Effect of downsizing on health among employees who remain in employment

Mika KivimakiProfessorDepartment of Epidemiology and Public HealthUCL

In the USA, 43 million jobs eliminated between 1979 and 1995 (Hurrell J. Am J Public Health 1998)

In Finland, 26% of employees worked in organisations where there had been reductions of personnel in the past year (Statistics Finland 1998)

The 10-Town study

VantaaEspoo

Naantali Raisio Turku

Tampere Valkeakoski

Virrat

Nokia

Oulu

An on-going Finnish study on health of municipal employees in ten towns in Finland.

These towns include the 5 biggest cities(except the Capital) and 5 smaller nearby towns.

1970 1975 1980 1985 1990 1995 20000

100

200

300

400

500

1 000 persons

Total

Males

Females

0

100

200

300

400

500

Unemployment in Finland

Statistics Finland

Reduction of workforce

• Not hiring cover for those absent from work

• Freeze on vacancies (retirement, turnover)

• Short-term temporary layoffs in 1993

Person-years worked in town Raisio during 1991—1997

1140

1062

977997

1015

1075 1075

850

900

950

1000

1050

1100

1150

1200

1991 1992 1993 1994 1995 1996 1997

Per

son

-yea

rs

Downsizing After downsizing

How to measure downsizing?

x 100(Total number of person-years before downsizing)

Contracted days - Absence days = Total number of person-years

(Total number of person-years before downsizing) – (Total number of person-years after downsizing)

Extent of downsizing by occupation

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Assessment of downsizing 1

Mortality 4

First half of the follow-up Second half

Design

Disability retirement 2Pre-downsizing •Health•Work characteristics

Data sources:1 Employers' records2 Local Government Pensions Institution 3 National Prescription Register 4 Statistics Finland

Psychotropic medication (ATC-codes) 3

Post-downsizing sickness absence 1

Perceived health, musculoskeletal symptoms

Sources: Lancet 1997; BMJ 2000, 2004; Occup Environ Med 2001, 2005; J Epidemiol Community Health 2005, 2007

J Appl Psychol 1997; Anxiety Stress Coping 2000; Am J Community Psychol 2003

RCT Design

Target population

Study population

Randomisation

Experimental group Control group

Incidence of outcome Incidence of outcome

Quasi-experiment

All 26 682 employees from 4 towns

Study population (29 had missing data)

Organisational downsizing 1991-1993

Non-downsized group Downsized group Those lost/left job n = 17 599 n = 4783 n = 4271

Outcome: Health status in 1994-2000

-20 -10 0 10 20 30

Workload

Skill discretion

Participation

Job insecurity

Supervisor support

Co-worker support

Spouse support

Alcohol intake

Smoking

Physical activity

Body mass

%

***

*

*

*

*P<0.05

Downsizing causes work stress

Source: Kivimäki et al. The Raisio Study. BMJ 2000

Difference in post-downsizing values (adjusted for pre-downsizing values) between groups of major vs no downsizing.

Effect of downsizing on self-rated health

Kivimäki et al. Anxiety Stress Coping 2000

Kivimäki et al. J Epidemiol Community Health 2007

Rate of psychotropic drug prescriptions and other prescriptions by postdownsizing status

Psychotropic drug = antidepressant, anxiolytics, hypnotics

Organisational downsizing and use of psychotropic drugs in men by

SEP

Non-manual Manual

Post-downsizing status

Employed in non-downsized group 1.00 1.00 Employed in downsized group 1.87 (1.1-3.1) 1.70 (1.1-2.6) Lost or left their job 1.40 (0.9-2.1) 2.16 (1.2-3.8)

Source: Kivimäki et al. The 10-Town Study. J Epidemiol Community Health (2007)

*Risk ratios adjusted for pre-downsizing characteristics

1.551.76

1.96

2.52

0.0

0.5

1.0

1.5

2.0

2.5

3.0

0% 1-5% 5-10% >10%

An

tidep

ress

ant u

se

Virtanen et al. Am J Psychiatry 2009

Hospital ward overcrowding

Nurses (N=6699)

