in differences

This paper examines the effect of tobacco and alcohol control policies on tobacco and alcohol consumption patterns and the evolution of crowding-out effects on other household expenditure in Kenya. The current literature on crowding-out does not provide a defensible instrumental variable for a system of demand equations. This paper uses Matched Difference in Differences (MDID) as an alternative strategy and data from two nationally representative surveys in Kenya conducted ten years apart (2005/6 and 2015/16). We find that tobacco-control policies contributed to a decrease in the proportion of tobacco-consuming households between 2005 and 2015. Alcohol-control policies were only effective in reducing the proportion of alcohol-consuming households in the bottom quartile of the expenditure distribution. Overall, tobacco-consuming households spent less on education, communication, and some food items. Alcohol-consuming households also spent less on some food items, but expenditure on transportation was the only non-food item crowded out. Tobacco and alcohol control policies, when they result in reduced consumption of these products, can increase household expenditure on human capital development in the long run.

Assessing the impact of a doctor in remote areas of Brazil

OBJECTIVES

The More Doctors Program (MDP) is an ongoing Brazilian policy that aims to improve healthcare by providing physicians to the most vulnerable municipalities. We aimed to measure the impact of MDP in mortality and infant mortality rate, the proportion of live births with low weight, prenatal appointments, childbirths at first and fifth min Apgar, public health investment and immunization in Brazil.

METHODS

Municipal health indicators were collected before and after the intervention (2012 and 2015). Effects were measured by applying propensity score matching with difference-in-differences.

RESULTS

Our findings show that infant mortality presented the highest improvement during the period (a decrease in 11 infant deaths per 1000 live births, p < 0.01). A significant effect, albeit smaller, was also found for the age-standardized total mortality (a decrease in five deaths per 10,000 residents), proportion of children with Apgar score lower than 8 in the fifth min and children with low birth weight.

CONCLUSIONS

MDP contributed to improve important health indicators, highlighting the importance of a doctor in remote areas of Brazil.

Educational Leave as a Time Resource for Participation in Adult Learning and Education (ALE)

The study investigates effects of the implementation of a law authorizing educational leave in Germany on individual participation in adult learning and education (ALE). In 2015, the federal state of Baden-Württemberg introduced the so-called Bildungszeitgesetz, legitimating an exemption for eligible employees of up to 5 days per year with continued payment of salary. Explaining participation in ALE is a central subject of educational research at national and international level. Current theoretical assumptions of rational choice and empirical findings of educational and socio-statistical research suggest that within the general population, individuals’ availability of time affects the decision to participate and therefore lastly determines participation in ALE. However, current academia mainly discusses time as either a prerequisite for learning activities or as an observable outcome of participation and not as an explanatory factor. Furthermore, since recent studies remain on a descriptive level regarding influences of time on participation in ALE, no causal effects of the availability of time on participation are estimated. Hence, our study addresses this research gap by investigating effects of educational policy interventions such as the Bildungszeitgesetz on participation in ALE. Policy interventions are ideally suited to examine the significance of time resources for participation, as the implementation of the Bildungszeitgesetz provides a specific timeframe for employees to participate in ALE outside of their working time. Drawing on data from the German National Educational Panel Study, we employ a difference-in-differences estimation strategy with propensity score matching and instrumental variable to identify the direct causal effect of the implementation of the Bildungszeitgesetz on participation in ALE (N = 709). This combination toward causal inference controls for observed and unobserved baseline differences as well as heterogeneous treatment effects. The results reveal a non-significant but heterogeneous treatment effect of the implementation of the Bildungszeitgesetz on individual participation in ALE. Contrary to our theoretical assumptions derived from rational choice approaches, we cannot confirm the hypothesis that the availability of time resources due to the implementation of the Bildungszeitgesetz causes a positive effect on participation in ALE. Furthermore, the results reveal that the implementation causes decreasing participation rates for younger adults, women and significantly for migrants.

The role of social integration in the adverse effect of unemployment on mental health - Testing the causal pathway and buffering hypotheses using panel data

Social integration is considered crucially important for understanding the adverse effect of unemployment on mental health. Social integration is assumed to either bring about the health effects of unemployment (causal pathway hypothesis) or shield the unemployed from such effects (buffering hypothesis). However, there is scarce empirical evidence, especially based on panel data, regarding these two hypotheses. In our analysis, we use up to ten waves of the "Labour Market and Social Security" (PASS) German panel study and apply fixed effects panel regressions to account for unobserved confounders. We test several indicators that cover different aspects of social integration (numbers of strong and weak ties, conflict in the household, employed friends, general and job search-specific social support). We find no empirical support for the causal pathway hypothesis and only very limited support for the buffering hypothesis.

