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Chronic Diseases and Employment:


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Chronic Diseases and Employment:

Impact on Social Inequalities

Rosemary Dray-Spira Inserm U1018-CESP

Epidemiology of occupational and social determinants of health

AVIESAN, ITMO Public Health 1st Annual Symposium October 26th, 2012


Burden of Chronic Disease and Risk Factors

 Epidemiological burden

• Responsible for most of the disease and deaths throughout the world

• In high income countries

(Source: WHO 2008) - 87% of deaths

- 86% of DALYs (i.e., lost years of "healthy" life)

Neuropsychiatric disorders 31%

Cardiovascular diseases 17%

Cancers 17%

- Rising burden on poor and young/middle-aged populations

60% of all DALYs attributable to chronic diseases lost before age 60 years

 Social and economic burden

• On individuals and households

- Workforce participation and labour productivity - Household financial situation

• On national health and welfare systems and economic growth


Social Inequalities in Health Two major underlying pathways

Diderichsen’s model of the social production of disease

Source: Diderichsen 2001


Chronic Disease and Employment Current context

 Consequences of chronic disease on employment may play a substantial role in the process of social health inequalities in the current context

• Increasing numbers of people affected by a chronic disease among the working aged population

- Increasing numbers of people affected by a chronic disease overall

Population ageing

Improvements in diagnosis

Therapeutic advances

- Decreasing age at onset of cardiovascular risk factors - Raising age at retirement

• Increasing rates of health-related work disability

- 6% of the working aged population in Europe (Source: OECD 2010) - Major contribution of chronic disease


Chronic Disease and Employment State of knowledge (1)

Consequences of chronic disease and risk factors on employment

• Evidence of an association between the presence of various chronic conditions and

- Decreased workforce participation - Early retirement

- Work limitations

- Sickness absence from work - Low access/return to work

• Unanswered questions

- Causal linkages?

- Underlying pathways?


Impact of HIV Infection on Employment










HIV diagnosis


HIV diagnosis


Dray-Spira et al, Am J Public Health 2007 Differential in employment rates* between the French general population

and people living with HIV infection in France in 2003 (ANRS-VESPA Study)

* Adjusted for age, gender, citizenship, and education using direct standardization


Impact of Diabetes on Early Work Cessation in the GAZEL Cohort Study

Participants With Diabetes


Participants Without Diabetes*

(N=2530) Hazard Ratio**

[95% CI]

# events Incidence Rate

per 1000 PY

# events Incidence Rate

per 1000 PY

Transition from employment to...

Disability 15 7.9 162 2.7 1.7 [1.0 ; 2.9]

Retirement 399 209.1 2221 37.6 1.6 [1.5 ; 1.8]

Death 13 6.8 22 0.4 7.3 [3.6 ; 14.6]

Herquelot et al, Diabetes Care 2011

* Matched for sex + year, age and occupational grade at hiring

** Multistate Cox model

Risks of disability, retirement and death in working aged (<60 years) participants with vs. without diabetes


Impact of Diabetes on Sickness Absence from Work in the GAZEL Cohort Study





43,7 49,4

0 10 20 30 40 50 60 70 80 90 100

-10 -5 0 5

5-year number of sickness absence days

Time from onset of cases' diabetes (years)

Dray-Spira et al, Diabetic Medicine (Accepted) Estimated* numbers of sickness absence days over time among

the 506 participants with diabetes ( ̶ ) and the 2530 without ( ̶ ) diabetes

* Linear mixed-effects models adjusted for sex + year, age and occup. grade at hiring


Chronic Disease and Employment State of knowledge (2)

Social inequalities in the employment

consequences of chronic disease and risk factors

• Data from the general population

- Evidence of social differences in the consequences of ill health ("limiting longstanding illness") on labour market outcomes

- Major role of

Labor market policies

Social protection system

Economic recession

• Limited data focusing on specific health conditions

- Essential to investigate underlying mechanisms of these inequalities - Role of

the nature of the health problem and/or its management?

characteristics of the healthcare system?


Inequalities in the Impact of Obesity on Employment

0,6 0,8 1 1,2 1,4

Normal BMI Obese Normal BMI Obese

H az ard R at io*

High occup. grade Low occup. grade

Impact of obesity at age 50 years on early retirement among participants of the GAZEL Cohort, by occupational grade

* Multistate Cox model adjusted for sex, characteristics at hiring (age, year and occupational grade) and comorbidities

Dray-Spira et al, ADELF 2012


* Cox model adjusted for characteristics at HIV diagnosis (age, geographic origin, education, occup. grade and employment status) and seld-reported experience of HIV-related discriminations

1 1

4,45 1,01

0 1 2 3 4 5 6 7 8 10 9

Neither AIDS nor CD4<200

in past year

AIDS or CD4<200

in past year

HR of work cessation

Men Women

HIV disease severity and the risk of work cessation over time since HIV diagnosis, by sex (ANRS-VESPA Study; N=478)

Dray-Spira et al, Occup Environ Med 2008

Inequalities in the Impact

of HIV infection on Employment (1)

Neither AIDS nor CD4<200

in past year

AIDS or CD4<200

in past year


Self-reported experience of discrimination and the risk of work cessation over time since HIV diagnosis, by education (ANRS-VESPA Study; N=478)

* Cox model adjusted for characteristics at HIV diagnosis (age, gender, geographic origin, occup. grade and employment status) and HIV disease severity

Dray-Spira et al, Occup Environ Med 2008

Inequalities in the Impact

of HIV infection on Employment (2)

1 1

8,85 1,09

0 5 10 15 20 25

No HIV-related discrimination

Experience of discrimination

HR of work cessation

High education Low education

No HIV-related discrimination

Experience of discrimination


 Pathways underlying employment consequences of chronic conditions and their socially differentiated nature?

• Respective role of

- Individual characteristics

Occupational factors

Health status

Health behaviors and lifestyle

Psychosocial factors

- Chronic condition specificities


Treatment and care

Associated stigma and discrimination - Macrosocial context

Access to healthcare

Labor market policies

Social protection system

Economic recession

Chronic Disease and Employment

Further questions


 At the healthcare level

• New models of healthcare delivery to achieve more integrated and comprehensive services (integrated care models)

- Implication of both health and social workers - Inclusion of work rehabilitation programs

 Beyond healthcare

• Social and economic policies to reduce the structural causes of social inequalities

• Employment policy

- Active labour market policy - Employment protection

• Health promotion

- Efforts to tackle stigma and discrimination

Chronic Disease and Employment

Public health implications



 Critical field of research for the comprehension and the reduction of social health inequalities

 Major contribution of epidemiology

• Diversity and complementarity of methods

• Detailed information both on health status and social aspects

 In France, implementation of several large cohorts ("Grand Emprunt" funding) constitutes a major

opportunity to investigate this field


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