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1.  Process Evaluation of a Multidisciplinary Care Program for Patients Undergoing Gynaecological Surgery 
Purpose This study describes the process evaluation of an innovative multidisciplinary care program for patients undergoing benign gynaecologic surgery. This care program aims at improving recovery and preventing delayed return to work and consists of two steps: (1) an interactive e-health intervention for all participants, and (2) integrated clinical and occupational care management for those participants whose sick leave exceeds 10 weeks. Methods Eligible for this study were employed women aged between 18–65 years scheduled for a laparoscopic adnexal surgery and/or hysterectomy. Data were collected from patients, their supervisors and their gynaecologists, by means of electronic questionnaires during a 6 month follow-up period and an automatically generated, detailed weblog of the patient web portal (www.ikherstel.nl). Investigated process measures included: reach, dose delivered, dose received, and fidelity. In addition, attitudes towards the intervention were explored among all stakeholders. Results 215 patients enrolled in the study and accounted to a reach of 60.2 % (215/357). All intervention group patients used their account at least once and total time spent on the patient web portal was almost 2 h for each patient (median 118 min, IQR 64–173 min). Most patients visited the website several times (median 11 times, IQR 6–16). Perceived effectiveness among patients was high (74 %). In addition, gynaecologists (76 %) and employers (61 %) were satisfied with the web portal as well. Implementation of the second step of the intervention was suboptimal. Motivating patients to consent to additional guidance and developing an accurate return-to-work-prognosis were two important obstacles. Conclusions The results of this study indicate good feasibility for implementation on a broad scale of the e-health intervention for patients undergoing benign gynaecological surgery. To enhance the implementation of the second step of the perioperative care program, adaptations in the integrated care protocol are needed.
Electronic supplementary material
The online version of this article (doi:10.1007/s10926-013-9475-4) contains supplementary material, which is available to authorized users.
doi:10.1007/s10926-013-9475-4
PMCID: PMC4118044  PMID: 24057871
Gynaecology; Telemedicine; Convalescence; Return to work; Program evaluation
2.  The concurrent validity between leptin, BMI and skin folds during pregnancy and the year after 
Nutrition & Diabetes  2013;3(9):e86-.
Background:
From a public health perspective it is important to know which of the currently used methods to estimate changes in maternal body fat during pregnancy and the year thereafter is the most adequate.
Objectives:
To evaluate the concurrent validity between leptin and surrogates of fat measures: body mass index (BMI) and the sum of four skin folds.
Design:
Data from the New Life(style) intervention study were analysed as a cohort study.
Setting:
Midwife practices in The Netherlands.
Population:
Healthy pregnant nulliparous women.
Methods:
Anthropometric measurements were done and blood was collected at 15, 25 and 35 weeks of pregnancy and at 6, 26 and 52 weeks after delivery. Data were used if at least 4 out of the 6 measurements were available, leaving 87 women in the analyses. Spearman's correlation coefficients between leptin and BMI and between leptin and the sum of skin folds were calculated for each time point and for the changes between the time points.
Results:
Correlations between leptin and BMI varied from 0.69 to 0.81. Correlations between leptin and the sum of skin folds were comparable, varying between 0.65 and 0.81.
Correlations between changes in leptin and changes in BMI and the sum of skin folds, respectively, were much lower compared with cross-sectional correlations.
Conclusion:
Because of the high correlation among the three methods and because of the overlapping intervals, all methods seem to be equally adequate to estimate changes in maternal body fat during pregnancy and the year thereafter.
