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1.  Socioeconomic and Psychosocial Adversity in Midlife and Depressive Symptoms Post Retirement: A 21-year Follow-up of the Whitehall II Study 
We examined whether socioeconomic and psychosocial adversity in midlife predicts post-retirement depressive symptoms.
Design and Setting
A prospective cohort study of British civil servants who responded to a self-administered questionnaire in middle-age and at older ages, 21 years later.
The study sample consisted of 3,939 Whitehall II Study participants (2,789 men, 1,150 women; mean age 67.6 years at follow-up) who were employed at baseline and retired at follow-up.
Midlife adversity was assessed by self-reported socioeconomic adversity (low occupational position; poor standard of living) and psychosocial adversity (high job strain; few close relationships). Symptoms of depression post-retirement were measured by the Center for Epidemiologic Studies Depression scale.
After adjustment for sociodemographic and health-related covariates at baseline and follow-up, there were strong associations between midlife adversities and post-retirement depressive symptoms: low occupational position (odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.15–2.51), poor standard of living (OR: 2.37, 95% CI: 1.66–3.39), high job strain (OR: 1.52, 95% CI: 1.09–2.14), and few close relationships (OR: 1.51, 95% CI: 1.12–2.03). The strength of the associations between socioeconomic, psychosocial, work-related, or non-work related exposures and depressive symptoms was similar.
Robust associations from observational data suggest that several socioeconomic and psychosocial risk factors for symptoms of depression post-retirement can be detected already in midlife.
PMCID: PMC4270962  PMID: 24816123
Depression; elderly; inequalities; life course; mood disorders; old age; prospective; stress
2.  Inflows of foreign-born physicians and their access to employment and work experiences in health care in Finland: qualitative and quantitative study 
In many developed countries, including Finland, health care authorities customarily consider the international mobility of physicians as a means for addressing the shortage of general practitioners (GPs). This study i) examined, based on register information, the numbers of foreign-born physicians migrating to Finland and their employment sector, ii) examined, based on qualitative interviews, the foreign-born GPs’ experiences of accessing employment and work in primary care in Finland, and iii) compared experiences based on a survey of the psychosocial work environment among foreign-born physicians working in different health sectors (primary care, hospitals and private sectors).
Three different data sets were used: registers, theme interviews among foreign-born GPs (n = 12), and a survey for all (n = 1,292; response rate 42%) foreign-born physicians living in Finland. Methods used in the analyses were qualitative content analysis, analysis of covariance, and logistic regression analysis.
The number of foreign-born physicians has increased dramatically in Finland since the year 2000. In 2000, a total of 980 foreign-born physicians held a Finnish licence and lived in Finland, accounting for less than 4% of the total number of practising physicians. In 2009, their proportion of all physicians was 8%, and a total of 1,750 foreign-born practising physicians held a Finnish licence and lived in Finland. Non-EU/EEA physicians experienced the difficult licensing process as the main obstacle to accessing work as a physician. Most licensed foreign-born physicians worked in specialist care. Half of the foreign-born GPs could be classified as having an ‘active’ job profile (high job demands and high levels of job control combined) according to Karasek’s demand-control model. In qualitative interviews, work in the Finnish primary health centres was described as multifaceted and challenging, but also stressful.
Primary care may not be able in the long run to attract a sufficient number of foreign-born GPs to alleviate Finland’s GP shortage, although speeding up the licensing process may bring in more foreign-born physicians to work, at least temporarily, in primary care. For physicians to be retained as active GPs there needs to be improvement in the psychosocial work environment within primary care.
PMCID: PMC4139137  PMID: 25103861
General practitioners; Finland; Physicians; Primary care; Professional migration
3.  Improving Diabetes care through Examining, Advising, and prescribing (IDEA): protocol for a theory-based cluster randomised controlled trial of a multiple behaviour change intervention aimed at primary healthcare professionals 
New clinical research findings may require clinicians to change their behaviour to provide high-quality care to people with type 2 diabetes, likely requiring them to change multiple different clinical behaviours. The present study builds on findings from a UK-wide study of theory-based behavioural and organisational factors associated with prescribing, advising, and examining consistent with high-quality diabetes care.
To develop and evaluate the effectiveness and cost of an intervention to improve multiple behaviours in clinicians involved in delivering high-quality care for type 2 diabetes.
We will conduct a two-armed cluster randomised controlled trial in 44 general practices in the North East of England to evaluate a theory-based behaviour change intervention. We will target improvement in six underperformed clinical behaviours highlighted in quality standards for type 2 diabetes: prescribing for hypertension; prescribing for glycaemic control; providing physical activity advice; providing nutrition advice; providing on-going education; and ensuring that feet have been examined. The primary outcome will be the proportion of patients appropriately prescribed and examined (using anonymised computer records), and advised (using anonymous patient surveys) at 12 months. We will use behaviour change techniques targeting motivational, volitional, and impulsive factors that we have previously demonstrated to be predictive of multiple health professional behaviours involved in high-quality type 2 diabetes care. We will also investigate whether the intervention was delivered as designed (fidelity) by coding audiotaped workshops and interventionist delivery reports, and operated as hypothesised (process evaluation) by analysing responses to theory-based postal questionnaires. In addition, we will conduct post-trial qualitative interviews with practice teams to further inform the process evaluation, and a post-trial economic analysis to estimate the costs of the intervention and cost of service use.
