Health outcomes during the 2008 financial crisis in Europe: systematic literature review

OBJECTIVE

 To systematically identify, critically appraise, and synthesise empirical studies about the impact of the 2008 financial crisis in Europe on health outcomes.

DESIGN

 Systematic literature review.

DATA SOURCES

 Structural searches of key databases, healthcare journals, and organisation based websites.

REVIEW METHODS

 Empirical studies reporting on the impact of the financial crisis on health outcomes in Europe, published from January 2008 to December 2015, were included. All selected studies were assessed for risk of bias. Owing to the heterogeneity of studies in terms of study design and analysis and the use of overlapping datasets across studies, studies were analysed thematically per outcome, and the evidence was synthesised on different health outcomes without formal meta-analysis.

RESULTS

 41 studies met the inclusion criteria, and focused on suicide, mental health, self rated health, mortality, and other health outcomes. Of those studies, 30 (73%) were deemed to be at high risk of bias, nine (22%) at moderate risk of bias, and only two (5%) at low risk of bias, limiting the conclusions that can be drawn. Although there were differences across countries and groups, there was some indication that suicides increased and mental health deteriorated during the crisis. The crisis did not seem to reverse the trend of decreasing overall mortality. Evidence on self rated health and other indicators was mixed.

CONCLUSIONS

 Most published studies on the impact of financial crisis on health in Europe had a substantial risk of bias; therefore, results need to be cautiously interpreted. Overall, the financial crisis in Europe seemed to have had heterogeneous effects on health outcomes, with the evidence being most consistent for suicides and mental health. There is a need for better empirical studies, especially those focused on identifying mechanisms that can mitigate the adverse effects of the crisis.

Effects of the great recession on drugs consumption in Spain

This paper presents evidence on how the consumption of legal and illegal drugs has changed in response to the Great Recession in Spain. We use a large scale survey from 2005 to 2011 to analyze the association between changes in local economic conditions and drug consumption among individuals aged 15-64. Although Spain was one of the countries hardest hit by the economic downturn, the crisis was unevenly felt across the country. Therefore, we exploit this difference in unemployment rates across provinces to identify the effects of business cycle variations on the consumption of legal and illegal drugs. To the best of our knowledge, this is the first study to find a relation between the deterioration of local economic conditions and a strong increase in the consumption of marihuana and cocaine. We also report a decrease in alcohol consumption but a significant escalation in abusive smoking behavior (smoking every day). We believe that these findings are important not only for the potential negative implications at the individual level but also for the costs to society as a whole.

On the relationship between economic conditions around the time of birth and late life cognitive abilities: Evidence from Taiwan

This study investigates the casual linkage between economic conditions around the time of birth and late life cognitive abilities. The zero-inflated negative binomial and multivariate logistic regression models were used to evaluate the direct and indirect effect of economic conditions around the time of birth on late life cognitive abilities, respectively. Both direct and indirect effects of economic conditions around the time of birth on late life cognitive abilities were identified. The relative risk ratio in adjusted mean scores of the Short Portable Mental Status Questionnaire (a means to measure cognitive impairment) indicates that being born in an economic recession year (experiencing economic recession during the year prior to birth) increases the risk of difficulties with cognition by 17.40% (11.70%). Being born in an economic recession year decreases the likelihood of high educational attainment in later life by an odds ratio of 0.962.

To Invest or Not to Invest, That Is the Question: Analysis of Firm Behavior under Anticipated Shocks

When companies are faced with an upcoming and expected economic shock some of them tend to react better than others. They adapt by initiating investments thus successfully weathering the storm, while others, even though they possess the same information set, fail to adopt the same business strategy and eventually succumb to the crisis. We use a unique setting of the recent financial crisis in Croatia as an exogenous shock that hit the country with a time lag, allowing the domestic firms to adapt. We perform a survival analysis on the entire population of 144,000 firms in Croatia during the period from 2003 to 2015, and test whether investment prior to the anticipated shock makes firms more likely to survive the recession. We find that small and micro firms, which decided to invest, had between 60 and 70% higher survival rates than similar firms that chose not to invest. This claim is supported by both non-parametric and parametric tests in the survival analysis. From a normative perspective this finding could be important in mitigating the negative effects on aggregate demand during strong recessionary periods.

