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1.  Association of Job Demands with Work Engagement of Japanese Employees: Comparison of Challenges with Hindrances (J-HOPE) 
PLoS ONE  2014;9(3):e91583.
Recent epidemiological research in Europe has reported that two groups of job demands, i.e., challenges and hindrances, are differently associated with work engagement. The purpose of the present study was to replicate the cross-sectional association of workload and time pressure (as a challenge) and role ambiguity (as a hindrance) with work engagement among Japanese employees.
Between October 2010 and December 2011, a total of 9,134 employees (7,101 men and 1,673 women) from 12 companies in Japan were surveyed using a self-administered questionnaire comprising the Job Content Questionnaire, National Institute for Occupational Safety and Health Generic Job Stress Questionnaire, short 10-item version of the Effort-Reward Imbalance Questionnaire, short nine-item version of the Utrecht Work Engagement Scale, and demographic characteristics. Multilevel regression analyses with a random intercept model were conducted.
After adjusting for demographic characteristics, workload and time pressure showed a positive association with work engagement with a small effect size (standardized coefficient [β] = 0.102, Cohen’s d [d] = 0.240) while role ambiguity showed a negative association with a large effect size (β = −0.429, d = 1.011). After additionally adjusting for job resources (i.e., decision latitude, supervisor support, co-worker support, and extrinsic reward), the effect size of workload and time pressure was not attenuated (β = 0.093, d = 0.234) while that of role ambiguity was attenuated but still medium (β = −0.242, d = 0.609).
Among Japanese employees, challenges such as having higher levels of workload and time pressure may enhance work engagement but hindrances, such as role ambiguity, may reduce it.
PMCID: PMC3948913  PMID: 24614682
2.  Key factors in work engagement and job motivation of teaching faculty at a university medical centre 
Perspectives on Medical Education  2013;2(5-6):264-275.
This study reports about teacher motivation and work engagement in a Dutch University Medical Centre (UMC). We examined factors affecting the motivation for teaching in a UMC, the engagement of UMC Utrecht teaching faculty in their work, and their engagement in teaching compared with engagement in patient care and research. Based on a pilot study within various departments at the UMCU, a survey on teaching motivation and work engagement was developed and sent to over 600 UMCU teachers. About 50 % responded. Work engagement was measured by the Utrecht Work Engagement Scale, included in this survey. From a list of 22 pre-defined items, 5 were marked as most motivating: teaching about my own speciality, noticeable appreciation for teaching by my direct superior, teaching small groups, feedback on my teaching performance, and freedom to determine what I teach. Feedback on my teaching performance showed the strongest predictive value for teaching engagement. Engagement scores were relatively favourable, but engagement with patient care was higher than with research and teaching. Task combinations appear to decrease teaching engagement. Our results match with self-determination theory and the job demands–resources model, and challenge the policy to combine teaching with research and patient care.
PMCID: PMC3824746  PMID: 24037742
Teaching motivation; Teaching workload; Roles of teacher; Management and/or staff development; Staff workload
3.  Measuring Engagement at Work: Validation of the Chinese Version of the Utrecht Work Engagement Scale 
Work engagement is a positive work-related state of fulfillment characterized by vigor, dedication, and absorption. Previous studies have operationalized the construct through development of the Utrecht Work Engagement Scale. Apart from the original three-factor 17-item version of the instrument (UWES-17), there exists a nine-item shortened revised version (UWES-9).
The current study explored the psychometric properties of the Chinese version of the Utrecht Work Engagement Scale in terms of factorial validity, scale reliability, descriptive statistics, and construct validity.
A cross-sectional questionnaire survey was conducted in 2009 among 992 workers from over 30 elderly service units in Hong Kong.
Confirmatory factor analyses revealed a better fit for the three-factor model of the UWES-9 than the UWES-17 and the one-factor model of the UWES-9. The three factors showed acceptable internal consistency and strong correlations with factors in the original versions. Engagement was negatively associated with perceived stress and burnout while positively with age and holistic care climate.
The UWES-9 demonstrates adequate psychometric properties, supporting its use in future research in the Chinese context.
PMCID: PMC3422451  PMID: 21681564
Work engagement; Validity; Reliability; Chinese
4.  Cardiovascular risk profile: Cross-sectional analysis of motivational determinants, physical fitness and physical activity 
BMC Public Health  2010;10:592.
Cardiovascular risk factors are associated with physical fitness and, to a lesser extent, physical activity. Lifestyle interventions directed at enhancing physical fitness in order to decrease the risk of cardiovascular diseases should be extended. To enable the development of effective lifestyle interventions for people with cardiovascular risk factors, we investigated motivational, social-cognitive determinants derived from the Theory of Planned Behavior (TPB) and other relevant social psychological theories, next to physical activity and physical fitness.
In the cross-sectional Utrecht Police Lifestyle Intervention Fitness and Training (UP-LIFT) study, 1298 employees (aged 18 to 62) were asked to complete online questionnaires regarding social-cognitive variables and physical activity. Cardiovascular risk factors and physical fitness (peak VO2) were measured.
For people with one or more cardiovascular risk factors (78.7% of the total population), social-cognitive variables accounted for 39% (p < .001) of the variance in the intention to engage in physical activity for 60 minutes every day. Important correlates of intention to engage in physical activity were attitude (beta = .225, p < .001), self-efficacy (beta = .271, p < .001), descriptive norm (beta = .172, p < .001) and barriers (beta = -.169, p < .01). Social-cognitive variables accounted for 52% (p < .001) of the variance in physical active behaviour (being physical active for 60 minutes every day). The intention to engage in physical activity (beta = .469, p < .001) and self-efficacy (beta = .243, p < .001) were, in turn, important correlates of physical active behavior.
In addition to the prediction of intention to engage in physical activity and physical active behavior, we explored the impact of the intensity of physical activity. The intentsity of physical activity was only significantly related to physical active behavior (beta = .253, p < .01, R2 = .06, p < .001). An important goal of our study was to investigate the relationship between physical fitness, the intensity of physical activity and social-cognitive variables. Physical fitness (R2 = .23, p < .001) was positively associated with physical active behavior (beta = .180, p < .01), self-efficacy (beta = .180, p < .01) and the intensity of physical activity (beta = .238, p < .01).
For people with one or more cardiovascular risk factors, 39.9% had positive intentions to engage in physical activity and were also physically active, and 10.5% had a low intentions but were physically active. 37.7% had low intentions and were physically inactive, and about 11.9% had high intentions but were physically inactive.
This study contributes to our ability to optimize cardiovascular risk profiles by demonstrating an important association between physical fitness and social-cognitive variables. Physical fitness can be predicted by physical active behavior as well as by self-efficacy and the intensity of physical activity, and the latter by physical active behavior.
Physical active behavior can be predicted by intention, self-efficacy, descriptive norms and barriers. Intention to engage in physical activity by attitude, self-efficacy, descriptive norms and barriers. An important input for lifestyle changes for people with one or more cardiovascular risk factors was that for ca. 40% of the population the intention to engage in physical activity was in line with their actual physical active behavior.
PMCID: PMC3091554  PMID: 20929529
5.  Measuring organisational readiness for patient engagement (MORE): an international online Delphi consensus study 
Widespread implementation of patient engagement by organisations and clinical teams is not a reality yet. The aim of this study is to develop a measure of organisational readiness for patient engagement designed to monitor and facilitate a healthcare organisation’s willingness and ability to effectively implement patient engagement in healthcare.
