Unemployment Is a Risk Factor for Hospitalization Due to Alcohol Problems: A Longitudinal Study Based on the Stockholm Public Health Cohort (SPHC).

OBJECTIVE: This study examined the associations between unemployment and alcohol-related hospitalization or mortality and to what extent these associations may be confounded by alcohol consumption and alcohol problems before unemployment. METHOD: The study was based on the Stockholm Public Health Cohort (SPHC), a population-based stratified random sample with a baseline questionnaire in 2002/2003 and record linkages up to year 2011. The final sample in the study consists of 15,841 people aged 18-60 years. Unemployment was defined as any registration at the public employment services during 2003-2005. The outcome was alcohol-related hospitalization and alcohol-related mortality during 2006-2011. Confounders were age, sex, and education, and we further adjusted for baseline alcohol consumption and alcohol-related hospitalization before the study period. Cox proportional hazard models were fit, and associations were expressed as hazard ratios (HRs). RESULTS: In the fully adjusted model, unemployment was associated with an increased risk of alcohol-related hospitalization or mortality, with a more than threefold hazard (HR = 3.38, 95% CI [1.81, 6.31]) compared with no unemployment during the exposure period. There was a moderate attenuating effect of prior alcohol consumption and alcohol-related hospitalization. CONCLUSIONS: Any unemployment in 2003-2005 was highly related to having experienced an alcohol-related diagnosis during the 6-year follow-up, even after controlling for risky use of alcohol and prior hospitalization.

What is the impact of flexicurity on the chances of entry into employment for people with low education and activity limitations due to health problems? A comparison of 21 European countries using Qualitative Comparative Analysis (QCA).

BACKGROUND: Employment and unemployment are key determinants of health inequalities and should be a priority when discussing policies to reduce such inequalities. Our aim is to investigate how flexicurity policies across European countries impact on the employment chances for people with low education and activity limitations. METHODS: The longitudinal EU-SILC dataset, pooled 2005-2010, was used to calculate labour market outcomes. The sample consisted of 25 countries and 19,881 individuals. The employment transitions of non-employed people with activity limitations was followed from one year to the next, and the outcomes were rates of return-to work (RTW) among those with low education, and relative equality of RTW between those with low and high education (rate ratio, RR). Data on flexicurity policy and labour market factors were accessed from Eurostat and the OECD. As policy data was only available for OECD countries, the sample was reduced to 21 countries. Fuzzy-set QCA (Qualitative Comparative Analysis) was used to examine how different combinations of the components of flexicurity were linked to the two outcomes. RESULTS: Where high rates of RTW were achieved, high employment rates were always present. In five countries (the Nordic countries and the Netherlands) these factors coexisted with high expenditure on active labour market policies and social services in old age. In three others (The Czech Republic, UK and Estonia) they were combined with low employment protection and low benefit expenditure. For equality in RTW, low unemployment rates were combined with either high benefit expenditure, or low employment protection. CONCLUSION: We found two routes that lead to high RTW: we characterise these as the high road and the low road. Taking the low road (relaxing employment protection and limiting benefits) may be a tempting option for poorly performing countries. However, without measures to stimulate female employment it may not be enough as high overall employment is so important in enabling people with activity limitations to access the labour market. To achieve equality in RTW, it seems that as long as unemployment is low, either flexibility or security is sufficient.

Do 'flexicurity' Policies Work for People With Low Education and Health Problems? A Comparison of Labour Market Policies and Employment Rates in Denmark, The Netherlands, Sweden, and the United Kingdom 1990-2010.

People with limiting longstanding illness and low education may experience problems in the labor market. Reduced employment protection that maintains economic security for the individual, known as "flexicurity," has been proposed as a way to increase overall employment. We compared the development of labor market policies and employment rates from 1990 to 2010 in Denmark and the Netherlands (representing flexicurity), the United Kingdom, and Sweden. Employment rates in all countries were much lower in the target group than for other groups over the study period. However, "flexicurity" as practiced in Denmark, far from being a "magic bullet," appeared to fail low-educated people with longstanding illness in particular. The Swedish policy, on the other hand, with higher employment protection and higher economic security, particularly earlier in the study period, led to higher employment rates in this group. Findings also revealed that economic security policies in all countries were eroding and shifting toward individual responsibility. Finally, results showed that active labor market policies need to be subcategorized to better understand which types are best suited for the target group. Increasing employment among the target group could reduce adverse health consequences and contribute to decreasing inequalities in health.

