Job insecurity, chances on the labour market and decline in self-rated health in a representative sample of the Danish workforce

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1 , hanes on the labour market and deline in self-rated health in a representative sample of the Danish workfore R Rugulies, 1,2 B Aust, 1 H Burr, 1 UBültmann 1,3 1 National Researh Centre for the Working Environment, Denmark; 2 Institute of Publi Health, University of Copenhagen, Denmark; 3 Department of Health Sienes, University Medial Center, Groningen, University of Groningen, The Netherlands Correspondene to: Reiner Rugulies, National Researh Centre for the Working Environment, Lerso Parkallé 105, DK-2100 Copenhagen, Denmark; rer@nrwe.dk Aepted 4 May 2007 ABSTRACT Objetive: To investigate if job inseurity and poor labour market hanes predit a deline in self-rated health in the Danish workfore. Design:, labour market hanes, self-rated health and numerous ovariates were measured in 1809 women and 1918 men who responded to a questionnaire in 1995 and again in Multivariate logisti regression analyses were used to analyse the impat of job inseurity and labour market hanes measured in 1995 on deline in health in Setting: Prospetive ohort study with a representative sample of the Danish workfore using the Danish Work Environment Cohort Study (DWECS). All partiipants were employed at baseline. Main results: Women with job inseurity had an inreased risk of a deline in health at follow-up, after adjustment for all ovariates (OR = 1.78, 95% CI: 1.24 to 2.54). Effet estimates were strongest among women 50 years of age or younger with poor labour market hanes (OR = 2.13, 95% CI: 1.32 to 3.45). Among men, there was no main effet for job inseurity. However, men aged 50 years or younger with poor labour market hanes showed an OR of 1.64 (95% CI: 0.95 to 2.84) for a deline in health. Conlusion: is a preditor for a deline in health in employed women in Denmark. Among men, a suggestive effet of job inseurity was found in employees aged 50 years or younger with poor labour market hanes. Over the past two deades, deregulations of the labour market have resulted in a onsiderable inrease in job inseurity in most European ountries, even during times of eonomi growth. 1 7 There is an inreasing interest in soial epidemiology on the impat of job inseurity on employees health, but knowledge in this area is still limited. 15 A metaanalysis reviewing 72 studies showed that employees with job inseurity generally had poorer health outomes. 8 However, the vast majority of studies were ross-setional in design. Reently, a landmark study from the Whitehall II ohort showed that job inseurity was a strong preditor of poor self-rated health and minor psyhiatri disorders at 2.5 years of follow-up. 910 Compared to employees with ontinued job seurity, employees with hroni job inseurity had the strongest deline in general and psyhologial health, followed by employees who lost job seurity during the follow-up period and employees who had job inseurity at baseline only. 10 However, as the authors pointed out, the generalisability of these findings is limited, as the study population onsisted exlusively of offie-based white-ollar ivil servants in Great Britain. The assoiations between job inseurity and health outomes may have been markedly different in other oupational groups. Moreover, it is widely aknowledged that fators at the soietal level, suh as employment protetion laws, availability and amount of unemployment benefits, availability of jobs and ative labour market poliies an influene the impat of job inseurity on health outomes. 5 Regarding flexibility and job seurity, Denmark has a very speial labour market system, alled flexiurity (flexibility plus seurity), whih is unique in Europe. It onsists of, on the one hand, weak employment protetion laws, whih make it relatively easy for employers to hire and dismiss employees, and on the other hand, relatively high unemployment benefits, whih an be paid for up to four years. Moreover, the Danish authorities have instituted an ative labour market poliy, whih inludes offering job training opportunities and information about job openings, but also pressure on the unemployed to seek and to aept new job offers. In addition to this flexiurity system, Denmark offers relatively generous early retirement shemes, whih probably redue fear of unemployment among older employees. The flexiurity system has been praised by eonomists, politiians and the publi media, and has been suggested