Unemployment and Mortality: A Comparative Study of Germany and the United States

Objectives. We examined the relationship between unemployment and mortality in Germany, a coordinated market economy, and the United States, a liberal market economy.Methods. We followed 2 working-age cohorts from the German Socio-economic Panel and the US Panel Study of Income Dynamics from 1984 to 2005. We defined unemployment as unemployed at the time of survey. We used discrete-time survival analysis, adjusting for potential confounders.Results. There was an unemployment–mortality association among Americans (relative risk [RR] = 2.4; 95% confidence interval [CI] = 1.7, 3.4), but not among Germans (RR = 1.4; 95% CI = 1.0, 2.0). In education-stratified models, there was an association among minimum-skilled (RR = 2.6; 95% CI = 1.4, 4.7) and medium-skilled (RR = 2.4; 95% CI = 1.5, 3.8) Americans, but not among minimum- and medium-skilled Germans. There was no association among high-skilled Americans, but an association among high-skilled Germans (RR = 3.0; 95% CI = 1.3, 7.0), although this was limited to those educated in East Germany. Minimum- and medium-skilled unemployed Americans had the highest absolute risks of dying.Conclusions. The higher risk of dying for minimum- and medium-skilled unemployed Americans, not found among Germans, suggests that the unemployment–mortality relationship may be mediated by the institutional and economic environment.The relationship between unemployment and mortality has been a well-studied phenomenon. Unemployment has been found to be associated with all-cause mortality1–4 for both men5–7 and women,8,9 for older workers,10–14 for cause-specific outcomes,15,16 and after controls for health selection into unemployment.17–20 Some studies have found that the relationship between unemployment and mortality is smaller during times of high unemployment than in times of low unemployment21,22; studies of plant closure conducted during times of high unemployment have found a consistent relationship.23,24Unemployment has almost always been viewed as an individual-level risk factor on health within the context of a single country or economy. When context has been considered it has been to investigate whether the effect of unemployment on health is different during times or places with high unemployment compared with low unemployment.22,25,26 Unemployment may influence health through material (e.g., loss of income) and psychosocial (e.g., loss of individual and social identity) pathways. These pathways are embedded in and influenced by societal and institutional context at every point, from determining who is unemployed (and who participates in the labor market), the meaning of unemployment, the material effect of unemployment, and the future employment consequences of unemployment.Recent scholarship in health inequalities has begun to characterize the structural and contextual features of a society that lead to better or worse population health outcomes.27,28 This research has emphasized the importance of welfare-regime type as the principal independent variable in explaining variation in health inequalities among countries. Welfare-regime typologies classify countries according to how the state provides social and economic protection to its citizens. Although there are many welfare-regime typologies,29 Esping-Andersen’s30 typology that classifies countries into social democratic (universal provision), conservative (class-based provision), and liberal or residual (mean-tested provision) welfare-regime clusters is the most common.Few studies have examined whether the relationship between unemployment and health varies across welfare-regime type. Bambra and Eikemo found that the unemployed in liberal welfare regimes had the highest odds of reporting poorer self-reported health status for both unemployed men and women, but that high odds ratios were also found for unemployed men in conservative welfare regimes and women in social democratic welfare regimes.31 Cooper et al. examined the relationship between unemployment and exit into poor health in 14 European countries, but did not find any relationship across welfare regimes.32,33 Rodriguez examined whether the receipt of means-tested (i.e., welfare or social assistance) and unemployment benefits moderated the relationship between unemployment and self-assessed health in Germany (a conservative welfare regime), the United Kingdom, and the United States (2 liberal welfare regimes).34 Regular unemployment benefits moderated the relationship between unemployment and health in all 3 countries compared with the unemployed in receipt of means-tested benefits. The unemployed not in receipt of any benefits in the United States also reported poorer self-assessed health.Hall and Soskice’s Varieties of Capitalism typology35 provides a more relevant way of understanding how the institutional environment may affect the health of the unemployed because it is based, more directly than Esping-Andersen’s typology, on the conditions of employment and unemployment. Economies of high-income countries are grouped into coordinated market economies (CMEs) and liberal market economies (LMEs) that have different production specializations, similar economic growth and aggregate levels of wealth, but different economic and labor market institutions. Within CMEs and LMEs there is an interdependent relationship between the coordinating features of the market economy, the goods and services produced, the skills required by workers, and the potential future consequences of unemployment. The CMEs (e.g., Germany and Sweden) are characterized by collaboration among firms, trade unions, and other market actors and specialize in the production of goods and services that require a high degree of firm- or industry-specific skills and require workers that are technically or vocationally trained. High levels of employment protection (i.e., restrictions on terminating employees) and unemployment protection (i.e., the availability and level of unemployment benefits) safeguard the educational investment of workers, as once unemployed there may not be demand for their skills in other firms or industries.36In LMEs, by contrast, competitive market institutions predominate, including a flexible labor market with low levels of unemployment and employment protection. These economies specialize in goods and services that require general skills that are readily transferred across firms and industries. In accordance, the risk of unemployment and its effect on the health of the unemployed may vary across countries and within countries by skill level, depending on the protections provided to the unemployed and the opportunities for reemployment. Specifically, in LMEs the flexible labor market advantages those with high general skills (i.e., a university degree), whereas in CMEs the more coordinated labor market is structured to support workers with firm- and industry-specific vocational skills.37We examined whether the relationship between unemployment and mortality differs between Germany, a CME, and the United States, an LME, with 2 comparable working-age cohorts. We hypothesized that the higher levels of unemployment protection in Germany will mediate the effect of unemployment on mortality compared with the United States and that the gradient in the risk of unemployment on mortality by general educational status will be steeper in the United States compared with Germany.     

Unemployment and Suicide During and After a Deep Recession: A Longitudinal Study of 3.4 Million Swedish Men and Women

