Unemployment and Health - a Public Health Perspective
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MEDICINE
REVIEW ARTICLE
Unemployment and Health –
a Public Health Perspective
Andreas Weber, Georg Hörmann, Walther Heipertz
SUMMARY
Introduction: Around 3.7 million people are currently unemployed in Germany. This article
presents evidence on the health effects of unemployment, from a public health perspective.
Methods: Selective review of articles from PubMed and PsycInfo over the last 20 years, and
discussion of key German language research articles addressing the health effects of
unemployment. Results: Unemployment has adverse effects on psychosocial health. It can lead
to resignation, withdrawal, decreased self-esteem, increased use of health services, conflict in
families and partnerships, social isolation, sleep disturbance, depression, anxiety disorder, drug
abuse and suicide and parasuicide attempts. Whether unemployment also has adverse somatic
consequences such as cardiovascular disease, gastrointestinal disturbances, or malignancy, is
scientifically less evident. The health related effects of unemployment are modified by
numerous variables such as age, sex, duration of unemployment, previous illnesses, socio-
economic status, qualification/education, biography/personality, social support, and individual
coping resources. Discussion: Future research needs to focus on the stressors associated with
contemporary working patterns, such as job insecurity, reduction in staff numbers, discontinuous
occupational biographies, and precarious working conditions. The commitment to health
promotion, particularly among the long term unemployed, should be strengthened.
Dtsch Arztebl 2007; 104(43): A 2957–62
Key words: unemployment, social medicine, emotional pressure, health behaviour, mortality
E ven now, at the beginning of the 21st century, work is the basis of material existence
for the majority of the population. Occupational activity is the source of social status,
power, self-esteem, and success. It has long been recognized that work is important not only
in the social setting, but also for the health of the individual. Sigmund Freud even defined
health in a way that was largely dependent on work ("Health is the ability to love and to
work"). Whether work makes the individual healthy or ill depends, among other things, on
specific working conditions such as the difficulty, intensity, hours, and organization of
work, the degree of fit between demands and abilities, and the individual's own experiential
world and value system. A health-oriented assessment of unemployment lays the emphasis
on certain clearly pathological aspects (1–3). On the basis of a selective review of the
literature, we will here present the current state of scientific knowledge about the negative
effects of unemployment on health and the possible implications from the point of view of
social medicine.
Definition and prevalence of unemployment
There is still no generally accepted, international definition of unemployment, nor is there
any uniform method of collecting data on its prevalence. In 2000, the International Labor
Organization (ILO) defined the unemployed as persons who are not gainfully employed but
are available to the labor market and are searching for work. In Germany, the applicable
definitions are contained in the legal enactments of §16 SGB and § 17 SGB III (Social Law
Code III – Promotion of Work) (see box 1). The long-term unemployed (§ 18 SGB III) are
persons who have been unemployed for at least 1 year. The young unemployed, according
to the German Labor Agency, are unemployed people under the age of 25 ("U 25") (3–5).
In August 2007, about 3.7 million persons were unemployed in Germany, among whom
Institut für Qualitätssicherung in Prävention und Rehabilitation an der Deutschen Sporthochschule, Köln (iqpr GmbH):
Prof. Dr. med. Weber; Lehrstuhl für Allgemeine Pädagogik und Gesundheitspädagogik/ Forschungsstelle für Kinder- und Jugend-
lichenpsychotherapie, Otto Friedrich Universität, Bamberg: Prof. Dr. mult. Hörmann; Bundesagentur für Arbeit, Nürnberg:
Dr. med. Heipertz
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BOX 1
The definition of unemployment
according to the German Social
Law Code, SGB III
§ 16: The unemployed are persons who
are temporarily not employed (lack of employment),
are searching an employment that would place them
under the coverage of the Social Insurance system and
are available for the occupational placement services of
the Labor Agency (availability), and
have reported themselves as unemployed to the Labor
Agency.
§ 17: Persons threatened with unemployment are
persons who
are employed in a job under the coverage of the Social
Insurance system,
face termination of their employment in the near future,
and
will in all likelihood become unemployed thereafter.
