Psychological Morbidity in the Farming Community: A Literature Review

The mental health of the farming community across industrialised nations has long been a major concern. Using an adapted procedure for a systematic literature review of observational epidemiological studies reporting prevalence (informed by the Joanna Briggs Institute method), this paper reviews peer-reviewed literature that explicitly compares farmer and non-farmer mental health (n = 48). In doing so, it provides a central and accessible evidence base for researchers and practitioners, and simultaneously reveals a stark lack of consensus; specifically, 54.0% of measures deployed to assess farmer mental health determined it to be the same as or even better than non-farming populations. This ambiguity sits in sharp contrast to the unequivocally worrisome farmer suicide statistics. Informed by the literature, the paper discusses potential reasons for this mismatch, including (i) farmers' progression through a different "pathway" to suicide that is not always preceded by mental illness, and (ii) a failure of current methods to accurately gauge the mental health status of farmers. The paper concludes by recommending more research into farmers' "pathway" to suicide, and highlights the need for a dedicated and multi-disciplinary programme of methods research that will afford a more culturally appropriate and effective means of understanding mental health in the farming community.

Occupational class suicide risk: 12-year study of national coronial data

BACKGROUND

Previous research showed that the Global Financial Crisis (GFC) was associated with a widening disparity in suicide rates between lower-class occupations and the highest-class occupations in Australia. There has been no research investigating whether this trend continued post-GFC.

AIMS

This study aimed to investigate suicide rates by occupational class among employed Australians aged 15 years and over, between 2007 and 2018.

METHOD

A population-level retrospective mortality study was conducted using data from the National Coronial Information System. Adjusted suicide rates were calculated over the period 2007 to 2018. Negative binomial regression models were used to assess the relationship between occupational class, gender and time, comparing post-GFC years (2010-2012, 2013-2015 and 2016-2018) with GFC years (2007-2009).

RESULTS

Relative to the GFC period of 2007-2009, a significant reduction in suicide disparity between managers and other occupation groups was only observed among male labourers (rate ratios (RR) = 0.65, 95% CI 0.49-0.86) and male technicians/trades workers (RR = 0.73, 95% CI 0.56-0.96) for the period 2013-2015.

CONCLUSION

Skilled manual and lower-skilled occupational classes remain at elevated risk of suicide in Australia. While a decreasing divergence in suicide rates was only observed between labourer and manager occupational classes post-GFC, this trend was not maintained over the later part of the study period (2016-2018). There is a need to further understand the relationship between contextual factors associated with suicide among the employed population, especially during periods of economic downturn.

Socioeconomic status and psychiatric comorbidity associated with suicidal behavior among a sample of Egyptian patients who attended Tanta University emergency hospital for suicide-related problems

Background

Many studies found association between psychosocial factors and suicidal behavior; this association differs from one community to another, and this difference could affect the risk assessment and the management of suicidal behavior. The aim of this work was to evaluate the role of socioeconomic, cultural, and psychosocial profile including psychiatric comorbidity on individuals with suicidal behavior who attended Tanta University emergency hospital.

Results

Family troubles were the commonest cause of suicidal behavior (28%), and drug overdose was the commonest method of attempt (38%). Positive correlation is between age and score of Beck scale for suicidal ideation (p = 0.000) which indicates that suicidal ideation increases with age. Significant association is between psychiatric comorbidity and Beck’s scale for suicidal ideation (p = 0.019), with size of association (η = 0.58).

Regression analysis showed that older age, female sex, illiterates, widows, cases with psychiatric illness, and low socioeconomic status when act altogether are the significant predictor of suicidal ideation of our studied sample.

Conclusions

Our study demonstrated that studying psychosocial factors in individuals who came to emergency hospital of Tanta University could be a reflection of the community visiting this hospital asking for medical emergency service; the comprehensive and multifactorial assessment we have been adopted in this work could help in better understanding of the suicidal risk factors in this community and consequently help in part in tailoring the clinical service for this sector of patient.

An exploration of the relationship between adverse events on the farm and suicidal ideation in farmers

BACKGROUND

The risk of suicide for agricultural workers in parts of the United Kingdom (UK) is almost twice the national average. Existing literature has suggested that adverse farming events, where failure is determined by uncontrollable and unpredictable forces, may be to blame. Yet, the impact of such events on farmer suicidality has not been explicitly explored.

AIMS

The present paper therefore aimed to investigate the relationship between adverse farming events and suicidal ideation in farmers.

