title: Unemployment, public-sector healthcare spending and stomach cancer mortality in the European Union, 1981-2009.
abstract: OBJECTIVE
  We sought to determine the association between changes in unemployment, healthcare spending and stomach cancer mortality.
  
  
  METHODS
  Multivariate regression analysis was used to assess how changes in unemployment and public-sector expenditure on healthcare (PSEH) varied with stomach cancer mortality in 25 member states of the European Union from 1981 to 2009. Country-specific differences in healthcare infrastructure and demographics were controlled for 1- to 5-year time-lag analyses and robustness checks were carried out.
  
  
  RESULTS
  A 1% increase in unemployment was associated with a significant increase in stomach cancer mortality in both men and women [men: coefficient (R)=0.1080, 95% confidence interval (CI)=0.0470-0.1690, P=0.0006; women: R=0.0488, 95% CI=0.0168-0.0809, P=0.0029]. A 1% increase in PSEH was associated with a significant decrease in stomach cancer mortality (men: R=-0.0009, 95% CI=-0.0013 to -0.005, P<0.0001; women: R=-0.0004, 95% CI=-0.0007 to -0.0001, P=0.0054). The associations remained when economic factors, urbanization, nutrition and alcohol intake were controlled for, but not when healthcare resources were controlled for. Time-lag analysis showed that the largest changes in mortality occurred 3-4 years after any changes in either unemployment or PSEH.
  
  
  CONCLUSIONS
  Increases in unemployment are associated with a significant increase in stomach cancer mortality. Stomach cancer mortality is also affected by public-sector healthcare spending. Initiatives that bolster employment and maintain public-sector healthcare expenditure may help to minimize increases in stomach cancer mortality during economic downturns.
authors.affiliation: aChair and Chief Executive's Office, NHS England bImperial College London cInstitute for Mathematical and Molecular Biomedicine, King's College London dThe Economist, London eSchool of Medical Sciences fFaculty of History gCancer Epidemiology Unit, University of Oxford, Oxford hSt Mark's Hospital and Academic Institute iEaling Hospital NHS Trust, Middlesex, UK jFaculty of Arts and Sciences, Harvard University, Cambridge, Massachusetts, USA kFaculty of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE lSpecial Envoy for Financing to the Director General of the World Health Organization (WHO), Geneva mUniversity of Bern, Bern, Switzerland.
authors.forename: Mahiben
authors.initials: M
authors.lastname: Maruthappu
authors.forename: Annabelle
authors.initials: A
authors.lastname: Painter
authors.forename: Johnathan
authors.initials: J
authors.lastname: Watkins
authors.forename: Callum
authors.initials: C
authors.lastname: Williams
authors.forename: Raghib
authors.initials: R
authors.lastname: Ali
authors.forename: Thomas
authors.initials: T
authors.lastname: Zeltner
authors.forename: Omar
authors.initials: O
authors.lastname: Faiz
authors.forename: Hemant
authors.initials: H
authors.lastname: Sheth
mesh_terms: D005060:Europe / Q000453:epidemiology; D005062:European Union / Q000706:statistics & numerical data; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data* / Q000639:trends; D006801:Humans; D008297:Male; D009026:Mortality / Q000639:trends; D017150:Public Sector / Q000191:economics*; D012737:Sex Factors; D012959:Socioeconomic Factors; D013274:Stomach Neoplasms / Q000401:mortality*; D014478:Unemployment / Q000706:statistics & numerical data* / Q000639:trends