Health effects of unemployment in Europe (2008-2011): a longitudinal analysis of income and financial strain as mediating factors

BACKGROUND

Unemployment has a number of negative consequences, such as decreased income and poor self-rated health. However, the relationships between unemployment, income, and health are not fully understood. Longitudinal studies have investigated the health effect of unemployment and income separately, but the mediating role of income remains to be scrutinized. Using longitudinal data and methods, this paper investigates whether the effect of unemployment on self-rated health (SRH) is mediated by income, financial strain and unemployment benefits.

METHODS

The analyses use data from the longitudinal panel of European Union Statistics on Income and Living Conditions (EU-SILC) over the 4 years of 2008 to 2011. Individual fixed effects models are applied, estimating the longitudinal change in SRH as people move from employment to unemployment, and investigating whether this change is reduced after controlling for possible mediating mechanisms, absolute income change, relative income change, relative income rank, income deprivation, financial strain, and unemployment benefits.

RESULTS

Becoming unemployed is associated with decreased SRH (-0.048, SE 0.012). This decrease is 19 % weaker (-0.039, SE 0.010) after controlling for change in financial strain. Absolute and relative changes in household equalized income, as well as changes in relative rank and transitions into income deprivation, are not found to be associated with change in SRH.

CONCLUSIONS

Financial strain is found to be a potential mediator of the individual health effect of unemployment, while neither absolute income, relative income, relative rank, income deprivation nor unemployment benefits are found to be mediators of this relationship.

Stroke-attributable death among older persons during the great recession

Epidemiological evidence indicates an elevated risk for stroke among stressed persons, in general, and among individuals who have lost their job, in particular. We, therefore, tested the hypothesis that stroke accounted for a larger fraction of deaths during the Great Recession than expected from other deaths and from trends, cycles, and other forms of autocorrelation. Based on vital statistics death data from California spanning 132 months from January 2000 through December 2010, we found support for the hypothesis. These findings appear attributable to non-Hispanic white men, who experienced a 5% increase in their monthly odds of stroke-attributable death. Total mortality in this group, however, did not increase. Findings suggest that 879 deaths among older white men shifted from other causes to stroke during the 36 months following the start of the Great Recession. We infer the Great Recession may have affected social, biologic, and behavioral risk factors that altered the life histories of older white men in ways that shifted mortality risk toward stroke.

Intimate Partner Violence in the Great Recession

In the United States, the Great Recession was marked by severe negative shocks to labor market conditions. In this study, we combine longitudinal data from the Fragile Families and Child Wellbeing Study with U.S. Bureau of Labor Statistics data on local area unemployment rates to examine the relationship between adverse labor market conditions and mothers' experiences of abusive behavior between 2001 and 2010. Unemployment and economic hardship at the household level were positively related to abusive behavior. Further, rapid increases in the unemployment rate increased men's controlling behavior toward romantic partners even after we adjust for unemployment and economic distress at the household level. We interpret these findings as demonstrating that the uncertainty and anticipatory anxiety that go along with sudden macroeconomic downturns have negative effects on relationship quality, above and beyond the effects of job loss and material hardship.

Informal payments in the Greek health sector amid the financial crisis: old habits die last

BACKGROUND

Under-the-table informal payments are commonplace as reimbursements for health care services in Greece. As the country faces a severe financial crisis, the need to investigate the extent of such payments, their incidence and their impact on household income is pressing.

METHODS

A survey of 2,741 persons from across the country was conducted between December 2011 and February 2012. The sample was defined via a multistage selection process using a quota for municipality of residence, sex and age. The maximum error margin was 2.41% with a confidence interval of 95%.