Health-improving interventions for obtaining employment in unemployed job seekers

BACKGROUND

Unemployment is associated with decreased health which may be a reason or a consequence of becoming unemployed. Decreased health can inhibit re-employment.

OBJECTIVES

To assess the effectiveness of health-improving interventions for obtaining employment in unemployed job seekers.

SEARCH METHODS

We searched (3 May 2018, updated 13 August 2019) the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, PsycINFO, CINAHL, SocINDEX, OSH Update, ClinicalTrials.gov, the WHO trials portal, and also reference lists of included studies and selected reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of the effectiveness of health-improving interventions for obtaining employment in unemployed job seekers. The primary outcome was re-employment reported as the number or percentage of participants who obtained employment. Our secondary outcomes were health and work ability.

DATA COLLECTION AND ANALYSIS

Two authors independently screened studies, extracted outcome data, and assessed risk of bias. We pooled study results with random-effect models and reported risk ratios (RRs) with 95% confidence intervals (CIs) and assessed the overall quality of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

We included 15 randomised controlled trials (16 interventions) with a total of 6397 unemployed participants. Eight studies evaluated therapeutic interventions such as cognitive behavioural therapy, physical exercise, and health-related advice and counselling and, in seven studies, interventions were combined using therapeutic methods and job-search training. Therapeutic interventions Therapeutic interventions compared to no intervention may increase employment at an average of 11 months follow-up but the evidence is very uncertain (RR = 1.41, 95% CI 1.07 to 1.87, n = 1142, 8 studies with 9 interventions, I² = 52%, very low-quality evidence). There is probably no difference in the effects of therapeutic interventions compared to no intervention on mental health (SMD 0.12, 95% CI -0.06 to 0.29, n = 530, 2 studies, low-quality evidence) and on general health (SMD 0.19, 95% CI -0.04 to 0.41, n = 318, 1 study, moderate-quality evidence). Combined interventions Combined interventions probably increase employment slightly compared to no intervention at an average of 10 months follow-up (RR 1.12, 95% CI 1.06 to 1.20, n = 4101, 6 studies, I² = 7%). There were no studies that measured work-ability, adverse events, or cost-effectiveness.

AUTHORS' CONCLUSIONS

Interventions combining therapeutic methods and job-search training probably have a small beneficial effect in increasing employment. Therapeutic interventions may have an effect on re-employment, but we are very uncertain. Therapeutic interventions may not improve health in unemployed job seekers. Large high-quality RCTs targeting short-term or long-term unemployed people are needed to increase the quality of the evidence. A cost-effectiveness assessment is needed of the small beneficial effects.

The effect of welfare reform on the health of the unemployed: evidence from a natural experiment in Germany

BACKGROUND

Over the past several decades, governments have enacted far-reaching reforms aimed at reducing the generosity and coverage of welfare benefits. Prior literature suggests that these policy measures may have deleterious effects on the health of populations. In this study, we evaluate the impact of one of the largest welfare reforms in recent history-the 2005 Hartz IV reform in Germany-with a focus on estimating its effect on the health of the unemployed.

METHODS

We employed a quasi-experimental difference-in-differences (DID) design using population-based data from the German Socio-Economic Panel Study, covering the period between 1994 and 2016. We applied DID linear probability modelling to examine the association between the Hartz IV reform and poor self-rated health, adjusting for a range of demographic and socioeconomic confounders.

RESULTS

The Hartz IV reform was associated with a 3.6 (95% CI 0.9 to 6.2) percentage point increase in the prevalence of poor self-rated health among unemployed persons affected by the reform relative to similar but unaffected controls. This negative association appeared immediately following the implementation of the reform and has persisted over time.

CONCLUSION

Governments in numerous European and North American jurisdictions have introduced measures to further diminish the generosity and coverage of welfare benefits. In line with growing concerns over the potential consequences of austerity and associated policy measures, our findings suggest that these reform efforts pose a threat to the health of socioeconomically disadvantaged populations.