The development of the MORE (Measuring Organisational Readiness for patient Engagement) scale was guided by Weiner’s theory of organisational readiness for change. Weiner postulates that an organisation’s readiness is determined by both the willingness and ability to implement the change (i.e. in this context: patient engagement). A first version of the scale was developed based on a literature search and evaluation of pre-existing tools. We invited multi-disciplinary stakeholders to participate in a two-round online Delphi survey. Respondents were asked to rate the importance of each proposed item, and to comment on the proposed domains and items. Second round participants received feedback from the first round and were asked to re-rate the importance of the revised, new and unchanged items, and to provide comments.
The first version of the scale contained 51 items divided into three domains: (1) Respondents’ characteristics; (2) the organisation’s willingness to implement patient engagement; and (3) the organisation’s ability to implement patient engagement. 131 respondents from 16 countries (health care managers, policy makers, clinicians, patients and patient representatives, researchers, and other stakeholders) completed the first survey, and 72 of them also completed the second survey. During the Delphi process, 34 items were reworded, 8 new items were added, 5 items were removed, and 18 were combined. The scale’s instructions were revised. The final version of MORE totalled 38 items; 5 on stakeholders, 13 on an organisation’s willingness to implement, and 20 on an organisation’s ability to implement patient engagement in healthcare.
The Delphi technique was successfully used to refine the scale’s instructions, domains and items, using input from a broad range of international stakeholders, hoping that MORE can be applied in a variety of healthcare contexts worldwide. Further assessment is needed to determine the psychometric properties of the scale.
PMCID: PMC4334597
Patient engagement; Implementation; Organisational readiness; Willingness; Ability; Scale development; Delphi consensus procedure
6.  Employee engagement within the NHS: a cross-sectional study 
Background: Employee engagement is the emotional commitment of the employee towards the organisation. We aimed to analyse baseline work engagement using Utrecht Work Engagement Scale (UWES) at a teaching hospital.
Methods: We have conducted a cross-sectional study within the National Health Service (NHS) Teaching Hospital in the UK. All participants were working age population from both genders directly employed by the hospital. UWES has three constituting dimensions of work engagement as vigor, dedication, and absorption. We conducted the study using UWES-9 tool. Outcome measures were mean score for each dimension of work engagement (vigor, dedication, absorption) and total score compared with control score from test manual.
Results: We found that the score for vigor and dedication is significantly lower than comparison group (P< 0.0001 for both). The score for absorption was significantly higher than comparison group (P< 0.0001). However, total score is not significantly different.
Conclusion: The study shows that work engagement level is below average within the NHS employees. Vigor and dedication are significantly lower, these are characterised by energy, mental resilience, the willingness to invest one’s effort, and persistence as well as a sense of significance, enthusiasm, inspiration, pride, and challenge. The NHS employees are immersed in work. Urgent need to explore strategies to improve work engagement as it is vital for improving productivity, safety and patient experience
PMCID: PMC4322631
Employee Engagement; Patient Safety; Vigor; Dedication; Absorption
7.  Measuring disability across cultures — the psychometric properties of the WHODAS II in older people from seven low- and middle-income countries. The 10/66 Dementia Research Group population-based survey 
We evaluated the psychometric properties of the 12-item interviewer-administered screener version of the World Health Organization Disability Assessment Schedule – version II (WHODAS II) among older people living in seven low- and middle-income countries. Principal component analysis (PCA), confirmatory factor analysis (CFA) and Mokken analyses were carried out to test for unidimensionality, hierarchical structure, and measurement invariance across 10/66 Dementia Research Group sites.
PCA generated a one-factor solution in most sites. In CFA, the two-factor solution generated in Dominican Republic fitted better for all sites other than rural China. The two factors were not easily interpretable, and may have been an artefact of differing item difficulties. Strong internal consistency and high factor loadings for the one-factor solution supported unidimensionality. Furthermore, the WHODAS II was found to be a ‘strong’ Mokken scale. Measurement invariance was supported by the similarity of factor loadings across sites, and by the high between-site correlations in item difficulties.
The Mokken results strongly support that the WHODAS II 12-item screener is a unidimensional and hierarchical scale confirming to item response theory (IRT) principles, at least at the monotone homogeneity model level. More work is needed to assess the generalizability of our findings to different populations. Copyright © 2010 John Wiley & Sons, Ltd.
PMCID: PMC2896722  PMID: 20104493
disability; elderly; developing countries; WHODAS II; psychometric properties
8.  Prolonged Grief Disorder: Psychometric Validation of Criteria Proposed for DSM-V and ICD-11 
PLoS Medicine  2009;6(8):e1000121.
Holly Prigerson and colleagues tested the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and care of bereaved individuals at heightened risk of persistent distress and dysfunction.
Bereavement is a universal experience, and its association with excess morbidity and mortality is well established. Nevertheless, grief becomes a serious health concern for a relative few. For such individuals, intense grief persists, is distressing and disabling, and may meet criteria as a distinct mental disorder. At present, grief is not recognized as a mental disorder in the DSM-IV or ICD-10. The goal of this study was to determine the psychometric validity of criteria for prolonged grief disorder (PGD) to enhance the detection and potential treatment of bereaved individuals at heightened risk of persistent distress and dysfunction.
Methods and Findings
A total of 291 bereaved respondents were interviewed three times, grouped as 0–6, 6–12, and 12–24 mo post-loss. Item response theory (IRT) analyses derived the most informative, unbiased PGD symptoms. Combinatoric analyses identified the most sensitive and specific PGD algorithm that was then tested to evaluate its psychometric validity. Criteria require reactions to a significant loss that involve the experience of yearning (e.g., physical or emotional suffering as a result of the desired, but unfulfilled, reunion with the deceased) and at least five of the following nine symptoms experienced at least daily or to a disabling degree: feeling emotionally numb, stunned, or that life is meaningless; experiencing mistrust; bitterness over the loss; difficulty accepting the loss; identity confusion; avoidance of the reality of the loss; or difficulty moving on with life. Symptoms must be present at sufficiently high levels at least six mo from the death and be associated with functional impairment.
The criteria set for PGD appear able to identify bereaved persons at heightened risk for enduring distress and dysfunction. The results support the psychometric validity of the criteria for PGD that we propose for inclusion in DSM-V and ICD-11.
Please see later in the article for Editors' Summary
Editors' Summary
Virtually everyone loses someone they love during their lifetime. Grief is an unavoidable and normal reaction to this loss. After the death of a loved one, bereaved people may feel sadness, anger, guilt, anxiety, and despair. They may think constantly about the deceased person and about the events that led up to the person's death. They often have physical reactions to their loss—problems sleeping, for example—and they may become ill. Socially, they may find it difficult to return to work or to see friends and family. For most people, these painful emotions and thoughts gradually diminish, usually within 6 months or so of the death. But for a few people, the normal grief reaction lingers and becomes increasingly debilitating. Experts call this complicated grief or prolonged grief disorder (PGD). Characteristically, people with PGD have intrusive thoughts and images of the deceased person and a painful yearning for his or her presence. They may also deny their loss, feel desperately lonely and adrift, and want to die themselves.
Why Was This Study Done?