RESULTS

The survey reports under-the-table payments for approximately 32.4% of public hospital admissions. Private clinics, which display the bulk of out-of-pocket payments, naturally display the lowest under-the-table payments. The highest percentage of under-the-table payments in the private sector appears at visits to private practitioners and dentists (36%). Informal payments are most frequently made upon request, prior to service provision, to facilitate access to care and to reduce waiting times, and at a much lower percentage, to post-service provision, and out of gratitude.

CONCLUSIONS

This survey reveals that, due to severe financial pressure, there is a growing unwillingness of citizens to pay informally and an increasing demand for these payments as a prerequisite for access to services or to redeem services provided. This "hidden" financial burden of at least 27% impacts negatively on the living conditions of households and is not reported as purchasing ability or cost of living.

The physiological impacts of wealth shocks in late life: Evidence from the Great Recession

Given documented links between individual socioeconomic status (SES) and health, it is likely that-in addition to its impacts on individuals' wallets and bank accounts-the Great Recession also took a toll on individuals' disease and mortality risk. Exploiting a quasi-natural experiment design, this study utilizes nationally representative, longitudinal data from the National Social Life, Health, and Aging Project (NSHAP) (2005-2011) (N = 930) and individual fixed effects models to examine how household-level wealth shocks experienced during the Great Recession relate to changes in biophysiological functioning in older adults. Results indicate that wealth shocks significantly predicted changes in physiological functioning, such that losses in net worth from the pre-to the post-Recession period were associated with increases in systolic blood pressure and C-reactive protein over the six year period. Further, while the association between wealth shocks and changes in blood pressure was unattenuated with the inclusion of other indicators of SES, psychosocial well-being, and health behaviors in analytic models, we document some evidence of mediation in the association between changes in wealth and changes in C-reactive protein, which suggests specificity in the social and biophysiological mechanisms relating wealth shocks and health at older ages. Linking macro-level conditions, meso-level household environments, and micro-level biological processes, this study provides new insights into the mechanisms through which economic inequality contributes to disease and mortality risk in late life.

Factors Associated with Long-Term Sickness Absence Due to Mental Disorders: A Cohort Study of 7.112 Patients during the Spanish Economic Crisis

Background

Mental health problems are very common and often lead to prolonged sickness absence, having serious economic repercussions for most European countries. Periods of economic crisis are important social phenomena that are assumed to increase sickness absence due to mental disorders, although research on this topic remains scarce. The aim of this study was to gather data on long-term sickness absence (and relapse) due to mental disorders in Spain during a period of considerable socio-economic crisis.

Methods

Relationships were analyzed (using chi-squared tests and multivariate modelling via binary logistic regression) between clinical, social/employment-related and demographic factors associated and long-term sickness absence (>60 consecutive days) due to mental disorders in a cohort of 7112 Spanish patients during the period 2008–2012.

Results

Older age, severe mental disorders, being self-employed, having a non-permanent contract, and working in the real estate and construction sector were associated with an increased probability of long-term sickness absence (gender had a mediating role with respect to some of these variables). Relapses were associated with short-term sick leave (return to work due to ‘improvement’) and with working in the transport sector and public administration.

Conclusions

Aside from medical factors, other social/employment-related and demographic factors have a significant influence on the duration of sickness absence due to mental disorders.

Financial crisis and criminality in Greece: 2008 vs 2011

Α number of previous articles have dealt with the negative impact of the Greek Economic crisis on public health, including significant increases in major depression prevalence and suicide and homicide rates. The mentally ill seem to represent a vulnerable social group, with particular difficulties in this context. The number of compulsory assessments and involuntary admissions was recorded by reviewing patient records in the Department of Psychiatry of the University Hospital of Patras, through years 2006-2013. Compulsory assessments increased from 176 in 2006 to 262 in 2009 and 354 in 2013, representing a 48.86% and 101.13% increase in the first and the fifth year of economic crisis, respectively. The assessments resulted in 160 involuntary admissions in 2006, which escalated to 262 admissions (63.75% rise) in 2013. Even though a rise in involuntary placements could be attributed to other factors as well, it may also partly represent a not so evident side of the Greek economic crisis.