Work overload and use of antidepressants

Source: Vahtera, Kivimäki, Pentti Lancet 1997

Source: Vahtera, Kivimäki, Pentti Lancet 1997

Source: Vahtera, Kivimäki, Pentti Lancet 1997

0

2

4

6

8

10

12

14

No absenceCertified absence

All cause Musculoskeletal Psychiatric

Cause specific absence and risk of disability pension

Ris

k ra

tio f

or d

isab

ility

pen

sion

Kivimäki et al. the Swedish County Study. J Epidemiol Community Health 2007

Diagnosis for sickness absence and disability pension

After excluding precipitating absences

People aged 18 to 49 at baseline

<8 8-18 >180,0

0,5

1,0

1,5

2,0

1,46

1,81

TK

-elä

kke

en r

iski

Henkilöstösupistusten määräExtent of downsizing

Rel

ativ

e ri

sk

Vahtera et al. J Epidemiol Community Health 2005

Organisational downsizing and risk of disability

pension

1.46

1.81

Development of atherosclerosis

Fatty streak Atheroma Fibrous Atheroma Complicated Atheroma

Risk factors x

Preclinical disease processes

Cardiovascular death

Manifest disease x

e.g., obesity, smoking, physical inactivity, high LDL cholesterol

e.g., atherosclerosis, endothelic dysfunction

e.g., angina, myocardial infarction

Work stress

1. indirect effect 2. etiological factor 3. trigger or prognostic risk factor

Work stress

confounding, bias, reversed causality

Risk factors x

Preclinical disease processes

Manifest disease x

Cardiovascular death

Stress at work

Stress at work

Kivimäki et al. Scand J Work Environ Health 2006

Work stress and cardiovascular disease

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Assessment of downsizing 1

Mortality 4

First half of the follow-up Second half

Design

Data sources:1 Employers' records2 Local Government Pensions Institution 3 National Prescription Register 4 Statistics Finland

No Minor Major0,0

0,5

1,0

1,5

2,0

trendns

trendp<0.05

trendp<0.05

1,21,1

1,5

2,0*

1,4*1,2

Haz

ard

ratio

Extent of downsizing

All deaths (N=347) Cardiovascular deaths (N=79) Other deaths (N=268)

Adjusted for age, sex, SES and type of employment.

Downsizing and relative risk of death

Vahtera et al. BMJ 2004

Organisational downsizing and relative risk of

death from cardiovascular diseases

*Adjusted for age, sex, socioeconomic status, type of employment, and town.

First half of the follow-up

Second half of the follow-up

Extent of downsizing

No 1.00 1.00 Intermediate 4.31 (1.3-14.7) 1.06 (0.5-2.1) High 5.33 (1.4-20.2) 1.44 (0.7-3.2)

Source: Vahtera, Kivimäki et al. The 10-Town Study. BMJ 2004

Trigger

Socioeconomic confounding?

material circumstances

mortality

work stress

The association between downsizing and cardiovascular mortality remained after adjustment for socioeconomic status.

SES, early living conditions and behavioural health risks are stable predictors of health that are not likely to produce temporary differences in mortality observed in this study.

Organisational downsizing and relative risk of SES-related mortality

*Adjusted for age, sex, socioeconomic status and type of employment.

Smoking-related cancer (49 deaths)

Alcohol-related causes (99 deaths)

Extent of downsizing

No 1.0 1.0 Intermediate 1.2 (0.6-2.3) 1.0 (0.6-1.6) High 0.7 (0.3-2.7) 1.4 (0.8-2.5)

Vahtera, Kivimaki et al. BMJ 2004

Downsizing was not associated with deaths from smoking-related cancer and alcohol-related causes, i.e. causes of mortality with well-documented socioeconomic gradients.

Summary: Effects of downsizing on survivors

INCREASED STRESS AT WORK :

Greater workload, decreased job control, increased job insecurity

INCREASED STRESS-RELATED MORBIDITY AND MORTALITY:

Self-reported health problems: musculoskeletal disorders, poor overall health, psychological distress and health complaints

Use of psychotropic drugs

Long-term sickness absence (older people, higher SEP), decrease in short-term sickness absence

Retirement on health grounds

Temporary increase in risk of cardiovascular mortality in vulnerable employees