PGD is not currently recognized as a mental disorder although it meets the requirements for one given in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) and in the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, 10thEdition (ICD-10). Before PGD can be recognized as a mental disorder (and included in DSM-V and ICD-11), bereavement and mental-health experts need to agree on standardized criteria for PGD. Such criteria would be useful because they would allow researchers and clinicians to identify risk factors for PGD and to find ways to prevent PGD. They would also help to ensure that people with PGD get appropriate treatments such as psychotherapy to help them change their way of thinking about their loss and re-engage with the world. Recently, a panel of experts agreed on a consensus list of symptoms for PGD. In this study, the researchers undertake a field trial to develop and evaluate algorithms (sets of rules) for diagnosing PGD based on these symptoms.
What Did the Researchers Do and Find?
The researchers used “item response theory” (IRT) to derive the most informative PGD symptoms from structured interviews of nearly 300 people who had recently lost a close family member. These interviews contained questions about the consensus list of symptoms; each participant was interviewed two or three times during the two years after their spouse's death. The researchers then used “combinatoric” analysis to identify the most sensitive and specific algorithm for the diagnosis of PGD. This algorithm specifies that a bereaved person with PGD must experience yearning (physical or emotional suffering because of an unfulfilled desire for reunion with the deceased) and at least five of nine additional symptoms. These symptoms (which include emotional numbness, feeling that life is meaningless, and avoidance of the reality of the loss) must persist for at least 6 months after the bereavement and must be associated with functional impairment. Finally, the researchers show that individuals given a diagnosis of PGD 6–12 months after a death have a higher subsequent risk of mental health and functional impairment than people not diagnosed with PGD.
What Do These Findings Mean?
These findings validate a set of symptoms and a diagnostic algorithm for PGD. Because most of the study participants were elderly women who had lost their husband, further validation is needed to check that these symptoms and algorithm also apply to other types of bereaved people such as individuals who have lost a child. For now, though, these findings support the inclusion of PGD in DSM-V and ICD-11 as a recognized mental disorder. Furthermore, the availability of a standardized way to diagnose PGD will help clinicians identify the minority of people who fail to adjust successfully to the loss of a loved one. Hopefully, by identifying these people and helping them to avoid the onset of PGD (perhaps by providing psychotherapy soon after a death) and/or providing better treatment for PGD, it should now be possible to reduce the considerable personal and societal costs associated with prolonged grief.
Additional Information
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Stephen Workman
The Dana Farber Cancer Institute has a page describing its Center for Psycho-oncology and Palliative Care Research
The UK Royal College of Psychiatrists has a leaflet on bereavement (in English, Welsh, Urdu, and Chinese)
The US National Cancer Institute also has information about coping with bereavement for patients and health professionals (in English and Spanish)
MedlinePlus has links to other information about bereavement (in English and Spanish)
The Journal of the American Medical Association has a patient page on abnormal grief
Harvard Medical School provides a short family health guide about complicated grief
Information on DSM-IV and ICD-10 is available
PMCID: PMC2711304  PMID: 19652695
9.  The association of leisure-time physical activity and active commuting with measures of socioeconomic position in a multiethnic population living in the Netherlands: results from the cross-sectional SUNSET study 
BMC Public Health  2012;12:815.
In most European origin populations measures of socioeconomic position are positively associated with leisure time physical activity (LTPA), this is unclear for active commuting. In addition, these associations have scarcely been studied in ethnic minority groups, who often have a high cardiovascular disease risk. Because of the expected public health potential, we assessed the relationship of active commuting and LTPA with measures of socioeconomic position across two large ethnic minority groups in the Netherlands as compared to the European-Dutch population.
We included South Asian-Surinamese (n = 370), African-Surinamese (n = 689), and European-Dutch (n = 567) from the cross-sectional population-based SUNSET study (2001–2003). Active commuting and LTPA were assessed by the SQUASH physical activity questionnaire and calculated in square-root-transformed metabolic equivalents of task-hours/week (SQRTMET). Socioeconomic position was indicated by level of education (low/high) and occupational class (low/high). We used age-adjusted linear regression models to assess the association between physical activity and socioeconomic position.
Compared to the European-Dutch men, South Asian-Surinamese men engaged in lower levels of commuting activity and LTPA, and South Asian-Surinamese women engaged in lower levels of LTPA than their European-Dutch counterparts. Differences between the African Surinamese and the European-Dutch were small. We observed a positive gradient in active commuting activity for education in European-Dutch men (beta high education was 0.93, 95%CI: 0.45-1.40 SQRTMET higher versus low education), in South Asian-Surinamese men (beta: 0.56, 0.19-0.92), but not in African-Surinamese men (−0.06, -0.45-0.33, p for ethnicity-interaction = 0.002). In women we observed a positive gradient in active commuting activity and occupational class in European-Dutch women, and less strongly in South Asian-Surinamese and African-Surinamese women (p for ethnicity-interaction = 0.02). For LTPA and socioeconomic position, we observed no statistically significant interaction by ethnicity.
The positive gradient for socioeconomic position observed in European-Dutch was less strong, in particular for active commuting, among the South Asian-Surinamese and the African-Surinamese. This indicates that the typical focus on physical activity interventions in lower socioeconomic groups could work for European-Dutch populations, but this strategy may not be entirely applicable in the ethnic minority groups.
PMCID: PMC3490879  PMID: 22998730
Ethnicity; African; Indian; Social class; Physical activity; Commuting; Transportation; Ethnic groups; Health behavior; Minority health
10.  Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma 
PLoS Medicine  2009;6(10):e1000148.
Aziz Sheikh and colleagues report on a qualitative study in the US and the UK to investigate ways to bolster recruitment of South Asians into asthma studies, including making inclusion of diverse populations mandatory.
There is international interest in enhancing recruitment of minority ethnic people into research, particularly in disease areas with substantial ethnic inequalities. A recent systematic review and meta-analysis found that UK South Asians are at three times increased risk of hospitalisation for asthma when compared to white Europeans. US asthma trials are far more likely to report enrolling minority ethnic people into studies than those conducted in Europe. We investigated approaches to bolster recruitment of South Asians into UK asthma studies through qualitative research with US and UK researchers, and UK community leaders.
Methods and Findings
Interviews were conducted with 36 researchers (19 UK and 17 US) from diverse disciplinary backgrounds and ten community leaders from a range of ethnic, religious, and linguistic backgrounds, followed by self-completion questionnaires. Interviews were digitally recorded, translated where necessary, and transcribed. The Framework approach was used for analysis. Barriers to ethnic minority participation revolved around five key themes: (i) researchers' own attitudes, which ranged from empathy to antipathy to (in a minority of cases) misgivings about the scientific importance of the question under study; (ii) stereotypes and prejudices about the difficulties in engaging with minority ethnic populations; (iii) the logistical challenges posed by language, cultural differences, and research costs set against the need to demonstrate value for money; (iv) the unique contexts of the two countries; and (v) poorly developed understanding amongst some minority ethnic leaders of what research entails and aims to achieve. US researchers were considerably more positive than their UK counterparts about the importance and logistics of including ethnic minorities, which appeared to a large extent to reflect the longer-term impact of the National Institutes of Health's requirement to include minority ethnic people.