Increasing health inequalities between women in and out of work--the impact of recession or policy change? A repeated cross-sectional study in Stockholm county, 2006 and 2010.

INTRODUCTION: The social insurance system in Sweden underwent extensive change between 2006 and 2010, with the overall aim of making people enter the labour market. At the same time, economic recession hit Sweden. Previous studies suggest that the economic recession particularly affected women. In light of these changes, the aim of this study is to investigate whether health inequalities between employed women and groups outside the labour market changed between 2006 and 2010. A second aim is to examine the explanatory weight of socio-demographic factors vs social and economic conditions. METHODS: Data consists of the Stockholm Public Health Surveys (SPHS) for 2006 and 2010. Women aged 18-64 were studied. Through logistic regression, levels of mental distress and limiting longstanding illness (LLI), were compared between four labour market groups; employed and unemployed, sickness absentees and disability pension recipients, at the two time points. RESULTS: Mental distress increased among women in all four labour market groups between 2006 and 2010. Differences in mental distress between those employed and groups outside the labour market also increased. These were explained primarily by social and economic conditions. Levels of LLI were unchanged except among the unemployed. The difference in LLI between the unemployed and the employed was mostly explained by social and economic conditions. In the other groups socio-demographic factors were more salient. For both health outcomes, the weight of social and economic conditions had increased in 2010 compared to 2006. CONCLUSIONS: Results indicate that levels of mental distress increased in all groups, but more so among groups outside the labour market, possibly due to stricter eligibility criteria and lower benefit levels, which particularly affected their social and economic conditions.

The influence of gender equality policies on gender inequalities in health in Europe.

Few studies have addressed the effect of gender policies on women's health and gender inequalities in health. This study aims to analyse the relationship between the orientation of public gender equality policies and gender inequalities in health in European countries, and whether this relationship is mediated by gender equality at country level or by other individual social determinants of health. A multilevel cross-sectional study was performed using individual-level data extracted from the European Social Survey 2010. The study sample consisted of 23,782 men and 28,655 women from 26 European countries. The dependent variable was self-perceived health. Individual independent variables were gender, age, immigrant status, educational level, partner status and employment status. The main contextual independent variable was a modification of Korpi's typology of family policy models (Dual-earner, Traditional-Central, Traditional-Southern, Market-oriented and Contradictory). Other contextual variables were the Gender Empowerment Measure (GEM), to measure country-level gender equality, and the Gross Domestic Product (GDP). For each country and country typology the prevalence of fair/poor health by gender was calculated and prevalence ratios (PR, women compared to men) and 95% confidence intervals (CI) were computed. Multilevel robust Poisson regression models were fitted. Women had poorer self-perceived health than men in countries with traditional family policies (PR = 1.13, 95%CI: 1.07-1.21 in Traditional-Central and PR = 1.27, 95%CI: 1.19-1.35 in Traditional-Southern) and in Contradictory countries (PR = 1.08, 95%CI: 1.05-1.11). In multilevel models, only gender inequalities in Traditional-Southern countries were significantly higher than those in Dual-earner countries. Gender inequalities in self-perceived health were higher, women reporting worse self-perceived health than men, in countries with family policies that were less oriented to gender equality (especially in the Traditional-Southern country-group). This was partially explained by gender inequalities in the individual social determinants of health but not by GEM or GDP.

Do working conditions explain the increased risks of disability pension among men and women with low education? A follow-up of Swedish cohorts.

OBJECTIVES: Rates of disability pension are greatly increased among people with low education. This study examines the extent to which associations between education and disability pensions might be explained by differences in working conditions. Information on individuals at age 13 years was used to assess confounding of associations. METHOD: Two nationally representative samples of men and women born in 1948 and 1953 in Sweden (22 889 participants in total) were linked to information from social insurance records on cause (musculoskeletal, psychiatric, and other) and date (from 1986-2008) of disability pension. Education data were obtained from administrative records. Occupation data were used for measurement of physical strain at work and job control. Data on paternal education, ambition to study, and intellectual performance were collected in school. RESULTS: Women were found to have higher rates of disability pension than men, regardless of diagnosis, whereas men had a steeper increase in disability pension by declining educational level. Adjustment of associations for paternal education, ambition to study, and intellectual performance at age 13 had a considerable attenuating effect, also when disability pension with a musculoskeletal diagnosis was the outcome. Despite this, high physical strain at work and low job control both contributed to explain the associations between low education and disability pensions in multivariable models. CONCLUSION: Working conditions seem to partly explain the increased rate of disability pension among men and women with lower education even though this association does reflect considerable selection effects based on factors already present in late childhood.