as a role model for other ountries in the European Union The aim of this paper is to analyse if an assoiation between job inseurity and a deline in health also exists under the speifi Danish soietal onditions. We hypothesised that job inseurity also has adverse health effets in Denmark, but that these effets would be onsiderably stronger among employees who were believed to have poor hanes of finding another job. We further hypothesised that assoiations would be stronger in young and middle-aged employees, as people at the beginning or in the middle of their areers would experiene job inseurity as more threatening for their future lives and as they would not have the hane to esape into early retirement in the foreseeable future. METHODS Study design and population The Danish Work Environment Cohort Study (DWECS) is a longitudinal study to assess soiodemographi fators, work environment harateristis, health behaviours and health status in the Danish working population. 14 We analysed the impat of job inseurity and labour market hanes in 1995 on a deline in self-rated health in In J Epidemiol Community Health 2008;62: doi: /jeh

2 1995, a representative sample of Danish residents were approahed and 8583 partiipated in the survey (response rate: 80%). Among the respondents, 5344 were employed at the time of the survey and were 60 years of age or younger and therefore inluded in the study. Of these, 11 emigrated or died during the follow-up period and 924 did not respond to the follow-up questionnaire, yielding a follow-up sample of 4409 (follow-up response rate: 83%). For the purpose of this paper, we further exluded 204 partiipants with a missing value on any variable inluded in the analyses. Finally, we exluded 478 partiipants with fair, poor or very poor self-rated health at baseline, resulting in a study sample of 3727 partiipants. Mean age was 38 years (SD 11 years, range: years) and 49% of the study sample were women. Measurement of self-rated health Self-rated health was measured with a question from a Danish translation of the Short Form 36 (SF-36) questionnaire. Partiipants were asked In general, how would you rate your health? with the response ategories very good, good, fair, poor or very poor. Self-rated health has been found to be a reliable indiator of health status and a strong preditor for mortality in many ountries, inluding Denmark We dihotomised responses into two ategories: (1) good health, whih inluded the responses very good and good, and (2) redued health, whih inluded the responses fair, poor and very poor. Study end point was deline in self-rated health, defined as moving from the good health ategory at baseline to the redued health ategory at follow-up. Measurement of job inseurity, labour market hanes and ovariates was measured with the question: Are you worried about beoming unemployed? Partiipants who answered yes were lassified as having job inseurity. Chanes on the labour market were assessed with the question Are you worried that it would be diffiult for you to find another job if you beame unemployed? Partiipants who answered yes were lassified as having poor hanes on the labour market. We ombined the two responses into the new variable job inseurity ombined with labour market hanes with the ategories: (1) no job inseurity, (2) job inseurity with good hanes on the labour market, and (3) job inseurity with poor hanes on the labour market. As ovariates, we assessed gender, age, smoking, body mass index (BMI), ohabitation, having small hildren at home (age 6 or below), soioeonomi position (SEP), type of employment (private ompany or publi employer) and self-rated health at baseline ( good versus very good ). We also reorded if a partiipant was unemployed at follow-up. More detailed desriptions of the ovariates have been published elsewhere. Statistial analysis All analyses were onduted with the statistial program pakage Stata 8.0. Differenes between women and men in Table 1 and deline in self-rated health in 1809 employed women in Denmark ( ) Exposed health Model 1 Model 2 Model 3 Model 4 No No (%) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) No job inseurity (10.1) (15.6) 1.77 (1.25 to 2.50) 1.82 (1.28 to 2.59) 1.79 (1.25 to 2.56) 1.78 (1.24 to 2.54) Age (inrement of 5 years) 1.19 (1.11 to 1.28) 1.17 (1.09 to 1.26) 1.15 (1.06 to 1.25) 1.14 (1.05 to 1.24) Current smoker No (9.7) Yes (13.4) 1.51 (1.12 to 2.05) 1.49 (1.10 to 2.03) 1.49 (1.09 to 2.03) Body mass index (kg/m 2 ) Underweight, (10.3) 1.01 (0.44 to 2.29) 0.99 (0.44 to 2.26) 