Unemployment in chronic airflow obstruction (CAO) around the world: Results from the Burden of Obstructive Lung Disease (BOLD) study

Objectives: We aimed to examine associations between CAO and unemployment across the world. Methods: Cross-sectional data from 26 sites in the Burden of Obstructive Lung Disease (BOLD) Study were used to analyze effects of CAO on unemployment. Odds ratios (OR) for unemployment in subjects 40-65 years old were estimated with multilevel mixed-effects generalized linear model with study site as random effect. Site-by-site heterogeneity was assessed using individual participant data meta-analyses. Results: Of 18710 participants, 11.3% had CAO. Ratio of unemployed subjects with CAO divided by unemployed subjects without CAO showed large discrepancies between sites, particularly in low-to-middle income countries with ratio from 0.5 (lower unemployment among CAO cases) in the Philippines to 5.8 (higher unemployment among CAO cases) in India. Site-adjusted OR for unemployment (95% confidence interval) was 1.79 (1.41, 2.27) for participants with CAO, decreasing to 1.43 (1.14, 1.79) after adjusting for gender, age, smoking, comorbidities, education and forced vital capacity (FVC). Risk factors for unemployment in high-income sites were age (OR (95%CI) 4.02 (3.53, 4.57), and primary education vs university education 3.86 (2.80, 5.30). Female gender was the most important factor for unemployment in low-to-middle-income sites (OR 3.23 (2.66, 3.91). Conclusions: CAO was associated with unemployment even after adjusting for sociodemographic factors, comorbidities and FVC. We observed that the association was particularly strong in high-income sites.