1. Effect of downsizing on health among employees who remain in employment Mika Kivimaki Professor Department of Epidemiology and Public Health UCL

2. èIn the USA, 43 million jobs eliminated between 1979 and 1995 (Hurrell J. Am J Public Health 1998) èIn Finland, 26% of employees worked in organisations where there had been reductions of personnel in the past year (Statistics Finland 1998)

3. The 10-Town study Vantaa Espoo Naantali Raisio Turku Tampere Valkeakoski Virrat Nokia Oulu An on-going Finnish study on health of municipal employees in ten towns in Finland. These towns include the 5 biggest cities (except the Capital) and 5 smaller nearby towns.

4. Unemployment in Finland Statistics Finland

5. Reduction of workforce Not hiring cover for those absent from work Freeze on vacancies (retirement, turnover) Short-term temporary layoffs in 1993

6. Person-years worked in town Raisio during 1991—1997 Downsizing After downsizing

7. How to measure downsizing? x 100 (Total number of person-years before downsizing) Contracted days - Absence days = Total number of person-years (Total number of person-years before downsizing) – (Total number of person-years after downsizing)

8. Extent of downsizing by occupation

9. 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Assessment of downsizing 1 Mortality 4 First half of the follow-up Second half Design Disability retirement 2 Pre-downsizing Health Work characteristics Data sources: 1 Employers' records 2 Local Government Pensions Institution 3 National Prescription Register 4 Statistics Finland Psychotropic medication (ATC-codes) 3 Post-downsizing sickness absence 1 Perceived health, musculoskeletal symptoms Sources: Lancet 1997; BMJ 2000, 2004; Occup Environ Med 2001, 2005; J Epidemiol Community Health 2005, 2007 J Appl Psychol 1997; Anxiety Stress Coping 2000; Am J Community Psychol 2003

10. RCT Design Target population Study population Randomisation Experimental groupControl group Incidence of outcomeIncidence of outcome

11. Quasi-experiment All 26 682 employees from 4 towns Study population (29 had missing data) Organisational downsizing 1991-1993 Non-downsized groupDownsized groupThose lost/left job n = 17 599 n = 4783 n = 4271 Outcome: Health status in 1994-2000

12. Workload Skill discretion Participation Job insecurity Supervisor support Co-worker support Spouse support Alcohol intake Smoking Physical activity Body mass % * * * * * * *P<0.05 Downsizing causes work stress Source: Kivimäki et al. The Raisio Study. BMJ 2000 Difference in post-downsizing values (adjusted for pre-downsizing values) between groups of major vs no downsizing.

13. Effect of downsizing on self-rated health Kivimäki et al. Anxiety Stress Coping 2000

14. Kivimäki et al. J Epidemiol Community Health 2007 Rate of psychotropic drug prescriptions and other prescriptions by postdownsizing status Psychotropic drug = antidepressant, anxiolytics, hypnotics

15. Organisational downsizing and use of psychotropic drugs in men by SEP Non-manualManual Post-downsizing status Employed in non-downsized group1.00 Employed in downsized group1.87 (1.1-3.1)1.70 (1.1-2.6) Lost or left their job1.40 (0.9-2.1)2.16 (1.2-3.8) Source: Kivimäki et al. The 10-Town Study. J Epidemiol Community Health (2007) *Risk ratios adjusted for pre-downsizing characteristics

16. Virtanen et al. Am J Psychiatry 2009 Hospital ward overcrowding Nurses (N=6699) Work overload and use of antidepressants

17. Source: Vahtera, Kivimäki, Pentti Lancet 1997

18. Source: Vahtera, Kivimäki, Pentti Lancet 1997

20. All cause Musculoskeletal Psychiatric Cause specific absence and risk of disability pension Risk ratio for disability pension Kivimäki et al. the Swedish County Study. J Epidemiol Community Health 2007 Diagnosis for sickness absence and disability pension After excluding precipitating absences People aged 18 to 49 at baseline

21. Extent of downsizing Relative risk Vahtera et al. J Epidemiol Community Health 2005 Organisational downsizing and risk of disability pension 1.46 1.81

22. Development of atherosclerosis Fatty streak Atheroma Fibrous Atheroma Complicated Atheroma

23. Work stress and cardiovascular disease

24. 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Assessment of downsizing 1 Mortality 4 First half of the follow-up Second half Design Data sources: 1 Employers' records 2 Local Government Pensions Institution 3 National Prescription Register 4 Statistics Finland

25. Adjusted for age, sex, SES and type of employment. Downsizing and relative risk of death Vahtera et al. BMJ 2004

26. Organisational downsizing and relative risk of death from cardiovascular diseases *Adjusted for age, sex, socioeconomic status, type of employment, and town. First half of the follow-up Second half of the follow-up Extent of downsizing No1.00 Intermediate4.31 (1.3-14.7)1.06 (0.5-2.1) High5.33 (1.4-20.2)1.44 (0.7-3.2) Source: Vahtera, Kivimäki et al. The 10-Town Study. BMJ 2004 Trigger

27. Socioeconomic confounding? material circumstances mortality work stress

28.  The association between downsizing and cardiovascular mortality remained after adjustment for socioeconomic status.  SES, early living conditions and behavioural health risks are stable predictors of health that are not likely to produce temporary differences in mortality observed in this study.

29. Organisational downsizing and relative risk of SES-related mortality *Adjusted for age, sex, socioeconomic status and type of employment. Smoking-related cancer (49 deaths) Alcohol-related causes (99 deaths) Extent of downsizing No1.0 Intermediate1.2 (0.6-2.3)1.0 (0.6-1.6) High0.7 (0.3-2.7)1.4 (0.8-2.5) Vahtera, Kivimaki et al. BMJ 2004 Downsizing was not associated with deaths from smoking-related cancer and alcohol-related causes, i.e. causes of mortality with well-documented socioeconomic gradients.

30. Summary: Effects of downsizing on survivors INCREASED STRESS AT WORK :  Greater workload, decreased job control, increased job insecurity INCREASED STRESS-RELATED MORBIDITY AND MORTALITY:  Self-reported health problems: musculoskeletal disorders, poor overall health, psychological distress and health complaints  Use of psychotropic drugs  Long-term sickness absence (older people, higher SEP), decrease in short-term sickness absence  Retirement on health grounds  Temporary increase in risk of cardiovascular mortality in vulnerable employees