BOX 2
Demographic features of the
unemployed
Approximately 3.7 million unemployed persons
ca. 1.9 million women
ca. 1.8 million men
ca. 470 000 persons under age 25
ca. 941 000 persons over age 50
ca. 1.3 million long-term unemployed (i.e., for more than
12 months), of whom ca. 50% are unskilled
(Source: Statistics of the Federal Labor Agency, August 2007)
1.3 million had been unemployed for more than 1 year (box 2). Unemployment affects all
social and educational strata and all age groups (4, 6). Despite the currently relatively open
labor market, the overall German unemployment rate now stands at 8.8% (August 2007).
The unemployment rate in what used to be East Germany is 14.7%, more than twice as high
as in the rest of the country (7.3%). There is also a north-south gradient, with the highest
unemployment rate in the state of Mecklenburg-Western Pomerania (18.2%) and the lowest
rates in Baden-Württemberg (4.9%) and Bavaria (5.1%). The ILO estimates that more than
400 million persons are unemployed worldwide (4, 5). The causes of unemployment are
many. It is partly due to inadequate demand occasioned by changes in the working world,
in society, and in values. Other factors include increasing globalization, heightened
competition and pressure to control costs, lack of individual motivation to work, insufficient
qualifications, and ineffective mediation of jobs to the unemployed.
Unemployment as a danger to health
As early as 1933, the Viennese sociologist Marie Jahoda (1907–2001) described in her
study "Die Arbeitslosen von Marienthal" ("The Unemployed of Marienthal") the social and
health consequences of prolonged unemployment after the closure of a textile factory in a
village in Lower Austria (7). Individuals cope better or worse with unemployment
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depending on many different moderator variables, including the duration of unemployment,
age, sex, financial resources, education/occupational qualifications, personality structure,
causal attribution, social support ("networks"), health problems, health-related behavior,
job-seeking behavior, and other activities such as hobbies, volunteer work, or black-market
labor (3, 5, 7, 8). The duration of unemployment, in particular, has a major effect on the
health-related well-being of the unemployed. Thus, the German Institute for Economic
Research (Deutsches Institut für Wirtschaftsforschung) reported that, according to data
collected by its Socioeconomic Panel in 2005, the level of satisfaction with one's current
way of living was just as low among long-term unemployed persons as it was among
persons dependent on nursing care. Dissatisfaction has risen in the past 10 years as well (9).
A telephone survey on health conducted by the Robert Koch Institute in 2003 revealed that
the long-term unemployed not only rate their health as poor, but also report a higher
frequency of overt illnesses (10). As far as gender is concerned, the adverse effects of
unemployment on women's health were probably underestimated in the past, because of
traditional role expectations. More recent research reveals no significant differences in
health-related vulnerability due to unemployment in men and women, likely because the
careers and professional orientation of men and women have become much more similar
than they used to be (5, 10). The findings with regard to age, however, are not entirely
consistent. The ill effects of unemployment among the young have been emphasized, as
have its ill effects among 35- to 44-year-olds, who are thought to be under maximum
emotional stress because their orientation toward gainful employment is the strongest (8).
On the other hand, recent research from the USA shows that 51- to 61-year-olds who
involuntarily lose their jobs are subject to an especially high health risk, including higher
rates of myocardial infarction, stroke, and depressive disorders (11, 12, 13).
Unemployment and health: selection or causation?