Most researchers and community leaders view the broadening of participation in research as important and are reasonably optimistic about the feasibility of recruiting South Asians into asthma studies provided that the barriers can be overcome. Suggested strategies for improving recruitment in the UK included a considerably improved support structure to provide academics with essential contextual information (e.g., languages of particular importance and contact with local gatekeepers), and the need to ensure that care is taken to engage with the minority ethnic communities in ways that are both culturally appropriate and sustainable; ensuring reciprocal benefits was seen as one key way of avoiding gatekeeper fatigue. Although voluntary measures to encourage researchers may have some impact, greater impact might be achieved if UK funding bodies followed the lead of the US National Institutes of Health requiring recruitment of ethnic minorities. Such a move is, however, likely in the short- to medium-term, to prove unpopular with many UK academics because of the added “hassle” factor in engaging with more diverse populations than many have hitherto been accustomed to.
Please see later in the article for the Editors' Summary
Editors' Summary
In an ideal world, everyone would have the same access to health care and the same health outcomes (responses to health interventions). However, health inequalities—gaps in health care and in health between different parts of the population—exist in many countries. In particular, people belonging to ethnic minorities in the UK, the US, and elsewhere have poorer health outcomes for several conditions than people belonging to the ethnic majority (ethnicity is defined by social characteristics such as cultural tradition or national origin). For example, in the UK, people whose ancestors came from the Indian subcontinent (also known as South Asians and comprising in the main of people of Indian, Pakistani, and Bangladeshi origin) are three times as likely to be admitted to hospital for asthma as white Europeans. The reasons underpinning ethnic health inequalities are complex. Some inequalities may reflect intrinsic differences between groups of people—some ethnic minorities may inherit genes that alter their susceptibility to a specific disease. Other ethnic health inequalities may arise because of differences in socioeconomic status or because different cultural traditions affect the uptake of health care services.
Why Was This Study Done?
Minority ethnic groups are often under-represented in health research, which could limit the generalizability of research findings. That is, an asthma treatment that works well in a trial where all the participants are white Europeans might not be suitable for South Asians. Clinicians might nevertheless use the treatment in all their patients irrespective of their ethnicity and thus inadvertently increase ethnic health inequality. So, how can ethnic minorities be encouraged to enroll into research studies? In this qualitative study, the investigators try to answer this question by talking to US and UK asthma researchers and UK community leaders about how they feel about enrolling ethnic minorities into research studies. The investigators chose to compare the feelings of US and UK asthma researchers because minority ethnic people are more likely to enroll into US asthma studies than into UK studies, possibly because the US National Institute of Health's (NIH) Revitalization Act 1993 mandates that all NIH-funded clinical research must include people from ethnic minority groups; there is no similar mandatory policy in the UK.
What Did the Researchers Do and Find?
The investigators interviewed 16 UK and 17 US asthma researchers and three UK social researchers with experience of working with ethnic minorities. They also interviewed ten community leaders from diverse ethnic, religious and linguistic backgrounds. They then analyzed the interviews using the “Framework” approach, an analytical method in which qualitative data are classified and organized according to key themes and then interpreted. By comparing the data from the UK and US researchers, the investigators identified several barriers to ethnic minority participation in health research including: the attitudes of researchers towards the scientific importance of recruiting ethnic minority people into health research studies; prejudices about the difficulties of including ethnic minorities in health research; and the logistical challenges posed by language and cultural differences. In general, the US researchers were more positive than their UK counterparts about the importance and logistics of including ethnic minorities in health research. Finally, the investigators found that some community leaders had a poor understanding of what research entails and about its aims.
What Do These Findings Mean?
These findings reveal a large gap between US and UK researchers in terms of policy, attitudes, practices, and experiences in relation to including ethnic minorities in asthma research. However, they also suggest that most UK researchers and community leaders believe that it is both important and feasible to increase the participation of South Asians in asthma studies. Although some of these findings may have been affected by the study participants sometimes feeling obliged to give “politically correct” answers, these findings are likely to be generalizable to other diseases and to other parts of Europe. Given their findings, the researchers warn that a voluntary code of practice that encourages the recruitment of ethnic minority people into health research studies is unlikely to be successful. Instead, they suggest, the best way to increase the representation of ethnic minority people in health research in the UK might be to follow the US lead and introduce a policy that requires their inclusion in such research.
Additional Information
Please access these Web sites via the online version of this summary at
Families USA, a US nonprofit organization that campaigns for high-quality, affordable health care for all Americans, has information about many aspects of minority health in the US, including an interactive game about minority health issues
The US Agency for Healthcare Research and Quality has a section on minority health
The UK Department of Health provides information on health inequalities and a recent report on the experiences of patients in Black and minority ethnic groups
The UK Parliamentary Office of Science and Technology also has a short article on ethnicity and health
Information on the NIH Revitalization Act 1993 is available
NHS Evidences Ethnicity and Health has a variety of policy, clinical, and research resources on ethnicity and health
PMCID: PMC2752116  PMID: 19823568
11.  Health numeracy in Japan: measures of basic numeracy account for framing bias in a highly numerate population 
Health numeracy is an important factor in how well people make decisions based on medical risk information. However, in many countries, including Japan, numeracy studies have been limited.
To fill this gap, we evaluated health numeracy levels in a sample of Japanese adults by translating two well-known scales that objectively measure basic understanding of math and probability: the 3-item numeracy scale developed by Schwartz and colleagues (the Schwartz scale) and its expanded version, the 11-item numeracy scale developed by Lipkus and colleagues (the Lipkus scale).
Participants’ performances (n = 300) on the scales were much higher than in original studies conducted in the United States (80% average item-wise correct response rate for Schwartz-J, and 87% for Lipkus-J). This high performance resulted in a ceiling effect on the distributions of both scores, which made it difficult to apply parametric statistical analysis, and limited the interpretation of statistical results. Nevertheless, the data provided some evidence for the reliability and validity of these scales: The reliability of the Japanese versions (Schwartz-J and Lipkus-J) was comparable to the original in terms of their internal consistency (Cronbach’s α = 0.53 for Schwartz-J and 0.72 for Lipkus-J). Convergent validity was suggested by positive correlations with an existing Japanese health literacy measure (the Test for Ability to Interpret Medical Information developed by Takahashi and colleagues) that contains some items relevant to numeracy. Furthermore, as shown in the previous studies, health numeracy was still associated with framing bias with individuals whose Lipkus-J performance was below the median being significantly influenced by how probability was framed when they rated surgical risks. A significant association was also found using Schwartz-J, which consisted of only three items.
Despite relatively high levels of health numeracy according to these scales, numeracy measures are still important determinants underlying susceptibility to framing bias. This suggests that it is important in Japan to identify individuals with low numeracy skills so that risk information can be presented in a way that enables them to correctly understand it. Further investigation is required on effective numeracy measures for such an intervention in Japan.
PMCID: PMC3511058  PMID: 22967200
Risk communications; Patient empowerment; Patient education; Risk perception; Decision making
12.  The relationship between transformational leadership and work engagement in governmental hospitals nurses: a survey study 
SpringerPlus  2014;3:25.
The aim of this study was to determine the effects of transformational leadership and its components on work engagement among hospital nurses. There are a few set of researches that have focused on the effects of transformational leadership on work engagement in nurses. A descriptive, correlational, cross-sectional design was used. In this study, 240 nurses have been chosen by stratified random sampling method which filled related self-reported scales include multifactor leadership questionnaire (MLQ) and work engagement scale. Data analysis has been exerted according to the statistical method of simple and multiple correlation coefficients. Findings indicated that the effect of this type of leadership on work engagement and its facets is positive and significant. In addition, the research illustrates that transformational leaders transfer their enthusiasm and high power to their subordinates by the way of modeling. This manner can increase the power as a component of work engagement in workers. Idealized influence among these leaders can result in forming a specific belief among employees toward those leaders and leaders can easily transmit their inspirational motivation to them. Consequently, it leads to make a positive vision by which, and by setting high standards, challenges the employees and establishes zeal along with optimism for attaining success in works. regarding to the results we will expand leadership and work engagement literature in hospital nurses. Also, we conclude with theoretical and practical implications and propose a clear horizon for future researches.