Intergenerational educational mobility and health satisfaction across the life course: Does the long arm of childhood conditions only become visible later in life?

The contemporaneous association of socioeconomic status (SES) with health is well-established, whereas much less is known about the health-related effects of social mobility (i.e., movements across different SES). This study investigates the impact of SES in childhood and adulthood on health satisfaction across the life course. Using data from the German Socio-Economic Panel (SOEP) and education as a central marker of SES, we test whether parental education (i.e., childhood SES) affects adult health satisfaction, directly and/or indirectly through own educational attainment (i.e., adult SES) as a mediating variable. Moreover, we apply diagonal reference models to disentangle the independent effect of intergenerational educational mobility. Our findings show that parental education has both direct and indirect effects. Yet, the relative weight of parents' education as a predictor of health satisfaction is found to depend on when in the life course health satisfaction is measured: parental education shows an increasing relevance as a predictor of health satisfaction at higher ages. On top of (additive) effects of parental and own education, we find significant mobility effects in earlier adulthood: upward educational mobility is conducive to health satisfaction and the reverse for downward educational mobility.

Impact of unemployment on self-perceived health : Evidence from French panel data

This article investigates the impact of unemployment on self-perceived health using the French Longitudinal Labour Force Survey over the period 2013-2016. We apply a difference-in-difference propensity score matching approach to identify the health effect of unemployment. By combining both methods, we minimise selection bias and remove unobserved individual fixed effects that are time-invariant as well as common period effects. In the French context, characterised by high and persistent unemployment and relatively long unemployment spells, we show that the experience of unemployment has no significant effect on self-perceived health. Moreover, we find no heterogenous effect by carrying out separate analyses by age, gender, marital status, education, occupation, employment contract, local unemployment rate, or past labour market history. Robustness checks, performed by testing alternative types of matching technology, different definitions of the unemployment experience, and other measures of health confirm our findings. Health selection and confounding factors appear to be important determinants of the cross-sectional association between unemployment and poor health.

The effects of prolonged working life on subjective quality of life across Europe

This paper examines the effect of prolonged working careers on subjective quality of life (QoL) in four European regions. The paper tests a basic assumption of the role accumulation theory and the active ageing approach that additional roles, including prolonged working careers, are beneficial for the quality of life of older people. The propensity score matching method was used on data from the Survey of Health, Ageing and Retirement in Europe (SHARE) for four European regions with distinctive economic, institutional, and cultural contexts connected to paid work. The context-sensitive effects of prolonged labour force participation on QoL as a whole, control, and pleasure are positive in regions in which financial need serves as a more important motivation to work than nonmaterial need. In contrast, the effects on QoL as a whole and autonomy are negative in wealthier and more developed European regions. The paper concludes that the main motivation for prolonged working careers seems to be to avoid deteriorating living standards; satisfactory retirement conditions should thus be an aim complementary to incentives for those who are willing and able to work longer.

The impact of employment protection on health: Evidence from fixed-term contract workers in South Korea

In this paper, we examine the impact of increased employment protection on the self-rated health of workers. We utilize the recent labor reform in South Korea which sharply increased the employment protection level of fixed-term contract workers meeting certain criteria. By applying a difference-in-differences framework to longitudinal data, we explore the causal impact of employment protection. We find that subjective health and perceived job security improved with increased statutory employment protection. Further analysis suggests that the improvement in subjective health is less likely to be driven by improvement in working conditions or health related behaviors.

Single transitions and persistence of unemployment are associated with poor health outcomes

Background

Although job loss has been associated with decline in health, the effect of long term unemployment is less clear and under-researched. Furthermore, the impact of an economic recession on this relationship is unclear. We investigated the associations of single transitions and persistence of unemployment with health. We subsequently examined whether these associations are affected by the latest recession, which began in 2008.

Methods

In total, 57,911 participants from the Dutch Health Interview Survey who belonged to the labour force between 2004 and 2014 were included. Based on longitudinal tax registration data, single employment transitions between time point 1 (t1) and time point 2 (t2) and persistent unemployment (i.e. number of years individuals were unemployed) between t1 and time point 5 (t5) were defined. General and mental health, smoking and obesity were assessed at respectively time point 3 (t3) and time point 6 (t6). Logistic regression models were performed and interactions with recession indicators (year, annual gross domestic product estimates and regional unemployment rates) were tested.