doi:10.1038/nutd.2013.27
PMCID: PMC3789130  PMID: 24018614
gestational weight gain; maternal leptin; maternal skin folds; BMI
3.  Predicting Return to Work in Workers with All-Cause Sickness Absence Greater than 4 Weeks: A Prospective Cohort Study 
Introduction Long-term sickness absence is a major public health and economic problem. Evidence is lacking for factors that are associated with return to work (RTW) in sick-listed workers. The aim of this study is to examine factors associated with the duration until full RTW in workers sick-listed due to any cause for at least 4 weeks. Methods In this cohort study, health-related, personal and job-related factors were measured at entry into the study. Workers were followed until 1 year after the start of sickness absence to determine the duration until full RTW. Cox proportional hazards regression analyses were used to calculate hazard ratios (HR). Results Data were collected from N = 730 workers. During the first year after the start of sickness absence, 71% of the workers had full RTW, 9.1% was censored because they resigned, and 19.9% did not have full RTW. High physical job demands (HR .562, CI .348–.908), contact with medical specialists (HR .691, CI .560–.854), high physical symptoms (HR .744, CI .583–.950), moderate to severe depressive symptoms (HR .748, CI .569–.984) and older age (HR .776, CI .628–.958) were associated with a longer duration until RTW in sick-listed workers. Conclusions Sick-listed workers with older age, moderate to severe depressive symptoms, high physical symptoms, high physical job demands and contact with medical specialists are at increased risk for a longer duration of sickness absence. OPs need to be aware of these factors to identify workers who will most likely benefit from an early intervention.
doi:10.1007/s10926-011-9326-0
PMCID: PMC3274679  PMID: 21842133
Return to work; Long-term sickness absence; Prognostic factors
4.  Should office workers spend fewer hours at their computer? A systematic review of the literature 
Worldwide, millions of office workers use a computer. Reports of adverse health effects due to computer use have received considerable media attention. This systematic review summarises the evidence for a relationship between the duration of work time spent using the computer and the incidence of hand–arm and neck–shoulder symptoms and disorders. Several databases were systematically searched up to 6 November 2005. Two reviewers independently selected articles that presented a risk estimate for the duration of computer use, included an outcome measure related to hand–arm or neck–shoulder symptoms or disorders, and had a longitudinal study design. The strength of the evidence was based on methodological quality and consistency of the results. Nine relevant articles were identified, of which six were rated as high quality. Moderate evidence was concluded for a positive association between the duration of mouse use and hand–arm symptoms. For this association, indications for a dose–response relationship were found. Risk estimates were in general stronger for the hand–arm region than for the neck–shoulder region, and stronger for mouse use than for total computer use and keyboard use. A pathophysiological model focusing on the overuse of muscles during computer use supports these differences. Future studies are needed to improve our understanding of safe levels of computer use by measuring the duration of computer use in a more objective way, differentiating between total computer use, mouse use and keyboard use, attaining sufficient exposure contrast, and collecting data on disability caused by symptoms.
doi:10.1136/oem.2006.026468
PMCID: PMC2078461  PMID: 17095550
5.  The effectiveness of graded activity for low back pain in occupational healthcare 
Background
Low back pain is a common medical and social problem associated with disability and absence from work. Knowledge on effective return to work (RTW) interventions is scarce.
Objective
To determine the effectiveness of graded activity as part of a multistage RTW programme.
Design
Randomised controlled trial.
Setting
Occupational healthcare.
Subjects
112 workers absent from work for more than eight weeks due to low back pain were randomised to either graded activity (n = 55) or usual care (n = 57).
Intervention
Graded activity, a physical exercise programme aimed at RTW based on operant‐conditioning behavioural principles.
Main outcome measures
The number of days off work until first RTW for more then 28 days, total number of days on sick leave during follow up, functional status, and severity of pain. Follow up was 26 weeks.
Results
Graded activity prolonged RTW. Median time until RTW was equal to the total number of days on sick leave and was 139 (IQR = 69) days in the graded activity group and 111 (IQR = 76) days in the usual care group (hazard ratio = 0.52, 95% CI 0.32 to 0.86). An interaction between a prior workplace intervention and graded activity, together with a delay in the start of the graded activity intervention, explained most of the delay in RTW (hazard ratio = 0.86, 95% CI 0.40 to 1.84 without prior intervention and 0.39, 95% CI 0.19 to 0.81 with prior intervention). Graded activity did not improve pain or functional status clinically significantly.
Conclusions
Graded activity was not effective for any of the outcome measures. Different interventions combined can lead to a delay in RTW. Delay in referral to graded activity delays RTW. In implementing graded activity special attention should be paid to the structure and process of care.
doi:10.1136/oem.2005.021675
PMCID: PMC2077992  PMID: 16847036
low back pain; graded activity; randomised controlled trial; effectiveness; cognitive behavioural; return‐to‐work
6.  Long term health complaints following the Amsterdam Air Disaster in police officers and fire‐fighters 
Background
On 4 October 1992, a cargo aircraft crashed into apartment buildings in Amsterdam, the Netherlands. Fire‐fighters and police officers assisted with the rescue work.
