Organisational downsizing, sickness absence, and mortality: 10-town prospective cohort study
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《英国医生杂志》
1 Finnish Institute of Occupational Health, Topeliuksenkatu 41 aA, FIN-00250 Helsinki, Finland, 2 University of Tampere, Medical School, FIN-33014 University of Tampere, Finland, 3 International Centre for Health and Society, Department of Epidemiology and Public Health, University College London Medical School, London WC1E 6BT
Correspondence to: J Vahtera, Finnish Institute of Occupational Health, H?meenkatu 10, FIN-20500 Turku, Finland jussi.vahtera@ttl.fi
Abstract
Since the recessions that hit most industrialised countries during the 1990s, evidence has accumulated of health risks to the survivors of corporate downsizing. One of the first studies in the field was conducted among municipal employees of town of Raisio, Finland. The Raisio study found that the risk of health problems, as indicated by medically certified sickness absence and other indicators of health, was at least twice as great after major downsizing as after no downsizing.1-3 Half of this excess risk was attributable to an elevated level of work stress after major downsizing.2 3 Adverse effects on the health of survivors of downsizing have since been shown in several other studies.4 However, some evidence exists that employees in downsizing organisations may be reluctant to take leave, in effect reducing measured sickness absence through an increased likelihood of attending work while ill.5 6 Recent research suggests that findings may vary by employment contract, with increased sickness absence among permanent employees and increased attendance during sickness among temporary employees.7
Although further research on sickness absence is needed to improve understanding of the health effects of downsizing, a major step forward would be the assessment of hard end points such as mortality. Evidence exists that work stress can increase cardiovascular deaths,8-10 and results from studies in non-occupational settings suggest that stressful life events may trigger fatal cardiovascular disease in the first years after the event.11 12 If downsizing is indeed a highly stressful event, then risk of cardiovascular death among employees should increase after major downsizing. We therefore studied the association between downsizing, sickness absence, and mortality in a large cohort of permanent and temporary employees.
Methods
Table 1 shows the demographic characteristics of the participants by degree of downsizing. The study population was predominantly female and working in non-manual occupations. Major downsizing was more common in manual occupations, among women, and among temporary employees. Major downsizing was less common in Espoo than in other towns. Age was not associated with downsizing.
Table 1 Characteristics of the participants by the extent of downsizing. Values are numbers (percentages)
Table 2 presents differences in absence rates before and after downsizing by degree of downsizing. In permanent employees, but not in temporary employees, the increase in sickness absence was greater among employees who had experienced major downsizing than in those who had experienced no downsizing (P for interaction between type of employment and downsizing 0.04). The difference between the major downsizing group and the no downsizing group was 18 spells per 100 person years. We found no sex differences (P for interaction between sex and downsizing 0.40 in permanent and temporary employees). Further adjustment for town had no effect on these results.
Table 2 Organisational downsizing and change in rate of medically certified sickness absence by type of employment
Table 3 shows the results for downsizing and mortality. A significant association occurred between downsizing and all cause mortality, which disappeared when we excluded deaths from cardiovascular diseases from all deaths. Employees who had experienced major downsizing had a twofold greater risk of death from cardiovascular diseases after adjustments. Further adjustment for town had little effect on these results (hazard ratio after major downsizing 1.9, 95% confidence interval 1.0 to 3.8). We found no sex differences (P for interaction 0.94 for all cause mortality and 0.22 for cardiovascular mortality). A stratified analysis of the 13 837 employees with no absence before downsizing gave similar results (hazard ratio after major downsizing 2.6, 1.0 to 6.5, P for trend 0.04). To study potential associations between downsizing and behavioural risk factors, we analysed mortality from smoking related cancer and alcohol related causes (data not shown). Major downsizing was not associated with death from these specific causes (adjusted hazard ratios 0.7, 0.3 to 1.7 and 1.4, 0.8 to 2.5).
Table 3 Organisational downsizing and relative risk of death from all causes, cardiovascular diseases, and causes other than cardiovascular diseases
Finally, we analysed the short term and long term associations of downsizing on mortality (data not shown). Excess cardiovascular mortality was very pronounced in the first half of the follow up period after downsizing (adjusted hazard ratio 5.1, 1.4 to 19.3), but the risk was much less in the second half (1.4, 0.6 to 3.1). We found no evidence of a time dependent hazard for mortality from non-cardiovascular causes, smoking related cancer, and alcohol related causes,.