1.00 (0.44 to 2.28) Normal (9.8) Overweight (13.3) 1.27 (0.86 to 1.86) 1.24 (0.84 to 1.83) 1.20 (0.81 to 1.77) Obese (32.1) 4.14 (2.22 to 7.69) 4.06 (2.16 to 7.63) 3.65 (1.93 to 6.92) Cohabitation Living with partner (11.3) 1 1 Living alone (10.4) 0.89 (0.61 to 1.29) 0.86 (0.59 to 1.26) Small hildren at home No (12.1) 1 1 Yes (7.5) 0.77 (0.50 to 1.20) 0.78 (0.51 to 1.22) Soioeonomi position I Exeutives/aademis (10.1) 1 1 II Middle managers/further eduation (8.6) 0.79 (0.42 to 1.52) 0.76 (0.40 to 1.46) III Other white-ollar workers (11.9) 1.05 (0.59 to 1.84) 0.98 (0.55 to 1.73) IV Skilled blue-ollar workers 68 5 (7.4) 0.58 (0.20 to 1.69) 0.48 (0.16 to 1.40) V Semi-skilled or unskilled blue-ollar workers (12.7) 1.24 (0.66 to 2.34) 1.12 (0.59 to 2.12) Type of employment Private ompany (10.0) 1 1 Publi employer (12.0) 1.20 (0.88 to 1.66) 1.20 (0.87 to 1.65) Self-rated health at baseline Very good (7.3) 1 Good (16.1) 2.23 (1.64 to 3.04) Logisti regression analyses: All variables are adjusted for eah other in the models. 246 J Epidemiol Community Health 2008;62: doi: /jeh

3 Table 2 and deline in self-rated health in 1918 employed men in Denmark ( ) Exposed health Model 1 Model 2 Model 3 Model 4 No No (%) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) No job inseurity (11.5) (14.5) 1.37 (0.96 to 1.96) 1.31 (0.91 to 1.88) 1.24 (0.86 to 1.79) 1.06 (0.73 to 1.55) Age (inrement of 5 years) 1.12 (1.05 to 1.20) 1.09 (1.02 to 1.17) 1.14 (1.06 to 1.23) 1.12 (1.04 to 1.21) Current smoker No (8.9) Yes (16.1) 1.94 (1.46 to 2.58) 1.79 (1.34 to 2.39) 1.68 (1.25 to 2.25) Body mass index (kg/m 2 ) Underweight, (33.3) 3.96 (0.96 to 16.36) 4.16 (1.00 to 17.35) 4.21 (0.96 to 18.50) Normal (9.5) Overweight (14.1) 1.54 (1.14 to 2.08) 1.51 (1.11 to 2.04) 1.45 (1.06 to 1.97) Obese (20.9) 2.28 (1.38 to 3.76) 2.15 (1.29 to 3.57) 1.99 (1.18 to 3.35) Cohabitation Living with partner (11.9) 1 1 Living alone (12.2) 1.18 (0.81 to 1.72) 1.22 (0.83 to 1.79) Small hildren at home No (12.3) 1 1 Yes (11.0) 1.16 (0.80 to 1.69) 1.19 (0.81 to 1.73) Soioeonomi position I Exeutives/aademis (9.0) 1 1 II Middle managers/further eduation (7.4) 0.77 (0.43 to 1.40) 0.75 (0.41 to 1.37) III Other white ollar workers (11.1) 1.20 (0.76 to 1.90) 1.19 (0.75 to 1.89) IV Skilled blue ollar workers (14.4) 1.90 (1.17 to 3.08) 1.80 (1.10 to 2.94) V Semiskilled or unskilled blue-ollar workers (16.8) 2.18 (1.35 to 3.51) 2.12 (1.30 to 3.45) Type of employment Private ompany (11.7) 1 1 Publi employer (12.8) 1.34 (0.95 to 1.89) 1.30 (0.91 to 1.85) Self-rated health at baseline Very good (6.7) 1 Good (19.5) 3.05 (2.26 to 4.12) Logisti regression analyses: All variables are adjusted for eah other in the models. job inseurity at baseline and unemployment at follow-up were analysed with x 2 tests. To investigate if job inseurity at baseline was preditive for unemployment at follow-up, we onduted a logisti regression analysis, adjusted for age, gender and SEP. The impat of job inseurity on a deline in self-rated health was alulated by gender-stratified odds ratios (OR) and 95% onfidene intervals (CI) with multivariate logisti regression models. We separately analysed the effets of job inseurity in general and of job inseurity ombined with labour market hanes. Covariates were inluded in four different models: model 1 was adjusted for age; model 2 was further adjusted for indiators of health behaviours (smoking, BMI); model 3 was further adjusted for ohabitation, small hildren at home, SEP and type of employment; and model 4 (full model) was further adjusted for self-rated health at baseline ( very good vs good health ). Correlation oeffiients between ovariates were in general low, indiating that there was no substantial olinearity in the analyses (data not shown). We further analysed the data in two subsamples. In the first subsample (n = 3628), we exluded 99 partiipants who were unemployed at the follow-up survey in order to distinguish the effets of job inseurity from the effets of atual unemployment. In the seond subsample (n = 3175) we analysed the data for employees 50 years or younger, in order to determine if the assoiation between job inseurity and a deline in health was stronger among young and middle-aged employees. RESULTS at baseline and unemployment at follow-up At baseline 3095 partiipants (83.0%) reported no job inseurity (2492 partiipants (66.9%) with good and 603 (16.2%) with poor labour market hanes), 334 (9.0%) reported job inseurity ombined with good labour market hanes and 298 (8.0%) reported job inseurity