title: Unemployment, government healthcare spending, and cerebrovascular mortality, worldwide 1981-2009: an ecological study.
abstract: BACKGROUND
  The global economic downturn has been associated with unemployment rises, reduced health spending, and worsened population health. This has raised the question of how economic variations affect health outcomes.
  
  
  OBJECTIVE
  We sought to determine the effect of changes in unemployment and government healthcare expenditure on cerebrovascular mortality globally.
  
  
  METHODS
  Data were obtained from the World Bank and World Health Organization. Multivariate regression analysis was used to assess the effect of changes in unemployment and government healthcare expenditure on cerebrovascular mortality. Country-specific differences in infrastructure and demographics were controlled for. One- to five-year lag analyses and robustness checks were conducted.
  
  
  RESULTS
  Across 99 countries worldwide, between 1981 and 2009, every 1% increase in unemployment was associated with a significant increase in cerebrovascular mortality (coefficient 187, CI: 86.6-288, P = 0.0003). Every 1% rise in government healthcare expenditure, across both genders, was associated with significant decreases in cerebrovascular deaths (coefficient 869, CI: 383-1354, P = 0.0005). The association between unemployment and cerebrovascular mortality remained statistically significant for at least five years subsequent to the 1% unemployment rise, while the association between government healthcare expenditure and cerebrovascular mortality remained significant for two years. These relationships were both shown to be independent of changes in gross domestic product per capita, inflation, interest rates, urbanization, nutrition, education, and out-of-pocket spending.
  
  
  CONCLUSIONS
  Rises in unemployment and reductions in government healthcare expenditure are associated with significant increases in cerebrovascular mortality globally. Clinicians may also need to consider unemployment as a possible risk factor for cerebrovascular disease mortality.
authors.affiliation: Imperial College London, London, UK.
authors.forename: Mahiben
authors.initials: M
authors.lastname: Maruthappu
authors.forename: Joseph
authors.initials: J
authors.lastname: Shalhoub
authors.forename: Zoon
authors.initials: Z
authors.lastname: Tariq
authors.forename: Callum
authors.initials: C
authors.lastname: Williams
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
authors.forename: Alun H
authors.initials: AH
authors.lastname: Davies
authors.forename: Thomas
authors.initials: T
authors.lastname: Zeltner
mesh_terms: D002561:Cerebrovascular Disorders / Q000191:economics* / Q000401:mortality*; D003695:Delivery of Health Care; D005260:Female; D014943:Global Health; D006076:Government; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D012044:Regression Analysis; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D014478:Unemployment / Q000706:statistics & numerical data*; D014944:World Health Organization
keywords: cerebrovascular disease; economic recession; mortality; public health expenditure; stroke; unemployment