Effect of downsizing on health among employees who remain in employment

1. Effect of downsizing on health among employees who remain in employment Mika Kivimaki Professor Department of Epidemiology and Public Health UCL

2. 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)

3. The 10-Town study 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. Oulu Virrat Nokia Tampere Valkeakoski Naantali Raisio Turku Vantaa Espoo

4. Unemployment in Finland Statistics Finland

5. Reduction of workforce • Not hiring cover for those absent from work • Freeze on vacancies (retirement, turnover) • Short-term temporary layoffs in 1993

6. Person-years worked in town Raisio during 1991—1997 Downsizing After downsizing

7. How to measure downsizing? Contracted days - Absence days = Total number of person-years (Total number of person-years before downsizing) – (Total number of person-years after downsizing) x 100 (Total number of person-years before downsizing)

8. Extent of downsizing by occupation

9. Design Perceived health, musculoskeletal symptoms Post-downsizing sickness absence1 • Pre-downsizing • Health • Work characteristics Disability retirement 2 Psychotropic medication (ATC-codes)3 Mortality 4 First half of the follow-up Second half 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Data sources: 1Employers' records 2Local Government Pensions Institution 3 National Prescription Register 4 Statistics Finland Assessment of downsizing 1 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

10. RCT Design Target population Study population Randomisation Experimental group Control group Incidence of outcome Incidence of outcome

11. 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

12. Downsizing causes work stress Workload Skill discretion Participation Job insecurity Supervisor support Co-worker support Spouse support Alcohol intake Smoking Physical activity Body mass * *P<0.05 * * * Difference in post-downsizing values (adjusted for pre-downsizing values) between groups of major vs no downsizing. * * % Source: Kivimäki et al. The Raisio Study. BMJ 2000

13. Effect of downsizing on self-rated health Kivimäki et al. Anxiety Stress Coping 2000

14. Rate of psychotropic drug prescriptions and other prescriptions by postdownsizing status Psychotropic drug = antidepressant, anxiolytics, hypnotics Kivimäki et al. J Epidemiol Community Health 2007

15. Organisational downsizing and use of psychotropic drugs in men by SEP *Risk ratios adjusted for pre-downsizing characteristics Source: Kivimäki et al. The 10-Town Study. J Epidemiol Community Health (2007)

16. Work overload and use of antidepressants Nurses (N=6699) Hospital ward overcrowding Virtanen et al.Am J Psychiatry 2009

17. Source: Vahtera, Kivimäki, Pentti Lancet 1997

18. Source: Vahtera, Kivimäki, Pentti Lancet 1997

19. Source: Vahtera, Kivimäki, Pentti Lancet 1997

20. Cause specific absence and risk of disability pension After excluding precipitating absences People aged 18 to 49 at baseline Risk ratio for disability pension All cause Musculoskeletal Psychiatric Diagnosis for sickness absence and disability pension Kivimäki et al. the Swedish County Study. J Epidemiol Community Health 2007

21. Organisational downsizing and risk of disability pension 1.81 1.46 Relative risk Extent of downsizing Vahtera et al. J Epidemiol Community Health 2005

22. Development of atherosclerosis Fatty streak Atheroma Fibrous Atheroma Complicated Atheroma

23. Work stress and cardiovascular disease

24. Design Mortality 4 First half of the follow-up Second half 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Data sources: 1Employers' records 2Local Government Pensions Institution 3 National Prescription Register 4 Statistics Finland Assessment of downsizing 1

25. Downsizing and relative risk of death Adjusted for age, sex, SES and type of employment. Vahtera et al. BMJ 2004

26. Organisational downsizing and relative risk of death from cardiovascular diseases *Adjusted for age, sex, socioeconomic status, type of employment, and town. Trigger Source: Vahtera, Kivimäki et al. The 10-Town Study. BMJ 2004

27. Socioeconomic confounding? work stress mortality material circumstances

28. 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.

29. Organisational downsizing and relative risk of SES-related mortality *Adjusted for age, sex, socioeconomic status and type of employment. Downsizing was not associated with deaths from smoking-related cancer and alcohol-related causes, i.e. causes of mortality with well-documented socioeconomic gradients. Vahtera, Kivimaki et al. BMJ 2004

30. 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