Unemployment and mortality: a comparative study of Germany and the United States

Effects of social determinants of health on mortality and incident liver-related events and cardiovascular disease in steatotic liver disease

BACKGROUND

Social determinants of health (SDOH) are becoming increasingly recognised as mediators of human health. In the setting of metabolic dysfunction-associated steatotic liver disease (MASLD), most of the literature on SDOH relates to individual-level risk factors. However, there are very limited data on neighbourhood-level SDOH in MASLD.

AIM

To assess whether SDOH impact fibrosis progression in patients who already have MASLD.

METHODS

This was a retrospective cohort study of patients with MASLD seen at Michigan Medicine. The primary predictors were two neighbourhood-level SDOH, 'disadvantage' and 'affluence'. The primary outcomes were mortality, incident liver-related events (LREs) and incident cardiovascular disease (CVD). We modelled these outcomes using Kaplan-Meier statistics for mortality and competing risk analyses for LREs and CVD, using a 1-year landmark.

RESULTS

We included 15,904 patients with MASLD with median follow-up of 63 months. Higher affluence was associated with lower risk of overall mortality (hazard ratio 0.49 [0.37-0.66], p < 0.0001 for higher vs. lower quartile), LREs (subhazard ratio 0.60 [0.39-0.91], p = 0.02) and CVD (subhazard ratio 0.71 [0.57-0.88], p = 0.0018). Disadvantage was associated with higher mortality (hazard ratio 2.08 [95% confidence interval 1.54-2.81], p < 0.0001 for the highest vs. lowest quartile) and incident CVD (subhazard ratio 1.36 [95% confidence interval 1.10-1.68], p < 0.0001). These findings were robust across several sensitivity analyses.

DISCUSSION

Neighbourhood-level SDOH are associated with mortality, incidence of LREs and incident CVD in patients with steatotic liver disease. Interventions aimed at disadvantaged neighbourhoods may improve clinical outcomes.

Unemployment Insurance and Mortality Among the Long-Term Unemployed: A Population-Based Matched-Cohort Study

Unemployment insurance is hypothesized to play an important role in mitigating the adverse health consequences of job loss. In this prospective cohort study, we examined whether receiving unemployment benefits is associated with lower mortality among the long-term unemployed. Census records from the 2006 Canadian Census Health and Environment Cohort (n = 2,105,595) were linked to mortality data from 2006-2016. Flexible parametric survival analysis and propensity score matching were used to model time-varying relationships between long-term unemployment (≥20 weeks), unemployment-benefit recipiency, and all-cause mortality. Mortality was consistently lower among unemployed individuals who reported receiving unemployment benefits, relative to matched nonrecipients. For example, mortality at 2 years of follow-up was 18% lower (95% confidence interval (CI): 9, 26) among men receiving benefits and 30% lower (95% CI: 18, 40) among women receiving benefits. After 10 years of follow-up, unemployment-benefit recipiency was associated with 890 (95% CI: 560, 1,230) fewer deaths per 100,000 men and 1,070 (95% CI: 810, 1,320) fewer deaths per 100,000 women. Our findings indicate that receiving unemployment benefits is associated with lower mortality among the long-term unemployed. Expanding access to unemployment insurance may improve population health and reduce health inequalities associated with job loss.

Quantification of Neighborhood-Level Social Determinants of Health in the Continental United States

IMPORTANCE

An association between social and neighborhood characteristics and health outcomes has been reported but remains poorly understood owing to complex multidimensional factors that vary across geographic space.

OBJECTIVES

To quantify social determinants of health (SDOH) as multiple dimensions across the continental United States (the 48 contiguous states and the District of Columbia) at a small-area resolution and to examine the association of SDOH with premature mortality within Chicago, Illinois.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, census tracts from the US Census Bureau from 2014 were used to develop multidimensional SDOH indices and a regional typology of the continental United States at a small-area level (n = 71 901 census tracts with approximately 312 million persons) using dimension reduction and clustering machine learning techniques (unsupervised algorithms used to reduce dimensions of multivariate data). The SDOH indices were used to estimate age-adjusted mortality rates in Chicago (n = 789 census tracts with approximately 7.5 million persons) with a spatial regression for the same period, while controlling for violent crime.