The question whether unemployment causes illness (the "causality hypothesis") or vice
versa (the "selection hypothesis") has still not been definitively answered. In individual
cases, unemployment can be both the effect and the cause, or one of the causes, of illness
("duality") (3, 14, 15). Evidence in favor of the selection hypothesis comes from the fact
BOX 3
Effects on social life
Loss of social contacts (social isolation)
Lack of time structure / lack of structure of daily activities
Financial problems, indebtedness
Poor living environment (noise, pollution, "ghettoization,"
impending homelessness)
Increased conflict within the family (domestic violence,
partnership-/sexuality problems)
Intergenerational effects (loss of self-esteem/higher
suicide rates among the children of the unemployed)
BOX 4
Lifestyle and health behavior
Increased consumption of alcohol, nicotine, and illicit
drugs
Poor nutrition (overweight, undernourishment,
over-reliance on "cheap food")
Physical inactivity ("Play Station syndrome")
Altered sleep habits (sleep deficit, abnormal sleep
rhythm)
Increased risk of accidents
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that about one-third of all terminations of employment in the 1980s and 1990s were
illness-related; according to the telephone survey of health conducted in 2003, about
one-quarter of all unemployed men had lost their jobs because of illness. According to the
statistics of the German Federal Labor Agency, about 25% of all unemployed persons, 40%
of those above 50 years old, and 50% of the long-term unemployed ( > 12 months) have
health impairments that lessen their ability to get a new job (4, 5, 9, 14). In an evaluation of
310 048 medical examinations performed by the Federal Labor Agency's Medical Service,
Hollederer found that 42% of the unemployed suffered from musculoskeletal conditions
and 25% from mental illness (15). Among the persons undergoing retraining for health
reasons in German occupational rehabilitation centers in 2003, about 75% were unemployed,
and 50% of these had been unemployed for more than 1 year (16). A not inconsiderable
number of the unemployed suffer from serious objective impairments of health. Among the
4.8 million persons registered as unemployed in Germany in 2005 (an average figure for the
year), 191 000 were classified as severely handicapped as defined by German law (SGB IX).
The number of severely handicapped persons in the overall population is about 6.8 million
(4). There are also, however, many studies that support the hypothesis that unemployment
causes illness (5, 17). These can be classified by their methodology into two types:
macrostudies are based on aggregate data, while microstudies are based on individual data.
In macrostudies, the unemployment rate in various areas is matched against mortality
figures (for example) in the same areas, even though there is no way of knowing whether
the persons who died were the same as those who suffered the stress of unemployment. In
contrast, microstudies involve cross-sectional or longitudinal assessment of data obtained
from individuals on the basis of their occupational status. Cross-sectional ("snapshot")
studies do not permit any causal inferences to be made. Thus, longitudinal studies based on
individual data are considered the gold standard for research on unemployment and health.
Such studies take account of data concerning the periods before and after the individual
becomes unemployed, as well as further data on the acquisition of new jobs and on important
confounding variables. Unfortunately, only a few studies are of high methodological quality
(5, 15, 17). The causality hypothesis, therefore, requires further support from secondary data
analyses, for example, statistical studies performed by health insurance carriers and data
from health surveys (10, 14). The health-related target parameters of studies on the negative
effects of unemployment usually include subjective well-being, changes in social life,
health behavior, use of medical services (care provision), mental and/or physical morbidity,
and (premature) mortality (3, 5, 10, 14).
How does unemployment make people ill?
The possible pathogenetic mechanisms of unemployment that are currently under discussion
include the stress model, health-damaging individual behavior (a risky lifestyle), the
deprivation theory, and the "vitamin model," which relates to socioeconomic deficits.
Stress theory considers unemployment to be a strong social stressor leading to
emotional, mental-cognitive, behavioral, pathophysiological, and biochemical reactions.
Neuroendocrine, metabolic, and immunological parameters play a large role in this model,
including elevated cortisol and cholesterol levels, pathological glucose tolerance, high
blood pressure, and a cellular immune deficiency. Further important pathogenetic factors
include stress-related emotional problems, such as anxiety and resignation, and health-
damaging individual behavior, such as excessive consumption of alcohol or nicotine as an
inappropriate coping strategy. These changes are interpreted as risk factors for, or preliminary
stages of, overt illnesses, in particular cardiovascular diseases such as hypertension,
myocardial infarction and stroke and psychosomatic conditions such as depression and
anxiety disorders. Both groups of illnesses can be thought of, to some extent, as a "final
common pathway" of chronic psychosocial stress in individuals whose coping mechanisms
are deficient. This mechanism is biologically plausible (1, 3, 5, 8, 17).
