The social gradient for cardiovascular disease (CVD) onset and outcomes is well established. The American Heart Association's Social Determinants of Risk and Outcomes of Cardiovascular Disease ...Scientific Statement advocates looking beyond breakthroughs in biological science toward a social determinants approach that focuses on socioeconomic position, race and ethnicity, social support, culture and access to medical care, and residential environments to curb the burden of CVD going forward. Indeed, the benefits of this approach are likely to be far reaching, enhancing the positive effects of advances in CVD related to prevention and treatment while reducing health inequities that contribute to CVD onset and outcomes. It is disappointing that the role of gender has been largely neglected despite being a critical determinant of cardiovascular health. It is clear that trajectories and outcomes of CVD differ by biological sex, yet the tendency for sex and gender to be conflated has contributed to the idea that both are constant or fixed with little room for intervention. Rather, as distinct from biological sex, gender is socially produced. Overlaid on biological sex, gender is a broad term that shapes and interacts with one's cognition to guide norms, roles, behaviors, and social relations. It is a fluid construct that varies across time, place, and life stage. Gender can interact with biological sex and, indeed, other social determinants, such as ethnicity and socioeconomic position, to shape cardiovascular health from conception, through early life when health behaviors and risk factors are shaped, into adolescence and adulthood. This article will illustrate how gender shapes the early adoption of health behaviors in childhood, adolescence, and young adulthood by focusing on physical activity, drinking, and smoking behaviors (including the influence of role modeling). We will also discuss the role of gender in psychosocial stress with a focus on trauma from life events (childhood assault and intimate partner violence) and work, home, and financial stresses. We conclude by exploring potential biological pathways, with a focus on autonomic functioning, which may underpin gender as a social determinant of cardiovascular health. Finally, we discuss implications for cardiovascular treatment and awareness campaigns and consider whether gender equality strategies could reduce the burden of CVD for men and women at the population level.
There is growing interest in brief contact interventions for self-harm and suicide attempt.
To synthesise the evidence regarding the effectiveness of brief contact interventions for reducing ...self-harm, suicide attempt and suicide.
A systematic review and random-effects meta-analyses were conducted of randomised controlled trials using brief contact interventions (telephone contacts; emergency or crisis cards; and postcard or letter contacts). Several sensitivity analyses were conducted to examine study quality and subgroup effects.
We found 14 eligible studies overall, of which 12 were amenable to meta-analyses. For any subsequent episode of self-harm or suicide attempt, there was a non-significant reduction in the overall pooled odds ratio (OR) of 0.87 (95% CI 0.74-1.04, P = 0119) for intervention compared with control. The number of repetitions per person was significantly reduced in intervention v. control (incidence rate ratio IRR = 066, 95% CI 0.54-0.80, P<0001). There was no significant reduction in the odds of suicide in intervention compared with control (OR = 0.58, 95% CI 0.24-1.38).
A non-significant positive effect on repeated self-harm, suicide attempt and suicide and a significant effect on the number of episodes of repeated self-harm or suicide attempts per person (based on only three studies) means that brief contact interventions cannot yet be recommended for widespread clinical implementation. We recommend further assessment of possible benefits in well-designed trials in clinical populations.
There have been a number of reviews on the association+ between unemployment and suicide, but none have investigated how this relationship is influenced by duration of unemployment.
A systematic ...review and meta-analysis was conducted of those studies that assessed duration of unemployment as a risk factor for suicide. Studies considered as eligible for inclusion were population-based cohort or case-control designs; population-based ecological designs, or hospital based clinical cohort or case-control designs published in the year 1980 or later.
The review identified 16 eligible studies, out of a possible 10,358 articles resulting from a search of four databases: PubMed, Web of Knowledge, Scopus and Proquest. While all 16 studies measured unemployment duration in different ways, a common finding was that longer duration of unemployment was related to greater risk of suicide and suicide attempt. A random effects meta-analysis on a subsample of six cohort studies indicated that the pooled relative risk of suicide in relation to average follow-up time after unemployment was 1.70 (95% CI 1.22 to 2.18). However, results also suggested a possible habituation effect to unemployment over time, with the greatest risk of suicide occurring within five years of unemployment compared to the employed population (RR = 2.50, 95% CI 1.83 to 3.17). Relative risk appeared to decline in studies of those unemployed between 12 and 16 years compared to those currently employed (RR = 1.21, 95% CI 1.10 to 1.33).
Findings suggest that long-term unemployment is associated with greater incidence of suicide. Results of the meta-analysis suggest that risk is greatest in the first five years, and persists at a lower but elevated level up to 16 years after unemployment. These findings are limited by the paucity of data on this topic.