MAIN OUTCOMES AND MEASURES

Fifteen variables, measured as a 5-year mean, were selected to characterize SDOH as small-area variations for demographic characteristics of vulnerable groups, economic status, social and neighborhood characteristics, and housing and transportation availability at the census-tract level. This SDOH data matrix was reduced to 4 indices reflecting advantage, isolation, opportunity, and mixed immigrant cohesion and accessibility, which were then clustered into 7 distinct multidimensional neighborhood typologies. The association between SDOH indices and premature mortality (defined as death before age 75 years) in Chicago was measured by years of potential life lost and aggregated to a 5-year mean. Data analyses were conducted between July 1, 2018, and August 30, 2019.

RESULTS

Among the 71 901 census tracts examined across the continental United States, a median (interquartile range) of 27.2% (47.1%) of residents had minority status, 12.1% (7.5%) had disabilities, 22.9% (7.6%) were 18 years and younger, and 13.6% (8.1%) were 65 years and older. Among the 789 census tracts examined in Chicago, a median (interquartile range) of 80.4% (56.3%) of residents had minority status, 10.2% (8.2%) had disabilities, 23.2% (10.9%) were 18 years and younger, and 9.5% (7.1%) were 65 years and older. Four SDOH indices accounted for 71% of the variance across all census tracts in the continental United States in 2014. The SDOH neighborhood typology of extreme poverty, which is of greatest concern to health care practitioners and policy advocates, comprised only 9.6% of all census tracts across the continental United States but characterized small areas of known public health crises. An association was observed between all SDOH indices and age-adjusted premature mortality rates in Chicago (R2 = 0.63; P < .001), even after accounting for violent crime and spatial structures.

CONCLUSIONS AND RELEVANCE

The modeling of SDOH as multivariate indices rather than as a singular deprivation index may better capture the complexity and spatial heterogeneity underlying SDOH. During a time of increased attention to SDOH, this analysis may provide actionable information for key stakeholders with respect to the focus of interventions.

Employment Cessation, Long Term Labour Market Engagement and HIV Infection Risk Among People Who Inject Drugs in an Urban Canadian Setting

The potential for changes in socio-economic status, such as employment exits, to increase HIV infection risk are not well examined among people who inject illicit drugs (PWID). We used longstanding cohort data from Vancouver, Canada, to longitudinally assess associations between employment cessation and outcomes with documented linkages to HIV infection risk among PWID. From 2005 to 2015, 1222 participants reported 1154 employment exits. Employment exits were significantly associated with transitions into unstable housing; moving to the inner-city; initiating informal, prohibited or illegal income generation; high risk drug use practices; and exiting methadone maintenance therapy. HIV infection rates were higher among participants with lower long-term labour market engagement. These findings suggest that employment cessation coincides with initiating exposure to aspects of socioeconomic marginalization and drug use associated with HIV infection risk. Support for employment retention that prevents poverty entrenchment and harmful drug use could contribute to HIV prevention measures for PWID.

Skill mapping for blue-collar employees and organisational performance

Purpose

The purpose of this paper is to explore the skill mapping process in a manufacturing organization and to examine its relationship with the select performance indicators, such as quality and defects. This paper also explores the role of the supervisor in the whole process of skill mapping of the blue-collar employees.

Design/methodology/approach

The study uses a case-based approach and the company selected is Mahindra and Mahindra Ltd, Swaraj Division, located in Phase 4, Industrial Area, Mohali (Punjab). The qualitative aspect of the paper is based on ten semi-structured interviews of the senior-level managers. These interviews are conducted in order to understand the role of the supervisor in skill mapping process and its relationship with the organizational performance. The quantitative aspect is based on the regression analysis to find out the impact of skill index on select performance indicators.

Findings

The results of the study indicate that the role of the supervisor in performance appraisal is very important in the whole process of skill mapping. Swaraj is an example where a robust skill mapping process for blue-collar employees have supported the business in improving the skill of employees and consequently supporting the business to perform well on key deliverables, such as better quality and less defects. The select variables are inter-correlated and variations in the select organizational performance indicators (production and defects) are due to variations in the skill index of the blue-collar employees in the manufacturing organization. The performance indicators of the manufacturing organization in terms of manufacturing defects have declined and also the production has increased, which is a good indicator for the organization.

Practical implications

The present study is of interest to researchers who are trying to understand the system for skill mapping and utilization of appraisal inputs in improving organizational performance.

Originality/value

To the authors’ best knowledge, this paper is one of the first to address the skill mapping process in a manufacturing organization especially for the blue-collar employees.