PMCID: PMC3895439  PMID: 24455469
Transformational leadership; Work engagement; Hospital nurses
13.  The Inventory of Personality Organisation: its psychometric properties among student and clinical populations in Japan 
The Inventory of Personality Organisation (IPO) is a self-report measure that reflects personality traits, as theorised by Kernberg.
In study 1, the Japanese version of the IPO was distributed to a population of Japanese university students (N = 701). The students were randomly divided into two groups. The factor structure derived from an exploratory factor analysis among one subsample was tested using a confirmatory factor structure among another subsample. In study 2, the factor-driven subscales of the IPO were correlated with other variables that would function as external criteria to validate the scale in a combined population of the students used in study 1 and psychiatric outpatients (N = 177).
In study 1 the five-factor structure presented by the original authors was replicated in exploratory factor analyses in one subgroup of students. However, this was through reduction of the number of items (the number of the primary items was reduced from 57 to 24 whereas the number of the additional items was reduced from 26 to 13) due to low endorsement frequencies as well as low factor loadings on a designated factor. The new factor structure was endorsed by a confirmatory factor analysis in the other student subgroup. In study 2 the new five subscales of the Japanese IPO were likely to be correlated with younger age, more personality psychopathology (borderline and narcissistic), more dysphoric mood, less psychological well-being, more insecure adult attachment style, lower self-efficacy, and more frequent history of childhood adversity. The IPO scores were found to predict the increase in suicidal ideation in a week's time in a longitudinal follow-up.
Although losing more than 40% of the original items, the Japanese IPO may be a reliable and valid measure of Kernberg's personality organisation for Japanese populations.
PMCID: PMC2685789  PMID: 19419541
14.  Can Persons With Dementia Be Engaged With Stimuli? 
To determine which stimuli are 1) most engaging 2) most often refused by nursing home residents with dementia, and 3) most appropriate for persons who are more difficult to engage with stimuli.
Participants were 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia. Stimulus engagement was assessed by the Observational Measure of Engagement.
The most engaging stimuli were one-on-one socializing with a research assistant, a real baby, personalized stimuli based on the person’s self-identity, a lifelike doll, a respite video, and envelopes to stamp. Refusal of stimuli was higher among those with higher levels of cognitive function and related to the stimulus’ social appropriateness. Women showed more attention and had more positive attitudes for live social stimuli, simulated social stimuli, and artistic tasks than did men. Persons with comparatively higher levels of cognitive functioning were more likely to be engaged in manipulative and work tasks, whereas those with low levels of cognitive functioning spent relatively more time responding to social stimuli. The most effective stimuli did not differ for those most likely to be engaged and those least likely to be engaged.
Nursing homes should consider both having engagement stimuli readily available to residents with dementia, and implementing a socialization schedule so that residents receive one-on-one interaction. Understanding the relationship among type of stimulus, cognitive function, and acceptance, attention, and attitude toward the stimuli can enable caregivers to maximize the desired benefit for persons with dementia.
PMCID: PMC3142782  PMID: 20306565
Dementia; engagement; nursing home residents; stimuli
15.  Scale development of health status for secondary data analysis using a nationally representative survey 
Scale development of health-related quality of life (HRQOL) measures, including physical and mental health measures, among public datasets from Japan is needed for comparative studies on health conditions among different age, gender, and socio-economic subgroups. Multi-attributable scales of continuous/discrete variables on HRQOL could be more flexible for different kinds of epidemiologic and socio-econometric studies rather than single-item measures. The objectives of this study were to create multi-dimensional scales for physical, mental, and summary health measures and to describe the age-related trends of these scales in Japan.
We utilized data from the 2007 Comprehensive Survey of the Living Conditions of People on Health and Welfare (LCPHW: Kokumin Seikatsu Kiso Chosa) (n = 383,745) to measure physical health (0 = worst score, 16 = best score) by summarizing four items: general health status, bedridden status/mobility, self-care/usual activities, and pain (0 = worst score, 4 = best score for each item). Mental health was measured using a Japanese version of K6 (0 = worst score, 4 = best score, modified from original version in which 24 = worst score and 0 = best score). We then created a summary health scale using the simple sum of physical and mental health (0 = worst score, 20 = best score). The reliability and validity of the scales were evaluated and their age-related trends described.
The internal consistency reliability of the physical and summary health scales was not sufficiently high (Cronbach’s α = 0.64 and 0.67, respectively) and the age-related trend was smooth and monotonous. The internal consistency reliability of the mental health scale (K6) was high (Cronbach’s α = 0.90), while the age-related trend peaked at age 65–74 years.
While K6 was a measure with high reliability for describing mental health, use of the physical and summary health scale in the Japanese population requires further discussion. Additional validation tests of the summary scales also need to be performed, in which our methodology is applied to other data sets that include strict diagnostic results based on a structural interview.
PMCID: PMC3348248  PMID: 21918867
Japan; Scale development; Health-related quality of life (HRQOL)
16.  Supervised and Unsupervised Self-Testing for HIV in High- and Low-Risk Populations: A Systematic Review 
PLoS Medicine  2013;10(4):e1001414.
By systematically reviewing the literature, Nitika Pant Pai and colleagues assess the evidence base for HIV self tests both with and without supervision.
Stigma, discrimination, lack of privacy, and long waiting times partly explain why six out of ten individuals living with HIV do not access facility-based testing. By circumventing these barriers, self-testing offers potential for more people to know their sero-status. Recent approval of an in-home HIV self test in the US has sparked self-testing initiatives, yet data on acceptability, feasibility, and linkages to care are limited. We systematically reviewed evidence on supervised (self-testing and counselling aided by a health care professional) and unsupervised (performed by self-tester with access to phone/internet counselling) self-testing strategies.
Methods and Findings
Seven databases (Medline [via PubMed], Biosis, PsycINFO, Cinahl, African Medicus, LILACS, and EMBASE) and conference abstracts of six major HIV/sexually transmitted infections conferences were searched from 1st January 2000–30th October 2012. 1,221 citations were identified and 21 studies included for review. Seven studies evaluated an unsupervised strategy and 14 evaluated a supervised strategy. For both strategies, data on acceptability (range: 74%–96%), preference (range: 61%–91%), and partner self-testing (range: 80%–97%) were high. A high specificity (range: 99.8%–100%) was observed for both strategies, while a lower sensitivity was reported in the unsupervised (range: 92.9%–100%; one study) versus supervised (range: 97.4%–97.9%; three studies) strategy. Regarding feasibility of linkage to counselling and care, 96% (n = 102/106) of individuals testing positive for HIV stated they would seek post-test counselling (unsupervised strategy, one study). No extreme adverse events were noted. The majority of data (n = 11,019/12,402 individuals, 89%) were from high-income settings and 71% (n = 15/21) of studies were cross-sectional in design, thus limiting our analysis.
Both supervised and unsupervised testing strategies were highly acceptable, preferred, and more likely to result in partner self-testing. However, no studies evaluated post-test linkage with counselling and treatment outcomes and reporting quality was poor. Thus, controlled trials of high quality from diverse settings are warranted to confirm and extend these findings.