Results

Compared with individuals who stayed employed at t1 and t2, the likelihood of poor mental health at the subsequent year was significantly higher in those who became unemployed at t2. Persistent unemployment was associated with poor mental health, especially for those who were persistently unemployed for 5 years. Similar patterns, although less pronounced for smoking, were found for general health and obesity. Indicators of the economic recession did not modify these associations.

Conclusions

Single transitions into unemployment and persistent unemployment are associated with poor mental and general health, obesity, and to a lesser extend smoking. Our study suggests that re-employment might be an important strategy to improve health of unemployed individuals. The relatively extensive Dutch social security system may explain that the economic recession did not modify these associations.

Mental health literacy and help-seeking among unemployed people with mental health problems

Background: Unemployed people with mental health problems often do not use available mental health services. Help-seeking may depend on knowledge, recognition and attitudes associated with mental health - a concept referred to as mental health literacy (MHL).Aim: To investigate the influence of MHL on help-seeking intentions and behaviors among unemployed individuals with mental health problems.Methods: A total of 301 unemployed individuals with mental health problems were recruited mainly from employment agencies in Southern Germany. MHL was assessed by the Mental Health Knowledge Schedule (MAKS), the Depression Literacy Scale (DLS), and the Depression with Suicidal Thoughts Vignette. Help-seeking intentions and behaviors were measured using the General Help-Seeking Questionnaire (GHSQ). Associations between MHL and help-seeking intentions and behaviors were tested using regression analyses and structural equation modeling (SEM).Results: All three MHL scales were significantly positively associated with help-seeking intentions and behaviors. In our SEM model, greater MHL was significantly associated with increased intentions and behaviors to seek help from health professionals (formal help) and from family and friends (informal help).Conclusions: Among unemployed persons with mental health problems, programs to improve MHL could facilitate formal as well as informal help-seeking. Future research should examine the efficacy of MHL-interventions to increase help-seeking.

Vocational Rehabilitation of Young Adults with Psychological Disabilities

Objective Vocational rehabilitation measures support youth and young adults with disabilities to obtain vocational training and to enter the labor market. In Germany, a growing number of young people with psychological disabilities in vocational rehabilitation can be observed. The study at hand focuses on this group and examines their (un-)unemployment biographies before vocational rehabilitation, their access to vocational rehabilitation and identifies their individual challenges within the process of vocational rehabilitation. Methods Using a multi-methods approach, we analyze representative administrative data of the German Federal Employment Agency as well as biographical interviews conducted with young rehabilitants. We compare the population of young rehabilitants with psychological disorders to those with other disabilities in terms of vocational rehabilitation and initial labor market entry in order to get a representative picture about their school to work transitions. Since rehabilitants with psychological disabilities tend to be older than the remaining population, analyses are stratified by age groups. In addition, qualitative in-depth interviews provide an additional and deeper understanding of specific employment barriers youth with psychological disorders have to overcome. Furthermore, the individual perspective gives insight on how the crucial transition from school to work is perceived by the population under study. Results The pathway into vocational rehabilitation of youth with psychological disorders is often characterized by obstacles in their transition from school to work. During rehabilitation, it appears essential to provide psychological stabilization along with vocational training. Although their average level of education is higher than those of other rehabilitants, labor market transition after (often company-external) vocational training challenges many young people with psychological disabilities, leaving many of them with comparatively poor labor market prospects. Conclusions Young persons with psychological disabilities, who come from regular schools or dropped out from regular school or university, seem to find their way to vocational rehabilitation more indirectly. Furthermore, vocational rehabilitation itself is often prolonged for those with psychological disabilities possibly due to a corresponding stabilization process. However, vocational rehabilitation can be a core element within the stabilization process of a psychological disease.

Effect of integrated urban and rural residents medical insurance on the utilisation of medical services by residents in China: a propensity score matching with difference-in-differences regression approach

OBJECTIVES

In this study, we aim to evaluate the effect of urban and rural resident medical insurance scheme (URRMI) on the utilisation of medical services by urban and rural residents in the four pilot provinces.

SETTING AND PARTICIPANTS

The sample used in this study is 13 305 individuals, including 2620 in the treatment group and 10 685 in the control group, from the 2011 and 2015 surveys of China Health and Retirement Longitudinal Study.