Is gender policy related to the gender gap in external cause and circulatory disease mortality? A mixed effects model of 22 OECD countries 1973-2008.

BACKGROUND: Gender differences in mortality vary widely between countries and over time, but few studies have examined predictors of these variations, apart from smoking. The aim of this study is to investigate the link between gender policy and the gender gap in cause-specific mortality, adjusted for economic factors and health behaviours. METHODS: 22 OECD countries were followed 1973-2008 and the outcomes were gender gaps in external cause and circulatory disease mortality. A previously found country cluster solution was used, which includes indicators on taxes, parental leave, pensions, social insurances and social services in kind. Male breadwinner countries were made reference group and compared to earner-carer, compensatory breadwinner, and universal citizen countries. Specific policies were also analysed. Mixed effect models were used, where years were the level 1-units, and countries were the level 2-units. RESULTS: Both the earner-carer cluster (ns after adjustment for GDP) and policies characteristic of that cluster are associated with smaller gender differences in external causes, particularly due to an association with increased female mortality. Cluster differences in the gender gap in circulatory disease mortality are the result of a larger relative decrease of male mortality in the compensatory breadwinner cluster and the earner-carer cluster. Policies characteristic of those clusters were however generally related to increased mortality. CONCLUSION: Results for external cause mortality are in concordance with the hypothesis that women become more exposed to risks of accident and violence when they are economically more active. For circulatory disease mortality, results differ depending on approach--cluster or indicator. Whether cluster differences not explained by specific policies reflect other welfare policies or unrelated societal trends is an open question. Recommendations for further studies are made.

Binge drinking--a predictor for or a consequence of unemployment?

BACKGROUND: Research on the association between alcohol use and unemployment has been conducted in various settings and subgroups. While most studies confirm that problem use is related to subsequent unemployment, results are inconclusive regarding the reverse association. Few studies have analyzed binge drinking as either a predictor or an outcome. METHODS: This study investigates 13,031 residents in Stockholm county, who participated in a 2002 survey with a follow-up in 2007, aged 20 to 59, and currently employed or on leave at T1. Associations between frequency of binge drinking and total unemployment duration in 2003 to 2006 were assessed using logistic regression, taking previous binge drinking and previous unemployment experience into account. RESULTS: After full adjustment, high frequency of binge drinking (1 per week or more) had a nonsignificant association with any subsequent unemployment for men and women and a significant association with long-term unemployment (>6 months) for women (OR 1.87). For men, both short-term unemployment and long-term unemployment were unrelated to later binge drinking after adjustment for previous binge drinking. Associations were stronger for women, but not significant in the full model. CONCLUSIONS: Frequent binge drinking among women was associated with long-term unemployment. There was little support for the social causation hypothesis.

Unemployment and mental health--who is (not) affected?

BACKGROUND: The aim of this study is first, to investigate the association between periods of unemployment and mental distress, adjusting for previous health status, and second, to study differences and similarities between groups defined by age, sex, family situation, socioeconomic position and work environment. METHODS: The analyses are based on a cohort of participants in Stockholm county council's Public Health Survey 2002 with a follow-up in 2007. Selected from the initial cohort are respondents 20-59 years who were employed at T1 and had no unemployment in 2001-02. Logistic regression is used and differences between groups are expressed as odds ratios. Interaction analyses are also performed. RESULTS: Initial odds ratios of 1.84 in the group with 1 year of unemployment or more compared to the reference group with no unemployment is reduced to 1.52 after adjustment for prior mental and somatic health. Analyses show that the impact of unemployment in this sample is stronger for men, those working overtime, those with high social support or low control at their previous job, self-employed and those with low occupational class or low previous wage. Regarding family situation, unemployment is least associated with mental distress among individuals living in couples without children. CONCLUSION: Results show an independent effect of unemployment on mental distress, but this effect varies between groups. Both proposed theories: role loss and differential susceptibility, receive some support. Since all interaction analyses are insignificant, results should be interpreted with caution.