Analysis of Time in Rehabilitation and Incidence of Successful Rehabilitation Within Individuals with Disabilities Receiving Occupational/Vocational Training

Objective To investigate the incidence of successful rehabilitation, defined as 90 successive days in employment, within individuals with disabilities receiving occupational/vocational training (OVT) service. Method The follow-up records between January 1, 2004 and December 31, 2012 of 5313 individuals aged 15-55 who obtained OVT in the vocational rehabilitation (VR) program of the State of Illinois were examined. Cox regression models were used to analyze the effect of study factors on VR outcomes. Results After controlling for the other factors, males (incidence ratio [IR] 1.11, 95% CI 1.03-1.20), individuals with learning disability (IR 1.14, 95% CI 1.03-1.26), had existing employment (IR 1.40, 95% CI 1.26-1.56), and persons who were referred from educational institutions (IR 1.17, 95% CI 1.01-1.36) or community agencies (IR 1.30, 95% CI 1.14-1.48) appeared to have a relatively high incidence of successful rehabilitation. In contrast, those who lived in densely populated areas (IR ranged from 0.56 to 0.89), had physical disability (IR 0.77, 95% CI 0.68-0.88), had disability of most significant degree (IR 0.85, 95% CI 0.79-0.93), and persons with Supplemental Security Income/Social Security Disability Insurance supports (IR 0.84, 95% CI 0.76-0.94), tended to have a lower incidence of rehabilitation than their counterparts. Conclusion The incidence of successful rehabilitation seems to be related to the demographic, disability, and pre-service characteristics, but not necessarily the provider factors.

Variation in the rate of well-controlled status of chronic disease by income level in Korea: 2010 to 2015

Although it is known that the prevalence rates of chronic diseases depend on income level, annual changes of the control rate have not been evaluated. In this cross-sectional study, we analyzed the variation in rate of well-controlled status of chronic diseases based on the annual income level using data from national nutrition surveys conducted between 2010 and 2015.Prevalence and controlled rate of hypertension, diabetes mellitus, and chronic kidney disease were analyzed in relation to annual income levels, using data from the Korea National Health and Nutrition Examination Survey (KNHANES), obtained from 2010 to 2015. We also analyzed the incidence of use of necessary medical care services and the reasons cited for not using these services.The data of 28,759 persons were analyzed. The average age increased, and sex ratio remained unchanged over the study period. Although the prevalence rates of diabetes increased, that of increased glycated hemoglobin gradually decreased. A significant change has been shown recently on the prevalence rates of hypertension patients. The prevalence rates of chronic kidney disease stayed unchanged during the course of the study period. The incidence of controlled chronic disease status increased with the income level, and over time during the study, in the case of diabetes and chronic kidney disease. However, while controlled hypertension status rate increased from year to year, there was no trend of increase with increased income level. The incidence of participants not using hospital services declined with increasing income level, but the rate of economic causes being cited as reasons for not using hospital services increased over time and showed no change among income levels. Results of regression analysis of prevalence rates of chronic diseases by income level showed that lower income groups tended to have higher odds ratios for chronic diseases.Our results suggest that the incidence rate of well-controlled chronic disease status remains low in lower income groups. These results imply that financial status may play an important role in the management of chronic diseases.

Risk factors for failure to enter vocational rehabilitation services among individuals with disabilities

PURPOSE

To investigate the risk factors for failure of individuals with disabilities to enter the vocational rehabilitation (VR) programme, including the cases where they had been formally accepted but were yet to receive any service.

METHODS

We used prospective cohort data from a Midwestern US state, and analysed 126,251 and 94,517 individuals, respectively, for acceptance and admission into VR services. Statistical analysis was conducted using Poisson regression models with robust variance estimator.

RESULTS

Individuals with blind/visual disability, had prior history of employment, and who received public support tended to have lower risks of non-acceptance and non-admission. Being non-White, at higher education, ever/currently married, and with physical/orthopaedic disability appeared to increase the risks of both outcomes. The adjusted relative risk of non-acceptance was 0.58 (95% confidence interval: 0.52, 0.64) if the individuals had 4 or more functional limitations as compared with those with fewer limitations. This factor was not significant for VR admission.

CONCLUSION

Disability factors, demographic determinants, and certain miscellaneous characteristics were associated with the risks of non-acceptance and non-admission into VR. Implications for Rehabilitation Individuals with disabilities are more likely to be unemployed than the population without disabilities, and they are thus more prone to adverse health effects of unemployment. Vocational rehabilitation (VR) is a proven intervention to improve employment outcomes among individuals with disabilities. Our study indicates that the complexity of the selection process for entering VR and various factors beyond disability may prevent individuals to benefit from the VR programme. Rehabilitation programme authorities need to monitor and simplify the selection process into VR services and, together with rehabilitation practitioners, promote a selection process that pays careful attention on the factors that are related to individual risk of failure for entering VR.