The deprivation theory and the "vitamin model," on the other hand, are mainly concerned
with the psychosocial consequences of unemployment. Certain functions of gainful work,
including the earning of money, structured time, social contact, status, identity, regular
activity, and environmental factors, are held to be important prerequisites for emotional
well-being and mental stability that are significantly impaired by unemployment. There is
also good empirical evidence that low income and a reduced standard of living are correlated
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BOX 5
Unemployment and somatic illnesses
Obesity
Lipid and carbohydrate metabolic disturbances
Metabolic syndrome, type 2 diabetes mellitus
Arterial hypertension
Coronary heart disease (myocardial infarction)
Stroke
Peripheral arterial occlusive disease
Gastrointestinal symptoms (e.g., gastritis, ulcers, irritable
bowel syndrome)
Hepatic disorders (e.g., fatty liver, hepatic cirrhosis)
Immune suppression (e.g., frequent infections)
Respiratory diseases (e.g., chronic obstructive pulmonary
disease)
Malignant neoplasia (e.g., bronchial carcinoma)
with impaired mental health (18). The major sociopathogenic factors causing impairment
of social health due to unemployment are financial deficits, stigmatization, role changes,
social isolation, and time restructuring (8). Beyond these pathogenetic considerations, the
negative health effects of unemployment can manifest themselves multidimensionally,
especially with respect to social life, lifestyle/heath behavior, psychosomatic morbidity, the
use of medical services, and mortality.
Social life and lifestyle
Unemployment affects social life mainly by reducing the individual's social contacts and
financial resources, leading to problems such as indebtedness. Thus, unemployment was
chosen as a major topic of the annual meeting of the German Medical Association in 2005
in view of its being the most important factor for the spread of poverty in Germany. The
negative effects of unemployment on social life, especially among long-term unemployed
persons, are summarized in box 3 (5, 19). The modes of behavior listed in box 4 (5, 8, 14,
17, 20) are held to be established risk factors for the acquisition of so-called diseases of
civilization. Certain somatic illnesses are found to be correlated with unemployment and
usually also with a lifestyle that puts the individual at greater risk: these include coronary
heart disease, arterial hypertension, stroke, chronic bronchitis, metabolic syndrome, and
fatty liver and hepatic cirrhosis (17).
Morbidity
The somatic illnesses most closely associated with unemployment are obesity, metabolic
disorders, and cardiovascular diseases, including arterial hypertension (sometimes of
questionable clinical significance) as well as coronary heart disease, myocardial infarction,
cerebrovascular insufficiency with stroke, and peripheral arterial occlusive disease (17,
21). Further objectified diseases are listed in box 5. The abnormalities described have often
been found in combination with a health-endangering lifestyle; thus, the potentially damaging
effect of unemployment on these organ systems should be seen in the context of behavioral
risks (5, 17, 22). Many methodologically sound studies, and three meta-analyses, have now
confirmed beyond any doubt that mental and psychosomatic illnesses can be caused by
unemployment (5, 14, 18, 22, 23, 24). Moreover, one can even discern a dose-related effect:
not only does continued unemployment lead to an increase of mental symptoms, but the
resumption of work also leads to improvement in mental well-being (5, 8, 10, 18). The types
of mental disturbances discussed in the literature include low self-esteem, helplessness and
hopelessness, isolation/loneliness, resignation, apathy, headache, sleep disturbances, chronic
fatigue, irritability, and aggression (3, 5, 14). In addition, the unemployed have also been
found to have a higher frequency of serious mental health problems including depression
and anxiety disorders, addiction, and suicidal behavior (3, 14, 22).
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Use of medical services
The increased incidence of mental disorders among the unemployed is also reflected in the
statistical findings of the German health insurance carriers concerning the use of medical
services. The number of days of inability to work due to mental illness (ICD-10 diagnosis
group F) among the unemployed has been rising for years. Their average number of days of
inability to work per year (22 days) is also higher than that of the employed (13 days) (1, 2,
14). Furthermore, the 1998 German Federal Health Survey (Bundesgesundheitssurvey)
revealed that the unemployed consult physicians in private practice more often than the
employed. An evaluation of the data obtained by one insurance carrier, the Gmünder
Ersatzkasse (GEK), showed that unemployed men and women are also more frequently
admitted as inpatients to acute-care hospitals than employed persons are. The single most
common diagnosis among the unemployed persons insured by GEK was alcoholism (14).