Objectives. We tested 2 hypotheses found in studies of the relationship between suicide and unemployment: causal (stress and adversity) and selective interpretation (previous poor health).Methods. We estimated Cox models for adults (n = 3 424 550) born between 1931 and 1965. We examined mortality during the recession (1993–1996), postrecession (1997–2002), and a combined follow-up. Models controlled for previous medical problems, and social, family, and employer characteristics.Results. During the recession there was no excess hazard of mortality from suicide or events of undetermined intent. Postrecession, there was an excess hazard of suicide mortality for unemployed men but not unemployed women. However, for unemployed women with no health-problem history there was a modest hazard of suicide. Finally, there was elevated mortality from events of undetermined intent for unemployed men and women postrecession.Conclusions. A small part of the relationship may be related to health selection, more so during the recession. However, postrecessionary period findings suggest that much of the association could be causal. A narrow focus on suicide mortality may understate the mortality effects of unemployment in Sweden.Recent studies that have examined unemployment and suicide mortality have reported an elevated, unadjusted, or minimally adjusted odds ratio or risk ratio ranging from 1.9 to almost 6 times that of employed individuals.1–5 Debate about this association is, however, exemplified by contradictory interpretations of findings in individual-level studies. The 2 central arguments have posited that the relationship is either causal or spurious. But studies of suicide mortality and unemployment frequently find evidence to support both hypotheses.2,6–8Those who have reported a predominantly causal relationship2,3 have often suggested a direct role of unemployment in which loss of control and resulting stress produce increased vulnerability to suicide9 especially with the accumulation of long-term unemployment.10,11 Job loss might also exacerbate preexisting social or mental health vulnerabilities.9 A variation on this view has suggested some heritable dispositions could even be activated by a stressor12 (e.g., unemployment). Ultimately, job loss and suicide are thought to be linked through an increase in mental distress and a decline in mental health or well-being.There is considerable support for this view. Findings from a recent, comprehensive meta-analysis estimated that job loss reduced the mental health of the unemployed by a half standard deviation. Effect sizes were larger for the long-term unemployed, blue-collar workers, and men.13 Curvilinear effects were found that suggested distress increased significantly with shorter-term unemployment. It leveled off during the second year, and then increased sharply with longer-term unemployment accumulation (> 29 months). In addition, small but statistically significant effect sizes related to health selection were evident. Individuals who suffered with impaired mental health while enrolled in school experienced more job loss after graduating.Other studies have suggested that job loss caused the development of mental health problems or reduced psychological well-being.9,13,14 A British longitudinal study that examined the effect of unemployment on the formation of depression and anxiety in young men has shown that both long-term unemployment exceeding 37 months and recent unemployment experience increased the risk of symptom reporting.9 These results are convincing because they were obtained after excluding men who had reported preexisting depression from the analysis.A longitudinal study of Danish workers who were present at the time of a shipyard closure demonstrated that changes in employment status were followed by changes in psychological well-being among employed and unemployed individuals.14 Psychological well-being was poorest for those who became unemployed and remained jobless for the study’s duration. It was best for those who maintained jobs by switching employers. However, individuals who were unemployed and then became reemployed showed improvements in self-reported well-being. Those who were employed and then became unemployed in one of the study’s later time periods experienced a decrease. Changes in well-being that followed changes in employment status were taken as strong evidence for a causal effect of employment status on well-being.By contrast, other studies have suggested that suicide and unemployment are unrelated and are predominantly attributable to preexisting, individual-level mental health, or psychiatric problems,1,6 which may have heritable links.15 The conclusions of such studies are undergirded by the idea that the majority of individuals who have died of suicide suffered from a preexisting mental illness.1 A meta-analysis of studies that utilized the psychological autopsy method for ascertaining the specific psychiatric disorders suffered by suicide completers found that 87% of the decedents had a preexisting mental disorder.16 The relative proportions of male and female completers who were diagnosed over a range of mental health conditions (substance-related, personality disorders, affective disorders, childhood disorders, and depressive disorders) were different.Studies that have examined parasuicide have also reported that the strongest associated risk factors were having either a psychiatric disorder or a history of hospitalization for psychiatric disorder.1,15,17 Beautrais et al. further suggested that the relationship between unemployment and parasuicide risk was completely explained by a combination of social risk factors and psychiatric disorder.17 However, those who died of suicide are likely to have been different from attempters,18 so a direct comparison with studies of suicide may not be warranted.It is also possible that other preexisting physical health problems confound the relationship between job loss and suicide such that poor health alone may lead to unemployment. Studies have shown a relationship between previous poor health, longer unemployment duration, and reduced exit rates from unemployment.19 Those that have examined unemployment and mortality have found only small confounding effects of previous poor health.11,20On the basis of these findings, a disjunctive interpretation of the association as either selective or causal is simplistic. We tested the validity of both hypotheses and assumed that the relative explanatory power of each depends on several factors including prevailing macroeconomic conditions, preexisting vulnerability (based on social risk factors, mental health, or both) to a stressor such as job loss, and individual-level unemployment duration.When unemployment is framed as a crisis event, selective confounders could play a greater role in more immediate suicides. As a long-term, chronic experience, causal factors may factor more prominently. For example, there may be less ambiguity when one is suggesting a causal relationship in a case where substantial unemployment experience has accumulated before a suicide because health status and factors related to social vulnerability are more likely to function as mediators in the causal chain rather than as determinants of the job loss.     

Early Effects of the San Francisco Paid Sick Leave Policy

Objectives. We examined employers’ responses to San Francisco, California’s 2007 Paid Sick Leave Ordinance.Methods. We used the 2009 Bay Area Employer Health Benefits Survey to describe sick leave policy changes and the policy’s effects on firm (n = 699) operations.Results. The proportion of firms offering paid sick leave in San Francisco grew from 73% in 2006 to 91% in 2009, with large firms (99%) more likely to offer sick leave than are small firms (86%) in 2009. Most firms (57%) did not make any changes to their sick leave policy, although 17% made a major change to sick leave policy to comply with the law. Firms beginning to offer sick leave reported reductions in other benefits (39%), worse profitability (32%), and increases in prices (18%) but better employee morale (17%) and high support for the policy (71%). Many employers (58%) reported some difficulty understanding legal requirements, complying administratively, or reassigning work responsibilities.Conclusions. There was a substantial increase in paid sick leave coverage after the mandate. Employers reported some difficulties in complying with the law but supported the policy overall.The Bureau of Labor Statistics estimates that in 2009 only 61% of workers nationwide in private industry had access to paid sick leave, with part-time (26%) and low-wage (33%) workers less likely to report access.1 There are health benefits to be gained by the adoption of a paid sick leave policy: reducing spread of influenza and infectious diseases in the workplace and childcare facilities2–4 and allowing workers to visit physicians, which may reduce unnecessary hospitalization and subsequent sickness absence.5 Previous research shows that the availability of paid sick leave is associated with increases in workers using sick leave, reductions in presenteeism (workers being on the job while sick), decreases in job loss because of sickness, and increases in the ability to care for sick children.6–20 Workers benefit from the insurance against loss of income or employment, and there may be economic benefits for employers, such as reducing job turnover and limiting productivity decreases because of presenteeism.21 However, mandated benefits may have detrimental effects on wages, employment, and business profitability.22,23In recent years, San Francisco, California, has been at the forefront of worker protection, implementing a citywide minimum wage requirement in 2004,24 mandatory paid sick leave in 2007,25 and an employer health benefit mandate in 2008.26 On February 5, 2007, San Francisco became the first jurisdiction to enact a policy25; recently, Connecticut27; New York City28; Portland, Oregon29; Seattle, Washington30; and Washington, DC31 passed laws requiring paid sick leave, and many other jurisdictions are considering similar policies.32 The San Francisco Paid Sick Leave Ordinance (PSLO) requires employers to provide paid sick leave to all employees (including part time and temporary). Paid sick leave must accrue at a rate of 1 hour for every 30 hours worked after the first 90 calendar days of employment.33 Enforcement is complaint driven, and the Office of Labor Standards Enforcement receives an average of 4 complaints a month.34 A small study (n = 26) 1 year after the PSLO went into effect found that San Francisco employers reported little benefit from reduced absenteeism, lower turnover, or improved morale and little impact on profitability.35 There is growing momentum for paid sick leave requirements across the United States32 but little evidence to inform us of their effects on employers, employees, or customers over the longer term.36We examined the 2009 Bay Area Employer Health Benefits Survey data to report changes employers made to comply with the sick leave mandate and the types of firms that made the greatest changes to sick leave policies. We analyzed the types of policies firms offer, employer-reported changes in other benefits, employee morale, prices, profitability, presenteeism, and absenteeism associated with changes in sick leave policy. We investigated employer sentiment, including support for the mandate and difficulties with implementation. We sought to inform policymakers about the impact of the PSLO on employers in San Francisco and allow policymakers in other cities or states considering similar legislation to assess the likely effects of such a policy.     