ombined with poor labour market hanes. was higher in women than in men (18.1% vs 15.9%, p = 0.06). Women also reported job inseurity ombined with poor labour market hanes more often (10.0% vs 6.2%, p,0.001). Partiipants with no job inseurity, job inseurity with good labour market hanes and job inseurity with poor labour market hanes had unemployment rates at follow-up of 2.3%, 2.7% and 6.0%, respetively. After adjustment for age, gender and SEP, partiipants with job inseurity with good labour market hanes had an OR = 1.20 (95% CI: 0.59 to 2.44) and partiipants with job inseurity with poor labour market hanes had an OR = 2.19 (95% CI: 1.27 to 3.76) for being unemployed at follow-up, ompared to partiipants with no job inseurity. and deline in health At the five-year follow-up 430 partiipants (11.5%) showed a deline in self-rated health that is, they moved from the good health ategory (inluding the responses very good and good health) to the redued health ategory (inluding the responses fair, poor and very poor health) in the J Epidemiol Community Health 2008;62: doi: /jeh

4 Table 3 ombined with labour market hanes and deline in self-rated health in 1809 employed women and 1918 employed men in Denmark ( ) Exposed health Model 1 Model 2 Model 3 Model 4 No No (%) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Women (n = 1809) and labour market hanes No job inseurity (10.1) with good labour market hanes (12.2) 1.42 (0.84 to 2.41) 1.45 (0.85 to 2.48) 1.44 (0.84 to 2.47) 1.44 (0.84 to 2.47) with poor labour market hanes (18.3) 2.04 (1.34 to 3.09) 2.11 (1.38 to 3.22) 2.07 (1.35 to 3.18) 2.04 (1.32 to 3.15) Men (n = 1918) and labour market hanes No job inseurity (11.5) with good labour market hanes (11.8) 1.15 (0.71 to 1.85) 1.11 (0.68 to 1.79) 1.05 (0.64 to 1.71) 0.87 (0.53 to 1.43) with poor labour market hanes (18.6) 1.70 (1.04 to 2.77) 1.60 (0.97 to 2.63) 1.52 (0.92 to 2.52) 1.37 (0.82 to 2.28) Logisti regression analyses: model 1 is adjusted for age, model 2 is additionally adjusted for smoking and body mass index; model 3 is additionally adjusted for ohabitation, small hildren at home, soioeonomi position and type of employment; model 4 is additionally adjusted for good versus very good self-rated health at baseline. dihotomised self-rated health variable. Rates were similar for women (11.1%) and men (12.0%). Table 1 shows the prospetive assoiations of job inseurity at baseline with a deline in health at follow-up among women. Women with job inseurity had an age-adjusted OR of 1.77 (p = 0.001). This effet size remained virtually the same, after adjustment for smoking, BMI, ohabitation, small hildren living at home, SEP, type of employment and self-rated health at baseline (OR = 1.78, p = 0.002, table 1). Exluding 68 women, who had been unemployed at follow-up, did not hange the effet estimate muh (OR = 1.84, 95% CI: 1.27 to 2.66, data not shown in table 1). Men with job inseurity at baseline had an age-adjusted OR of 1.37 (p = 0.08) for a deline in health (table 2). Further adjustment for ovariates resulted into an attenuation of the effet estimate and in the full model, job inseurity was unrelated to a deline in health (OR = 1.06, p = 0.75). Exluding 31 men, who had been unemployed at follow-up, did not hange the effet estimate muh (OR = 1.09, 95% CI: 0.74 to 1.59, data not shown in table 2). Among the ovariates, higher age, smoking, obesity and good instead of very good health at baseline predited a deline in health among both women and men in the full model. In addition, among men, being overweight and being a blueollar worker were risk fators for a deline in health. ombined with labour market hanes and deline in health Table 3 shows how job inseurity ombined with labour market hanes was prospetively assoiated with a deline in health. Compared to partiipants with no job inseurity, both women and men with job inseurity with poor labour market hanes had an inreased age-adjusted risk of a deline in health (OR = 2.04, p = and OR = 1.70, p = 0.03, respetively). Further adjustment for the other ovariates did not alter effet estimates substantially among women (OR = 2.04, p = 0.001), whereas among men effet estimates were attenuated to a statistially non-signifiant level (OR = 1.37, p = 0.24). Effet of job inseurity and labour market hanes among employees aged 50 years or younger and labour market hanes were stronger preditors for a deline in health in young and middle-aged partiipants ompared to the whole study population (table 4). Among women, job inseurity in