Quality of Life and Its Related Factors in Chinese Unemployed People: A Population-Based Cross-Sectional Study

With the global economic crisis and industrial restructuring, the unemployed are suffering from job loss-related stress and loss of income, which is believed to impair their mental and physical health, while coping and self-efficacy could combat the adverse effects of unemployment on health. Thus, this study aims to describe quality of life (QOL) among unemployed Chinese people and explore the associated factors. A cross-sectional study was conducted by convenience sampling, composed of 1825 unemployed people, from January 2011 to September 2011. Questionnaires pertaining to demographic characteristics, the 36-item Short-Form Health Survey (SF-36), the abbreviated version of the Cope Inventory (Brief COPE) and self-efficacy scales were used to collect information from unemployed people in the eastern, central, and western regions of China. Hierarchical multiple regression analysis was performed to explore the related factors of QOL. A structural equation model (SEM) was used to test the relations among coping, self-efficacy, and QOL. Mental QOL was significantly lower than physical QOL in Chinese unemployed people. Coping had significant effects on both physical component summary (PCS) and mental component summary (MCS), while self-efficacy played the mediating role in the association between Coping and QOL. Unemployed Chinese people’s mental QOL was disrupted more seriously than their physical QOL. An increase in coping could improve QOL by promoting better management of issues brought about by unemployment. In addition, self-efficacy has the ability to reduce the impact of unemployment on QOL, through the mediating path of coping on QOL. This study highlights the need of coping skills training and self-efficacy enhancement for better management of unemployment in order to improve QOL and well-being.

Late-career unemployment and all-cause mortality, functional disability and depression among the older adults in Taiwan: A 12-year population-based cohort study

OBJECTIVE

To evaluate whether late-career unemployment is associated with increased all-cause mortality, functional disability, and depression among older adults in Taiwan.

METHOD

In this long-term prospective cohort study, data were retrieved from the Taiwan Longitudinal Study on Aging. This study was conducted from 1996 to 2007. The complete data from 716 men and 327 women aged 50-64 years were retrieved. Participants were categorized as normally employed or unemployed depending on their employment status in 1996. The cumulative number of unemployment after age 50 was also calculated. Logistic regression analysis was used to examine the effect of the association between late-career unemployment and cumulative number of late-career unemployment on all-cause mortality, functional disability, and depression in 2007.

RESULTS

The average age of the participants in 1996 was 56.3 years [interquartile range (IQR)=7.0]. A total of 871 participants were in the normally employed group, and 172 participants were in the unemployed group. After adjustment of gender, age, level of education, income, self-rated health and major comorbidities, late-career unemployment was associated with increased all-cause mortality [Odds ratio (OR)=2.79; 95% confidence interval (CI)=1.74-4.47] and functional disability [OR=2.33; 95% CI=1.54-3.55]. The cumulative number of late-career unemployment was also associated with increased all-cause mortality [OR=1.91; 95% CI=1.35-2.70] and functional disability [OR=2.35; 95% CI=1.55-3.55].

CONCLUSION

Late-career unemployment and cumulative number of late-career unemployment are associated with increased all-cause mortality and functional disability. Older adults should be encouraged to maintain normal employment during the later stage of their career before retirement. Employers should routinely examine the fitness for work of older employees to prevent future unemployment.

Work as treatment? The effectiveness of re-employment programmes for unemployed persons with severe mental health problems on health and quality of life: a systematic review and meta-analysis

Given the importance of unemployment in health inequalities, re-employment of unemployed persons into paid employment may be a powerful intervention to increase population health. It is suggested that integrated programmes of vocational reintegration with health promotion may improve the likelihood of entering paid employment of long-term unemployed persons with severe mental health problems. However, the current evidence regarding whether entering paid employment of this population will contribute to a reduction in health problems remains unambiguous. This systematic review and meta-analysis aimed to assess the effects of re-employment programmes with regard to health and quality of life. Three electronic databases were searched (up to March 2015). Two reviewers independently selected articles and assessed the risk of bias on prespecified criteria. Measures of effects were pooled and random effect meta-analysis of randomised controlled trials was conducted, where possible. Sixteen studies were included. Nine studies described functioning as an outcome measure. Five studies with six comparisons provided enough information to calculate a pooled effect size of -0.01 (95% CI -0.13 to 0.11). Fifteen studies presented mental health as an outcome measure of which six with comparable psychiatric symptoms resulted in a pooled effect size of 0.20 (95% CI -0.23 to 0.62). Thirteen studies described quality of life as an outcome measure. Seven of these studies, describing eight comparisons, provided enough information to calculate a pooled effect size of 0.28 (95% CI 0.04 to 0.52). Re-employment programmes have a modest positive effect on the quality of life. No evidence was found for any effect of these re-employment programmes on functioning and mental health.

