1. Poor health as cause and consequence of unemployment: mechanisms and interventions Alex Burdorf Department of Public Health Erasmus Medical Centre in Rotterdam

2. Erasmus himself

3. People who use their erudition to write for a learned minority don’t seem to me favoured by fortune but rather to be pitied for their continuous self-torture... for they continuously add, change, delete, and rewrite their treatis, only to be read and critised by colleagues. Praise of Folly 1511

4. Schuring et. al. Int Arch Occup Environ Health 2009;82:1023-30. 1. Role of employment in health inequalities

5. Roelfs et al. Soc Sci Med 2011;72:840-54 1. Role of employment in health inequalities Meta-analysis on unemployment and mortality

6. Two well-established mechanisms Selection process: Health problems are a barrier to enter paid employment AND health problems may cause loss of paid employment Causation process: Unemployment may cause health problems AND re-employment will decrease health problems (paid employment as health intervention) 1. How does health influences paid employment ?

7. Burdorf et. al. Rotterdam, 2008 1. Role of work in health inequalities Unemployment in the neighbourhood and life expectancy in Rotterdam

8. Neighbourhood effect on all cause mortality, men (upper quartile % unemployment) ARIC (US) Eindhoven London Helsinki Turin Madrid Model 1: adjusted for age Model 2: adjusted for age, education and occupation Van Lenthe et al., JECH 2005;59:231-7 1. Role of work in health inequalities

9. Conclusions part I: 1.Profound differences in health status across employment status: men: disabled > unemployed / retired > employed women: disabled > unemployed / retired / homemaker > employed 2.Unemployment is associated with substantially higher mortality 3.Living in a neighbourhood with high unemployment is associated with higher mortality  Unemployment affects individuals and groups 1. Role of work in health inequalities

10. 2. What are potential benefits of interventions ?

11. Relevant questions: -what is the relative contribution of working conditions and lifestyle factors to the occurrence of poor health? -how large is the direct effect of poor health on labour force displacement? -how large is the direct effects of determinants of poor health on labour force displacement? -what are the potential benefits of interventions on (determinants of ) poor health for labour force participation?

12. Relative probability of displacement from the labour market during 2 year follow-up 2004 to 2006 in the SHARE study [Van den Berg et al. Occup Environ Med 2010;67:845-52] 2. What are potential benefits of interventions ?

13. Persons 50 - 65 y, employed at wave 1 (n=4797), prospective analysis of SHARE study Early retirement Unemployment (n = 631) (n=130)OR Less than good health1.65*2.25* Overweight1.12 Obesitas1.75* Alcohol (> 2 units/day)1.25* Lack of job control1.112.22* Effort-reward imbalance1.54*1.11 (adjusted for age, sex, education, and country) 2. What are potential benefits of interventions ?

14. Persons 50 - 65 y, unemployed at wave 1 (n=386), prospective analysis Entering paid employment (n=110) OR Poor health vs excellent0.23 Fair health vs excellent0.28 Overweight vs normal0.72 Obesitas vs normal0.43 (adjusted for age, sex, education, and country) 2. What are potential benefits of interventions ?

15. Van den Berg et al. J Occup Environ Med 2010;52:576-83. 2. What are potential benefits of interventions ?

16. Life table analysis 2004 based on associations between self-assessed health and exit from paid employment (longitudinal analysis of SHARE) 2. What are potential benefits of interventions ?

17. Life table analysis 2004 based on associations between self-assessed health and exit from paid employment (longitudinal analysis of SHARE) 2. What are potential benefits of interventions ?

18. Theoretical effects on work life expectancy through elimination of ill health and work-related determinants MenWomen Improved job control &  0.4 yr  0.5 yr better effort-reward balance Reduced physical load at work  0.3 yr  0.4 yr Self-rated good health  0.4 yr  0.5 yr 2. What are potential benefits of interventions ?

19. Conclusions part III:  Prevention of poor health will have a noticeable influence on labour force participation, especially among older workers  ill health matters ! Working conditions and lifestyle matter !  This provides important entry-points for policies aimed at increasing labour force participation. 2. What are potential benefits of interventions ?

20. 3. What are the challenges in the near future?

21. Working longer, but how ?

22. 3. What are the challenges in the near future?

23. What to do ?

24. Health promotion among unemployed persons: consider carefully ! 3. What are the challenges in the near future?

25. Many studies suffer from selection bias: more work-ready claimants Financial incentives often too low or too short Personal advisors and individual case management helped some persons 3. What are the challenges in the near future?

26. Need for a tailored approach ? 3. What are the challenges in the near future?

28. Essential components in re-employment interventions ? *Combined approach of employment, health, and other problems *Integrated support *Create realistic perspective (what can you do, you can do it) *Health as a resource, but not as independent goal 3. What are the challenges in the near future?

29. Research questions: 1.What are effective interventions that prevent long-term displacement from the labour force? [health, working conditions, lifestyle, work ability] 2.What are effects of social and physical environment on health and lifestyle behaviours of workers and those unemployed? 3.How do we support workers with chronic diseases? 4.What is the cost-effectiveness of re-employment programmes? 5.How to communicate the importance of health at work? [work life expectancy]

30. …and then life after work… “The health gap between the lowest and highest paid occupational groups widens in retirement. A lifetime on a low wage physically ages a person eight years earlier than high earners. Retirement does not level the playing field. These health inequalities actually increase.” Chandola, Whitehall study, BBC News May 18, 2009

31. …and then life after work…

32. a.burdorf@erasmusmc.nl www.erasmusmc.nl/mgz www.nihes.nl