Nonoccupational and Occupational Injuries to US Workers With Disabilities

Objectives. We examined medically treated injuries among US workers with disability.Methods. Using 2006–2010 National Health Interview Survey data, we compared 3-month rates of nonoccupational and occupational injuries to workers with disability (n = 7729) and without disability (n = 175 947). We fitted multivariable logistic regression models to calculate odds ratios and 95% confidence intervals of injuries by disability status, controlling for sociodemographic variables. We also compared leading causes of injuries by disability status.Results. In the 3-month period prior to the survey, workers with disability were more likely than other workers to have nonoccupational injuries (odds ratio [OR] = 2.35; 95% confidence interval [CI] = 2.04, 2.71) and occupational injuries (OR = 2.39; 95% CI = 1.89, 3.01). For both groups, the leading cause was falls.Conclusions. Disability status was strongly associated with risk of nonoccupational and occupational injuries among US workers. The safety issues facing US workers with disability in the workplace warrant future research. Federal agencies with an interest in the employment of workers with disability and their safety in the workplace should take a lead in further assessing injury risk and in promoting a safe working environment for workers with disability.In the United States, persons with disabilities constitute 12.0% of the population.1 Both the World Health Organization and the US surgeon general have released reports addressing disparities in the health of persons with disabilities.2,3 These reports identify community participation and health promotion as societal priorities. According to the 2008 American Community Survey, about 4.6 million adults (aged 16–64 years) with disabilities are employed in the United States, and the number of workers with disabilities is expected to increase in the coming years as the workforce ages.4 A public health concern is that workers with disabilities may be at high risk of occupational injuries.5–8 Reducing the proportion of individuals with disabilities who report nonfatal injuries is among the objectives of US Healthy People 2020.9A number of studies have shown that adults with disabilities are more vulnerable to injuries than nondisabled adults.10–14 Studies using nationally representative data sets have found that the odds of injury increased with increasing severity of disability10,12 and with the number of disabilities.13 The settings and external causes of these injuries differed between individuals with and without disabilities.11,12 Falls, for example, were a leading mechanism of injury reported more frequently among those with disabilities.10–12Occupational injuries among workers with disabilities have also been previously studied.5,15–19 A number of studies from the 1990s showed an elevated risk of injury among workers with disabilities.5,15–17,19 However, much of the prior research examined only those with specific types of disabilities.15–19 For example, older workers with poor hearing and poor vision were shown to have an elevated risk for occupational injuries.17 By contrast, recent research based on workers’ compensation insurance claims found that workers with cognitive disabilities sustained fewer injuries and experienced fewer absences due to injury than workers without cognitive disabilities.18Previous work has also been critiqued because of the conceptualization and definition of disability5 and because environmental factors or work accommodations for workers with disability could not be taken into account.20,21 Zwerling et al. found that approximately 12% of workers with impairments reported receiving some type of workplace accommodation.22 Recent work by Leff et al. explored the role of environmental factors (e.g., societal attitudes, the natural environment, and policies) in the functioning and societal participation of people with disabilities.14 Environmental factors were found to be independently associated with injury regardless of disability status; however, disability status remained a risk factor for injury, although environmental factors attenuated the association. One current conceptualization of disability, the World Health Organization’s International Classification of Functioning, Disability and Health (ICF), emphasizes environmental factors and has been used in recent studies to evaluate injury risks of persons with disabilities.10,12,23 The ICF defines disability as physical impairments, activity limitations, and participation restrictions that affect one’s interaction with the physical and social environment.24 However, the impact of this refined definition on the number of injuries to workers with disabilities has yet to be determined.Given the significant number of US workers with disabilities and the advancements in disability and injury definitions,25 we compared medically attended nonoccupational and occupational injuries among workers with and without disabilities, using data from the 2006–2010 National Health Interview Survey (NHIS). Our current study improves on previous studies by our team and other researchers by examining both nonoccupational and occupational injuries to workers with disabilities using a single data source and a newer definition of disability based on the ICF.     

Work Organization and Health Among Immigrant Women: Latina Manual Workers in North Carolina

Objectives. We sought to describe work organization attributes for employed immigrant Latinas and determine associations of work organization with physical health, mental health, and health-related quality of life.Methods. We conducted a cross-sectional survey with 319 employed Latinas in western North Carolina (2009–2011). Measures included job demands (heavy load, awkward posture, psychological demand), decision latitude (skill variety, job control), support (supervisor control, safety climate), musculoskeletal symptoms, mental health (depressive symptoms), and mental (MCS) and physical component score (PCS) health-related quality of life.Results. Three fifths reported musculoskeletal symptoms. Mean scores for depression, MCS, and PCS were 6.2 (SE = 0.2), 38.3 (SE = 0.5), and 42.8 (SE = 0.3), respectively. Greater job demands (heavy load, awkward posture, greater psychological demand) were associated with more musculoskeletal and depressive symptoms and worse MCS. Less decision latitude (lower skill variety, job control) was associated with more musculoskeletal and depressive symptoms. Greater support (supervisor’s power and safety climate) was associated with fewer depressive symptoms and better MCS.Conclusions. Work organization should be considered to improve occupational health of vulnerable women workers. Additional research should delineate the links between work organization and health among vulnerable workers.Immigrant and low-income workers constitute a vulnerable population that is at significant risk for occupational injury and illness. These workers often have the most demanding jobs in the most dangerous industry sectors (e.g., agriculture, construction).1-5 When they work in less hazardous sectors, such as manufacturing, they generally work in industries such as poultry and meat processing, which have substantial hazards and few protections.6-7 These manufacturing hazards include exposure to toxicants (e.g., cleaners, solvents), exposure to biological materials (e.g., feces, dander), repetitive motion injuries, slips and falls, and lacerations and amputation from sharp tools and machinery.Although addressing conventional risk factors (e.g., chemical and mechanical exposures) remains important for improving the health of immigrant and low-income workers, greater attention is being given to how work organization affects their health and safety.5,8 The National Institute for Occupational Safety and Health (NIOSH)9 defines “work organization” as the processes and organizational practices that influence job design. Work organization domains include the timing of when work is performed, such as shifts and hours worked, seasonality, and flexibility; the physical and psychological demands of work; the control or decision latitude workers have, including variation in effort and choice in performing work; and style of supervision and support, including supervisor support and control and work safety climate.10,11Work organization has most often been considered in its effects on job satisfaction and health of white-collar workers. Although work organization is believed to be particularly influential in the health and safety of vulnerable workers, little research has examined work organization and health outcomes for vulnerable populations such as immigrant workers.5,8,12 Even less research has focused on work organization among immigrant women. For example, recent analyses of work organization and health among US immigrant workers in agriculture13-15 and construction16-18 have shown that, among agricultural workers, job demands are associated with poorer physical health13; high worker control is associated with better mental health14; and poor safety climate is associated with greater musculoskeletal discomfort.15 Among construction workers, poor work safety climate is associated with poor work safety behavior.16 However, participants in these studies have been almost exclusively male.Recent analyses of work organization and health among immigrant poultry processing workers have included a substantial number of women.19-22 These analyses showed that management practices, such as poor safety commitment, and job design, such as authority, variety, psychological workload, frequent awkward posture, and repetitive movement, are associated with risk of recent musculoskeletal problems, respiratory problems, and self-reported injury or illness.19-21 In a similar way, organizational hazards, including low job control and high psychological demand, are associated with increased risk for epicondylitis, rotator cuff syndrome, and back pain.22 However, these analyses have not focused on women or on gender differences. A qualitative analysis of female immigrant household domestic workers in Spain reported that such work organization factors as job control affect health.23,24The job demand–control–support model10,11 provides a framework for examining the association of work organization and health among women immigrant manual workers. This model posits that jobs with greater physical and psychological demand or stressors will result in poorer health. However, jobs with greater control or decision latitude can result in better health and can offset the effects of demand leading to poor health. Finally, support of peers and supervisors, including perceived safety climate25 (how workers perceive supervisors’ valuing safety over production) reduces occupational injury and buffers the effects of job demands.The place of work organization in the health of immigrant women is particularly important. These women have major family, child care, and domestic responsibilities that they need to integrate into their work responsibilities.12,26 Immigrant women are also extremely vulnerable to workplace physical and sexual harassment, as they often do not speak English, do not know their rights, and may lack proper work documents.27-29This analysis had 2 goals. The first was to delineate work organization attributes of full-time employed immigrant Latinas with manual occupations. The work organization attributes included indicators of job demands, decision latitude, and support. The second goal was to determine the associations of work organization attributes with health characteristics of these women, including physical health, mental health, and health-related quality of life. We tested 3 hypotheses: (1) greater job demands will be associated with poorer physical health, mental health, and health-related quality of life; (2) greater decision latitude will be associated with better physical health, mental health, and health-related quality of life; and (3) greater job support (higher perceived supervisor control, better job safety climate) will be associated with better physical health, mental health, and health-related quality of life.     