Unemployment and hospitalization owing to an alcohol-related diagnosis among middle-aged men in Sweden.

BACKGROUND: Unemployment is associated with alcohol-related morbidity. However, the extent to which the association is causal is unclear, and it is not known whether other risk factors remain uncontrolled for. This study examines the association between unemployment and later alcohol-related hospitalization, adjusted for preexisting alcohol disorders, psychiatric diagnoses, behavioral risk factors, and social factors. METHODS: The study was based on a military conscription cohort (men born in 1949 to 1951), with information on psychiatric diagnosis and psychological assessment and from a drug-use survey, which was then linked to national registers. The analyses were performed on data on the 37,798 individuals who were in paid employment in 1990 to 1991. RESULTS: It was found that short- and long-term unemployment (1 to 89 days and ≥90 days) were associated with hospitalization owing to an alcohol-related diagnosis at 12-year follow-up (HR(crude) = 2.25, 95% CI 1.64 to 3.09 and HR(crude) = 2.95, 95% CI 2.51 to 3.48, respectively). After adjustment for confounders, the hazard ratios (HRs) decreased but were still significantly elevated (HR(adjusted) = 1.52, 95% CI 1.10 to 2.10 and HR(adjusted) = 1.61, 95% CI 1.36 to 1.92, respectively). When follow-up was split into 3 time bands, it was found that the short- and medium-term associations were about the same and independent of unemployment duration, with adjusted HRs ranging between 1.70 and 1.76. No significant long-term associations were found after adjustment. CONCLUSIONS: Unemployment was related to becoming hospitalized owing to an alcohol-related diagnosis. A substantial part of the elevated relative risk of alcohol-related hospitalization related to unemployment was found to be associated with already existing individual risk factors.

Gender policy developments and policy regimes in 22 OECD countries, 1979-2008.

This study investigates trends and clustering of gender policy in 22 OECD (Organization for Economic Cooperation and Development) countries during 1979-2008. The starting point was Sainsbury's gender policy regime framework, and the study included indicators reflecting the male bread-winner, individual earner-carer, and separate gender roles regimes. The indicators were followed over seven time points for mean, range, and distribution. Cluster analyses were performed for the years 1979, 1989, 1999, and 2004. In accordance with previous studies, the authors found a Nordic cluster of earner-carer countries, while several Southern European countries and the United States were marked by their low generosity and high pension requirements. Though aspects of the separate gender roles regime have become more widespread, no country could be classified as fully belonging to this regime type. The two aspects of the model--compensatory measures in the pension system, and benefits for caring activities--were never present simultaneously.

Involvement and structure: a qualitative study of organizational change and sickness absence among women in the public sector in Sweden.

BACKGROUND: Organizational changes in modern corporate life have become increasingly common and there are indications that they often fail to achieve their ends. An earlier study of 24,036 employees showed that those who had repeatedly been exposed to large increases in staffing during 1991-1996 had an excess risk of both long-term sickness absence and hospital admission during 1997-1999, while moderate expansion appeared to be protective. The former was most salient among female public sector employees. We used qualitative interviews to explore work environment factors underlying the impact of organizational changes (moderate and large expansions in staffing) on sickness absence from an employee perspective. METHOD: We interviewed 21 strategically selected women from the earlier study using semi-structured telephone interviews focusing on working conditions during the organizational changes. We identified 22 themes which could explain the association between organizational changes and sickness absence. We then used Qualitative Comparative Analysis (QCA) to reduce the number of themes and discover patterns of possible causation. RESULTS: The themes that most readily explained the outcomes were Well Planned Process of Change (a clear structure for involvement of the employees in the changes), Agent of Change (an active role in the implementation of the changes), Unregulated Work (a lack of clear limits and guidelines regarding work tasks from the management and among the employees), and Humiliating Position (feelings of low status or of not being wanted at the workplace), which had been salient throughout the analytic process, in combination with Multiple Contexts (working in several teams in parallel) and Already Ill (having already had a debilitating illness at the beginning of 1991), which may indicate degree of individual exposure and vulnerability. Well Planned Process of Change, Agent of Change and Multiple Contexts are themes that were associated with low sickness absence. Unregulated Work, Humiliating Position and Already Ill were associated with high sickness absence. CONCLUSIONS: These findings suggest that promising areas for future research and improvement in change management could be the structured involvement of the employees in the planning of organizational changes, and the development of methods to avoid highly unregulated working conditions.