New York State Dental Establishments and Dentists: 2007-2012. Economic Survey

Every five years a series of studies is carried out by the Census Bureau which provides an opportunity to review the basic economic well-being of the many industries at the national, state and county levels. A comparison of dental economic data from the 2007 and 2012 studies for the period that encompassed the 2007-2009 "Great Recession" details the general economic difficulties faced by the dental profession during this period.

How do economic crises affect migrants' risk of infectious disease? A systematic-narrative review

BACKGROUND

It is not well understood how economic crises affect infectious disease incidence and prevalence, particularly among vulnerable groups. Using a susceptible-infected-recovered framework, we systematically reviewed literature on the impact of the economic crises on infectious disease risks in migrants in Europe, focusing principally on HIV, TB, hepatitis and other STIs.

METHODS

We conducted two searches in PubMed/Medline, Web of Science, Cochrane Library, Google Scholar, websites of key organizations and grey literature to identify how economic changes affect migrant populations and infectious disease. We perform a narrative synthesis in order to map critical pathways and identify hypotheses for subsequent research.

RESULTS

The systematic review on links between economic crises and migrant health identified 653 studies through database searching; only seven met the inclusion criteria. Fourteen items were identified through further searches. The systematic review on links between economic crises and infectious disease identified 480 studies through database searching; 19 met the inclusion criteria. Eight items were identified through further searches. The reviews show that migrant populations in Europe appear disproportionately at risk of specific infectious diseases, and that economic crises and subsequent responses have tended to exacerbate such risks. Recessions lead to unemployment, impoverishment and other risk factors that can be linked to the transmissibility of disease among migrants. Austerity measures that lead to cuts in prevention and treatment programmes further exacerbate infectious disease risks among migrants. Non-governmental health service providers occasionally stepped in to cater to specific populations that include migrants.

CONCLUSIONS

There is evidence that migrants are especially vulnerable to infectious disease during economic crises. Ring-fenced funding of prevention programs, including screening and treatment, is important for addressing this vulnerability.

Who suffers during recessions? Economic downturns, job loss, and cardiovascular disease in older Americans

Job loss in the years before retirement has been found to increase risk of cardiovascular disease (CVD), but some studies suggest that CVD mortality among older workers declines during recessions. We hypothesized that recessionary labor market conditions were associated with reduced CVD risk among persons who did not experience job loss and increased CVD risk among persons who lost their jobs. In our analyses, we used longitudinal, nationally representative data from Americans 50 years of age or older who were enrolled in the Health and Retirement Study and surveyed every 2 years from 1992 to 2010 about their employment status and whether they had experienced a stroke or myocardial infarction. To measure local labor market conditions, Health and Retirement Study data were linked to county unemployment rates. Among workers who experienced job loss, recessionary labor market conditions at the time of job loss were associated with a significantly higher CVD risk (hazard ratio = 2.54, 95% confidence interval: 1.39, 4.65). In contrast, among workers who did not experience job loss, recessionary labor market conditions were associated with a lower CVD risk (hazard ratio = 0.50, 95% confidence interval: 0.31, 0.78). These results suggest that recessions might be protective in the absence of job loss but hazardous in the presence of job loss.

ALL IN IT TOGETHER? THE EFFECTS OF RECESSION ON POPULATION HEALTH AND HEALTH INEQUALITIES IN ENGLAND AND SWEDEN, 1991-2010

This article is the first to comparatively examine the effects of two recessions on population health and health inequalities in the two historically contrasting welfare states of England and Sweden. Data from 1991-2010 on self-reported general health, age, gender, and educational status were obtained from the Health Survey for England, the Swedish Survey of Living Conditions, and the European Union Survey of Income and Living Conditions, for individuals aged over 16. Generalized linear models were used to test the effects of recessions on self-reported health and educational inequalities in health. Overall, recessions had a significant positive effect on the health of women--but not men-in both England (4%) and Sweden (7%). In England, this improvement was only enjoyed by the most educated women, with the health of less educated women declining during recession. In contrast, in Sweden, the health of all women improved significantly during recession regardless of their educational status, although the most educated benefitted the most. Relative educational inequalities in self-reported health therefore increased during recessions in both countries by 14 percent (England) and 17 percent (Sweden) but for different reasons. This study suggests that Sweden's welfare state protects the health of all during recessions.