OUTCOME MEASURES

Propensity score matching and difference-in-differences regression approach (PSM-DID) is used in the study. First, we match the baseline data by using kernel matching. Then, the average treatment effect of the four outcome variables are analysed by using the DID model. Finally, the robustness of the PSM-DID estimation is tested by simple model and radius matching.

RESULTS

Kernel matching have improved the overall balance after matching. The URRMI policy has significantly reduced the need-but-not outpatient care and significantly increased outpatient care cost and inpatient care cost for rural residents, with DID value of -0.271, 0.090 and 0.256, respectively. After robustness test, the DID competing results of four outcome variables are consistent.

CONCLUSIONS

URRMI has a limited effect on the utilisation of medical and health services by all residents, but the effect on rural residents is obvious. The government should establish a unified or income-matching payment standard to prevent, control the use of medical insurance funds and increase its efforts to implement URRMI integration in more regions to improve overall fundraising levels.

Unemployment, unemployment duration, and health: selection or causation?

This study aims at disentangling the causal effects of unemployment on physical and mental health from the selection of the unhealthy into unemployment. To identify causal effects, it explores hypotheses concerning how physical and mental health deterioration gain additional momentum with a longer duration of unemployment. In contrast, mere selection into unemployment implies time-constant effects of unemployment on physical and mental health. Fixed-effects models are applied to data from the German Socio-Economic Panel (GSOEP, 2002-2014, 74,572 observations). Pointing at causal effects of unemployment, the findings show that physical health does not deteriorate before, during or immediately after the period in which individuals lose their jobs, but that deterioration gains momentum later. The effect further depends on age at transition to unemployment. In contrast, a large part of the poorer mental health of the unemployed might be due to the selection of the unhealthy into unemployment; mental health declines even before job loss. Only for people who experience unemployment early in life, mental health deterioration gains some momentum in the time after the transition, indicating a (weak) causal effect of unemployment on mental health for younger individuals.

The association between unemployment and depression-Results from the population-based LIFE-adult-study

BACKGROUND

Unemployment is a risk factor for impaired mental health. Based on a large population-based sample, in this study we therefore sought to provide detailed information on the association between unemployment and depression including information on (i) differences between men and women, (ii) differences between different types of unemployment, and (iii) on the impact of material and social resources on the association.

METHODS

We studied 4,842 participants (18-65 years) of the population-based LIFE-Adult-Study. Depression was assessed using the Center for Epidemiological Studies Depression Scale. Employment status was divided into three groups: being employed, being unemployed receiving entitlement-based benefits, being unemployed receiving means-tested benefits. Multivariate logistic regression models were applied to assess the association between employment status and depression.

RESULTS

Statistically significantly increased depression risk was solely found for unemployed persons receiving means-tested benefits. Adjusting for differences in sociodemographic factors, net personal income and risk of social isolation, comparable associations of being unemployed and receiving means-tested benefits with elevated depression risk were found for men (Odds Ratio/OR = 2.17, 95%-CI = 1.03-4.55) and women (OR = 1.98, 95%-CI:1.22-3.20).

LIMITATIONS

No conclusions regarding causality can be drawn due to the cross-sectional study design. It was not possible to assess length of unemployment spells.

CONCLUSION

Unemployed persons receiving means-tested benefits in Germany constitute a risk group for depression that needs specific attention in the health care and social security system. The negative impact of unemployment on depression risk cannot be explained solely by differences in material and social resources. Contrasting earlier results, women are equally affected as men.

Improving the performance of social health insurance system through increasing outpatient expenditure reimbursement ratio: a quasi-experimental evaluation study from rural China

Background

China has set up a universal coverage social health insurance system since the 2009 healthcare reform. Due to the inadequate funds, the social health insurance system reimbursed the inpatient expenditures with much higher ratio than outpatient expenditure. The gap in reimbursement ratios resulted in a rapid rising hospitalization rate but poor health outcomes among the Chinese population. A redistribution of social health insurance funds has become one of the main challenges for the performance of Social Health Insurance.