METHODS

A cross-sectional questionnaire battery was disseminated between July 2018 and February 2019, and completed by 170 adult farmers.

RESULTS

Over a 12-month period, 88.8% reported that they had experienced an adverse farming event and 32.9% said that they had experienced suicidal thoughts. Correlational analysis revealed a relationship between these variables.

CONCLUSIONS

The high prevalence of suicidal ideation within farmers demonstrates a critical need for intervention. Likewise, the prevalence of adverse farming events suggests that interventions need to be appropriately tailored, with greater understanding about the impact of such events on the mental wellbeing of farmers.

Mortality of Suicide and Cerebro-Cardiovascular Diseases by Occupation in Korea, 1997-2020

Although studies on occupational mortality have been conducted in Korea, the results for occupations with high mortality around 2010 are inconsistent. This study aimed to examine occupational mortality from overwork-related suicide and cerebro-cardiovascular diseases (CCVD) from 1997 to 2020. We used microdata of the Causes of Death Statistics (CDS) and Economically Active Population Survey (EAPS) to obtain indirect standardized mortality ratio (SMR) and standardized proportional mortality ratio (PMR) of suicide (X60-X84) and CCVD deaths (I20-I25 and I60-I69) by gender and eight occupational categories. The trend of SMR of suicide and CCVD by occupation was similar within individual genders. The SMR of managers (MNG) was the highest for men and women in 2012-2017 and 2008-2020, respectively, whereas the SMR of professionals and related workers (PRF) was consistently low. Despite the similar socioeconomic status of MNG and PRF, we suggest that their mortality should be analyzed separately in Korea. SMR of suicide and CCVD in female MNG were consistently highest, although the PMR was low. Female MNG may have been more directly affected by the economic crisis. There is a need for work-related stress management, early intervention, and prevention policies in occupations vulnerable to mortality.

Suicide rates by occupation in Korea, 1993-2017: the impacts of financial crisis and suicide policy

This study compared the suicide rates among different groups of occupations in Korea and their changes from 1993 through 2017. The suicide rate tended to be low in the high skill occupations except the manager group. The suicide rates showed increases around the financial crises of 1997 and 2008 in most occupations, and the sharpest increase was observed in the managers. The suicide rate in the manager group, which was the lowest among all occupation groups until the mid 2000s, showed the sharpest increase and became the highest since 2012 among all occupation groups. The sustained reduction in suicide rates among the skilled agricultural, forestry and fishery workers in Korea, following the implementation of paraquat control since 2005, shows that means restriction is an effective and essential way for reducing suicides. While more efforts should be put into means restriction, policy makers should focus on changing public perceptions of suicide in order that it would not be accepted as a possible solution for the difficulties in life.

Social factors and Australian farmer suicide: a qualitative study

BACKGROUND

Farmers and farm workers have been recognised as a group at high risk of suicide in Australia; however this risk is not without geographic and demographic variation. This study aims to identify and better understand the complex interplay of risk and protective factors surrounding farmer suicide, with an emphasis on social influences, so as to inform tailored and effective suicide prevention initiatives.

METHODS

Focus groups were conducted in three diverse sites across two states in Australia with men and women separately to gain perceptions about suicide risk and protective factors and attitudes towards suicide and help seeking. The three communities in each state represented areas with a suicide rate similar to, above, and below the state average. The communities were also diverse in their population, types of farming, geographic location, distance from and access to services. There were a total of 33 female and 30 male participants.

RESULTS

Qualitative analysis indicated three major interrelated social factors: (1) changing rural communities, (2) community attitudes and stigma and (3) relationship issues.

CONCLUSIONS

The biopsycho-ecological model is considered useful to better understand and address social, as well as individual and environmental factors, pertaining to farmer suicide.

Farm suicides in New Zealand, 2007-2015: A review of coroners' records

OBJECTIVE

Economic recessions and severe weather events are often associated with increased suicide rates. The Global Dairy Crisis 2015/2016 led to an economic downturn in the New Zealand dairy farming industry and, coupled with droughts in some regions and floods in others, raised fears about increased suicide rates among farmers. However, little was known about suicides in the farming sector. This study reviews characteristics of recent farm-related suicides in New Zealand and assesses the extent to which financial stresses contributed to the deaths.

METHODS

Data were abstracted from coroners' records for a consecutive series of 185 people in farm- and agriculture-related occupations who died by suicide between 2007 and 2015 and for whom coronial inquiries had been completed.