Discussion
Vahtera J, Kivim?ki M, Pentti J. Effect of organisational downsizing on health of employees. Lancet 1997;350: 1124-8.
Kivim?ki M, Vahtera J, Pentti J, Thomson L, Griffiths A, Cox T. Downsizing, changes in work, and self-rated health of employees: a 7-year 3-wave panel study. Anxiety, Stress and Coping 2001;14: 59-73.
Kivim?ki M, Vahtera J, Pentti J, Ferrie JE. Factors underlying the effect of organisational downsizing on health of employees: longitudinal cohort study. BMJ 2000;320: 971-5.
Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv 2001;31: 335-414.
Theorell T, Oxenstierna G, Ferrie J, Hagberg J, Alfredsson L. Downsizing of staff is associated with lowered medically certified sick leave in female employees. Occup Environ Med 2003;60: e9.
Aronsson G, Gustafsson K, Dallner M. Sick but yet at work: an empirical study of sickness presenteeism. J Epidemiol Community Health 2000;54: 502-9.
Virtanen M, Kivim?ki M, Elovainio M, Vahtera J, Ferrie JE. From insecure to secure employment: changes in work, health, health related behaviours, and sickness absence. Occup Environ Med 2003;60: 948-53.
Bosma H, Peter R, Siegrist J, Marmot M. Two alternative job stress models and the risk of coronary heart disease. Am J Public Health 1998;88: 68-74.
Hemingway H, Marmot M. Psychosocial factors in the aetiology and prognosis of coronary heart disease: systematic review of prospective cohort studies. BMJ 1999;318: 1460-7.
Kivim?ki M, Leino-Arjas P, Luukkonen R, Riihim?ki H, Vahtera J, Kirjonen J. Work stress and risk of cardiovascular mortality: prospective cohort study of industrial employees. BMJ 2002;325: 857-61.
Martikainen P, Valkonen T. Mortality after the death of a spouse: rates and causes of death in a large Finnish cohort. Am J Public Health 1996;86: 1087-93.
Lichtenstein P, Gatz M, Berg S. A twin study of mortality after spousal bereavement. Psychol Med 1998;28: 635-43.
Classification of occupations: handbook no 14. Helsinki: Statistics Finland, 1987.
Kivim?ki M, Head J, Ferrie JE, Shipley M, Vahtera J, Marmot MG. Sickness absence as a global measure of health: evidence from mortality in the Whitehall II prospective cohort study. BMJ 2003;327: 364-8.
Davey Smith G, Shipley M, Leon DA. Height and mortality from cancer among men: prospective observational study. BMJ 1998;317: 1351-2.
Hart CL, Smith GD, Hole DJ, Hawthorne VM. Alcohol consumption and mortality from all causes, coronary heart disease, and stroke: results from a prospective cohort study of Scottish men with 21 years of follow up. BMJ 1999;318: 1725-9.
North F, Syme SL, Feeney A, Head J, Shipley MJ, Marmot MG. Explaining socioeconomic differences in sickness absence: the Whitehall II study. BMJ 1993;306: 361-6.
Melchior M, Niedhammer I, Berkman LF Goldberg M. Do psychosocial work factors and social relations exert independent effects on sickness absence? A six year prospective study of the GAZEL cohort. J Epidemiol Community Health 2003;57: 285-93.
Everson SA, Lynch JW, Chesney MA, Kaplan GA, Goldberg DE, Shade SB, et al. Interaction of workplace demands and cardiovascular reactivity in progression of carotid atherosclerosis: population based study. BMJ 1997;314: 553-8.
Weiss NS. Can the specificity of an association be rehabilitated as a basis for supporting a causal hypothesis? Epidemiology 2002;13: 6-8.
McLeod J, Davey Smith G, Heslop P, Metcalfe C, Carroll D, Hart C. Psychological stress and cardiovascular disease: empirical demonstration of bias in a prospective observational study of Scottish men. BMJ 2002;324: 1247-51.
Lynch JW, Kaplan GA, Pamuk ER, Cohen RD, Heck KE, Balfour JL, et al. Income inequality and mortality in metropolitan areas of the United States. Am J Public Health 1998;88: 1074-80.