Mortality
As early as the 1970's, Brenner reported several macrostudies that showed an elevated risk
of premature death associated with unemployment (25). Though such observations were
made in multiple further studies, the design of these studies permitted no causal inferences
to be made (17, 21). Grobe, evaluating the individual data of GEK, found an elevated risk
of death that depended on the duration of unemployment: persons insured by GEK who had
been unemployed for less than two years had a relative mortality of 1.6 compared to
persons who were continually employed, while those unemployed for more than two years
had a relative mortality of 3.4 (14).
Conclusions and prospects
The major effect of unemployment is to impair psychosocial health. There is strong
evidence for the validity of the causality hypothesis (3, 5, 10, 14, 18, 24). The evidence is
reinforced by consistent data, the occurrence of dose-related effects, and long-term
observation. In contrast, the direct causation of somatic illness by unemployment is less
well documented. Significant in this context is the fact that the unemployed behave in
health-damaging ways more commonly than the employed (17).
In the globalized service economy, new psychosocial stressors are taking on increasing
importance, such as the fear of unemployment, job insecurity, downsizing, worsening
conditions in the workplace, or poverty despite employment. The health effects of these
stressors are certainly comparable with those of unemployment itself (box 6). From the
scientific point of view, there is an unaltered need for methodologically sound longitudinal
studies not just of pathogenetic mechanisms, but also of "salutogenic," that is, protective ones.
The lack of knowledge in this area does not lessen society's duty to be committed to the
BOX 6
Effects of job insecurity
and downsizing
Sleep disturbances
Depression and anxiety disorders
"Internal unemployment" - loss of emotional connection
to one's job
Increased incidence of work accidents
Increased use of medical services
High blood pressure
Obesity
Increased nicotine consumption
Among persons who do not lose their jobs, there is, at
first, relief; this can be followed by anger, frustration,
helplessness, sadness, anxiety for the future,
and resignation.
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prevention of illness and to the rehabilitation of those in need of it. Important types of
intervention include "preventive reintegration," that is, the prevention of job loss, and the
finding of a new job as soon as possible for those who become unemployed. In many cases,
these things will be able to be done effectively only if there is a change in the mentality of
employers and employees, and of the employees' treating physicians as well. "Company-level
reintegration management" ("betriebliches Eingliederungsmanagement," BEM), a concept
incorporated in current German labor law (SGB IX § 84 Para. 2), may open up new
possibilities here (1, 2, 5).
Once an individual loses his or her job, efforts should be made not just toward rapid
reintegration through retraining and optimal help with job placement, but also toward
preventing or at least lessening the negative health consequences of (potentially long-term)
unemployment. Important areas that can be addressed here include reinforcement of
self-esteem, avoidance of social isolation, regular physical exercise, a balanced diet, and
prevention of addiction. Persons who have never been in a regular work situation in their
lives can have difficulty in acquiring even the most basic prerequisites for gainful employment,
for example, time structuring, discipline, perseverance, and reliability. Moreover, a number
of specific programs to promote reintegration are currently being planned or already being
tested: examples include the "AmigA" project for work promotion with integrated health
management in the state of Brandenburg, the "Job-Fit NRW" in North Rhine-Westphalia,
and the "Job Train" program of the occupational rehabilitation centers (3, 5). Experts in the
labor market currently predict that mass unemployment will continue to be a reality in
Germany over the next decade. Thus, the coming years will presumably see increased
nationwide discussion of the importance of gainful employment in the framework of the
German Social Insurance scheme, as well as of alternative opportunities for the unemployed
to participate in the life of society.
Conflict of Interest Statement
The authors state that they have no conflict of interest as defined by the guidelines of the International Committee of Medical
Journal Editors.
Manuscript received on 27 April 2007; final version accepted on 12 July 2007.
Translated from the original German by Ethan Taub, M.D.
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Corresponding author
Prof. Dr. med. Andreas Weber
Institut für Qualitätssicherung in Prävention und
Rehabilitation an der Deutschen Sporthochschule – IQPR GmbH
Sürther Str. 171
50999 Köln, Germany
weber@iqpr.de
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