Unemployment, health, and education of HIV-infected males in Germany

Objectives

The present study on people living with HIV/AIDS (PLWHA) identifies socio-demographic and health-related factors corresponding with their labour market participation.

Methods

The study sample bases on a German observational sub-study of 527 male PLWHA. The present analysis is restricted to male PLWHA in working age. By means of a multivariate regression, we identify factors that contribute to unemployment and job loss.

Results

The probability to be unemployed is significantly negatively correlated with age above 40 years and graduation from university and positively correlated with problems with daily activities (frailty) and disease severity (CDC stage C). The probability of employment loss during the 2-year observation period is significantly negatively correlated with the educational level, whereas frailty and hepatitis C (HCV) co-infection increase the odds of employment loss.

Conclusions

As problems to manage daily activities and disease progression are associated with unemployment, an effective HIV treatment is an important cornerstone for employment. This is also true for the management of comorbidities, such as HCV co-infection, which also negatively affects employment status in our study.

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

PURPOSE

Individual-level unemployment has been consistently linked to poor health and higher mortality, but some scholars have suggested that the negative effect of job loss may be lower during times and in places where aggregate unemployment rates are high. We review three logics associated with this moderation hypothesis: health selection, social isolation, and unemployment stigma. We then test whether aggregate unemployment rates moderate the individual-level association between unemployment and all-cause mortality.

METHODS

We use six meta-regression models (each using a different measure of the aggregate unemployment rate) based on 62 relative all-cause mortality risk estimates from 36 studies (from 15 nations).

RESULTS

We find that the magnitude of the individual-level unemployment-mortality association is approximately the same during periods of high and low aggregate-level unemployment. Model coefficients (exponentiated) were 1.01 for the crude unemployment rate (P = .27), 0.94 for the change in unemployment rate from the previous year (P = .46), 1.01 for the deviation of the unemployment rate from the 5-year running average (P = .87), 1.01 for the deviation of the unemployment rate from the 10-year running average (P = .73), 1.01 for the deviation of the unemployment rate from the overall average (measured as a continuous variable; P = .61), and showed no variation across unemployment levels when the deviation of the unemployment rate from the overall average was measured categorically. Heterogeneity between studies was significant (P < .001), supporting the use of the random effects model.

CONCLUSIONS

We found no strong evidence to suggest that unemployment experiences change when macroeconomic conditions change. Efforts to ameliorate the negative social and economic consequences of unemployment should continue to focus on the individual and should be maintained regardless of periodic changes in macroeconomic conditions.

Unemployment is associated with high cardiovascular event rate and increased all-cause mortality in middle-aged socially privileged individuals

PURPOSE

To assess prospectively the association between employment status and cardiovascular health outcomes in socially privileged individuals.

METHODS

The incidence of fatal and non-fatal cardiovascular events and all-cause mortality rate were monitored during 12 years in a national sample of 5,852 French volunteers, aged 45-64 years, who were free of cardiovascular disease or other overt disease at baseline. The association between health outcomes and employment status was tested using Cox proportional modelling with adjustment for confounding factors.

RESULTS

Compared to randomly selected individuals, these volunteers were characterized by higher education level and socio-economic status and lower cardiovascular risk and mortality rate. A total of 242 cardiovascular events (3.5 events per 1,000 person-years) and 152 deaths from all causes (2.2 deaths per 1,000 person-years) occurred during follow-up. After adjustment for age and gender, both cardiovascular event risk [HR (95% CI) 1.84 (1.15-2.83), p = 0.01] and all-cause mortality [2.79 (1.66-4.47), p = 0.0002] were increased in unemployed individuals compared to workers. These poor health outcomes were observed to the same extent after further adjustment for clinical, behavioural and socio-demographic characteristics of individuals at baseline [HR (95% CI) 1.74 (1.07-2.72), p = 0.03 and 2.89 (1.70-4.69), p = 0.0002, respectively]. In contrast, neither cardiovascular event risk nor all-cause mortality was significantly increased in retired individuals compared to workers after adjustment for confounding factors.