Paid Sick Leave and Nonfatal Occupational Injuries

Objectives. We examined the association between US workers’ access to paid sick leave and the incidence of nonfatal occupational injuries from the employer’s perspective. We also examined this association in different industries and occupations.Methods. We developed a theoretical framework to examine the business value of offering paid sick leave. Data from the National Health Interview Survey were used to test the hypothesis that offering paid sick leave is associated with a reduced incidence of occupational injuries. We used data on approximately 38 000 working adults to estimate a multivariate model.Results. With all other variables held constant, workers with access to paid sick leave were 28% (95% confidence interval = 0.52, 0.99) less likely than workers without access to paid sick leave to be injured. The association between the availability of paid sick leave and the incidence of occupational injuries varied across sectors and occupations, with the greatest differences occurring in high-risk sectors and occupations.Conclusions. Our findings suggest that, similar to other investments in worker safety and health, introducing or expanding paid sick leave programs might help businesses reduce the incidence of nonfatal occupational injuries, particularly in high-risk sectors and occupations.Paid sick leave is one of the nonwage benefits that US employers can offer to their workers. Although the 1993 Family and Medical Leave Act requires public agencies and private-sector establishments to provide up to 12 weeks of leave to eligible workers,1 this leave can be paid or unpaid.2,3 At the state level, only California and New Jersey have implemented paid family leave systems that provide workers with partial wage replacement.4 For workers, paid sick leave is associated with shorter recovery times3 and reduced complications from minor health problems.5–10 Paid sick leave also enables workers to care for loved ones when they most need it,11 can help prevent the spread of contagious diseases in day-care facilities and schools,12–15 and would enable compliance with pandemic influenza mitigation recommendations.16Employers can realize gains from offering paid sick leave through the reduction of productivity losses associated with sick workers who continue to work but are not fully productive (i.e., “presenteeism”).3,7,17–19 Paid sick leave also can help prevent the spread of contagious diseases to coworkers, which reduces the cost of unscheduled leave (absenteeism).20 The costs associated with sick workers who continue to work can be substantial. For example, Goetzel et al.21 estimated presenteeism costs to be the largest component of the overall costs of absenteeism, productivity losses, and short-term disability.Working while sick also can increase workers’ probability of suffering an injury.22 Sick or stressed workers who continue to work are likely to take medications, experience sleep problems, or be fatigued.23–25 These factors can impair their ability to concentrate or make sound decisions, which can in turn increase their probability of suffering an additional illness or sustaining a workplace injury. A recent study comparing workers with severe occupational injuries and those with nonsevere injuries demonstrated that a family member’s hospitalization, which is likely to be a major stressor for the entire family, increased by 9% the probability that a worker would suffer a severe occupational injury.26Despite the advantages of paid sick leave for both workers and employers, the number of private-sector workers who have access to it remains low. For example, between 1996 and 1998 nearly 90% of workers in state and local governments had access to paid sick leave, compared with only 45% of workers in the private sector.3 A more recent study concluded that in 2010, after consideration of the average job tenure requirement of 78 days that is imposed by employers before workers have access to paid sick leave, only 40 million workers in the private sector had access to this job benefit, a figure well below the 44 million workers who were estimated to be eligible for such leave by the Bureau of Labor Statistics (BLS).27Additional empirical evidence on the advantages and costs of paid sick leave would help inform employers’ decisions about offering or expanding paid sick leave benefits to workers. We examined the hypothesis that offering paid sick leave to workers would be associated with a lower incidence of nonfatal occupational injuries. We also assessed whether this association varied by occupation and industry sector, with the expectation that greater differences would be observed in occupations and sectors in which workers are at higher risk of suffering nonfatal occupational injuries. To our knowledge, this is the first US study to empirically examine these issues.     

Health Effects of Neighborhood Demolition and Housing Improvement: A Prospective Controlled Study of 2 Natural Experiments in Urban Renewal

Objectives. We took advantage of a 2-intervention natural experiment to investigate the impacts of neighborhood demolition and housing improvement on adult residents’ mental and physical health.Methods. We identified a longitudinal cohort (n = 1041, including intervention and control participants) by matching participants in 2 randomly sampled cross-sectional surveys conducted in 2006 and 2008 in 14 disadvantaged neighborhoods of Glasgow, United Kingdom. We measured residents’ self-reported health with Medical Outcomes Study Short Form Health Survey version 2 mean scores.Results. After adjustment for potential confounders and baseline health, mean mental and physical health scores for residents living in partly demolished neighborhoods were similar to the control group (mental health, b = 2.49; 95% confidence interval [CI] = −1.25, 6.23; P = .185; physical health, b = −0.24; 95% CI = −2.96, 2.48; P = .859). Mean mental health scores for residents experiencing housing improvement were higher than in the control group (b = 2.41; 95% CI = 0.03, 4.80; P = .047); physical health scores were similar between groups (b = −0.66; 95% CI = −2.57, 1.25; P = .486).Conclusions. Our findings suggest that housing improvement may lead to small, short-term mental health benefits. Physical deterioration and demolition of neighborhoods do not appear to adversely affect residents’ health.The quality of residential environments, at both the home and the neighborhood level, is associated with residents’ physical and mental health.1–7 Some longitudinal studies suggest that exposure to poor housing8 or to neighborhood-level deprivation9–18 increases the risk of morbidity or mortality beyond what might be predicted from individual-level socioeconomic factors. A causal association between residential environments and health would have important public health implications: improvements to residential environments might contribute positively to public health goals, and deteriorating residential environments could be harmful.Policymakers expect that improving home and neighborhood environments, particularly in disadvantaged areas, will benefit population health and help reduce health inequalities.19,20 Terms such as urban renewal and regeneration are used to describe a range of interventions, such as home improvement programs, housing clearance and demolition, and neighborhood-level improvements.19Research supports assumptions that housing-led urban renewal benefits residents’ health.21–29 A systematic review found that improvements in respiratory, general, and mental health followed housing improvement, with particularly robust evidence of health benefits relating to warmth-improvement interventions.21,30–32 More recently, an evaluation of a multisite urban renewal program in the United Kingdom found relative improvements in residents’ Medical Outcomes Study 36-item Short Form Health Survey mental health scores and self-reported general health at 10-year follow-up.33However, the evidence base is neither comprehensive nor conclusive, particularly regarding neighborhood-level renewal. Reviews have noted some evidence that such interventions may have unintended consequences.34 A study of neighborhood renewal in the United Kingdom found that self-reported health satisfaction worsened, possibly reflecting the intervention’s failure to deliver sufficient changes to residents’ lives and opportunities.35 A recent series of reviews identified 11 interventions considered to have sufficient evidence of effectiveness to warrant implementation,24–28 only 1 of which was a neighborhood-level intervention (rental vouchers to assist relocations to more desirable areas36). The reviews identified 34 interventions of unknown or inconclusive health effects and 7 that were potentially ineffective.24 Neighborhood-level interventions such as demolishing and revitalizing poor public housing (e.g., HOPE VI37), relocating residents, and various forms of neighborhood redesign yielded too little evidence to draw conclusions.28Some commentators have emphasized the social harms linked to housing clearance and demolition programs.38 Paris and Blackaby note that such programs have “frequently been accused of the ‘destruction of communities.’”39^(p18) This alleged destruction is partly a social phenomenon involving the separation of neighbors and closing down of amenities that may have been used as social hubs (e.g., schools, community centers, cafés). It is also a physical phenomenon that increases the proportion of derelict properties and turns neighborhoods into worksites and buildings into rubble.39,40 Furthermore, large-scale clearances can take years to complete, while residents waiting to be relocated are exposed to steadily worsening neighborhood environments.41 If deteriorating residential environments are harmful to health, then residents who remain in neighborhoods undergoing demolition risk being harmed. However, we have not identified any experimental or quasi-experimental study that focuses on the potentially harmful effects of continued residence in neighborhoods undergoing demolition and clearance.We studied a multifaceted renewal program implemented across the city of Glasgow, United Kingdom. In many neighborhoods, existing properties were improved to meet new government standards. However, some neighborhoods began a long-term process of demolition and rebuilding, and residents often lived for several years in neighborhoods undergoing clearance and demolition while they awaited relocation to better-quality housing.42 We treated housing improvement and the experience of living in a demolition area as 2 distinct natural experiments, and we used quasi-experimental methods to test our hypotheses: (1) residents who spent 2 years living in neighborhoods undergoing clearance and demolition would experience worsening health, and (2) residents who experienced housing improvement (and who did not live in neighborhoods undergoing clearance and demolition) would experience improved physical and mental health.     