Occupational class differences in suicide: evidence of changes over time and during the global financial crisis in Australia

BACKGROUND

Previous research showed an increase in Australian suicide rates during the Global Financial Crisis (GFC). There has been no research investigating whether suicide rates by occupational class changed during the GFC. The aim of this study was to investigate whether the GFC-associated increase in suicide rates in employed Australians may have masked changes by occupational class.

METHODS

Negative binomial regression models were used to investigate Rate Ratios (RRs) in suicide by occupational class. Years of the GFC (2007, 2008, 2009) were compared to the baseline years 2001-2006.

RESULTS

There were widening disparities between a number of the lower class occupations and the highest class occupations during the years 2007, 2008, and 2009 for males, but less evidence of differences for females.

CONCLUSIONS

Occupational disparities in suicide rates widened over the GFC period. There is a need for programs to be responsive to economic downturns, and to prioritise the occupational groups most affected.

Short-run effects of job loss on health conditions, health insurance, and health care utilization

Job loss in the United States is associated with reductions in income and long-term increases in mortality rates. This paper examines the short-run changes in health, health care access, and health care utilization after job loss that lead to these long-term effects. Using a sample with more than 10,000 individual job losses and longitudinal data on a wide variety of health-related outcomes, we show that job loss results in worse self-reported health, activity limitations, and worse mental health, but is not associated with statistically significant increases in a variety of specific chronic conditions. Among the full sample of workers, we see reductions in insurance coverage, but little evidence of reductions in health care utilization after job loss. Among the subset of displaced workers with chronic conditions and those for whom the lost job was their primary source of insurance we do see reductions in doctor's visits and prescription drug usage.

A collection of evidence for the impact of the economic recession on road fatalities in Great Britain

There was a considerable reduction in the number of fatalities on British roads between 2007 and 2010. This substantial change led to debate as to the cause of the reduction. Multiple sources of information and evidence have been collated including STATS19 road accident data, population data, socio-demographic data, economic patterns, weather trends and traffic and vehicle data. Summary analyses of these data sources show a reduction in overall traffic, a large reduction in HGV traffic, a reduction in young male drivers, a reduction in speeding, and a reduction in drink driving during the recession period. All of these reductions can be associated with a reduction in fatal accidents and have led to the conclusion that the economic recession changed behaviours in such a way that fewer people were killed on the roads in Britain during this period.

The Dow is Killing Me: Risky Health Behaviors and the Stock Market

We investigate how risky health behaviors and self-reported health vary with the Dow Jones Industrial Average (DJIA) and during stock market crashes. Because stock market indices are leading indicators of economic performance, this research contributes to our understanding of the macroeconomic determinants of health. Existing studies typically rely on the unemployment rate to proxy for economic performance, but this measure captures only one of many channels through which the economic environment may influence individual health decisions. We find that large, negative monthly DJIA returns, decreases in the level of the DJIA, and stock market crashes are widely associated with worsening self-reported mental health and more cigarette smoking, binge drinking, and fatal car accidents involving alcohol. These results are consistent with predictions from rational addiction models and have implications for research on the association between consumption and stock prices.

Sickness absence, moral hazard, and the business cycle

The procyclical nature of sickness absence has been documented by many scholars in literature. So far, explanations have been based on labor force composition and reduced moral hazard caused by fear of job loss during recessions. In this paper, we propose and test a third mechanism caused by reduced moral hazard during booms and infections. We suggest that the workload is higher during economic booms and thus employees have to go to work despite being sick. In a theoretical model focusing on infectious diseases, we show that this will provoke infections of coworkers leading to overall higher sickness absence during economic upturns. Using state-level aggregated data from 112 German public health insurance funds (out of 145 in total), we find that sickness absence due to infectious diseases shows the largest procyclical pattern, as predicted by our theoretical model.