Please see later in the article for the Editors' Summary
Editors' Summary
About 34 million people (most living in resource-limited countries) are currently infected with HIV, the virus that causes AIDS, and about 2.5 million people become infected with HIV every year. HIV is usually transmitted through unprotected sex with an infected partner. HIV infection is usually diagnosed by looking for antibodies to HIV in blood or saliva. Early during infection, the immune system responds to HIV by beginning to make antibodies that recognize the virus and target it for destruction. “Seroconversion”—the presence of detectable amounts of antibody in the blood or saliva—usually takes 6–12 weeks. Rapid antibody-based tests, which do not require laboratory facilities, can provide a preliminary result about an individual's HIV status from a simple oral swab or finger stick sample within 20 minutes. However preliminary rapid positive results have to be confirmed in a laboratory, which may take a few days or weeks. If positive, HIV infection can be controlled but not cured by taking a daily cocktail of powerful antiretroviral drugs throughout life.
Why Was This Study Done?
To reduce the spread of HIV, it is essential that HIV-positive individuals get tested, change behaviors avoid transmitting the virus to other people by, for example, always using a condom during sex, and if positive get on to treatment that is available worldwide. Treatment also reduces transmission of virus to the partner and controls the virus in the community. However, only half the people currently living with HIV know their HIV status, a state of affairs that increases the possibility of further HIV transmission to their partners and children. HIV positive individuals are diagnosed late with advanced HIV infection that costs health care services. Although health care facility-based HIV testing has been available for decades, people worry about stigma, visibility, and social discrimination. They also dislike the lack of privacy and do not like having to wait for their test results. Self-testing (i.e., self-test conduct and interpretation) might alleviate some of these barriers to testing by allowing individuals to determine their HIV status in the privacy of their home and could, therefore, increase the number of individuals aware of their HIV status. This could possibly reduce transmission and, through seeking linkages to care, bring HIV under control in communities. In some communities and countries, stigma of HIV prevents people from taking action about their HIV status. Indeed, an oral (saliva-based) HIV self-test kit is now available in the US. But how acceptable, feasible, and accurate is self-testing by lay people, and will people who find themselves self-test positive seek counseling and treatment? In this systematic review (a study that uses pre-defined criteria to identify all the research on a given topic), the researchers examine these issues by analyzing data from studies that have evaluated supervised self-testing (self-testing and counseling aided by a health-care professional) and unsupervised self-testing (self-testing performed without any help but with counseling available by phone or internet).
What Did the Researchers Do and Find?
The researchers identified 21 eligible studies, two-thirds of which evaluated oral self-testing and a third of which evaluated blood-based self-testing. Seven studies evaluated an unsupervised self-testing strategy and 14 evaluated a supervised strategy. Most of the data (89%) came from studies undertaken in high-income settings. The study populations varied from those at high risk of HIV infection to low-risk general populations. Across the studies, acceptability (defined as the number of people who actually self-tested divided by the number who consented to self-test) ranged from 74% to 96%. With both strategies, the specificity of self-testing (the chance of an HIV-negative person receiving a negative test result is true negative) was high but the sensitivity of self-testing (the chance of an HIV-positive person receiving a positive test result is indeed a true positive) was higher for supervised than for unsupervised testing. The researchers also found evidence that people preferred self-testing to facility-based testing and oral self-testing to blood-based self testing and, in one study, 96% of participants who self-tested positive sought post-testing counseling.
What Do These Findings Mean?
These findings provide new but limited information about the feasibility, acceptability, and accuracy of HIV self-testing. They suggest that it is feasible to implement both supervised and unsupervised self-testing, that both strategies are preferred to facility-based testing, but that the accuracy of self-testing is variable. However, most of the evidence considered by the researchers came from high-income countries and from observational studies of varying quality, and data on whether people self-testing positive sought post-testing counseling (linkage to care) were only available from one evaluation of unsupervised self-testing in the US. Consequently, although these findings suggest that self-testing could engage individuals in finding our their HIV status and thereby help modify behavior thus, reduce HIV transmission in the community, by increasing the proportion of people living with HIV who know their HIV status. The researchers suggested that more data from diverse settings and preferably from controlled randomized trials must be collected before any initiatives for global scale-up of self-testing for HIV infection are implemented.
Additional Information
Please access these Web sites via the online version of this summary at
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS and summaries of recent research findings on HIV care and treatment
Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on HIV testing, and on HIV transmission and testing (in English and Spanish)
The UK National Health Service Choices website provides information about all aspects of HIV and AIDS; a “behind the headlines” article provides details about the 2012 US approval for an over-the-counter HIV home-use test
The 2012 World AIDS Day Report provides information about the percentage of people living with HIV who are aware of their HIV status in various African countries, as well as up-to-date information about the AIDS epidemic
Patient stories about living with HIV/AIDS are available through Avert; the nonprofit website Healthtalkonline also provides personal stories about living with HIV, including stories about getting a diagnosis
PMCID: PMC3614510  PMID: 23565066
17.  Using Rasch rating scale model to reassess the psychometric properties of the Persian version of the PedsQLTM 4.0 Generic Core Scales in school children 
Item response theory (IRT) is extensively used to develop adaptive instruments of health-related quality of life (HRQoL). However, each IRT model has its own function to estimate item and category parameters, and hence different results may be found using the same response categories with different IRT models. The present study used the Rasch rating scale model (RSM) to examine and reassess the psychometric properties of the Persian version of the PedsQLTM 4.0 Generic Core Scales.
The PedsQLTM 4.0 Generic Core Scales was completed by 938 Iranian school children and their parents. Convergent, discriminant and construct validity of the instrument were assessed by classical test theory (CTT). The RSM was applied to investigate person and item reliability, item statistics and ordering of response categories.
The CTT method showed that the scaling success rate for convergent and discriminant validity were 100% in all domains with the exception of physical health in the child self-report. Moreover, confirmatory factor analysis supported a four-factor model similar to its original version. The RSM showed that 22 out of 23 items had acceptable infit and outfit statistics (<1.4, >0.6), person reliabilities were low, item reliabilities were high, and item difficulty ranged from -1.01 to 0.71 and -0.68 to 0.43 for child self-report and parent proxy-report, respectively. Also the RSM showed that successive response categories for all items were not located in the expected order.
This study revealed that, in all domains, the five response categories did not perform adequately. It is not known whether this problem is a function of the meaning of the response choices in the Persian language or an artifact of a mostly healthy population that did not use the full range of the response categories. The response categories should be evaluated in further validation studies, especially in large samples of chronically ill patients.
PMCID: PMC3353856  PMID: 22414135
quality of life; school children; Iran; Rasch model
18.  The development and validation of a job crafting measure for use with blue-collar workers 
Work and Stress  2012;26(4):365-384.
Job crafting describes a set of proactive behaviours in which employees may engage to shape their work in order to minimize hindering job demands and maximize resources and challenging demands. Such behaviours may be particularly important among blue-collar workers whose jobs are characterized by poor working conditions and low well-being. We present the development and adaptation of a job crafting measure that may be used among blue-collar workers, based on an existing scale by Tims, Bakker, and Derks (2012) that was not specifically developed for blue-collar workers. We test the validity and reliability of the measure in a longitudinal study based on multiple source information from mail delivery workers in Denmark (N = 362 at Time 1; N = 408 at Time 2). Results indicate the presence of five job crafting dimensions: increasing challenging demands, decreasing social job demands, increasing social job resources, increasing quantitative demands and decreasing hindering job demands. These can be reliably measured with 15 items. The measure shows acceptable discriminant and criterion validity, and test-retest reliability. The findings extend the application of the original questionnaire. They also add to knowledge of the job crafting behaviours in which blue-collar workers engage and link them to well-being outcomes.