Job Satisfaction and Expected Turnover Among Federal,State, and Local Public Health Practitioners

Objectives. To use data on the governmental public health workforce to examine demographics and elucidate drivers of job satisfaction and intent to leave one’s organization.Methods. Using microdata from the 2014 Federal Employee Viewpoint Survey and 2014 Public Health Workforce Interests and Needs Survey, we drew comparisons between federal, state, and local public health staff. We fitted logistic regressions to examine correlates of both job satisfaction and intent to leave one’s organization within the coming year.Results. Correlates of job satisfaction included pay satisfaction, organizational support, and employee involvement. Approximately 40% of federal, state, and local staff said they were either considering leaving their organization in the next year or were planning to retire by 2020.Conclusions. Public health practitioners largely like their jobs, but many are dissatisfied with their pay and are considering working elsewhere. More should be done to understand the determinants of job satisfaction and how to successfully retain high-quality staff.Public Health Implications. Public health is at a crossroads. Significant turnover is expected in the coming years. Retention efforts should engage staff across all levels of public health.The mission of public health is to prevent disease, promote health, and prolong life for the United States population through the core functions of public health (assessment, policy development, and assurance).1–4 To fulfill this mission, there are approximately 300 000 public health employees at the federal, state, and local levels.5 The governmental public health workforce comprises federal (20%), state (30%), and local health department employees (50%).5 Each of these groups makes essential contributions to the public health enterprise. A recent study found that 38% of state health agency (SHA) employees intend to leave governmental public health before 2020.6 However, the number of local and federal public health employees planning to leave is not well studied,6 although the consequences of employee turnover are well documented. High levels of employee turnover lead to a loss of expertise and institutional knowledge, high costs to the organization, and a decrease in organizational performance.7–9 Retaining institutional knowledge through employees is especially important in the public sector, which undergoes high levels of change.10 Additionally, the cost to recruit and train new employees can amount to 50% to 200% of the employee’s annual salary.11 Furthermore, organizational and individual performance suffers because workers who intend to leave are less efficient and effective in their job roles.12Studies show that a variety of factors contribute to turnover and can be categorized into external, work-related, and personal factors.7,12,13 Two external factors related to intent to leave are perception of job alternatives, which is positively related to turnover, and the presence of a union, which is negatively related to turnover.7,9,12–16 Pay satisfaction was consistently identified as an important factor in intent to leave; 29 of 32 studies in a meta-analysis showed a negative association.13 Finally, personal factors such as age, education, number of dependents, health status, and race/ethnicity have been significantly related to turnover and intent to leave.13 Although there are many contributors to workers’ intent to leave, a review of the literature shows a consistently negative relationship between worker turnover and job satisfaction.14,17,18 Although the field is beginning to study this area among SHA workers,14,19 relatively little is known about local or federal level job satisfaction or intent to leave. We address that gap.     

The Impact of a Free Older Persons’ Bus Pass on Active Travel and Regular Walking in England

Objectives. We assessed the potential public health benefit of the National Bus Pass, introduced in 2006, which permits free local bus travel for older adults (≥ 60 years) in England.Methods. We performed regression analyses with annual data from the 2005–2008 National Travel Survey. Models assessed associations between being a bus pass holder and active travel (walking, cycling, and use of public transport), use of buses, and walking 3 or more times per week.Results. Having a free pass was significantly associated with greater active travel among both disadvantaged (adjusted odds ratio [AOR] = 4.06; 95% confidence interval [CI] = 3.35, 4.86; P < .001) and advantaged groups (AOR = 4.72; 95% CI = 3.99, 5.59; P < .001); greater bus use in both disadvantaged and advantaged groups (AOR = 7.03; 95% CI = 5.53, 8.94; P < .001 and AOR = 7.11; 95% CI = 5.65, 8.94; P < .001, respectively); and greater likelihood of walking more frequently in the whole cohort (AOR = 1.15; 95% CI = 1.07, 1.12; P < .001).Conclusions. Public subsidies enabling free bus travel for older persons may confer significant population health benefits through increased incidental physical activity.Physical activity levels are decreasing globally.1 In 2008, 31% of people worldwide were insufficiently active contributing to 3.2 million deaths each year related to physical inactivity.2 Remaining physically active is as important in older as in younger adults because it reduces the risk of loss of mobility and muscle strength, falls, and fractures, and promotes social and mental well-being.3 Responding to this evidence, the US Surgeon General recommends regular moderate physical activity for older adults,4 and the UK Department of Health recommends at least 30 minutes of moderate exercise 5 times a week.3 Even lower activity levels may have significant benefits: the relative risk of disability is reduced by 7% for each additional hour of relatively gentle physical activity undertaken each week,5 and 15 minutes of moderate daily exercise is associated with a 12% decrease in all-cause mortality in persons older than 60 years.6Incidental physical activity may be defined as physical activity that is a byproduct of an activity with a different primary purpose. There is increasing interest in the promotion of incidental physical activity, including greater use of active transport—walking, cycling, and use of public transport.7–9 By swapping private vehicle travel for public transport—which may involve walking or cycling to transport access points or interchanges—physical activity levels are raised, offering significant health benefits, such as a reduced risk of obesity and cardiovascular ill health.10–12 Research from the United States finds that those commuting on public transport walk for an average of 19 minutes each day, and that nearly one third of commuters reach recommended daily physical activity levels just through active transport.13 In the United Kingdom, 19% of adults achieve recommended activity levels through active transport alone.14 Although commuting may not be as relevant to retired populations,15 incidental active travel may still have a key role to play in keeping older adults physically fit.16,17     

Predictors of Active Injection Drug Use in a Cohort of Patients Infected With Hepatitis C Virus

Objectives. We investigated potential risk factors for active injection drug use (IDU) in an inner-city cohort of patients infected with hepatitis C virus (HCV).Methods. We used log-binomial regression to identify factors independently associated with active IDU during the first 3 years of follow-up for the 289 participants who reported ever having injected drugs at baseline.Results. Overall, 142 (49.1%) of the 289 participants reported active IDU at some point during the follow-up period. In a multivariate model, being unemployed (prevalence ratio [PR] = 1.93; 95% confidence interval [CI] = 1.24, 3.03) and hazardous alcohol drinking (PR = 1.67; 95% CI = 1.34, 2.08) were associated with active IDU. Smoking was associated with IDU but this association was not statistically significant. Patients with all 3 of those factors were 3 times as likely to report IDU during follow-up as those with 0 or 1 factor (PR = 3.3; 95% CI = 2.2, 4.9). Neither HIV coinfection nor history of psychiatric disease was independently associated with active IDU.Conclusions. Optimal treatment of persons with HCV infection will require attention to unemployment, alcohol use, and smoking in conjunction with IDU treatment and prevention.Hepatitis C virus (HCV) infection is a major cause of chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. About 130 million people are estimated to be infected worldwide with HCV,1 including 3.2 million in the United States,2 and mortality from HCV in the United States is increasing.3 Injection drug use (IDU) is the single most important risk factor for HCV infection in the United States 2,4 with an estimated 40% to 50% of infections attributable to IDU.5 Of increasing concern is the substantial proportion of HCV-infected patients who are coinfected with HIV.6 Because HIV and HCV are each transmitted by blood-contaminated needles and syringes, approximately 30% of all HIV-infected individuals are also infected with HCV1,7; in cohorts of intravenous drug users, the proportion of HCV-infected persons with HIV coinfection can be as high as 41%.8Because IDU is a significant risk factor for HCV transmission, ongoing drug abuse is common in HCV-infected populations. Such ongoing drug use has been documented as a potential barrier in managing the infection.9,10 Moreover, former IDUs can be concerned about relapse with performing self-injection as part of interferon treatment.11 Thus, understanding factors associated with active IDU may inform pragmatic approaches to improving acceptability of HCV treatment and increasing patients’ chances of successfully treating their disease.Other barriers to treatment of HCV infection have been described and are associated with IDU, such as alcohol use, psychiatric disease, and HIV coinfection.9,10,12–14 Concurrent alcohol abuse has, in some studies, distinguished persistence of IDU from cessation of IDU; however, in other reports, the association of heavy alcohol use did not remain after adjustment for known risk factors.15,16 Co-occurring mental disorders are frequently associated with poorer health and worse treatment outcomes among drug users and may lead to an increased level of drug use and riskier drug use behavior.17 HIV infection has been hypothesized to be associated with IDU in contrasting ways. Those who are HIV-infected may have more frequent contact with health services and thus referral to drug treatment; conversely, increased depression following diagnosis may lead to increased drug use.16Individual patterns of drug use vary over time. Whereas some studies have indicated a trend toward decreased IDU over time in longer-term cohort studies, others have found that many injection drug users are unable to maintain sustained cessation of IDU.17–23 In addition to the direct morbidity and mortality associated with IDU, continued use may make it more difficult for patients to effectively manage their disease. Evaluating predictors of ongoing IDU in these populations may help identify avenues to facilitate long-term cessation of IDU. Our goals were to investigate risk factors for active IDU in a cohort of patients infected with hepatitis C, with specific focus on alcohol use, smoking, psychiatric disease, and HIV coinfection.     