The Icelandic economic collapse, smoking, and the role of labor-market changes

Smoking is related to health deterioration through increased risk of various diseases. Changes in this health behavior could contribute to the documented health improvements during economic downturns. Furthermore, the reasons for changes in behavior are not well understood. We explore smoking behavior in Iceland before and after the sudden and unexpected economic crisis in 2008. Furthermore, to explore the mechanisms through which smoking could be affected we focus on the role of labor-market changes. Both real income and working hours fell significantly and economic theory suggests that such changes can affect health behaviors which in turn affect health. We use individual longitudinal data from 2007 to 2009, incidentally before and after the crisis hit. The data originates from a postal survey, collected by The Public Health Institute in Iceland. Two outcomes are explored: smoking participation and smoking intensity, using pooled ordinary least squares (OLS) and linear probability models. The detected reduction in both outcomes is not explained by the changes in labor-market variables. Other factors in the demand function for tobacco play a more important role. The most notable are real prices which increased in particular for imported goods because of the devaluation of the Icelandic currency as a result of the economic collapse.

Disability Insurance and the Great Recession

The US Social Security Disability Insurance (SSDI) program is designed to provide income support to workers who become unable to work because of a severe, long-lasting disability. In this study, we use administrative data to estimate the effect of labor market conditions, as measured by the unemployment rate, on the number of SSDI applications, the number and composition of initial allowances and denials, and the timing of applications relative to disability onset. We analyze the period of the Great Recession, and compare this period with business cycle effects over the past two decades, from 1992 through 2012.

Home foreclosure, health, and mental health: a systematic review of individual, aggregate, and contextual associations

BACKGROUND

The U.S. foreclosure crisis intensified markedly during the Great Recession of 2007-09, and currently an estimated five percent of U.S. residential properties are more than 90 days past due or in the process of foreclosure. Yet there has been no systematic assessment of the effects of foreclosure on health and mental health.

METHODS AND FINDINGS

I applied systematic search terms to PubMed and PsycINFO to identify quantitative or qualitative studies about the relationship between home foreclosure and health or mental health. After screening the titles and abstracts of 930 publications and reviewing the full text of 76 articles, dissertations, and other reports, I identified 42 publications representing 35 unique studies about foreclosure, health, and mental health. The majority of studies (32 [91%]) concluded that foreclosure had adverse effects on health or mental health, while three studies yielded null or mixed findings. Only two studies examined the extent to which foreclosure may have disproportionate impacts on ethnic or racial minority populations.

CONCLUSIONS

Home foreclosure adversely affects health and mental health through channels operating at multiple levels: at the individual level, the stress of personally experiencing foreclosure was associated with worsened mental health and adverse health behaviors, which were in turn linked to poorer health status; at the community level, increasing degradation of the neighborhood environment had indirect, cross-level adverse effects on health and mental health. Early intervention may be able to prevent acute economic shocks from eventually developing into the chronic stress of foreclosure, with all of the attendant benefits this implies for health and mental health status. Programs designed to encourage early return of foreclosed properties back into productive use may have similar health and mental health benefits.

The role of marriage in the causal pathway from economic conditions early in life to mortality

This paper analyzes the interplay between early-life conditions and marital status, as determinants of adult mortality. We use individual data from Dutch registers (years 1815-2000), combined with business cycle conditions in childhood as indicators of early-life conditions. The empirical analysis estimates bivariate duration models of marriage and mortality, allowing for unobserved heterogeneity. Results show that conditions around birth and school going ages are important for marriage and mortality. Men typically enjoy a protective effect of marriage, whereas women suffer during childbearing ages. However, having been born under favorable economic conditions reduces female mortality during childbearing ages.