Objectives
To examine the long term health complaints in rescue workers exposed to a disaster.
Methods
A historical cohort study was performed among police officers (n = 834) and fire‐fighters (n = 334) who performed at least one disaster related task and reference groups of their non‐exposed colleagues (n = 634 and n = 194, respectively). The main outcome measures included digestive, cardiovascular, musculoskeletal, nervous system, airway, skin, post‐traumatic stress, fatigue, and general mental health complaints; haematological and biochemical laboratory values; and urinalysis outcomes.
Results
Police officers and fire‐fighters who were professionally exposed to a disaster reported more physical and mental health complaints, compared to the reference groups. No clinically relevant statistically significant differences in laboratory outcomes were found.
Conclusions
This study is the first to examine long term health complaints in a large sample of rescue workers exposed to a disaster in comparison to reference groups of non‐exposed colleagues. Findings show that even in the long term, and in the absence of laboratory abnormalities, rescue workers report more health complaints.
doi:10.1136/oem.2005.024687
PMCID: PMC2078049  PMID: 16644894
health effects; long‐term; disaster; rescue workers; ESADA
7.  Physical capacity in relation to low back, neck, or shoulder pain in a working population 
Aims
To investigate the longitudinal relation between physical capacity (isokinetic lifting strength, static endurance of the back, neck, and shoulder muscles, and mobility of the spine) and low back, neck, and shoulder pain.
Methods
In this prospective cohort study, 1789 Dutch workers participated. At baseline, isokinetic lifting strength, static endurance of the back, neck, and shoulder muscles, and mobility of the spine were measured in the pain free workers, as well as potential confounders, including physical workload. Low back, neck, and shoulder pain were self‐reported annually at baseline and three times during follow up.
Results
After adjustment for confounders, Poisson generalised estimation equations showed an increased risk of low back pain among workers in the lowest sex specific tertile of performance in the static back endurance tests compared to workers in the reference category (RR = 1.42; 95% CI 1.19 to 1.71), but this was not found for isokinetic trunk lifting strength or mobility of the spine. An increased risk of neck pain was shown for workers with low performance in tests of isokinetic neck/shoulder lifting strength (RR = 1.31; 95% CI 1.03 to 1.67) and static neck endurance (RR = 1.22; 95% CI 1.00 to 1.49). Among workers in the lowest tertiles of isokinetic neck/shoulder lifting strength or endurance of the shoulder muscles, no increased risk of shoulder pain was found.
Conclusions
The findings of this study suggest that low back or neck endurance were independent predictors of low back or neck pain, respectively, and that low lifting neck/shoulder strength was an independent predictor of neck pain. No association was found between lifting trunk strength, or mobility of the spine and the risk of low back pain, nor between lifting neck/shoulder strength or endurance of the shoulder muscles and the risk of shoulder pain.
doi:10.1136/oem.2006.026914
PMCID: PMC2078108  PMID: 16709701
cohort studies; muscle strength; endurance; low back pain; neck pain
8.  Counselling increases physical activity behaviour nine weeks after rehabilitation 
Background
For people with disabilities, a physically active lifestyle can reduce the risk of secondary health problems and improve overall functioning.
Objectives
To determine the effects of the sport stimulation programme “rehabilitation and sports” (R&S) and R&S combined with the daily physical activity promotion programme “active after rehabilitation” (AaR) on sport participation and daily physical activity behaviour nine weeks after inpatient or outpatient rehabilitation.
Methods
Subjects in four intervention rehabilitation centres were randomised to a group receiving R&S only (n  =  315) or a group receiving R&S and AaR (n  =  284). Subjects in six control rehabilitation centres (n  =  603) received the usual care. Most common diagnoses were stroke, neurological disorders, and back disorders. Two sport and two daily physical activity outcomes were assessed with questionnaires seven weeks before and nine weeks after the end of rehabilitation. Data were analysed by intention to treat and on treatment multilevel analyses, comparing both intervention groups with the control group.