Methods

Two comparable counties, Dangyang County and Zhijiang County, in Hubei Province of China, were sampled as the intervention group and the control group, respectively. The Social Health Insurance Management Department of the intervention group budgeted 600 yuan per capita per year to the patients with 3rd stage hypertension to cover their outpatient expenditures. The outpatient spending in the control group were paid out-of-pocket. The inpatient expenditures reimbursement policies in both groups were not changed. Besides, the Social Health Insurance Management Department of the intervention group budgeted 100 yuan per patient per year to township physicians and hospitals to provide health management services for the patients. While, the health management services in the control group were still provided by health workers. A Propensity Score Matching model and Difference-in-differences model were used to estimate the net effects of the intervention in dimensions of medical services utilization, medical expenditures, SHI reimbursement, and health outcomes.

Results

One thousand, six hundred and seventy three pairs of patients were taken as valid subjects to conduct Difference-in-differences estimation after the Propensity Score Matching. The net intervention effect is to increase outpatient frequency by 3.3 (81.0%) times (P < 0.05), to decrease hospitalization frequency by 0.075 (− 60.0%) times (P < 0.05), and to increase the per capita total medical service utilization frequency by 3.225 (76.8%) times (P < 0.05). The per capita total medical expenditure decreased 394.2 (− 27.7%) yuan. The SHI reimbursed 90.3 yuan more per capita for the outpatient spending, but the per capita inpatient expenditure reimbursement and per capita total medical expenditure reimbursement decreased significantly by 282.6 (− 44.0%) yuan and 192.3 (− 28.5%) yuan, respectively (P < 0.05). The intervention reduced the per capita inpatient out-of-pocket expenditure and the per capita total out-of-pocket expenditure by 192.8 (− 36.7%) yuan and 201.9 (− 29.9%) yuan, respectively (P < 0.05). The intervention significantly decreased the diastolic blood pressure of the intervention group by 2.9 mmHg (P < 0.05) but had no significant impact on the systolic blood pressure (− 7.9 mmHg, P > 0.05).

Conclusion

For China and countries attempting to establish a universal coverage SHI with inadequate funds, inpatient services were expensive but might not produce good health outcomes. Outpatient care for patients with chronic diseases should be fundamental, and outpatient expenditures should be reimbursed with a higher ratio.

Early-life conditions and health at older ages: The mediating role of educational attainment, family and employment trajectories

Objectives

We examine to what extent the effect of early-life conditions (health and socioeconomic status) on health in later life is mediated by educational attainment and life-course trajectories (fertility, partnership, employment).

Methods

Using data from the Survey of Health, Ageing and Retirement in Europe (N = 12,034), we apply, separately by gender, multichannel sequence analysis and cluster analysis to obtain groups of similar family and employment histories. The KHB method is used to disentangle direct and indirect effects of early-life conditions on health.

Results

Early-life-conditions indirectly impact on health in later life as result of their influence on education and family and employment trajectories. For example, between 22% and 42% of the effect of low parental socio-economic status at childhood on the three considered health outcomes at older age is explained by educational attainment for women. Even higher percentages are found for men (35% - 57%). On the contrary, the positive effect of poor health at childhood on poor health at older ages is not significantly mediated by education and life-course trajectories. Education captures most of the mediating effect of parental socio-economic status. More specifically, between 66% and 75% of the indirect effect of low parental socio-economic status at childhood on the three considered health outcomes at older age is explained by educational attainment for women. Again, higher percentages are found for men (86% - 93%). Early-life conditions, especially socioeconomic status, influence family and employment trajectories indirectly through their impact on education. We also find a persistent direct impact of early-life conditions on health at older ages.

Conclusions

Our findings demonstrate that early-life experiences influence education and life-course trajectories and health in later life, suggesting that public investments in children are expected to produce long lasting effects on people’s lives throughout the different phases of their life-course.

Age and gender differences in the impact of labour-market transitions on subjective health in Germany

AIMS

Applying a gender- and age group-sensitive approach, we investigated the effect of labour-market transitions (job loss and re-employment) on subjective physical and mental health.

METHODS

A combination of the difference-in-differences approach and propensity score matching controls for selectivity and initial health differences. This allowed us to analyse the causal effect of job loss and re-employment on subjective health. We made use of data from the German Panel Study Labour Market and Social Security and combined survey information with administrative records of the Federal Employment Agency for employed and unemployed men and women 31-60 years of age ( n = 2213). We controlled for labour-market experiences before the time period under study and for labour-market transitions between the interviews. Subjective health was assessed using the SF-12 health questionnaire, enabling us to differentiate between subjective mental and physical health functioning.