ObjectivesJob stressors are known determinants of common mental disorders. Over the past 10 years, there has been evidence that job stressors may also be risk factors for suicidality. The current ...paper sought to examine this topic through the first comprehensive systematic review and meta-analysis of the literature to date.MethodsWe used a three-tier search strategy of seven electronic databases. Studies were included if they reported on a job stressor or job-related stress as an exposure and suicide ideation, self-harm, suicide attempt or suicide as an outcome. Two researchers independently screened articles. All extracted effect estimates were converted to log-transformed ORs.ResultsThere were 22 studies that were included in meta-analysis. Overall, exposure to job stressors was associated with elevated risk of suicide ideation and behaviours. The OR for suicide ideation (14 studies) ranged from 1.45 (95% CI 1.01 to 2.08) for poor supervisor and colleague support to 1.91 (95% CI 1.22 to 2.99) for job insecurity. For suicide (six studies), exposure to lower supervisor and collegial support produced an OR of 1.16 (95% CI 0.98 to 1.38), while low job control resulted in an OR of 1.23 (95% CI 1.00 to 1.50). There were only two studies that examined suicide attempt, both of which suggested an adverse effect of exposure to job stressors.ConclusionsThis study provides some evidence that job stressors may be related to suicidal outcomes. However, as most studies in the area were cross-sectional and observational in design, there is a need for longitudinal research to assess the robustness of observed associations.
Previous research has shown that those employed in certain occupations, such as doctors and farmers, have an elevated risk of suicide, yet little research has sought to synthesise these findings ...across working-age populations.
To summarise published research in this area through systematic review and meta-analysis.
Random effects meta-analyses were used to calculate a pooled risk of suicide across occupational skill-level groups.
Thirty-four studies were included in the meta-analysis. Elementary professions (e.g. labourers and cleaners) were at elevated risk compared with the working-age population (rate ratio (RR) = 1.84, 95% CI 1.46-2.33), followed by machine operators and deck crew (RR = 1.78, 95% CI 1.22-2.60) and agricultural workers (RR = 1.64, 95% CI 1.19-2.28). Results suggested a stepwise gradient in risk, with the lowest skilled occupations being at greater risk of suicide than the highest skill-level group.
This is the first comprehensive meta-analytical review of suicide and occupation. There is a need for future studies to investigate explanations for the observed skill-level differences, particularly in people employed in lower skill-level groups.
Objectives Psychosocial work stressors are common exposures affecting the working population, and there is good evidence that they have adverse health consequences. There is some evidence that they ...may impact on mortality, but this has not been systematically examined. We performed a systematic review, including risk of bias, and meta-analyses of observational studies to examine the association between psychosocial work stressors and all-cause mortality and death due to coronary heart disease (CHD). Methods Electronic databases were searched to identify studies and information on study characteristics and outcomes extracted in accordance with PRISMA guidelines. Risk estimates of outcomes associated with psychosocial work stressors: specifically, all-cause mortality, and death due to CHD were pooled using inverse variance weighted random effects meta-analysis. Results We identified 45 eligible cohort studies, of which 32 were included in the quantitative analyses of psychosocial work stressors and mortality. Low job control was associated with an increased risk of all-cause mortality hazard ratio (HR) 1.21, 95% confidence interval (CI) 1.07-1.37, minimally-adjusted; HR 1.05, 95% CI 1.01-1.10, multivariable-adjusted; HR 1.03, 95% CI 1.00-1.06 exclusion of low quality studies and multivariable-adjusted and CHD mortality HR 1.50, 95% CI 1.42-1.58, minimally-adjusted; HR 1.23, 95% CI 1.17-1.30, multivariable-adjusted; HR 1.19, 95% CI 1.01-1.40, exclusion of low quality studies and multivariable-adjusted. Conclusions Workers with low job control are at increased risk of all-cause and CHD mortality compared to workers with high job control. Policy and practice interventions to improve job control could contribute to reductions in all-cause and CHD mortality.
Mental health problems are prevalent and costly in working populations. Workplace interventions to address common mental health problems have evolved relatively independently along three main threads ...or disciplinary traditions: medicine, public health, and psychology. In this Debate piece, we argue that these three threads need to be integrated to optimise the prevention of mental health problems in working populations.
To realise the greatest population mental health benefits, workplace mental health intervention needs to comprehensively 1) protect mental health by reducing work-related risk factors for mental health problems; 2) promote mental health by developing the positive aspects of work as well as worker strengths and positive capacities; and 3) address mental health problems among working people regardless of cause. We outline the evidence supporting such an integrated intervention approach and consider the research agenda and policy developments needed to move towards this goal, and propose the notion of integrated workplace mental health literacy.