Pioneers and laggards - is the effect of gender equality on health dependent on context?

This study combines data at individual and area level to examine interactions between equality within couples and gender equality in the municipality in which individuals live. The research question is whether the context impacts on the association between gender equality and health. The material consists of data on 37,423 men and 37,616 women in 279 Swedish municipalities, who had their first child in 1978. The couples were classified according to indicators of their level of gender equality in 1980 in the public sphere (occupation and income) and private sphere (child care leave and parental leave) compared to that of their municipality. The health outcome is compensated days from sickness insurance during 1986-1999 with a cut-off at the 85% percentile. Data were analysed using logistic regression with the overall odds as reference. The results concerning gender equality in the private sphere show that among fathers, those who are equal in an equal municipality have lower levels of sick leave than the average while laggards (less equal than their municipality) and modest laggards have higher levels. In the public sphere, pioneers (more equal t han their municipality) fare better than the average while laggards fare worse. For mothers, those who are traditional in their roles in the public sphere are protected from high levels of sick leave, while the reverse is true for those who are equal. Traditional mothers in a traditional municipality have the lowest level of sick leave and pioneers the highest. These results show that there are distinct benefits as well as disadvantages to being a gender pioneer and/or a laggard in comparison to your municipality. The associations are markedly different for men and women.

The relationship between a less gender-stereotypical parenthood and alcohol-related care and death: a registry study of Swedish mothers and fathers.

BACKGROUND: In general men tend to drink more alcohol and experience more alcohol-related sickness, injuries and mortality than women. In this paper, the overall hypothesis was that increased gender similarity in the division of parental duties would lead to convergence in alcohol-related harm. The aim was to analyse whether the risk of alcohol harm differs between parents who fit a gender-stereotypical versus those with a less gender-stereotypical division of childcare and paid work. METHODS: The study sample was a retrospective registry-based cohort study of all Swedish couples who had their first child together in 1978 (N = 49,120). A less gender-stereotypical parenthood was indicated by paternity leave for fathers (1978-1979) and full-time work for mothers (1980). The outcome was inpatient care and/or death caused by alcohol psychosis, alcoholism, liver disease, or alcohol intoxication in the two decades following (1981-2001). Our main statistical method was multivariate logistic regression with odds ratios used to estimate relative risks. RESULTS: The main results show that fathers who took paternity leave had 18% lower risk of alcohol-related care and/or death than other fathers. Mothers who worked full-time about two years after having a child had 71% higher risk than mothers who were unemployed or worked part-time. CONCLUSION: A less gender-stereotypical division of duties between parents in early parenthood may contribute to a long-term decreased gender disparity regarding risky alcohol consumption and alcohol-related harm. In order to know more about the causal direction however, future research has to consider subjects' drinking patterns in the years prior to parenthood.

Does increased gender equality lead to a convergence of health outcomes for men and women? A study of Swedish municipalities.

This study examines associations between indicators of gender equality and public health. We compare Swedish municipalities on nine indicators in both the private and public sphere, and an additive index, and study the correlations with indicators of morbidity and mortality. The hypothesis that a higher level of gender equality is associated with a convergence of health outcomes (life expectancy, sickness absence) between men and women was supported for equality of part-time employment, managerial positions and economic resources for morbidity, and for temporary parental leave for mortality. Our main finding is that gender equality was generally correlated with poorer health for both men and women. Our conclusions are tentative due to the methodological uncertainties. However, the results suggest an unfortunate trade-off between gender equality as we know it and public health. Sweden may have reached a critical point where further one-sided expansion by women into traditionally male roles, spheres and activities will not lead to positive health effects unless men also significantly alter their behaviour. Negative effects of this unfinished equality might be found both for women, who have become more burdened, and men, who as a group have lost many of their old privileges. We propose that this contention be confronted and discussed by policymakers, researchers and others. Further studies are also needed to corroborate or dispute these findings.