Gender-Stratified Models to Examine the Relationship Between Financial Hardship and Self-Reported Oral Health for Older US Men and Women

Objectives. We evaluated the relationship between financial hardship and self-reported oral health for older men and women.Methods. We focused on adults in the 2008 Health and Retirement Study (n = 1359). The predictor variables were 4 financial hardship indicators. We used Poisson regression models to estimate the prevalence ratio of poor self-reported oral health.Results. In the non–gender-stratified model, number of financial hardships was not significantly associated with self-reported oral health. Food insecurity was associated with a 12% greater prevalence of poor self-reported oral health (95% confidence interval [CI] = 1.04, 1.21). In the gender-stratified models, women with 3 or more financial hardships had a 24% greater prevalence of poor self-reported oral health than women with zero (95% CI = 1.09, 1.40). Number of hardships was not associated with self-reported oral health for men. For men, skipping medications was associated with 50% lower prevalence of poor self-reported oral health (95% CI = 0.32, 0.76).Conclusions. Number of financial hardships was differentially associated with self-reported oral health for older men and women. Most financial hardship indicators affected both genders similarly. Future interventions to improve vulnerable older adults’ oral health should account for gender-based heterogeneity in financial hardship experiences.The Institute of Medicine’s 1998 publication Gender Differences in Susceptibility of Environmental Factors called attention to how socioeconomic factors differentially affect health outcomes for men and women.1 Gender-based health disparities are pronounced among older adults.2,3 In 2010, 25% of the US population was aged 55 years or older, a 15% increase from 2000.4 Advances in chronic disease management have improved adult life expectancy,5–12 making older adults the fastest growing subgroup in the United States. The close relationship between oral and systemic health13–15 has motivated interest in addressing oral health disparities in older adults, particularly among those who are financially vulnerable.16Poverty and low socioeconomic status (SES) are associated with tooth decay, gum diseases, and oral cancers—all of which are indicators of poor oral health.17–28 Older men and women are at differential risk for dental diseases and conditions.29,30 For instance, older men are more likely to have untreated tooth decay,31,32 gum disease,33 and oropharyngeal cancer34 whereas older women are more likely to have missing teeth and to be edentulous.29 Dental care use by women partially explains this heterogeneity in disease risk35 although the mechanisms underlying gender-based differences have not been elucidated. Differential risk for dental disease may translate to differences in self-reported oral health. Based on 1999–2004 US National Health and Nutrition Examination Survey data, a larger proportion of men aged 65 years and older reported fair or poor oral health compared with women (40.1% and 36.9%, respectively).29 Although 2 studies suggest that self-reported oral health measures are weakly associated with dental disease status as assessed by a dentist,36,37 most studies have concluded that self-reported oral health is a valid and reliable measure of clinical oral health.38–41There is a growing body of literature on gender, socioeconomic inequality, and health disparities.42–45 Most studies have focused on traditional measures of SES such as education, income, or occupation.46–48 However, these measures do not adequately capture the multiple pathways by which socioeconomic and financial circumstances influence health.49–53 For example, focusing on income alone may not fully capture an individual’s ability to garner resources to meet financial obligations.54 Alternative SES measures such as financial hardship have been shown to have an impact on health over and above traditional measures of SES.55,56 Furthermore, recent studies suggest that alternative SES measures, which account for economic resources, assets, and household material conditions, are moderated by gender on outcomes such as self-rated health, psychological distress, musculoskeletal disorders, and mortality.55–58 This interaction is particularly relevant for older adults, many of whom are retired or are preparing to exit the workforce.59Currently, there is little understanding of how gender and financial hardship interact on oral health outcome measures. In addition, the studies relevant to adult oral health have 2 limitations: (1) the inclusion of both younger and older adults in the same models, which assumes that the relationship between socioeconomic indicators and oral health is homogeneous across the adult life span20,22,27,47; and (2) the lack of gender-stratified models,28 which treats gender as a confounder rather than as an effect modifier.The aim of the present study was to test the hypothesis that the association between financial hardship and self-reported oral health is different for women and men. This research continues the line of work aimed at identifying ways to improve the oral health of vulnerable older adults, and has important implications in the development of interventions and policies that address gender-based disparities in adult oral health.60,61     

Self-Reported Experience of Racial Discrimination and Health Care Use in New Zealand: Results From the 2006/07 New Zealand Health Survey

Objectives. We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences.Methods. We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables.Results. Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants.Conclusions. Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.Racism is increasingly recognized as an important determinant of health and driver of ethnic health inequalities.1 Regardless of its health effects, racism breaches fundamental human rights and is morally wrong. It is important to understand how racism operates as a health risk to develop interventions that reduce ethnic inequalities in health within a context of eliminating racism.2Racism is an organized system that categorizes racial/ethnic groups and structures opportunity, leading to inequities in societal goods and resources and a racialized social order.3–5 Racism operates via institutional and individual practices (racial discrimination) and varies in form and type.6,7 The pathways whereby racism leads to poor health are also multiple, with direct and indirect mechanisms such as race-based assaults and violence, physiological and psychological stress mechanisms, differential exposures to health risk factors, differential access to and experiences of health care, and differential access to goods, resources, and power in society.6,8–10Research on racism and health, particularly self-reported racism, has increased. Self-reported experience of racism has been linked to multiple health measures (including mental and physical health outcomes and health risk factors) across a variety of countries and for different ethnic groups.10–12 Research on how self-reported experience of racism may negatively affect health has largely focused on racism as a stressor with mental and physical health consequences.10,13 Comparatively less evidence is available on how experience of racism may influence health service use,10 although this is another potentially important pathway to poor health.14,15Studies on the association between self-reported racism and health care experience and use have included racism experienced within the health care system, outside of the health care system, or both.16–19 Health care measures have included use of specific services such as cancer screening19–24 and receipt of optimal care,20,25 measures of unmet need,16,26 measures of adherence to care,17,27,28 and measures of satisfaction and experiences with care.18,29–31Various mechanisms have been suggested to explain how the experience of racism may negatively affect health care use, experiences of health care, and subsequent poor health. Experiences of racism within the health care system may influence health by shaping decision making of both providers and patients and influencing future health behaviors, including future health care use behaviors and potential disengagement from the health care system.14,18,26 Experiences of racism in wider society also may lead to general mistrust and avoidance of dominant culture institutions, including health care systems.15,30 This is supported by evidence that both experiences of racism and general discrimination within and outside of health care have been associated with negative health care use measures.15,16,19,22New Zealand has a population of approximately 4.4 million people, with the major ethnic groupings being Maori (indigenous peoples, 15% of the population), European (77%), Pacific (7%), and Asian (10%).32 Ethnic inequalities in health and socioeconomic status persist, with racism a potentially important contributor to these inequalities.33 Previous research in New Zealand has shown reported experience of racial discrimination by a health professional to be higher among non-European ethnic groups with experiences of racial discrimination in different settings associated with multiple health outcomes and risk factors.34In this study, we focused on the relationship between racial discrimination and health service use and experience, an area not previously examined in New Zealand. We provide important information on how racial discrimination may affect health care use as a possible pathway to poor health outcomes and ethnic health inequalities in New Zealand. In addition, our study contributes to the limited evidence on racial discrimination and health care internationally.Primary health care in New Zealand is available to all residents and is usually provided at general practices. Costs of visits are universally subsidized by government to enable lower patient copayments with additional limited provision for extra funding based on high need.35 Currently, 2 publicly funded national cancer screening programs are available.36 Breast cancer screening is free to all eligible women through BreastScreen Aotearoa. Cervical cancer screening usually incurs a fee and is available through patients’ usual primary care provider or specific cervical cancer screening providers.We specifically examined the association between self-reported experience of racial discrimination and the use of health care in 2 domains—cancer screening and negative patient perceptions of health care encounters. We hypothesized that experience of racial discrimination both within and outside the health care system may negatively affect how individuals use and experience health care.     