PMCID: PMC3516817  PMID: 23236220
job crafting; validation; well-being; questionnaire; scale development
19.  Measurement and correlates of empathy among female Japanese physicians 
BMC Medical Education  2012;12:48.
The measurement of empathy is important in the assessment of physician competence and patient outcomes. The prevailing view is that female physicians have higher empathy scores compared with male physicians. In Japan, the number of female physicians has increased rapidly in the past ten years. In this study, we focused on female Japanese physicians and addressed factors that were associated with their empathic engagement in patient care.
The Jefferson Scale of Empathy (JSE) was translated into Japanese by using the back-translation procedure, and was administered to 285 female Japanese physicians. We designed this study to examine the psychometrics of the JSE and group differences among female Japanese physicians.
The item-total score correlations of the JSE were all positive and statistically significant, ranging from .20 to .54, with a median of .41. The Cronbach’s coefficient alpha was .81. Female physicians who were practicing in “people-oriented” specialties obtained a significantly higher mean empathy score than their counterparts in “procedure-” or “technology-oriented” specialties. In addition, physicians who reported living with their parents in an extended family or living close to their parents, scored higher on the JSE than those who were living alone or in a nuclear family.
Our results provide support for the measurement property and reliability of the JSE in a sample of female Japanese physicians. The observed group differences associated with specialties and living arrangement may have implications for sustaining empathy. In addition, recognizing these factors that reinforce physicians’ empathy may help physicians to avoid career burnout.
PMCID: PMC3493267  PMID: 22726449
Empathy; Female physicians; Career development
20.  The prevalence of common mental disorders among hospital physicians and their association with self-reported work ability: a cross-sectional study 
We studied the prevalence of common mental disorders among Dutch hospital physicians and investigated whether the presence of a mental disorder was associated with insufficient self-reported work ability.
A questionnaire was sent to all (n = 958) hospital physicians of one academic medical center, using validated scales to assess burnout, work-related fatigue, stress, posttraumatic stress disorder (PTSD), anxiety and depression. Furthermore, respondents were asked to rate their current work ability against the work ability in their own best period (adapted version of the first WAI item). The prevalence of each common mental disorder was calculated. In addition, odds ratios of reporting insufficient work ability for subjects with high complaint scores compared to physicians with low complaint scores were calculated for each mental disorder.
The response rate was 51%, and 423 questionnaires were eligible for analysis. The mental disorder prevalence rates were as follows: work-related fatigue 42%, depression 29%, anxiety 24%, posttraumatic stress complaints 15%, stress complaints 15% and burnout 6%. The mean score for self-reported work ability was 8.1 (range 0–10), and 4% of respondents rated their own work ability as insufficient. Physicians with high mental health complaints were 3.5- for fatigue, 5.6- for PTSD, 7.1- for anxiety, 9.5- for burnout, 10.8- for depression and 13.6-fold for stress more likely to report their work ability as insufficient.
The prevalence of common mental disorders among hospital physicians varied from 6% for burnout to 42% for work-related fatigue. Those physicians with high complaints had significantly 4- to 14 times increased odds of reporting their own work ability as insufficient. This work suggests that to ensure future workers health and patients safety occupational health services should plan appropriate intervention strategies.
PMCID: PMC3459739  PMID: 22938170
21.  The development of instruments to measure the work disability assessment behaviour of insurance physicians 
BMC Public Health  2011;11:1.
Variation in assessments is a universal given, and work disability assessments by insurance physicians are no exception. Little is known about the considerations and views of insurance physicians that may partly explain such variation. On the basis of the Attitude - Social norm - self Efficacy (ASE) model, we have developed measurement instruments for assessment behaviour and its determinants.
Based on theory and interviews with insurance physicians the questionnaire included blocks of items concerning background variables, intentions, attitudes, social norms, self-efficacy, knowledge, barriers and behaviour of the insurance physicians in relation to work disability assessment issues. The responses of 231 insurance physicians were suitable for further analysis. Factor analysis and reliability analysis were used to form scale variables and homogeneity analysis was used to form dimension variables. Thus, we included 169 of the 177 original items.
Factor analysis and reliability analysis yielded 29 scales with sufficient reliability. Homogeneity analysis yielded 19 dimensions. Scales and dimensions fitted with the concepts of the ASE model. We slightly modified the ASE model by dividing behaviour into two blocks: behaviour that reflects the assessment process and behaviour that reflects assessment behaviour.
The picture that emerged from the descriptive results was of a group of physicians who were motivated in their job and positive about the Dutch social security system in general. However, only half of them had a positive opinion about the Dutch Work and Income (Capacity for Work) Act (WIA). They also reported serious barriers, the most common of which was work pressure. Finally, 73% of the insurance physicians described the majority of their cases as 'difficult'.
The scales and dimensions developed appear to be valid and offer a promising basis for future research. The results suggest that the underlying ASE model, in modified form, is suitable for describing the assessment behaviour of insurance physicians and the determinants of this behaviour. The next step in this line of research should be to validate the model using structural equation modelling. Finally, the predictive value should be tested in relation to outcome measurements of work disability assessments.
PMCID: PMC3086528  PMID: 21199570
22.  Safe To Walk? Neighborhood Safety and Physical Activity Among Public Housing Residents 
PLoS Medicine  2007;4(10):e306.
Despite its health benefits, physical inactivity is pervasive, particularly among those living in lower-income urban communities. In such settings, neighborhood safety may impact willingness to be regularly physically active. We examined the association of perceived neighborhood safety with pedometer-determined physical activity and physical activity self-efficacy.
Methods and Findings
Participants were 1,180 predominantly racial/ethnic minority adults recruited from 12 urban low-income housing complexes in metropolitan Boston. Participants completed a 5-d pedometer data-collection protocol and self-reported their perceptions of neighborhood safety and self-efficacy (i.e., confidence in the ability to be physically active). Gender-stratified bivariate and multivariable random effects models were estimated to account for within-site clustering. Most participants reported feeling safe during the day, while just over one-third (36%) felt safe at night. We found no association between daytime safety reports and physical activity among both men and women. There was also no association between night-time safety reports and physical activity among men (p = 0.23) but women who reported feeling unsafe (versus safe) at night showed significantly fewer steps per day (4,302 versus 5,178, p = 0.01). Perceiving one's neighborhood as unsafe during the day was associated with significantly lower odds of having high physical activity self-efficacy among both men (OR 0.40, p = 0.01) and women (OR 0.68, p = 0.02).
Residing in a neighborhood that is perceived to be unsafe at night is a barrier to regular physical activity among individuals, especially women, living in urban low-income housing. Feeling unsafe may also diminish confidence in the ability to be more physically active. Both of these factors may limit the effectiveness of physical activity promotion strategies delivered in similar settings.
Garry Bennett and colleagues measured exercise levels and obtained opinions on neighborhood safety. They concluded that residing in a neighborhood perceived to be unsafe at night is a barrier to regular physical activity.
