Losing life and livelihood: A systematic review and meta-analysis of unemployment and all-cause mortality

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Abstract

Unemployment rates in the United States remain near a 25-year high and global unemployment is rising. Previous studies have shown that unemployed persons have an increased risk of death, but the magnitude of the risk and moderating factors have not been explored. The study is a random effects meta-analysis and meta-regression designed to assess the association between unemployment and all-cause mortality among working-age persons. We extracted 235 mortality risk estimates from 42 studies, providing data on more than 20 million persons. The mean hazard ratio (HR) for mortality was 1.63 among HRs adjusted for age and additional covariates. The mean effect was higher for men than for women. Unemployment was associated with an increased mortality risk for those in their early and middle careers, but less for those in their late career. The risk of death was highest during the first 10 years of follow-up, but decreased subsequently. The mean HR was 24% lower among the subset of studies controlling for health-related behaviors. Public health initiatives could target unemployed persons for more aggressive cardiovascular screening and interventions aimed at reducing risk-taking behaviors.

Highlights

► The risk of death for unemployed persons was 63% higher than the risk of death for employed persons. ► The relative mortality risk associated with unemployment was 37% higher for men than for women. ► The relative mortality risk associated with unemployment was significantly lower for workers approaching retirement age (50-65 years of age). ► The relative mortality risk associated with unemployment remained elevated among studies with lengthy follow-up periods, suggesting that becoming unemployed induces a long-term change in the underlying mortaity risk.

Section snippets

Mediating and confounding health factors in unemployment research

Early work on the association between unemployment and mortality suggested that the relationship is causal (Moser et al., 1987). More recent work, however, has called this into question and the issue of causation remains unsettled (Martikainen, 1990, Martikainen et al., 2007). Many studies, for example, have documented that persons with pre-existing health conditions are more likely to become and remain unemployed (Bartley and Owen, 1996, Bockerman and Ilmakunnas, 2009, Claussen, 1993, Salm,

Search strategy and coding procedures

In June 2005, we conducted a search of electronic bibliographic databases to retrieve all publications combining the concepts of psychosocial stress, including unemployment, and all-cause mortality. We re-ran the electronic keyword searches in these databases in July 2008 and completed the search and coding stages in January 2009. We used 100 search clauses for Medline, 97 for EMBASE, 81 for CINAHL, and 20 for Web of Science. See Section 1 of Appendix for the full search algorithm used for

Results

Table 1 provides summary information on the 42 publications included in this study. This table is presented in lieu of the standard meta-analysis forest plot because of space limitations and the inherent difficulty in garnering data heterogeneity information from a plot that contains 235 point estimates and confidence intervals. The mean relative risk from each of the 42 publications, however, was included in Table 1 in the interest of providing information from which some heterogeneity

Discussion

Our findings show that unemployment was associated with an increased relative risk of all-cause mortality. We show that the risk of death was 63% higher among those who experienced unemployment than among those who did not, after adjustment for age and other covariates. Before proceeding to a more detailed discussion of the specific findings, however, some important limitations must be considered.

Discussion

Three findings from our study support the idea that the pathway between unemployment and mortality is not completely spurious, and could be consistent with a causal association. First, unemployment remains associated with an increased risk of death even after the exclusion of individuals who were not in the labor force. This supports Moser et al.’s (1987) finding that elevated risk levels among the unemployed were not simply an artifact of misclassification. Second, the lack of significant

Conclusion

This study shows that unemployment was associated with a substantially increased risk of death among broad segments of the population. Future research should continue to focus on possible mediating, moderating, and confounding factors and on whether this risk is modifiable, either at the health system level or the individual level. Until more is known about the mechanisms by which this association occurs, more proactive primary prevention screening and interventions among the unemployed are

Acknowledgments

The authors are grateful for the support provided by grant HL-76857 from the National Institutes of Health. The funding source had no involvement in the collection, analysis and interpretation of the data, in the writing of the report, and in the decision to submit the paper for publication.

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