Effects of Statewide Job Losses on Adolescent Suicide-Related Behaviors

Objectives. We investigated the impact of statewide job loss on adolescent suicide-related behaviors.Methods. We used 1997 to 2009 data from the Youth Risk Behavior Survey and the Bureau of Labor Statistics to estimate the effects of statewide job loss on adolescents’ suicidal ideation, suicide attempts, and suicide plans. Probit regression models controlled for demographic characteristics, state of residence, and year; samples were divided according to gender and race/ethnicity.Results. Statewide job losses during the year preceding the survey increased girls’ probability of suicidal ideation and suicide plans and non-Hispanic Black adolescents’ probability of suicidal ideation, suicide plans, and suicide attempts. Job losses among 1% of a state’s working-age population increased the probability of girls and Blacks reporting suicide-related behaviors by 2 to 3 percentage points. Job losses did not affect the suicide-related behaviors of boys, non-Hispanic Whites, or Hispanics. The results were robust to the inclusion of other state economic characteristics.Conclusions. As are adults, adolescents are affected by economic downturns. Our findings show that statewide job loss increases adolescent girls’ and non-Hispanic Blacks’ suicide-related behaviors.Suicide among young people has been identified as a serious public health concern. Among youths and young adults 10 to 24 years of age, suicide is the third leading cause of death, resulting in 4600 deaths each year.1 Every year, 157 000 young people in the 10- to 24-year age group are treated for self-inflicted injuries.1A number of individual characteristics and circumstances serve as risk factors for suicide and suicide-related behaviors among adolescents, including suicidal ideation and suicide attempts. Risk factors for suicide-related behaviors include a history of previous suicide attempts, a family history of suicide, a history of depression or other mental illness, alcohol or drug use, stressful life events, and exposure to the suicidal behavior of others.2 In addition, low levels of parental monitoring and engagement in risk-taking behaviors are associated with increased suicidal ideation and suicide attempts.3 What is less well understood, however, is how broader contextual factors, such as economic conditions, alter adolescents’ risk for suicide and suicide-related behaviors.Economic downturns such as the recent “Great Recession” represent large changes in the economic context and have well-known effects on adults’ physical and mental health, although these physical and mental effects work in opposite directions.4–6 Economic downturns have been shown to improve adults’ physical health, including decreasing health risk behaviors such as smoking and decreasing mortality.4–6 In contrast, however, economic downturns worsen adults’ mental health, including increasing suicide, one of the most serious mental health consequences.6–8 A recent review article concluded that the economic context of a geographic area is related to the area’s overall suicide rate.9 Across many studies of different geographic areas, the review showed that, at any given point in time, areas with worse economic contexts have higher suicide rates. Work that has considered changes in economic contexts, rather than static conditions, has shown that recessions and unemployment rate increases are positively correlated with suicide rates.6–8,10Despite the well-known associations between economic contractions and adult suicide rates and the great public concern around adolescent suicide, the relationships between changes in economic circumstances and the suicide-related behaviors of adolescents have received relatively little attention. Evidence exists that adolescent suicide and suicide-related behaviors are more likely to occur in neighborhoods with increased levels of economic disadvantage.11 In addition, recent studies suggest that adolescents’ mental health is affected by changes in local economic contexts. Research focused on one US state showed that job losses attributable to mass layoffs increased use of emergency psychiatric care among young people, and increases were especially large among Black youths.12–14Statewide job loss may increase adolescent suicide-related behaviors through changes in parental well-being as well as through changes in the broader community context. Within families, parental job loss has been associated with increased mental health problems and lower quality parent–child interactions, which in turn affect adolescents’ mental health.15–17 Adolescents may be more aware of their families’ worsening economic circumstances than younger children and may be more likely to bear the brunt of their families’ increased stress. In the broader community context, changes in the economic and psychological well-being of adults outside of the family may lead indirectly to changes in adolescent functioning.18 When parents, teachers, coaches, and other adults with whom adolescents interact experience increased stress, this increase in stress may affect adolescents’ mental health. Statewide job loss could also lead to loss of resources that affect adolescents’ neighborhood, school, or extracurricular activities.Previous literature suggests that risk of adolescent suicide and suicide-related behaviors varies according to gender and race/ethnicity. Boys are more likely than girls to commit suicide, but girls are more likely to attempt suicide.2 Among all racial and ethnic groups, non-Hispanic Black adolescents are least likely to have planned or attempted suicide,19 and they also display lower levels of mental disorder.20,21Racial/ethnic differences in suicide-related behaviors may be particularly relevant given that economic downturns disproportionately affect minority households.22 In addition, because non-Hispanic Black and Hispanic adolescents are more likely than non-Hispanic White adolescents to live in households with lower incomes and fewer assets,23 they may be less able to buffer the economic consequences of downturns. Even in the case of families who do not experience household job loss, minority adolescents may be more worried than non-Hispanic White adolescents about their future job prospects, insofar as minority workers are more vulnerable to economic downturns than are White workers.22 Consistent with these theories, Black youths’ use of emergency psychiatric care has been shown to increase more after statewide job losses than that of White youths.12,14In our study, we sought to build on previous literature by considering how changes over time in statewide job loss rates across the United States affect the suicide-related behaviors of a nationally representative survey of adolescents in high school. We used the state as the geographic unit because data on suicide-related behaviors for smaller areas of aggregation are not readily available across the country and over time. An important component of the study was our examination of 3 behaviors that are precursors to suicide: suicidal ideation, suicide planning, and suicide attempts.2 Understanding factors that influence these precursors may facilitate suicide prevention efforts.Our measure of economic downturns, statewide job losses attributable to mass layoffs and closings, offers several advantages over more conventionally used measures such as unemployment rates. For example, our measure of job loss, unlike the unemployment rate, can be considered an unanticipated “shock” to a community and is therefore likely to be exogenously related to suicide-related behaviors. Research in economics has demonstrated that statewide job losses typically reflect global changes in technology and trade rather than being driven by changes in either individual or community characteristics that might themselves be related to adolescent suicide-related behaviors.24–26In addition, a change in our measure of job loss represents an unequivocally bad piece of economic news. In contrast, the unemployment rate can change for either positive or negative reasons. For example, it can decrease because workers become discouraged and stop looking for work. This “positive” change in the unemployment rate may reflect worker discouragement rather than job growth. The reverse may also be true: as economic conditions improve, workers may decide to reenter the labor market, leading the unemployment rate to increase.     

The Influence of Past Unemployment Duration on Symptoms of Depression Among Young Women and Men in the United States

Objectives. I examined whether unemployment while looking for a job and being out of the labor force while not seeking work have distinct effects on symptoms of depression among young women and men in the United States. I also investigated whether past unemployment duration predicts depressive symptoms.Methods. I used ordinary least squares regression to analyze data from the 1979–1994 National Longitudinal Survey of Youth.Results. Cross-sectional results suggested that current unemployment status and out-of-the-labor-force status were significantly associated with depressive symptoms at ages 29 through 37 years. The association between being out of the labor force and depressive symptoms was stronger for men. Longitudinal results revealed that past unemployment duration across 15 years of the transition to adulthood significantly predicted depressive symptoms, net of demographics, family background, current socioeconomic status, and prior depressive symptoms. However, duration out of the labor force did not predict depressive symptoms.Conclusions. Longer durations of unemployment predict higher levels of depressive symptoms among young adults. Future research should measure duration longitudinally and distinguish unemployment from being out of the labor force to advance our understanding of socioeconomic mental health disparities.Numerous studies have documented a relationship between disadvantaged socioeconomic status (SES) and symptoms of depression.^1,2 The primary indicators of SES are education, employment status, income, occupation, and wealth.^1–3 What warrants further inquiry is whether unemployment when looking for a job and being “out of the labor force” when not seeking work have distinct effects on symptoms of depression⁴ and whether these effects vary by gender.⁵ Furthermore, longitudinal studies are necessary to understand the mental health consequences of long-term unemployment, because the majority of studies have measured SES at a single point in time.^1–6Some groundbreaking longitudinal studies have demonstrated that past unemployment at multiple points in time predicts symptoms of depression. A Chicago study found that prior job disruption (being fired, laid off, downgraded, or leaving work because of illness) during a 4-year interval was associated with subsequent depressive symptoms.⁷ A Southeastern Michigan study discovered that unemployment at some time in the past 5 years was a risk factor for depression.⁸ According to a study of women in Sweden, 2 years of unemployment with no realistic expectation of getting a job was associated with depressive symptoms.⁹ Research that used data from the US National Longitudinal Survey of Mature Women revealed that being continuously out of the labor force from 1982 to 1989 predicted depressive symptoms in 1989, regardless of earlier emotional health in 1982.¹⁰ A US National Longitudinal Survey of Youth study found that changing from employment status in 1992 to unemployment status or out-of-the-labor-force status in 1994 was associated with depressive symptoms in 1994, net of prior depressive symptoms in 1992.⁴ In a comparison of average levels of depressive symptoms at ages 19 to 24 years, a South Australian study discovered that unemployment for 9 months or more was a significant threshold.¹¹ According to a meta-analysis of longitudinal studies, there is international evidence that changing from employment status to unemployment status measured between 6 months and 3 years leads to worse mental health in general.¹²Taking into account earlier mental health acknowledges the selection hypothesis, which argues that mental health problems could lead to job loss or prolonged unemployment.^4,13 A study of young adults in New Zealand found that unemployment for greater than 6 months did not increase the odds of depression after the researchers controlled for earlier psychological adjustment problems.¹³ Longitudinal research on young adults in the United States is necessary to examine whether failure to find employment for longer durations is more psychologically distressing than being out of the labor force when not looking for a job, independent of earlier mental health.Studying the influence of unemployment histories on mental health during the transition to adulthood is important because employment is a marker of adulthood,¹⁴ and early adulthood is the stage at which the onset of depression usually occurs.¹⁵ Moreover, whether the mental health ramifications of long-term unemployment and out-of-the-labor-force status differ for young women and men needs further investigation. Our knowledge remains limited about women''s psychological reactions to the time spent unemployed when looking for work or out of the labor force while not seeking employment.^5,9,10Using data from the National Longitudinal Survey of Youth, I examined whether the duration of past unemployment status and out-of-the-labor-force status across 15 years of the transition to adulthood predicts symptoms of depression among young women and men in the United States. To evaluate the strength of these relationships, I controlled for gender, age, race/ethnicity, marital status, family socioeconomic background, multiple indicators of current SES, and earlier depressive symptoms. Finally, I also investigated whether the influence of unemployment status and out-of-the-labor-force status on depressive symptoms varies by gender.     