Results
The R&S group showed no significant change. Intention to treat analyses of the R&S+AaR group showed significant improvements in one sport (p  =  0.02) and one physical activity outcome (p  =  0.03). On treatment analyses in the R&S+AaR group showed significant improvements in both sport outcomes (p<0.01 and p  =  0.02) and one physical activity outcome (p<0.01).
Conclusions
Only the combination of R&S and AaR had increased sports participation and daily physical activity behaviour nine weeks after the end of inpatient or outpatient rehabilitation.
doi:10.1136/bjsm.2005.021139
PMCID: PMC2491980  PMID: 16505078
rehabilitation; disabilities; physical exercise; leisure activities; counselling
9.  An economic evaluation of a proprioceptive balance board training programme for the prevention of ankle sprains in volleyball 
Objectives: To evaluate the cost effectiveness of a proprioceptive balance board training programme for the prevention of ankle sprains in volleyball.
Methods: A total of 116 volleyball teams participated in this study which was carried out during the 2001–2002 volleyball season. Teams were randomly allotted to an intervention group (66 teams, 628 players) or a control group (52 teams, 494 players). Intervention teams followed a prescribed balance board training programme as part of their warm up. Control teams followed their normal training routine. An ankle sprain was recorded if it occurred as a result of volleyball and caused the subject to stop volleyball activity. The injured player completed a cost diary for the duration of the ankle sprain. Analyses were performed according to the intention to treat principle. Mean direct, indirect, and total costs were calculated and were compared between the two groups.
Results: The total costs per player (including the intervention material) were significantly higher in the intervention group (€36.99 (93.87)) than in the control group (€18.94 (147.09)). The cost of preventing one ankle sprain was approximately €444.03. Sensitivity analysis showed that a proprioceptive balance board training programme aimed only at players with previous ankle sprains could be cost effective over a longer period of time.
Conclusions: Positive effects of the balance board programme could only be achieved at certain costs. However, if broadly implemented, costs associated with the balance board programme would probably be lower.
doi:10.1136/bjsm.2003.011031
PMCID: PMC1725110  PMID: 15665210
10.  The effectiveness of ergonomic interventions on return-to-work after low back pain; a prospective two year cohort study in six countries on low back pain patients sicklisted for 3–4 months 
Aims: To study occurrence and effectiveness of ergonomic interventions on return-to-work applied for workers with low back pain (LBP).
Methods: A multinational cohort of 1631 workers fully sicklisted 3–4 months due to LBP (ICD-9 codes 721, 722, 724) was recruited from sickness benefit claimants databases in Denmark, Germany, Israel, Sweden, the Netherlands, and the United States. Medical, ergonomic, and other interventions, working status, and return-to-work were measured using questionnaires and interviews at three months, one and two years after the start of sickleave. Main outcome measure was time to return-to-work. Cox's proportional hazards model was used to calculate hazard ratios regarding the time to return-to-work, adjusted for prognostic factors.
Results: Ergonomic interventions varied considerably in occurrence between the national cohorts: 23.4% (mean) of the participants reported adaptation of the workplace, ranging from 15.0% to 30.5%. Adaptation of job tasks and adaptation of working hours was applied for 44.8% (range 41.0–59.2%) and 46.0% (range 19.9–62.9%) of the participants, respectively. Adaptation of the workplace was effective on return-to-work rate with an adjusted hazard ratio (HR) of 1.47 (95% CI 1.25 to 1.72; p < 0.0001). Adaptation of job tasks and adaptation of working hours were effective on return-to-work after a period of more than 200 days of sickleave with an adjusted HR of 1.78 (95% CI 1.42 to 2.23; p < 0.0001) and 1.41 (95% CI 1.13 to 1.76; p = 0.002), respectively.
Conclusions: Results suggest that ergonomic interventions are effective on return-to-work of workers long term sicklisted due to LBP.
doi:10.1136/oem.2002.006460
PMCID: PMC1740746  PMID: 15031385
11.  Worksite health promotion using individual counselling and the effectiveness on sick leave; results of a randomised controlled trial 
Aims: To investigate the effectiveness of a worksite health promotion programme by individual counselling on sick leave.