An integrated approach to workplace mental health combines the strengths of medicine, public health, and psychology, and has the potential to optimise both the prevention and management of mental health problems in the workplace.
Objectives: To report age‐standardised rates and methods of suicide by health professionals, and to compare these with suicide rates for other occupations.
Study design: Retrospective mortality ...study.
Setting, participants: All intentional self‐harm cases recorded by the National Coronial Information System during the period 2001–2012 were initially included. Cases were excluded if the person was unemployed at the time of death, if their employment status was unknown or occupational information was missing, or if they were under 20 years of age at the time of death. Suicide rates were calculated using Australian Bureau of Statistics population‐level data from the 2006 census.
Main outcome measures: Suicide rates and method of suicide by occupational group.
Results: Suicide rates for female health professionals were higher than for women in other occupations (medical practitioners: incidence rate ratio IRR, 2.52; 95% CI, 1.55–4.09; P < 0.001; nurses and midwives: IRR, 2.65; 95% CI, 2.22–3.15; P < 0.001). Suicide rates for male medical practitioners were not significantly higher than for other occupations, but the suicide rate for male nurses and midwives was significantly higher than for men working outside the health professions (IRR, 1.50; 95% CI 1.12–2.01; P = 0.006). The suicide rate for health professionals with ready access to prescription medications was higher than for those in health professions without such access or in non‐health professional occupations. The most frequent method of suicide used by health professionals was self‐poisoning.
Conclusion: Our results indicate the need for targeted prevention of suicide by health professionals.
Unsafe abortion is one of the commonest causes of maternal mortality. Abortion-related maternal deaths are higher in countries with the most restrictive abortion laws. We assess whether maternal ...mortality varies within and between countries over time according to the flexibility of abortion laws (the number of reasons a woman can have an abortion).
We conducted an ecological study to assess the association between abortion laws and maternal mortality in 162 countries between 1985 and 2013. Aggregate-level data on abortion laws and maternal mortality were extracted from United Nations (UN), and World Health Organization's (WHO) database respectively. A flexibility score of abortion laws (Score 0-7) was calculated by summing the number of reasons for which abortion was legally allowed in each country. The outcome was maternal mortality ratio (MMR), which represented maternal deaths per 100,000 live births. MMR was modelled as a continuous variable and flexibility score as an ordinal ranked variable (categories 0-7 with 0 as the reference, and < 3 vs > = 3). We used fixed effects linear regression models to estimate the association between flexibility score and MMR, adjusting for gross domestic product per capita (GDP per capita), and time in five-year intervals.
Compared to when a country's flexibility score was < 3, maternal deaths were reduced by 45 per 100,000 live births (95% CI: -64, - 26) when the flexibility score increased ≥3, after adjusting for the GDP per capita and five-year time intervals. With the exception of a flexibility score 6, MMR was lower when higher than zero. This may indicate the role of other country- specific effects.
This study provides evidence that abortion law reform in countries with restricted abortion laws may reduce maternal mortality.
Perceived social support is associated with overall better mental health. There is also evidence that unemployed workers with higher social support cope better psychologically than those without such ...support. However, there has been limited research about the effect of social support among people who have experienced both unemployment and employment. We assessed this topic using 12 years of annually collected cohort data.
The sample included 3190 people who had experienced both unemployment and employment. We used longitudinal fixed-effects modelling to investigate within-person changes in mental health comparing the role of social support when a person was unemployed to when they were employed.
Compared to when a person reported low social support, a change to medium (6.35, 95% 5.66 to 7.04, p < 0.001) or high social support (11.58, 95%, 95% CI 10.81 to 12.36, p < 0.001) was associated with a large increase in mental health (measured on an 100 point scale, with higher scores representing better mental health). When a person was unemployed but had high levels of social support, their mental health was 2.89 points (95% CI 1.67 to 4.11, p < 0.001) higher than when they were employed but had lower social support. The buffering effect of social support was confirmed in stratified analysis.
There was a strong direct effect of social support on mental health. The magnitude of these differences could be considered clinically meaningful. Our results also suggest that social support has a significant buffering effect on mental health when a person is unemployed.
•There was a strong direct effect of social support on mental health.•Compared to when a person was employed, being unemployed was generally associated with a reduction in mental health.•The relationship between social support and mental health differs for people when they are employed versus unemployed.•The presence of high social support buffers the mental health impact of unemployment considerably.•Improvements in social support for the unemployed may reduce the mental health impacts of job loss.
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