Self-Reported Health Among Recently Incarcerated Mothers

Objectives. We examined self-reported health among formerly incarcerated mothers.Methods. We used data from the Fragile Families and Child Wellbeing Study (n = 4096), a longitudinal survey of mostly unmarried parents in urban areas, to estimate the association between recent incarceration (measured as any incarceration in the past 4 years) and 5 self-reported health conditions (depression, illicit drug use, heavy drinking, fair or poor health, and health limitations), net of covariates including health before incarceration.Results. In adjusted logistic regression models, recently incarcerated mothers, compared with their counterparts, have an increased likelihood of depression (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.18, 2.17), heavy drinking (OR = 1.79; 95% CI = 1.19, 2.68), fair or poor health (OR = 1.49; 95% CI = 1.08, 2.06), and health limitations (OR = 1.78; 95% CI = 1.27, 2.50). This association is similar across racial/ethnic subgroups and is larger among mothers who share children with fathers who have not been recently incarcerated.Conclusions. Recently incarcerated mothers struggle with even more health conditions than expected given the disadvantages they experience before incarceration. Furthermore, because incarceration is concentrated among those who are most disadvantaged, incarceration may increase inequalities in population health.The US incarceration rate, though recently stabilized, has increased rapidly over the past 4 decades. Accordingly, researchers have become acutely aware of the sheer number of individuals who experience incarceration and the vulnerabilities these individuals face before, during, and after incarceration.1 In particular, a growing literature has documented the consequences of mass incarceration, defined as the historically and comparatively extreme rates of incarceration in the United States, for population health.2–5 Formerly incarcerated individuals, compared with their counterparts, have elevated rates of mortality,6 infectious diseases,7 cardiovascular diseases,8 and disability,9 as well as an array of mental health problems including depression,10 anxiety,9 and life dissatisfaction.11Despite the fact that, since the early 1980s, women’s incarceration rates have increased faster than men’s incarceration rates,12,13 very little research has explicitly considered the health of formerly incarcerated women. Instead, research on incarcerated women often focuses on the consequences of incarceration for their families and children.14–19 The dearth of research on formerly incarcerated women’s health is an important oversight because these women are an extremely vulnerable population and present a pressing public health concern. Formerly incarcerated mothers are an especially important group because poor physical and mental health among mothers may have deleterious consequences for their children.20–23We used data from the Fragile Families and Child Wellbeing Study, a longitudinal study of mostly unmarried parents living in urban areas, to provide the first examination of the relationship between recent incarceration, measured as any incarceration experience in the past 4 years, and 5 self-reported health conditions among mothers: depression, illicit drug use, heavy drinking, fair or poor health, and health limitations. First, we estimated the association between recent incarceration and self-reported health. We then estimated this association by race/ethnicity and by romantic partner’s incarceration history. Our analyses adjusted for a large number of individual characteristics that may render the association between recent incarceration and health conditions spurious (including health before incarceration). Adjusting for these characteristics is especially important because incarcerated mothers are at risk for poor physical and mental health before incarceration.5,24–26     

Community Health Workers in Low- and Middle-Income Countries: What Do We Know About Scaling Up and Sustainability?

Objectives. We sought to provide a systematic review of the determinants of success in scaling up and sustaining community health worker (CHW) programs in low- and middle-income countries (LMICs).Methods. We searched 11 electronic databases for academic literature published through December 2010 (n = 603 articles). Two independent reviewers applied exclusion criteria to identify articles that provided empirical evidence about the scale-up or sustainability of CHW programs in LMICs, then extracted data from each article by using a standardized form. We analyzed the resulting data for determinants and themes through iterated categorization.Results. The final sample of articles (n = 19) present data on CHW programs in 16 countries. We identified 23 enabling factors and 15 barriers to scale-up and sustainability, which were grouped into 3 thematic categories: program design and management, community fit, and integration with the broader environment.Conclusions. Scaling up and sustaining CHW programs in LMICs requires effective program design and management, including adequate training, supervision, motivation, and funding; acceptability of the program to the communities served; and securing support for the program from political leaders and other health care providers.Community health workers (CHWs) play a critical role in primary health care delivery, particularly in low- and middle-income countries (LMICs). Also known in some contexts as village health workers, community health promoters, lay health workers, or promotores, CHWs provide basic public health services and medical care and are typically members of the communities in which they work.1,2 Activities of CHWs may include educating community members about health risks, promoting healthy behaviors, or linking community members with providers at formal health care facilities. Community health workers can range from volunteers working without material compensation to paid employees of a country’s public health system; in some cases, even when CHWs do not receive a salary, they may receive other material benefits such as periodic training stipends, financial incentives, or preferential access to health care or microcredit.1,2 Community health workers lack a professional health care certification, which distinguishes them from other health care providers such as doctors or nurses.3 Because of their ability to reach community members at relatively low cost, CHWs have been proposed and deployed as a means for achieving a wide range of disease prevention and health system strengthening objectives.4,5The positive impact of CHWs on disease prevention, healthy behavior adoption, and access to care has been documented in diverse contexts.2,3,6 In LMICs, CHWs have been found to be effective in reducing neonatal mortality,7 child mortality attributable to pneumonia,8 and mortality caused by malaria.9,10 In addition, CHWs have been successful in promoting improved health behaviors including exclusive breastfeeding,11 adherence to HIV antiretroviral therapy and counseling,5,12 childhood immunization,3 early prenatal care usage,13 and tuberculosis treatment completion.14 They have also been a central component in the implementation of Integrated Management of Childhood Illness strategies, which have succeeded in reducing child mortality in multiple LMICs.1,15Despite the substantial evidence about the positive impact of CHWs as a model of care, less is known about effective approaches to scaling up and sustaining CHW programs. One challenge in synthesizing this evidence is the absence of explicit definitions for scale-up and sustainability in the empirical literature about CHW programs. Previous definitions of health program scale-up have focused on either the process of a program expanding from a smaller to a larger implementation arena or the state of a program being implemented in a widespread manner.16,17 Sustainability of health programs has been defined in previous literature as “the continued use of program components and activities for the continued achievement of desirable program and population outcomes,”^18(p2060) and it has been measured in diverse ways such as a program’s duration, the resources required to enable the program to survive, or the duration of the program’s benefits.19–22 A related challenge is one of comparability across CHW programs and countries; a program considered large-scale and sustained in one country might be viewed as small-scale or short-term in another setting. Therefore, we sought to develop criteria for identifying cases of scale-up, sustainability, and success of CHW programs and to apply these criteria in a systematic review of the existing empirical literature on scaling up and sustaining the CHW model in LMICs to extract key enabling factors for success. This information can provide useful guidance to policymakers, practitioners, and researchers seeking to promote CHW models of primary care more broadly.