RESULTS

We found that physical health was affected mainly in older persons between 45 and 60 years old. Controlling for covariates using propensity score matching, mental health was affected only when living-wage jobs (i.e. jobs that provide sufficient income to achieve a defined minimum standard of living above the social benefit level) are gained or lost. Younger women showed a significant improvement in mental health after re-employment. In contrast, job loss affected only older individuals' mental health, with a particularly negative effect observed for men.

CONCLUSIONS

Our results not only showed that women and men are affected differently by job loss and re-employment, but also that age is an important factor. Older men were affected most severely by job loss, whereas re-employment was found to improve mental health only in women aged 31-44 years. It is therefore important to address the health problems of different socio-demographic groups separately, and to apply active labour-market policies with regard to unemployed men and women with health impairments. Based on our results, we suggest the promotion of employment with income levels above the maximum welfare benefit award.

Oral versus intravenous iron therapy in patients with inflammatory bowel disease and iron deficiency with and without anemia in Germany - a real-world evidence analysis

Background

Iron-deficiency anemia and iron deficiency are common comorbidities associated with inflammatory bowel disease (IBD) resulting in impaired quality of life and high health care costs. Intravenous iron has shown clinical benefit compared to oral iron therapy.

Aim

This study aimed to compare health care outcomes and costs after oral vs intravenous iron treatment for IBD patients with iron deficiency or iron deficiency anemia (ID/A) in Germany.

Methods

IBD patients with ID/A were identified by ICD-10-GM codes and newly commenced iron treatment via ATC codes in 2013 within the InGef (formerly Health Risk Institute) research claims database. Propensity score matching was performed to balance both treatment groups. Non-observable covariates were adjusted by applying the difference-in-differences (DID) approach.

Results

In 2013, 589 IBD patients with ID/A began oral and 442 intravenous iron treatment. After matching, 380 patients in each treatment group were analyzed. The intravenous group had fewer all-cause hospitalizations (37% vs 48%) and ID/A-related hospitalizations (5% vs 14%) than the oral iron group. The 1-year preobservation period comparison revealed significant health care cost differences between both groups. After adjusting for cost differences by DID method, total health care cost savings in the intravenous iron group were calculated to be €367. While higher expenditure for medication (€1,876) was observed in the intravenous iron group, the inpatient setting achieved most cost savings (€1,887).

Conclusion

IBD patients receiving intravenous iron were less frequently hospitalized and incurred lower total health care costs compared to patients receiving oral iron. Higher expenditures for pharmaceuticals were compensated by cost savings in other domains.

Changes in the Employment Status and Risk of Stroke and Stroke Types

Background and Purpose—

Because of limited evidence, we investigated a long-term impact of changes in employment status on risk of stroke.

Methods—

This was a prospective study of 21 902 Japanese men and 19 826 women aged 40 to 59 years from 9 public health centers across Japan. Participants were followed up from 1990 to 1993 to the end of 2009 to 2014. Cox proportional hazard ratio of stroke (incidence and mortality) and its types (hemorrhagic and ischemic) was calculated according to changes in the employment status within 5 years interval between 1990 to 1993 and 1995 to 1998 (continuously employed, job loss, reemployed, and continuously unemployed).

Results—

During the follow-up period, 973 incident cases and 275 deaths from stroke in men and 460 cases and 131 deaths in women were documented. Experiencing 1 spell of unemployment was associated with higher risks of morbidity and mortality from total, hemorrhagic, and ischemic stroke in both men and women, even after propensity score matching. Compared with continuously employed subjects, the multivariable hazard ratio (95% confidence interval) for total stroke incidence in job lost men was 1.58 (1.18–2.13) and in job lost women was 1.51 (1.08–2.29), and those for total stroke mortality were 2.22 (1.34–3.68) in men and 2.48 (1.26–4.77) in women. The respective hazard ratio (95% confidence interval) in reemployed men was 2.96 (1.89–4.62) for total stroke incidence and 4.21 (1.97–8.97) for mortality, whereas those in reemployed women were 1.30 (0.98–1.69) for incidence and 1.28 (0.76–2.17) for mortality.

Conclusions—

Job lost men and women and reemployed men had increased risks for both hemorrhagic and ischemic stroke incidence and mortality.