Methods: Three municipal services of Enschede, the Netherlands, participated in this trial. A total of 299 civil servants were measured at baseline and were randomised by cluster into the intervention (n = 131) or the control group (n = 168). During nine months, subjects in the intervention group received a total of seven consultations, particularly aimed at increasing their physical activity level and improving their dietary habits. Both the intervention and the control subjects received written information as to several lifestyle factors. Sick leave data regarding the nine month intervention period (from May until January) were collected from each municipal service's personnel department. In addition, sick leave data concerning the nine month period pre- and post-intervention were collected. Sick leave data were analysed using multilevel analysis.
Results: For both groups, the mean sick leave rate during the intervention increased compared to before the intervention. After the intervention period, the control group increased even more (from 22.9 to 27.6 days), whereas the intervention group slightly decreased (from 21.5 to 20.5 days). Median values of sick leave rate decreased for both groups. No statistically significant intervention effect was found. In both groups, the mean sick leave frequency slightly decreased over time (intervention effects were not significant).
Conclusions: Results showed no significant effect of individual counselling on sick leave. Continued research investigating the effectiveness of this individual counselling programme on several health related outcomes is useful to clarify the trend observed in sick leave.
doi:10.1136/oem.2002.005769
PMCID: PMC1740726  PMID: 14985524
12.  Once a week is not enough: effects of a widely implemented group based exercise programme for older adults; a randomised controlled trial 
Objectives: To determine the effects of gymnastics on the health related quality of life (HRQoL) and functional status of independently living people, aged 65 to 80 years. Gymnastics formed part of the More Exercise for Seniors (MBvO in Dutch) programme, a group based exercise programme for older adults in the Netherlands. It has been widely implemented since 1980.
Design: Randomised controlled trial with pretest and post-test measurements.
Intervention: The exercise programme given by experienced instructors lasted 10 weeks and was given weekly (MBvO1; n = 125, six groups) or twice weekly (MBvO2; n = 68, six groups). The control group (n = 193) was offered a health education programme.
Setting: Community dwelling of older people, with a comparatively low level of fitness as assessed with the Groningen Fitness test for the Elderly.
Results: No significant effects were found on the HRQoL (Vitality Plus Scale, TAAQoL, and RAND-36) and the functional status (Physical Performance Test and the Groningen Activity Restriction Scale). The MBvO2 group, with a low level of physical activity at baseline, showed the only improvement found on the Vitality Plus Scale (F = 4.53; p = 0.01).
Conclusions: MBvO gymnastics once a week did not provide benefits in HRQoL and functional status after 10 weeks. However, participants with a low level of physical activity may benefit from MBvO gymnastics if they participate twice a week. To improve the health of the general public, sedentary older adults should be recruited and encouraged to combine MBvO with the health enhancing physical activity guidelines.
doi:10.1136/jech.58.2.83
PMCID: PMC1732684  PMID: 14729881
13.  Short term effect of feedback on fitness and health measurements on self reported appraisal of the stage of change 
Background: An individual's current status of physical activity and nutrition and readiness to change can be determined using PACE assessment forms. Practitioners have suggested that feedback on the fitness and health components can produce a change in a subject's awareness of their behaviour and thereby lead to a beneficial change in stage of behaviour change.
Objective: To evaluate the short term effect of personalised feedback on fitness and health status on self reported appraisal of the stage of change.
Methods: A total of 299 civil servants were randomised to an intervention or a reference group. After having been tested for fitness and health, the intervention group received immediate feedback on their test results, whereas the reference group did not. PACE assessment forms were completed twice: before testing and after testing (reference group), or after testing and feedback (intervention group). The time interval between was one hour. The influence of feedback was determined using a x2 test and analysis of variance.
Results: On the basis of the x2 test, no significant effect of feedback was found on the stage of change of physical activity, nor on the stage of change with regard to nutrition. Analysis of variance results showed no significant effect on the raw PACE score as to physical activity, intake of fruit and vegetables and dietary fat. However, a significant effect was observed on the PACE score of "calorie intake and weight management". Subjects in the intervention group significantly more often regressed on their PACE score on this topic than the reference subjects.
Conclusions: Feedback at baseline on measurements of an intervention study can influence PACE scores and can be considered as a small but relevant start of the intervention itself.
doi:10.1136/bjsm.37.6.529
PMCID: PMC1724704  PMID: 14665593
14.  Occupational health guidelines for the management of low back pain: an international comparison 
Background: The enormous socioeconomic burden of low back pain emphasises the need for effective management of this problem, especially in an occupational context. To address this, occupational guidelines have been issued in various countries.