Editors' Summary
Nowadays we are all encouraged to do more physical activity, as it has been shown that inactivity increases the risk of many medical conditions, including obesity, heart attacks, and strokes. Inactive people die younger. Previous research has shown that people on a low income and those from ethnic or racial minorities have the lowest activity levels. There are, however, many barriers to being active. It has been claimed that people who live in neighborhoods that are unsafe face particular difficulties. They might want to walk, cycle, or take other forms of outdoor exercise near their home, but they fear they would be injured as a result of a violent attack. It is usually the poorest members of society who live in unsafe areas. It is also known that those poor people who belong to minority racial or ethnic groups are particularly likely to feel unsafe.
Why Was This Study Done?
The researchers who did this study wanted to find out whether people in a low-income urban area in the US considered themselves to be unsafe in their neighborhood, and how much physical activity they took part in. Their aim was to establish whether there was an association between the perceived safety level and the amount of activity taken, or if the two were unrelated. Other researchers have tried to look for such an association before, but they have usually relied on how much activity people say they remember taking, not on the actual measured amount. The results from such research have been very varied and inconclusive.
What Did the Researchers Do and Find?
Working in one low-income district of one US city (Boston), they found over 1,000 people to participate in their study, most of whom were from ethnic minorities. They asked them the question: “How safe do you feel walking alone in your neighborhood?” Response options included “safe,” “a little unsafe,” and “unsafe.” The same question was asked about walking alone in the daylight and walking alone after dark. The people in the study also agreed to wear a pedometer for five days. This instrument measures the number of steps that the wearer takes. It is thus a much more accurate way of finding out about activity levels than asking people how much activity they think they have engaged in.
Four out of five people said they did feel safe during the day, but there was no association between daytime safety and physical activity. This was the case for both men and women. Two-thirds of the people in the study felt unsafe in the night-time. There was no association between perceived night-time safety and physical activity among men, but women who reported feeling unsafe at night took around 1,000 fewer steps per day than other women. That amounts to around 20% less physical activity.
What Do These Findings Mean?
Even the women who felt safe at night were only taking around 5,000 steps per day, around half of what the US Surgeon General recommends for good health. So all the women in the study would benefit from more physical activity. However, the much lower amount of activity of the women who felt unsafe does suggest that a perceived lack of safety is an important factor, which could increase the risks to their health. It is interesting that the association between perceived safety and activity was not found in men and only applied to night-time safety. However, the authors argue that their findings provide preliminary evidence that perceived low neighborhood safety may serve as a barrier to physical activity in low-income areas. They discuss in the article the need for further research.
Additional Information.
Please access these Web sites via the online version of this summary at
• The UK National Health Service publishes the online NHS Direct Health Encyclopedia, which describes the benefits of exercise and gives recommendations
• Information on exercise may also be found on MedlinePlus, a service of the US National Library of Medicine and the National Institutes of Health
PMCID: PMC2039759  PMID: 17958465
23.  Evaluating Existing Measures of Health Numeracy Using Item Response Theory 
Patient education and counseling  2009;75(3):308-314.
To evaluate existing measures of health numeracy using Item Response Theory (IRT).
A cross-sectional study was conducted. Participants completed assessments of health numeracy measures including the Lipkus Expanded Health Numeracy Scale (Lipkus), and the Medical Data Interpretation Test (MDIT). The Lipkus and MDIT were scaled with IRT utilizing the 2-parameter logistic model.
Three-hundred and fifty-nine (359) participants were surveyed. Classical test theory parameters and IRT scaling parameters of the numeracy measures found most items to be at least moderately discriminating. Modified versions of the Lipkus and MDIT were scaled after eliminating items with low discrimination, high difficulty parameters, and poor model fit. The modified versions demonstrated a good range of discrimination and difficulty as indicated by the Test Information Functions.
An IRT analysis of the Lipkus and MDIT indicate that both health numeracy scales discriminate well across a range of ability.
Practice Implications
Health numeracy skills are needed in order for patients to successfully participate in their medical care. The accurate assessment of health numeracy may help health care providers to tailor patient education interventions to the patient’s level of understanding and ability. Item response theory scaling methods can be used to evaluate the discrimination and difficulty of individual items as well as the overall assessment.
PMCID: PMC2760293  PMID: 19443170
Item Response Theory; Numeracy; Health Literacy; Measurement
24.  Self-reported work ability of Norwegian women in relation to physical and mental health, and to the work environment 
To examine the self-reported level of work ability among female employees and the relationship between work ability and demographic characteristics, physical health, mental health, and various psychosocial and organizational work environment factors.
Participants were 597 female employees with an average age of 43 years from urban and rural areas in Norway. Trained personnel performed a structured interview to measure demographic variables, physical health, and characteristics of the working environment. Mental health was assessed using the 25-item version of the Hopkins Symptoms Checklist (HSCL-25). Work ability was assessed using a question from the Graded Reduced Work Ability Scale.
Of the 597 female employees, 8.9% reported an extremely or very reduced ability to work. Twenty-four percent reported poor physical health and 21.9% reported mental distress (≥ 1.55 HSCL-25 cut-off). Women, who reported moderately and severely reduced work ability, did not differ a lot. Moderately reduced work ability increased with age and was associated with physical and mental health. Severely reduced work ability was strongly associated only with physical health and with unskilled occupation. Of eight work environment variables, only three yielded significant associations with work ability, and these associations disappeared after adjustment in the multivariate analysis.
Results indicate that ageing, in addition to poor self-reported physical health and unskilled work, were the strongest factors associated with reduced work ability among female employees. Impact of work environment in general was visible only in univariate analysis.
PMCID: PMC2373783  PMID: 18430207
25.  Association between job strain and prevalence of hypertension: a cross sectional analysis in a Japanese working population with a wide range of occupations: the Jichi Medical School cohort study 
OBJECTIVES—To explore the association between the prevalence of hypertension in a Japanese working population and job strain (a combination of low control over work and high psychological demands), and to estimate this association in different sociodemographic strata.
METHODS—From a multicentre community based cohort study of Japanese people, sex specific cross sectional analyses were performed on 3187 men and 3400 women under 65 years of age, all of whom were actively engaged in various occupations throughout Japan. The baseline period was 1992-4. The association between job characteristics—measured with a Japanese version of the Karasek demand-control questionnaire—and the prevalence of hypertension defined by blood pressure and from clinical diagnoses were examined. Adjustments were made for possible confounders. The analyses were repeated for stratified categories of occupational class, educational attainment, and age group.
RESULTS—In men, the level of job strain (the ratio of psychological job demands to job control) correlated with the prevalence of hypertension. In a multiple logistic regression model, job strain was significantly related to hypertension (odds ratio 1.18; 95% confidence interval 1.05 to 1.32), after adjustment for age, employment (white collar v blue collar), marital status, family history of hypertension, cigarette smoking, alcohol intake, physical activity, and body mass index. The stratified analyses showed significant excess risks in the subordinate groups compared with managers, blue collar workers, less educated workers, and the older age groups. This association was not significant in women. Multiple linear regression analyses, with systolic and diastolic blood pressures as dependent variables, did not show any significant association.
CONCLUSIONS—The findings provided limited proof that job strain is related to hypertension in Japanese working men. Older men in a lower social class may be more vulnerable to the hypertensive effects of job strain.

Keywords: hypertension; stress; psychological; work
PMCID: PMC1740148  PMID: 11351051

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