RESULTS

Farm suicides were heterogeneous: six distinct risk profiles were identified. Financial stresses made negligible contributions to farm suicides. Overall, risk factors for farm suicides differed little from risk factors for suicide in the general population. However, suicide risk in farmers was exacerbated by ready access to firearms: almost 40% of farm suicides involved firearms, compared to 8% in the general population over the same time. Among farm suicides, young male farm labourers predominated, rather than farm owners or managers. For many young men, relationship losses, acute alcohol intoxication and ready access to a firearm formed a common constellation of risk factors.

CONCLUSIONS

While coroners' records are variable and do not record specific information about financial stresses and weather events, it was clear that these issues made a negligible contribution to farm suicides. A range of rural suicide prevention initiatives are needed to address various farm suicide risk profiles. In particular, young male labourers often had no contact with health services prior to death, suggesting that rural suicide prevention efforts need to be positioned within community, farming and sports organisations, as well as health and social service providers.

Suicide Mortality Across Broad Occupational Groups in Greece: A Descriptive Study

Background

Several studies have investigated the relationship between specific occupations and suicide mortality, as suicide rates differ by profession. The aim of this study was to investigate suicide mortality ratios across broad occupational groups in Greece for both sexes in the period 2000–2009.

Methods

Data of suicide deaths were retrieved from the Hellenic Statistical Authority and comparative mortality ratios were calculated. Occupational classification was based on the International Classification of Occupations (ISCO-88) and the coding for Intentional self-harm (X60–X84) was based on the international classification of diseases (ICD-10).

Results

Male dominant occupations, mainly armed forces, skilled farmers and elementary workers, and female high-skilled occupations were seen as high risk groups for suicide in a period of 10 years. The age-productive group of 30–39 years in Greek male elementary workers and the 50–59 age-productive group of Greek professional women proved to have the most elevated number of suicide deaths.

Conclusion

Further research is needed into the work-related stressors of occupations with high suicide mortality risk and focused suicide prevention strategies should be applied within vulnerable working age populations.

Suicide in U.S. Workplaces, 2003-2010: a comparison with non-workplace suicides

INTRODUCTION

Suicide rates have risen considerably in recent years. National workplace suicide trends have not been well documented. The aim of this study is to describe suicides occurring in U.S. workplaces and compare them to suicides occurring outside of the workplace between 2003 and 2010.

METHODS

Suicide data originated from the Census of Fatal Occupational Injury database and the Web-Based Injury Statistics Query and Reporting System. Suicide rates were calculated using denominators from the 2013 Current Population Survey and 2000 U.S. population census. Suicide rates were compared among demographic groups with rate ratios and 95% CIs. Suicide rates were calculated and compared among occupations. Linear regression, adjusting for serial correlation, was used to analyze temporal trends. Analyses were conducted in 2013-2014.

RESULTS

Between 2003 and 2010, a total of 1,719 people died by suicide in the workplace. Workplace suicide rates generally decreased until 2007 and then sharply increased (p=0.035). This is in contrast with non-workplace suicides, which increased over the study period (p=0.025). Workplace suicide rates were highest for men (2.7 per 1,000,000); workers aged 65-74 years (2.4 per 1,000,000); those in protective service occupations (5.3 per 1,000,000); and those in farming, fishing, and forestry (5.1 per 1,000,000).

CONCLUSIONS

The upward trend of suicides in the workplace underscores the need for additional research to understand occupation-specific risk factors and develop evidence-based programs that can be implemented in the workplace.

International perspectives on psychosocial working conditions, mental health, and stress of dairy farm operators

Dairy farm operators-farmers, workers, and family members-are faced with many demands and stressors in their daily work and these appear to be shared across countries and cultures. Dairy operators experience high psychosocial demands with respect to a hard work and production ethos, economic influences, and social and environmental responsibility. Furthermore, both traditional and industrial farms are highly dependent on external conditions, such as weather, fluctuating markets, and regulations from government authorities. Possible external stressors include disease outbreaks, taxes related to dairy production, and recent negative societal attitudes to farming in general. Dairy farm operators may have very few or no opportunities to influence and control these external conditions, demands, and expectations. High work demands and expectations coupled with low control and lack of social support can lead to a poor psychosocial work environment, with increased stress levels, ill mental health, depression, and, in the worst cases, suicide. Internationally, farmers with ill mental health have different health service options depending on their location. Regardless of location, it is initially the responsibility of the individual farmer and farm family to handle mental health and stress, which can be of short- or long-term duration. This paper reviews the literature on the topics of psychosocial working conditions, mental health, stress, depression, and suicide among dairy farm operators, farm workers, and farm family members in an international perspective.