CONCLUSIONS

These results support the existence of a link between unemployment and poor cardiovascular health and suggest that this link is not mediated by conventional risk factors in middle-aged socially privileged individuals.

Recessions, job loss, and mortality among older US adults

OBJECTIVES

We analyzed how recessions and job loss jointly shape mortality risks among older US adults.

METHODS

We used data for 50 states from the Health and Retirement Study and selected individuals who were employed at ages 45 to 66 years during 1992 to 2011. We assessed whether job loss affects mortality risks, whether recessions moderate the effect of job loss on mortality, and whether individuals who do and do not experience job loss are differentially affected by recessions.

RESULTS

Compared with individuals not experiencing job loss, mortality risks among individuals losing their job in a recession were strongly elevated (hazard ratio = 1.6; 95% confidence interval = 1.1, 2.3). Job loss during normal times or booms is not associated with mortality. For employed workers, we found a reduction in mortality risks if local labor market conditions were depressed, but this result was not consistent across different model specifications.

CONCLUSIONS

Recessions increase mortality risks among older US adults who experience job loss. Health professionals and policymakers should target resources to this group during recessions. Future research should clarify which health conditions are affected by job loss during recessions and whether access to health care following job loss moderates this relation.

Do generous unemployment benefit programs reduce suicide rates? A state fixed-effect analysis covering 1968-2008

The recent economic recession has led to increases in suicide, but whether US state unemployment insurance programs ameliorate this association has not been examined. Exploiting US state variations in the generosity of benefit programs between 1968 and 2008, we tested the hypothesis that more generous unemployment benefit programs reduce the impact of economic downturns on suicide. Using state linear fixed-effect models, we found a negative additive interaction between unemployment rates and benefits among the US working-age (20-64 years) population (β = -0.57, 95% confidence interval: -0.86, -0.27; P < 0.001). The finding of a negative additive interaction was robust across multiple model specifications. Our results suggest that the impact of unemployment rates on suicide is offset by the presence of generous state unemployment benefit programs, though estimated effects are small in magnitude.

Mortality following unemployment in Canada, 1991-2001

BACKGROUND

This study describes the association between unemployment and cause-specific mortality for a cohort of working-age Canadians.

METHODS

We conducted a cohort study over an 11-year period among a broadly representative 15% sample of the non-institutionalized population of Canada aged 30-69 at cohort inception in 1991 (888,000 men and 711,600 women who were occupationally active). We used cox proportional hazard models, for six cause of death categories, two consecutive multi-year periods and four age groups, to estimate mortality hazard ratios comparing unemployed to employed men and women.

RESULTS

For persons unemployed at cohort inception, the age-adjusted hazard ratio for all-cause mortality was 1.37 for men (95% confidence interval (CI): 1.32-1.41) and 1.27 for women (95% CI: 1.20-1.35). The age-adjusted hazard ratio for unemployed men and women was elevated for all six causes of death: malignant neoplasms, circulatory diseases, respiratory diseases, alcohol-related diseases, accidents and violence, and all other causes. For unemployed men and women, hazard ratios for all-cause mortality were equivalently elevated in 1991-1996 and 1997-2001. For both men and women, the mortality hazard ratio associated with unemployment attenuated with age.

CONCLUSIONS

Consistent with results reported from other long-duration cohort studies, unemployed men and women in this cohort had an elevated risk of mortality for accidents and violence, as well as for chronic diseases. The persistence of elevated mortality risks over two consecutive multi-year periods suggests that exposure to unemployment in 1991 may have marked persons at risk of cumulative socioeconomic hardship.

How society shapes the health gradient: work-related health inequalities in a comparative perspective

Analyses in comparative political economy have the potential to contribute to understanding health inequalities within and between societies. This article uses a varieties of capitalism approach that groups high-income countries into coordinated market economies (CME) and liberal market economies (LME) with different labor market institutions and degrees of employment and unemployment protection that may give rise to or mediate work-related health inequalities. We illustrate this approach by presenting two longitudinal comparative studies of unemployment and health in Germany and the United States, an archetypical CME and LME. We find large differences in the relationship between unemployment and health across labor-market and institutional contexts, and these also vary by educational status. Unemployed Americans, especially of low education or not in receipt of unemployment benefits, have the poorest health outcomes. We argue for the development of a broader comparative research agenda on work-related health inequalities that incorporates life course perspectives.