Ferrie JE. Labour market status, insecurity and health. J Health Psychol 1997;2: 373-97.(Jussi Vahtera, senior res)
Correspondence to: J Vahtera, Finnish Institute of Occupational Health, H?meenkatu 10, FIN-20500 Turku, Finland jussi.vahtera@ttl.fi
Abstract
Since the recessions that hit most industrialised countries during the 1990s, evidence has accumulated of health risks to the survivors of corporate downsizing. One of the first studies in the field was conducted among municipal employees of town of Raisio, Finland. The Raisio study found that the risk of health problems, as indicated by medically certified sickness absence and other indicators of health, was at least twice as great after major downsizing as after no downsizing.1-3 Half of this excess risk was attributable to an elevated level of work stress after major downsizing.2 3 Adverse effects on the health of survivors of downsizing have since been shown in several other studies.4 However, some evidence exists that employees in downsizing organisations may be reluctant to take leave, in effect reducing measured sickness absence through an increased likelihood of attending work while ill.5 6 Recent research suggests that findings may vary by employment contract, with increased sickness absence among permanent employees and increased attendance during sickness among temporary employees.7
Although further research on sickness absence is needed to improve understanding of the health effects of downsizing, a major step forward would be the assessment of hard end points such as mortality. Evidence exists that work stress can increase cardiovascular deaths,8-10 and results from studies in non-occupational settings suggest that stressful life events may trigger fatal cardiovascular disease in the first years after the event.11 12 If downsizing is indeed a highly stressful event, then risk of cardiovascular death among employees should increase after major downsizing. We therefore studied the association between downsizing, sickness absence, and mortality in a large cohort of permanent and temporary employees.
Methods
Table 1 shows the demographic characteristics of the participants by degree of downsizing. The study population was predominantly female and working in non-manual occupations. Major downsizing was more common in manual occupations, among women, and among temporary employees. Major downsizing was less common in Espoo than in other towns. Age was not associated with downsizing.
Table 1 Characteristics of the participants by the extent of downsizing. Values are numbers (percentages)
Table 2 presents differences in absence rates before and after downsizing by degree of downsizing. In permanent employees, but not in temporary employees, the increase in sickness absence was greater among employees who had experienced major downsizing than in those who had experienced no downsizing (P for interaction between type of employment and downsizing 0.04). The difference between the major downsizing group and the no downsizing group was 18 spells per 100 person years. We found no sex differences (P for interaction between sex and downsizing 0.40 in permanent and temporary employees). Further adjustment for town had no effect on these results.
Table 2 Organisational downsizing and change in rate of medically certified sickness absence by type of employment
Table 3 shows the results for downsizing and mortality. A significant association occurred between downsizing and all cause mortality, which disappeared when we excluded deaths from cardiovascular diseases from all deaths. Employees who had experienced major downsizing had a twofold greater risk of death from cardiovascular diseases after adjustments. Further adjustment for town had little effect on these results (hazard ratio after major downsizing 1.9, 95% confidence interval 1.0 to 3.8). We found no sex differences (P for interaction 0.94 for all cause mortality and 0.22 for cardiovascular mortality). A stratified analysis of the 13 837 employees with no absence before downsizing gave similar results (hazard ratio after major downsizing 2.6, 1.0 to 6.5, P for trend 0.04). To study potential associations between downsizing and behavioural risk factors, we analysed mortality from smoking related cancer and alcohol related causes (data not shown). Major downsizing was not associated with death from these specific causes (adjusted hazard ratios 0.7, 0.3 to 1.7 and 1.4, 0.8 to 2.5).
Table 3 Organisational downsizing and relative risk of death from all causes, cardiovascular diseases, and causes other than cardiovascular diseases
Finally, we analysed the short term and long term associations of downsizing on mortality (data not shown). Excess cardiovascular mortality was very pronounced in the first half of the follow up period after downsizing (adjusted hazard ratio 5.1, 1.4 to 19.3), but the risk was much less in the second half (1.4, 0.6 to 3.1). We found no evidence of a time dependent hazard for mortality from non-cardiovascular causes, smoking related cancer, and alcohol related causes,.
Discussion
Vahtera J, Kivim?ki M, Pentti J. Effect of organisational downsizing on health of employees. Lancet 1997;350: 1124-8.