A regional approach to understanding farmer suicide rates in Queensland

PURPOSE

Elevated suicide rates among farmers have been observed across a number of countries, including Australia. However, studies on farmer suicide have typically treated farmers as a homogenous group, and have predominately been focussed at a national level. This overlooks potential variability in suicide rates (and, by extension, contributory factors) within different groups of farmers (for example, different age groups), as well as across different geographical locations.

METHODS

Using a unique data source, the Queensland Suicide Register, the current study examined variation in farmer suicide rates by age, sex, and location within Queensland.

RESULTS

Although farmer suicide rates varied substantially across different regions of Queensland, no significant associations were found between rates of farmer and non-farmer suicide, or between the proportion of farmers in a region and farmer suicide rates.

CONCLUSIONS

This suggests that farmer suicide may be characterised by unique combinations of occupational and location-related effects that are likely to vary substantially within and between different regions, and provides caution against treating farmer suicide as a homogenous phenomenon. The highest rates of farmer suicide were observed among younger farmers (aged 18-34 years), highlighting a need for targeted suicide prevention initiatives for this group.

Suicidal ideation and occupational pesticide exposure among male farmers

BACKGROUND

The occupation of farming has been reported to be associated with a high suicide rate, and suicidal ideation is an important risk factor for suicide. The objective of this study was to explore the association between occupational pesticide exposure or poisoning history and suicidal ideation among male farmers in South Korea.

METHODS

Through a nationwide sampling survey, a total of 1958 male farmers were interviewed in 2011 in South Korea. Detailed occupational pesticide exposure and pesticide poisoning information were obtained from face-to-face interviews. Suicidal ideation was defined as whether they had thought of harming themselves or trying to take their own lives over the preceding year. Logistic regression analyses were conducted to examine the effect of pesticide poisoning on suicidal ideation.

RESULTS

Among all farmers, 4.7% (n=92) reported suicidal ideation in 2010. After controlling for potential confounders, lifetime hospitalization due to pesticide poisoning showed a 2.48-fold increase in risk (95% CI: 1.26, 4.91). Those with multiple poisonings showed more significant associations with suicidal ideation (OR=2.33 for once, OR=3.02 for more than once). Moderate- or severe-symptom severity of acute pesticide poisoning cases (OR=2.23; 95% CI: 1.21-4.11) also showed increased risks of suicidal ideation than the milder classes did. However, no significant association was identified with cumulative lifetime pesticide application and suicidal ideation.

CONCLUSIONS

Our findings suggest that risk of suicidal ideation is related to occupational pesticide poisoning among male farmers.

Occupation and suicide: Colorado, 2004-2006

BACKGROUND

Occupation has been identified as a risk factor for suicide. Changes in work environments over time suggest occupations at high risk of suicide may also change. Therefore, periodic examination of suicide by occupation is warranted. The purpose of this article is to describe suicide rates by occupation, sex, and means used in Colorado for the period 2004-2006.

METHODS

To provide information useful in designing suicide prevention programs, the methods used in suicide across occupational groups also are examined. Data from the Colorado Violent Death Reporting System (COVDRS) were obtained for suicides that occurred between 2004 and 2006. Denominators to calculate rates by age, sex, and race used are from the 2000 US Census of the Population data.

RESULTS

Men had higher suicide rates than women in all occupation categories except computers and mathematics. Among men, those in farming, fishing, and forestry (475.6 per 100,000) had the highest age-adjusted suicide rates. Among women, workers with the highest suicide rates were in construction and extraction (134.3 per 100,000). The examination of lethal means showed that workers in farming, fishing, and forestry had higher rates of suicide by firearms (50.18 per 100,000) compared with other workers. Healthcare practitioners and technicians had the highest rate of suicide by poisoning (14.25 per 100,000). Workers involved in construction and extraction (26.43 per 100,000) had higher rates of suicide by hanging, suffocation, or strangling.

CONCLUSIONS

Significant differences in means of suicide were seen by occupation, which could guide future suicide prevention interventions that may decrease work-related suicide risks.