Aims: To compare available international guidelines dealing with the management of low back pain in an occupational health care setting.
Methods: The guidelines were compared regarding generally accepted quality criteria using the AGREE instrument, and also summarised regarding the guideline committee, the presentation, the target group, and assessment and management recommendations (that is, advice, return to work strategy, and treatment).
Results and Conclusions: The results show that the quality criteria were variously met by the guidelines. Common flaws concerned the absence of proper external reviewing in the development process, lack of attention to organisational barriers and cost implications, and lack of information on the extent to which editors and developers were independent. There was general agreement on numerous issues fundamental to occupational health management of back pain. The assessment recommendations consisted of diagnostic triage, screening for "red flags" and neurological problems, and the identification of potential psychosocial and workplace barriers for recovery. The guidelines also agreed on advice that low back pain is a self limiting condition and, importantly, that remaining at work or an early (gradual) return to work, if necessary with modified duties, should be encouraged and supported.
doi:10.1136/oem.60.9.618
PMCID: PMC1740612  PMID: 12937181
16.  Ineffective disability management by doctors is an obstacle for return-to-work: a cohort study on low back pain patients sicklisted for 3–4 months 
Aims: To determine obstacles for return-to-work in disability management of low back pain patients sicklisted for 3–4 months.
Methods: A cohort of 467 low back pain patients sicklisted for 3–4 months was recruited. A questionnaire was sent to their occupational physicians (OPs) concerning the medical management, obstacles to return-to-work, and the communication with treating physicians.
Results: The OPs of 300 of 467 patients participated in this study. In many cases OPs regarded the clinical waiting period (43%), duration of treatment (41%), and view (25%) of the treating physicians as obstacles for return-to-work. Psychosocial obstacles for return-to-work such as mental blocks, a lack of job motivation, personal problems, and conflicts at work were all mentioned much less frequently by OPs. In only 19% of the patients was there communication between OP and treating physician. Communication almost always entailed an exchange of information, and less frequently an attempt to harmonise the management policy. Surprisingly communication was also limited, when OPs felt that the waiting period (32%), duration of treatment (30%), and view (28%) of treating physicians inhibited return-to-work. Communication was significantly associated with the following obstacles for return-to-work: passivity with regard to return-to-work and clinical waiting period; adjusted odds ratios were 3.35 and 2.23, respectively.
Conclusions: Medical management of treating physicians is often an obstacle for return to work regarding low back pain patients sicklisted for 3–4 months, in the opinion of OPs. Nevertheless communication between OPs and the treating physicians in disability management of these patients is limited. More attention to prevention of absenteeism and bilateral communication is needed in medical courses.
doi:10.1136/oem.59.11.729
PMCID: PMC1740234  PMID: 12409530
17.  Comparison of two different approaches for the analysis of data from a prospective cohort study: an application to work related risk factors for low back pain 
Aims: To compare the results of a traditional approach using standard regression for the analysis of data from a prospective cohort study with the results of generalised estimating equations (GEE) analysis.
Methods: The research was part of a three year prospective cohort study on work related risk factors for low back pain. The study population consisted of a cohort of 1192 workers with no low back pain at baseline. Information on work related physical and psychosocial factors and the occurrence of low back pain was obtained by means of questionnaires at baseline and at the three annual follow up measurements. In a traditional standard logistic regression model, physical and psychosocial risk factors at baseline were related to the cumulative incidence of low back pain during the three year follow up period. In a GEE logistic model, repeated measurements of the physical and psychosocial risk factors were related to low back pain reported at one measurement point later.
Results: The traditional standard regression model showed a significant effect of flexion and/or rotation of the upper part of the body (OR = 1.8; 95% CI: 1.2 to 3.0), but not of moving heavy loads (OR = 1.4; 95% CI: 0.7 to 3.1). The GEE model showed a significant effect of both flexion and/or rotation of the upper part of the body (OR = 2.2; 95% CI: 1.5 to 3.3) and moving heavy loads (OR = 1.5; 95% CI: 1.0 to 2.4). No significant associations with low back pain were found for the psychosocial work characteristics with either method, but the GEE model showed weaker odds ratios for these variables than the traditional standard regression model.