general (OR = 1.88, p = 0.002) and job inseurity with poor labour market hanes (OR = 2.13, p = 0.002) were assoiated with an inreased risk of a deline in health in the full model. Among men, job inseurity with poor labour market hanes showed a suggestive assoiation with a deline in health (OR = 1.64, p = 0.08). We further stratified the sample into young (18 35 years) and middle-aged (36 50 years) partiipants. Among women, we found similar odds ratios for job inseurity with poor labour market hanes (OR = 2.13, 95% CI: 0.96 to 4.72 and OR = 2.21, 95% CI: 1.19 to 4.12 in young and middle-aged women, respetively). Among men, odds ratios for job inseurity with poor labour market hanes were lower in young (OR = 1.25, 95% CI: 0.44 to 3.51) than in middle-aged employees (OR = 1.81, 95% CI: 0.91 to 3.60, data not shown in table 4). DISCUSSION Women who pereived their jobs as inseure had an odds ratio of 1.78 for experiening a deline in self-rated health over the next 5 years in this study of a representative sample of the Danish workfore. As hypothesised, the health-hazardous effet of job inseurity was stronger among women who believed they had poor hanes on the labour market. Also, as hypothesised, effet estimates were stronger among women at the beginning or in the middle of their areers. These results onfirm findings from other ountries and study populations that job inseurity is a risk fator for poor health among women Among men, the assoiations were less lear. After adjustment for all ovariates, job inseurity in general was not assoiated with a deline in health. with poor labour market hanes predited a deline in health in the age and health-behaviour adjusted model, but effet sizes were substantially attenuated in further adjustments. However, men aged 50 years or younger with job inseurity with poor labour market hanes showed an odds ratio of 1.64, whih approahed statistial signifiane. Strength and weaknesses of the study To our knowledge this is the first prospetive analyses on the effet of job inseurity ombined with labour market hanes on self-rated health within a representative sample of a national workfore. Owing to the prospetive nature of the study, temporal order between exposure and outome variable was established, whih is an important riterion for determination of ausality. Moreover, the use of the representative sample allows generalising the findings to the Danish workfore. By adding information on labour market hanes we were able to 248 J Epidemiol Community Health 2008;62: doi: /jeh

5 Table 4 and job inseurity ombined with labour market hanes and deline in self-rated health in 1557 employed women and 1618 employed men aged 50 or younger in Denmark ( ) Exposed health No No (%) OR (95% CI) Women (n = 1557) No job inseurity (9.3) (15.5) 1.88 (1.27 to 2.78) and labour market hanes No job inseurity (9.3) 1 with good labour market hanes (12.4) 1.59 (0.91 to 2.80) with poor labour market hanes (18.3) 2.13 (1.32 to 3.45) Men (n = 1618) No job inseurity (10.3) (14.9) 1.23 (0.83 to 1.83) and labour market hanes No job inseurity (10.3) 1 with good labour market hanes (12.1) 1.00 (0.60 to 1.66) with poor labour market hanes (19.6) 1.64 (0.95 to 2.84) Logisti regression analyses: adjusted for age, smoking, body mass index, ohabitation, small hildren at home, soioeonomi position, type of employment, and good versus very good self-rated health at baseline (model 4). inlude an important aspet of job inseurity, whih had not been used in most previous studies. The relatively long follow-up period of five years provided enough time to observe a suffiient number of partiipants experiening a deline in self-rated health. However, the length of the follow-up is also a weakness, as job inseurity and labour market hanes might have hanged for a ertain number of partiipants over time. We do not know how many partiipants had moved from inseure to seure jobs (and vie versa) nor when this hange had happened during follow-up. Consequently, we do not know the extent of non-differential mislassifiation in the measurement of the exposure variable, a bias whih would result into a potential underestimation of the effet size. As we measured job inseurity in both the baseline and the follow-up survey, we ould have analysed if partiipants with ontinued job inseurity had a higher risk for a deline in health. However, we deided not to do this, beause by using information on job inseurity and self-rated health, both measured at follow-up, we would have inluded a rosssetional element. 