Kivim?ki M, Vahtera J, Pentti J, Thomson L, Griffiths A, Cox T. Downsizing, changes in work, and self-rated health of employees: a 7-year 3-wave panel study. Anxiety, Stress and Coping 2001;14: 59-73.
Kivim?ki M, Vahtera J, Pentti J, Ferrie JE. Factors underlying the effect of organisational downsizing on health of employees: longitudinal cohort study. BMJ 2000;320: 971-5.
Quinlan M, Mayhew C, Bohle P. The global expansion of precarious employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv 2001;31: 335-414.
Theorell T, Oxenstierna G, Ferrie J, Hagberg J, Alfredsson L. Downsizing of staff is associated with lowered medically certified sick leave in female employees. Occup Environ Med 2003;60: e9.
Aronsson G, Gustafsson K, Dallner M. Sick but yet at work: an empirical study of sickness presenteeism. J Epidemiol Community Health 2000;54: 502-9.
Virtanen M, Kivim?ki M, Elovainio M, Vahtera J, Ferrie JE. From insecure to secure employment: changes in work, health, health related behaviours, and sickness absence. Occup Environ Med 2003;60: 948-53.
Bosma H, Peter R, Siegrist J, Marmot M. Two alternative job stress models and the risk of coronary heart disease. Am J Public Health 1998;88: 68-74.
Hemingway H, Marmot M. Psychosocial factors in the aetiology and prognosis of coronary heart disease: systematic review of prospective cohort studies. BMJ 1999;318: 1460-7.
Kivim?ki M, Leino-Arjas P, Luukkonen R, Riihim?ki H, Vahtera J, Kirjonen J. Work stress and risk of cardiovascular mortality: prospective cohort study of industrial employees. BMJ 2002;325: 857-61.
Martikainen P, Valkonen T. Mortality after the death of a spouse: rates and causes of death in a large Finnish cohort. Am J Public Health 1996;86: 1087-93.
Lichtenstein P, Gatz M, Berg S. A twin study of mortality after spousal bereavement. Psychol Med 1998;28: 635-43.
Classification of occupations: handbook no 14. Helsinki: Statistics Finland, 1987.
Kivim?ki M, Head J, Ferrie JE, Shipley M, Vahtera J, Marmot MG. Sickness absence as a global measure of health: evidence from mortality in the Whitehall II prospective cohort study. BMJ 2003;327: 364-8.
Davey Smith G, Shipley M, Leon DA. Height and mortality from cancer among men: prospective observational study. BMJ 1998;317: 1351-2.
Hart CL, Smith GD, Hole DJ, Hawthorne VM. Alcohol consumption and mortality from all causes, coronary heart disease, and stroke: results from a prospective cohort study of Scottish men with 21 years of follow up. BMJ 1999;318: 1725-9.
North F, Syme SL, Feeney A, Head J, Shipley MJ, Marmot MG. Explaining socioeconomic differences in sickness absence: the Whitehall II study. BMJ 1993;306: 361-6.
Melchior M, Niedhammer I, Berkman LF Goldberg M. Do psychosocial work factors and social relations exert independent effects on sickness absence? A six year prospective study of the GAZEL cohort. J Epidemiol Community Health 2003;57: 285-93.
Everson SA, Lynch JW, Chesney MA, Kaplan GA, Goldberg DE, Shade SB, et al. Interaction of workplace demands and cardiovascular reactivity in progression of carotid atherosclerosis: population based study. BMJ 1997;314: 553-8.
Weiss NS. Can the specificity of an association be rehabilitated as a basis for supporting a causal hypothesis? Epidemiology 2002;13: 6-8.
McLeod J, Davey Smith G, Heslop P, Metcalfe C, Carroll D, Hart C. Psychological stress and cardiovascular disease: empirical demonstration of bias in a prospective observational study of Scottish men. BMJ 2002;324: 1247-51.
Lynch JW, Kaplan GA, Pamuk ER, Cohen RD, Heck KE, Balfour JL, et al. Income inequality and mortality in metropolitan areas of the United States. Am J Public Health 1998;88: 1074-80.
Ferrie JE. Labour market status, insecurity and health. J Health Psychol 1997;2: 373-97.(Jussi Vahtera, senior res)