Conclusions: Results show that there are differences between the two analytical approaches in both the magnitude and the precision of the observed odds ratios.
doi:10.1136/oem.59.7.459
PMCID: PMC1740320  PMID: 12107294
18.  High physical work load and low job satisfaction increase the risk of sickness absence due to low back pain: results of a prospective cohort study 
Objective: To determine whether physical and psychosocial load at work influence sickness absence due to low back pain.
Methods: The research was a part of the study on musculoskeletal disorders, absenteeism, stress, and health (SMASH), a 3 year prospective cohort study on risk factors for musculoskeletal disorders. Workers from 21 companies located throughout The Netherlands participated in the part of this study on sickness absence due to low back pain. The study population consisted of 732 workers with no sickness absences of 3 days or longer due to low back pain in the 3 months before the baseline survey and complete data on the reasons for absences during the follow up period. The mean (range) period of follow up in this group was 37 (7–44) months. Physical load at work was assessed by analyses of video recordings. Baseline information on psychosocial work characteristics was obtained by a questionnaire. Data on sickness absence were collected from company records. The main outcome measure was the rate of sickness absences of 3 days or longer due to low back pain during the follow up period.
Results: After adjustment of the work related physical and psychosocial factors for each other and for other potential determinants, significant rate ratios ranging from 2.0 to 3.2 were found for trunk flexion, trunk rotation, lifting, and low job satisfaction. A dose-response relation was found for trunk flexion, but not for trunk rotation or lifting. Non-significant rate ratios of about 1.4 were found for low supervisor support and low coworker support. Quantitative job demands, conflicting demands, decision authority, and skill discretion showed no relation with sickness absence due to low back pain.
Conclusions: Flexion and rotation of the trunk, lifting, and low job satisfaction are risk factors for sickness absence due to low back pain. Some indications of a relation between low social support, either from supervisors or coworkers, and sickness absence due to low back pain are also present.
doi:10.1136/oem.59.5.323
PMCID: PMC1740286  PMID: 11983847
19.  Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study 
OBJECTIVE—To study the relation between neck pain and work related neck flexion, neck rotation, and sitting.
METHODS—A prospective cohort study was performed with a follow up of 3 years among 1334 workers from 34 companies. Work related physical load was assessed by analysing objectively measured exposure data (video recordings) of neck flexion, neck rotation, and sitting posture. Neck pain was assessed by a questionnaire. Adjustments were made for various physical factors that were related or not related to work, psychosocial factors, and individual characteristics.
RESULTS—A significant positive relation was found between the percentage of the working time in a sitting position and neck pain, implying an increased risk of neck pain for workers who were sitting for more than 95% of the working time (crude relative risk (RR) 2.01, 95% confidence interval (95% CI) 1.04 to 3.88; adjusted RR 2.34, 95% CI 1.05 to 5.21). A trend for a positive relation between neck flexion and neck pain was found, suggesting an increased risk of neck pain for people working with the neck at a minimum of 20° of flexion for more than 70% of the working time (crude RR 2.01, 95% CI 0.98 to 4.11; adjusted RR 1.63, 95% CI 0.70 to 3.82). No clear relation was found between neck rotation and neck pain.
CONCLUSION—Sitting at work for more than 95% of the working time seems to be a risk factor for neck pain and there is a trend for a positive relation between neck flexion and neck pain. No clear relation was found between neck rotation and neck pain.


Keywords: neck pain; physical risk factors; longitudinal cohort study
doi:10.1136/oem.58.3.200
PMCID: PMC1740110  PMID: 11171934
21.  What works in school-based energy balance behaviour interventions and what does not? A systematic review of mediating mechanisms 
Objective:
Obesity prevention requires effective interventions targeting the so-called energy balance-related behaviours (that is, physical activity, sedentary and dietary behaviours). To improve (cost-)effectiveness of these interventions, one needs to know the working mechanisms underlying behavioural change. Mediation analyses evaluates whether an intervention works via hypothesised working mechanisms. Identifying mediators can prompt intervention developers to strengthen effective intervention components and remove/adapt ineffective components. This systematic review aims to identify psychosocial and environmental mediators of energy balance-related behaviours interventions for youth.
