A main function of social security arrangements is to provide assistance and income support to workers who leave the active labor force before the legal retirement age, due to early retirement, unemployment or permanent disability.1,2 For these workers, income replacement schemes play a key role in maintaining their living status and –related to that– also their health status. In this respect, it has been shown that social inequalities in health/mortality between citizens in different social statuses vary between countries with different levels of social protection.3

Our aim was to address this fundamental question for the first time using social security registry data. More specifically we aim to explore mortality differences according to social status in older working-aged men, in Belgium and Spain.

The MR (Table 1) for individuals still working at the beginning of follow-up (reference category) was 52.87 (95%CI: 48.13-57.95) per 10,000 person-years for Belgium and 46.6 (95%CI: 43.39-49.98) for Spain. The MR (Tables 1 and 2) for those individuals that were disabled at the beginning of follow-up, was considerably higher in both Belgium [MR=244.64 (95%CI: 147.29–382.03); adjusted MRR=4.27 (95%CI: 2.69–6.76)] and Spain [MR=333.02 (95%CI: 247.17–439.04); adjusted MRR=7.01 (95%CI: 5.26-9.34)]. The MR for those individuals that were unemployed at the beginning of follow-up compared with those who remained working, was significantly higher in Spain [MR=76.44 (95%CI: 57.09-100.24); adjusted MRR=1.62 (95%CI: 1.22-2.15)], but not in Belgium [MR=61.84 (95%CI: 44.18-84.20); MRR=0.85 (95%CI: 0.44–1.64)].

In this study, mortality differences in two comparable national samples of older workers were analyzed separately. MRR for workers who became unemployed in the year prior to mortality follow-up, compared to those who remained employed was not significant in Belgium, while it was in Spain. At the same time, for both countries, the MRR of those becoming disabled in the year prior to follow-up was significant when compared to the same reference category of workers who remained employed.

Regarding the differences in mortality for unemployed, it could be assumed that differences in social security coverage explain the more favourable situation of the Belgian unemployed. We must take into account that unemployment insurance benefit duration has no limit in Belgium, while it is limited to 24 months in Spain.6 Furthermore, along the mortality follow-up period, the replacement rates for long term unemployment vary, depending on the family burdens, between 35 and 81% in Belgium and 0 and 54% in Spain.7 These replacement rates, i.e. the losses in purchasing power, can be a crucial pathway through which unemployment affects health.8,9 In order to better confirm these hypotheses, future studies should ideally include additional information, for example on the composition of the category of the unemployed (e.g. the economic sectors and occupations), the selection criteria of other income replacement schemes,10 detailed socio-economic and demographic background characteristics, etc. On the other hand, results were similar when the association between permanent disability and mortality was assessed, founding higher mortality for disability pensioners in both countries. A result which is consistent with previous results.11,12

The main limitations of this study include difficulties related to making datasets comparable. This obliged the researchers to make compromises related to the study design as well as the number of covariates and the extent of detail of the categorization of central indicators. Also, as it was remarked in the methods section, the absence of data for women was due to problems related to the reliability of the data. A future inclusion of women employees in our analysis will give a necessary gender perspective. Finally, the absence of disability and mortality medical diagnoses on the CWLS has been, to date, a major challenge that must be taken into account as well as the absence of other health measures.

Nevertheless, bearing these limitations in mind, we would like to highlight the value for occupational health research of comparing cohorts of workers coming from social security registry data from different countries. Nowadays, in Europe, more countries dispose of detailed administrative datasets allowing for the reconstruction of detailed and long-term employment careers and relating these to outcomes of mortality, disability or medical consumption.13

In this respect, a cross-country panel of normalized data taken from administrative registers would improve our knowledge on this important issue.

Miguel Ángel Negrín Hernández.

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

This work was supported by grants from the Instituto Salud Carlos III-FEDER (FIS PI14/00057), the Spanish National Health Institute Carlos III (FIS 08/0914 and FIS 11/01470), the CIBER of Epidemiology and Public Health and the Research Foundation Flanders (G036816N).

P. Deboosere and F.G. Benavides conceived the idea of this paper and designed the study with X. Duran and C. Vanroelen. X. Duran conducted the statistical analyses. X. Duran and C. Vanroelen wrote the initial draft. All of the authors critically reviewed numerous drafts of the manuscript and agreed on this final version.

None.