23 Instead, we are planning to merge the DWECS dataset with a national hospitalisation registry, in order to analyse if ontinued job inseurity inreases the risk for developing speifi diseases. When both exposure and outome variables are measured by self-report, there is the possibility that assoiations are aused by a third variable for example, personality aspets, suh as negative affetivity This is of partiular a onern in rosssetional studies, but an also apply to longitudinal analyses that are not suffiiently adjusted for baseline values of the outome variable. 23 In the present study, however, we exluded partiipants with less than good self-rated health at baseline, and we further adjusted for a variable indiating if self-rated health at baseline was good or very good. We are therefore onfident that negative affetivity has not influened our study results. Moreover, biologial and behavioural risk fators (age, smoking, obesity) strongly predited a deline in health in both women and men, further indiating that self-rated health in this study refleted first and foremost objetive health status and not personality aspets. Potential explanations of how job inseurity ontributes to a deline in health It seems reasonable to assume that job inseurity triggers negative emotions, suh as worrying, anxiety, low mood or hostility, espeially in employees who have poor labour market hanes and who do not have the possibility to esape into early retirement. People with high levels of negative emotions tend to show poorer health behaviours, inluding smoking, heavy alohol onsumption, high alorie intake and low leisure time physial ativity, all of whih are important risk fators for numerous diseases. 30 Chroni presene of negative emotions might also inrease the risk of psyhologial disorders, suh as major depression. Researh indiates that anxiety is not just a preursor but a ausal fator in the aetiology of depression Hene, it is possible that anxiety, indued by job inseurity, inreased the risk of major depression in our study population. Other studies have indeed shown that job inseurity is a risk fator for depression This inludes one study that also used the DWECS dataset and that showed that job inseurity was assoiated with an inreased risk in the inidene of severe depressive symptoms in men. 22 Negative emotions and psyhologial disorders, aused by job inseurity, might also affet physial health via psyhoneuroendorinologial and psyho-immunologial pathways. There is growing evidene that negative emotions, partiularly depressive mood, inrease the risk of oronary heart disease, independent of health behaviours Moreover, experimental researh has shown that feelings of distress an lower immune ompetene, resulting into an inreased suseptibility for infetious diseases. Finally, job inseurity might affet health in ombination with other psyhosoial working onditions. Studies have found, for example, that an imbalane between high efforts and low rewards (a onstrut that inludes job seurity) at work inreases psyho-physiologial distress reations and subsequent risk of disease Publi health impliation The follow-up period of this study ( ) was a time of eonomi prosperity with low unemployment rates in J Epidemiol Community Health 2008;62: doi: /jeh

6 What is already known about the topi What this paper adds has been found to be assoiated with poor health in several studies Generalisations of findings between ountries are diffiult to make owing to differential soietal onditions (for example, employment protetion laws, availability and amount of unemployment benefits) It is not lear whether pereived hanes on the labour market influene the relation between job inseurity and health This prospetive analysis shows that among women, pereived job inseurity is a risk fator for a deline in health, also under the speifi onditions of the Danish flexiurity labour market system The analyses further show that job inseurity, among both women and men, had a stronger effet on health, when it was ombined with poor hanes on the labour market Denmark, whih is still ontinuing. 41 Only a small proportion of employees reported job inseurity in this study, a finding that is onfirmed by a survey onduted in 1998, whih showed that Danish employees had the lowest level of job inseurity among 16 European ountries. 7 Beause of the relatively low perentage of job inseurity, we believe that the publi health impat of job inseurity in Denmark during the time of this study was only modest. 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