Method:
Studies were identified by a systematic search of electronic databases (Pubmed, Embase, PsycINFO, ERIC and SPORTDiscus). Studies were included if they (1) were school-based randomised controlled or quasi-experimental studies; (2) targeted energy balance behaviours; (3) conducted among children and adolescents (4–18 years of age); (4) written in English; and (5) conducted mediation analyses.
Results:
A total of 24 studies were included. We found strong evidence for self-efficacy and moderate evidence for intention as mediators of physical activity interventions. Indications were found for attitude, knowledge and habit strength to be mediators of dietary behaviour interventions. The few sedentary behaviour interventions reporting on mediating effects prevented us from forming strong conclusions regarding mediators of sedentary behaviour interventions. The majority of interventions failed to significantly change hypothesised mediators because of ineffective intervention strategies, low power and/or use of insensitive measures.
Conclusion:
Despite its importance, few studies published results of mediation analysis, and more high-quality research into relevant mediators is necessary. On the basis of the limited number of published studies, self-efficacy and intention appear to be relevant mediators for physical activity interventions. Future intervention developers are advised to provide information on the theoretical base of their intervention including the strategies applied to provide insight into which strategies are effective in changing relevant mediators. In addition, future research is advised to focus on the development, validity, reliability and sensitivity of mediator measures.
doi:10.1038/ijo.2011.68
PMCID: PMC3191379  PMID: 21487398
mediator; physical activity; diet; intervention; sedentary behaviour; youth
22.  The Implementation of Multiple Lifestyle Interventions in Two Organizations 
Objective:
To evaluate the implementation of a multicomponent lifestyle intervention at two different worksites.
Methods:
Data on eight process components were collected by means of questionnaires and interviews. Data on the effectiveness were collected using questionnaires.
Results:
The program was implemented partly as planned, and 84.0% (max 25) and 85.7% (max 14) of all planned interventions were delivered at the university and hospital, respectively. Employees showed high reach (96.6%) and overall participation (75.1%) but moderate overall satisfaction rates (6.8 ± 1.1). Significant intervention effects were found for days of fruit consumption (β = 0.44 days/week, 95% CI: 0.02 to 0.85) in favor of the intervention group.
Conclusions:
The study showed successful reach, dose, and maintenance but moderate fidelity and satisfaction. Mainly relatively simple and easily implemented interventions were chosen, which were effective only in improving employees’ days of fruit consumption.
doi:10.1097/JOM.0000000000000241
PMCID: PMC4219515  PMID: 25376415
23.  Relation between the longitudinal development of lipoprotein levels and biological parameters during adolescence and young adulthood in Amsterdam, The Netherlands. 
STUDY OBJECTIVES: To analyse the relation between the longitudinal development of total serum cholesterol (TC), high density lipoprotein cholesterol (HDL), and the TC/ HDL ratio and the longitudinal development of the biological parameters body fatness (SSF), lean body mass (LBM), and cardiopulmonary fitness (VO2-max). The relations were analysed with generalised estimating equations (GEE). SETTING: The relations were investigated with data from the Amsterdam growth and health study, a longitudinal study in which six measurements were carried out within a period of 15 years. PARTICIPANTS: Altogether 98 females and 84 males aged 13 years at the start of the study. MAIN RESULTS: Adjusted for lifestyle and other biological parameters, the longitudinal development of TC was inversely related to the development of LBM (standardised regression coefficient beta = -0.27; p < or = 0.01) and positively to SSF (beta males = 0.32; p < or = 0.01 and beta females = 0.15; p < or = 0.01). HDL was inversely related to LBM (beta = -0.26; p < or = 0.01) and positively to VO2-max (beta = 0.08; p < or = 0.05). The TC/HDL ratio was positively related to SSF (beta males = 0.39; p < or = 0.01 and beta females = 0.13; p < or = 0.01) and inversely to VO2-max (beta = -0.09; p < or = 0.05). CONCLUSIONS: The longitudinal analyses showed that body fatness was related to a high risk profile with respect to hypercholesterolaemia, and cardiopulmonary fitness to a low risk profile. Furthermore, it was shown that using body mass index as an indicator of body fatness in relation to lipoprotein values, has some important drawbacks.
PMCID: PMC1060340  PMID: 8944855

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