Do health literacy, physical health and past rehabilitation utilization explain educational differences in the subjective need for medical rehabilitation? Results of the lidA cohort study.

BACKGROUND: Medical rehabilitation can be helpful for maintaining workers' health and work ability. Its contribution to longer working lives is of high economic relevance in aging populations. In Germany, individuals must apply for rehabilitative measures themselves. Therefore, the subjective need for rehabilitation (SNR) is a prerequisite for rehabilitation access. A low education level is associated with poor health, lower health literacy and more frequent utilization of health services. In the present study, we investigated whether lower educational levels are also associated with a greater SNR and whether health literacy, past rehabilitation utilization and physical health play a mediating role in this path in older employees. METHODS: 3,130 socially insured older employees (born in 1959 or 1965) who participated in the German prospective lidA (leben in der Arbeit) cohort-study in 2011, 2014 and 2018 were included. A causal mediation analysis with an inverse odds weighting approach was performed with the SNR as the dependent variable; educational level as the independent variable; and health, health literacy and past rehabilitation utilization as the mediating variables. Sociodemographic variables were adjusted for. RESULTS: The SNR was significantly greater in subjects with a low education level, poor physical health, inadequate health literacy and those who had utilized rehabilitation in the past. For health literacy, past rehabilitation utilization and physical health, a significant partial mediating effect on the SNR was found for employees with low compared to those with high education levels. However, the combined mediating effect of all the mediators was lower than the sum of their individual effects. Among those with medium or high education levels, none of the variables constituted a significant mediator. CONCLUSIONS: The path between a low education level and a high SNR is mediated by inadequate health literacy, past rehabilitation utilization and poor physical health; these factors do not act independently of each other. Promoting health education may lower the SNR by improving physical health and health literacy. While improving physical health is beneficial for individuals, improved health literacy can be economically advantageous for the health system by reducing inappropriate expectations of rehabilitation benefits and subsequent applications for rehabilitation.

Associations between precarious employment trajectories and mental health among older workers in Germany: Vertical and horizontal inequalities.

OBJECTIVE: The aim of the study was to investigate the longitudinal association between multi-dimensionally measured precarious employment (PE) trajectories and mental health among older employees in Germany. METHODS: Current data from the German lidA study was used, including panel cases, who participated in all four survey waves (2011, 2014, 2018, 2022). The study comprised 1636 subjects, aged 46 and 52 years at baseline. Group-based trajectory modelling was used to model PE trajectories based on a score combining multiple items from the dimensions employment insecurity and income inadequacy. The association between PE trajectories (2011-2022) and mental health (2022) was tested using weighted logistic regression. RESULTS: We identified a PE trajectory with upward movement that best described 13.6% of the study sample. Representation in this group was socially unequally distributed with noticeably larger shares of female, lower-educated and lower-skilled workers in PE. Women following this trajectory had increased odds [odds ratio (OR) 1.68-1.82] of reporting poor mental health in 2022 compared to their counterparts in constant non-PE. This was not the case for men (OR 0.37-0.51). CONCLUSIONS: Our findings highlight horizontal and vertical inequalities with respect to exposure to and consequences of PE. Future labor market reforms should improve protection of women, who will likely be disadvantaged by accumulating employment-related mental health risks over the course of their lives.

The contribution of work and health-related lifestyle to educational inequalities in physical health among older workers in Germany. A causal mediation analysis with data from the lidA cohort study.

OBJECTIVES: The objective of the study was to investigate the contribution of work factors and health-related lifestyle to educational inequalities in physical health among older workers in Germany by applying causal mediation analysis with longitudinal data. METHODS: Data from the German lidA study was used. 2653 persons (53% female, 47% male) aged 46 (born 1965) and 52 (born 1959) at baseline were followed up for seven years with exposure and outcome assessments in 2011 (t0), 2014 (t1) and 2018 (t2). The total effect of education on physical health was decomposed into a natural direct effect (NDE) and a natural indirect effect (NIE) by using a sex-stratified causal mediation analysis with an inverse odds weighting approach. Baseline health, partner status and working hours were entered as a first set of mediators preceding the putative mediators of interest. All analyses were adjusted for age and migrant status. RESULTS: Independent of the first set of mediators, work factors explained 21% of educational inequalities in physical health between low and high educated women and 0% comparing moderate versus high educated women. The addition of health behaviors explained further 26% (low vs. high education) and 20% (moderate vs. high education), respectively. Among men, net of the first set of mediators, work factors explained 5% of educational inequalities in physical health between low and high educated and 6% comparing moderate versus high educated persons. Additional 24% (low vs. high education) and 27% (moderate vs. high education) were explained by adding health behaviors to the models. CONCLUSIONS: To reduce educational inequalities in physical health among older workers in Germany, interventions to promote healthy behaviors are promising. Improving working conditions is likely an important prerequisite.

Social inequalities in early exit from employment in Germany: a causal mediation analysis on the role of work, health, and work ability.

OBJECTIVE: The aim of this study was to investigate the contribution of work factors, health, and work ability to social inequalities in early exit from employment among older employees in Germany. METHODS: Longitudinal data from the representative German lidA Cohort study was linked with employment register data to obtain maximum information on exit routes out of paid employment. Information of N=2438 respondents, aged 46 and 52 at baseline, were obtained for a follow-up of six years (2011-2017). Causal mediation analysis with inverse odds weighting was conducted using discrete-time survival outcomes and baseline measurements of the socioeconomic status (SES: education), work factors, health, and work ability. RESULTS: Older employees with low SES were at an increased risk of exiting employment early by receiving disability pension and through long-term unemployment but not through an unspecified labor market exit when compared to those with high and moderate SES. Low work ability accounted for up to 38% of the social inequalities in work exits into disability pension. Less-than-good physical health accounted for up to 59% of inequalities in work exits into long-term unemployment. Work factors contributed considerably to inequalities in exits through unemployment but not disability pension. CONCLUSIONS: This study finds social inequalities in early exits through disability pension and long-term unemployment among older employees in Germany, predominantly attributable to differences in work ability (disability pension) and physical health (unemployment). Investments in work ability and promotion of physical health may constitute promising approaches to counteract an increase of these inequalities.