Active coping, personal satisfaction, and attachment to land in older African-American farmers

Elevated suicide mortality rates have been reported for farmers and for the elderly. Very little literature exists that looks at the health of older minority farmers. This mixed-method study describes older African-American farmers (N = 156) in the contexts of active coping, personal satisfaction from farm work, and attachment to their farmland to provide insight into the psychosocial dimensions of their mental health. Findings show that the farmers have positive perspectives on work and farm future, and strong attachment to the land. Differences were noted by gender. Nurses can use these findings to frame culturally appropriate strategies for aging farmers to maximize positive outcomes.

Suicidality in the Veterinary Profession

Background: Suicide rates are elevated in the veterinary profession in several countries, yet little is known about possible contributory and preventive factors. Aims: To obtain information from veterinarians with a history of suicidal ideation or behavior about the factors associated with suicidality in their profession. Methods: We conducted a mixed-methods interview study with 21 UK veterinarians who had attempted suicide or reported recent suicidal ideation. Interview topics included work and nonwork contributory factors, coping mechanisms, and preventive factors. Results: Self-poisoning was the most common method used or considered by participants. Common contributory factors were workplace relationships, career concerns, patient issues, number of hours and volume of work, and responsibility, although two-thirds of participants reported co-occurring difficult life events. Around half had received a psychiatric diagnosis following their suicidal behavior. Several possible preventive measures were suggested by participants. Conclusions: Several work- and non-work-related contributory factors to suicidality in the veterinary profession were identified. Future preventive measures may involve better promotion of support services, formal support for recent graduates, and improving employers’ attitudes toward work-life balance.

Suicidal behaviour and psychosocial problems in veterinary surgeons: a systematic review

PURPOSE

Rates of suicide are elevated among veterinary surgeons in several countries, yet little is known about contributory factors. We have conducted a systematic review of studies investigating suicidal behaviour and psychosocial problems in veterinary surgeons.

METHODS

A systematic search of the international research literature was performed in May 2008. Data from 52 studies of non-fatal suicidal behaviour, mental health difficulties, stress and burnout, occupational difficulties, and psychological characteristics of veterinary surgeons were extracted by two independent reviewers and analysed. Studies were rated for quality and greater emphasis placed on findings from higher quality studies.

RESULTS

The majority of studies were of stress and occupational difficulties experienced by veterinary surgeons. Occupational stressors included managerial aspects of the job, long working hours, heavy workload, poor work-life balance, difficult client relations, and performing euthanasia. Few studies investigated suicidal behaviour or mental health difficulties in the profession. Some studies suggested that young and female veterinarians are at greatest risk of negative outcomes such as suicidal thoughts, mental health difficulties, and job dissatisfaction.

CONCLUSIONS

The review highlights the difficulties faced by veterinary surgeons that may contribute to poor mental wellbeing and suicidal behaviour. Future research might include further examination of the influence of euthanasia on attitudes towards suicide and more direct examination of the impact that occupational risk factors might have on suicidal behaviour. Suggestions about the review's implications for suicide prevention in this group are also made.

Work-related suicide in Victoria, Australia: a broad perspective

While unintentional work-related injury is increasingly recognised as important and preventable, population studies of the full range of work related suicides have received less attention. The objective of this study is to investigate the epidemiology of work-related suicide in Victoria, July 2000-December 2007. The study draws on a database of all work-related deaths reported to the Victorian Coroner, inclusive of broadly defined work-relatedness. Inclusion criteria for work-related suicide were at least one of: suicide means was work related, work stressors were identified in police reports to the Coroners or the Coroner's finding, the suicide method involved another person's work (e.g. rail suicide, heavy vehicle) or the suicide location was a workplace. Cases still open for investigation were excluded. Of 642 work-related suicides, 55% had an association with work stressors; 32% jumped or lay in front of a train or heavy vehicle; 7% involved a work location and 6% involved work agents. Work stressor cases identified included business difficulties, recent or previous work injury, unemployment/redundancy or conflict with supervisors/colleagues (including workplace bullying). Work-related suicide is a substantial problem, for which few detailed population wide studies are available. Further research is required to understand the contribution of work stressors and effective interventions.

Suicide by occupation: does access to means increase the risk?

OBJECTIVE

To examine suicide by identified occupational groups in New Zealand over a period of 30 years, focusing on groups predicted to have high suicide rates because of access to and familiarity with particular methods of suicide.

METHOD

Suicide data (including open verdicts) for the period 1973-2004 were examined, excluding 1996 and 1997 for which occupational data were not available. Occupational groups of interest were dentists, doctors, farmers (including farm workers), hunters and cullers, military personnel, nurses, pharmacists, police and veterinarians. Crude mortality rates were calculated based on numbers in each occupational group at each quinquennial census, 1976-2001. Standardized mortality ratios were calculated using suicide rates in all employed groups (the standard population).

RESULTS

Few of the occupations investigated had high risks of suicide as assessed by standardized mortality ratios, and some were at lower risk than the total employed population. Standardized mortality ratios were elevated for male nurses (1.7; 95% CI: 1.2-2.5), female nurses (1.3; 95% CI: 1.0-1.6), male hunters and cullers (3.0; 95% CI: 1.7-4.8), and female pharmacists (2.5; 95% CI: 0.8-5.9). Doctors, farmers and veterinarians were not at high risk, and men in the police and armed forces were at low risk. Access to means appeared to have influenced the method chosen. Nurses, doctors and pharmacists were more likely to use poisoning than were other employed people (3, 4 and 5 times respectively, compared with all others employed). Farmers and hunters and cullers were more than twice as likely as all others employed to use firearms.

CONCLUSIONS

Access to means may be less important in some circumstances than in others, perhaps because of the presence of other factors that confer protection. Nevertheless, among the groups we studied with access to lethal means were three groups whose risk of suicide has so far received little attention in New Zealand: nurses, female pharmacists, and hunters and cullers.

Suicide in selected occupations in Queensland: evidence from the State suicide register

OBJECTIVE

Prior research has suggested an association between suicide and certain occupations. The aim of the present study was to report on suicide rates in selected occupations in Queensland (QLD).

METHOD

Suicide mortality data from the QLD Suicide Register and population data from the Australian Bureau of Statistics were obtained for the period 1990-2006. Suicide rates were calculated for each occupational group and compared to rates within the general population (15-64 year age group) and the employed population of QLD.

RESULTS

There was significantly higher risk of suicide for male subjects in the agricultural, transport and construction sectors of QLD. High suicide rates were also found in female nurses, artists, agricultural workers and cleaners, while education professionals (of both genders) appeared at lower risk.

CONCLUSIONS

The significantly higher suicide rates for employees of the agriculture, construction, and transport industries indicate a need for further research into the occupation-specific conditions and individual or other social-environmental factors that may accentuate suicide risk within these professions. Use of higher quality occupational data is also warranted in future studies.

Management of suicidal cut throat injuries in a developing nation: three case reports

Introduction

Suicidal cut throat injuries are either unreported or fortunately rare in our country. The management of these injuries requires a multi-disciplinary approach.

Case presentations

This paper presents our experiences with managing three unemployed adult Nigerian males - two of Hausa ethnicity and one from the Tiv ethnic group presenting with cut throat injuries following suicidal attempts.

Conclusion

The purpose of these reports is to emphasize that suicidal cut throat injuries do occur in our environment and there is a need for the collaboration of the otorhinolaryngologist, anesthesiologist and psychiatrist in the effective management of these patients. We recommend the socioeconomic improvement of individuals as a way of reducing the incidence of these injuries as unemployment was cited as a motivating factor for suicide in our patients. Ways must also be found to identify the many people in society without mental disorders who are at risk of suicidal behaviors.

Under Pressure, Out of Control, or Home Alone? Reviewing Research and Policy Debates on the Occupational Health and Safety Effects of Outsourcing and Home-Based Work

The practice of outsourcing or subcontracting of work has grown rapidly in most countries over the past two decades. Outsourcing, de-institutionalization, and a range of other practices have also resulted in a growth of home-based work. Home-based workers, even when not part of a subcontracting process, operate in an isolated situation remote from their employer and other workers. Do such work arrangements expose workers to greater risk of injury, illness, or assault? The authors reviewed international studies of the occupational health and safety (OHS) effects of subcontracting and home-based work undertaken over the past 20 years. Of the 25 studies analyzed, 92 percent found poorer OHS outcomes. The studies were examined for clues about the reasons for these negative outcomes. The authors also identified similarities and differences between subcontracting and home-based work. Despite the evidence of poor OHS outcomes, research into outsourcing has stalled in recent years. With notable exceptions, governments have taken little account of findings on these work arrangements in their laws and policies, in part because neoliberal ideas dominate national and global policy agendas. The authors examine policy challenges and regulatory responses and make suggestions for future research and policy interventions.