Consistent with UK Medical Research Council guidance and building on previous development research, this pragmatic cluster randomised trial will evaluate the effectiveness of a theory-based complex intervention focusing on changing multiple clinical behaviours to improve quality of diabetes care.
Trial registration
PMCID: PMC4049486  PMID: 24886606
4.  Extending Employment beyond the Pensionable Age: A Cohort Study of the Influence of Chronic Diseases, Health Risk Factors, and Working Conditions 
PLoS ONE  2014;9(2):e88695.
In response to the economic consequences of ageing of the population, governments are seeking ways with which people might work into older age. We examined the association of working conditions and health with extended employment (defined as >6 months beyond the pensionable age) in a cohort of older, non-disabled employees who have reached old-age retirement.
A total of 4,677 Finnish employees who reached their old-age pensionable date between 2005 and 2011 (mean age 59.8 years in 2005, 73% women) had their survey responses before pensionable age linked to national health and pension registers, resulting in a prospective cohort study.
In all, 832 participants (17.8%) extended their employment by more than 6 months beyond the pensionable date. After multivariable adjustment, the following factors were associated with extended employment: absence of diagnosed mental disorder (OR 1.25, 95% confidence interval = 1.01–1.54) and psychological distress (OR 1.68; 1.35–2.08) and of the work characteristics, high work time control (OR 2.31; 1.88–2.84). The projected probability of extended employment was 21.3% (19.5–23.1) among those free of psychiatric morbidity and with high work time control, while the corresponding probability was only 9.2% (7.4–11.4) among those with both psychiatric morbidity and poor work time control. The contribution of chronic somatic diseases was modest.
In the present study, good mental health in combination with the opportunity to control work time seem to be key factors in extended employment into older age. In addition, high work time control might promote work life participation irrespective of employees' somatic disease status.
PMCID: PMC3929527  PMID: 24586372
5.  Differences in Well-being between GPs, Medical Specialists, and Private Physicians: The Role of Psychosocial Factors 
Health Services Research  2011;47(1 Pt 1):68-85.
To examine the well-being differences among physicians working in different health care sectors and to test whether psychosocial stressors account for these differences. The well-being indicators used were psychological distress, self-rated health, and work ability.
Data Sources/Study Setting
A total of 2,841 randomly selected Finnish physicians (response rate 57 percent) returned the postal questionnaire, of which 2,047 (1,241 women) fulfilled all the participant criteria.
Study Design
This is a cross-sectional questionnaire study.
Principal Findings
General practitioners and medical specialists experienced lower well-being than private physicians and this difference was partly explained by differences in psychosocial stressors.
General practitioners and medical specialists report more problems in well-being than private physicians. It is of particular importance to be aware of the sector-specific difficulties in work environments.
PMCID: PMC3447254  PMID: 22091688
Primary care; secondary care; private health care; physician well-being; psychosocial factors
6.  The prospective effects of workplace violence on physicians’ job satisfaction and turnover intentions: the buffering effect of job control 
Health care professionals, including physicians, are at high risk of encountering workplace violence. At the same time physician turnover is an increasing problem that threatens the functioning of the health care sector worldwide. The present study examined the prospective associations of work-related physical violence and bullying with physicians’ turnover intentions and job satisfaction. In addition, we tested whether job control would modify these associations.
The present study was a 4-year longitudinal survey study, with data gathered in 2006 and 2010.The present sample included 1515 (61% women) Finnish physicians aged 25–63 years at baseline. Analyses of covariance (ANCOVA) were conducted while adjusting for gender, age, baseline levels, specialisation status, and employment sector.
The results of covariance analyses showed that physical violence led to increased physician turnover intentions and that both bullying and physical violence led to reduced physician job satisfaction even after adjustments. We also found that opportunities for job control were able to alleviate the increase in turnover intentions resulting from bullying.
Our results suggest that workplace violence is an extensive problem in the health care sector and may lead to increased turnover and job dissatisfaction. Thus, health care organisations should approach this problem through different means, for example, by giving health care employees more opportunities to control their own work.
PMCID: PMC3898009  PMID: 24438449
Job control; Work-related violence; Psychosocial resources; Intentions to quit; Physicians
7.  Socio-economic position and mental disorders in a working-age Finnish population: the health 2000 study 
Background: Mental disorders are more common in people with lower socio-economic position (SEP) but it is not known which specific SEP component is most strongly linked to poor mental health. We compared the strength of associations of three SEP components—occupation, income and education—with common mental disorders in a Finnish population. Methods: Cross-sectional analysis of a nationally representative sample of 4561 men and women aged 30–65 years. Mental disorders were assessed using the Composite International Diagnostic Interview resulting in 12-month DSM-IV diagnoses of depressive, anxiety and alcohol use disorders. Participants were classified as having low SEP if they worked in a manual occupation, lacked secondary-level education or had income below the Organisation for Economic Co-operation and Development (OECD) definition of relative poverty. Results: In models comparing the simultaneous association of all three socio-economic indicators with mental disorders, low income was associated with increased risk for depressive disorder [odds ratio (OR)=1.73, 95% confidence interval (CI) =1.31–2.29] and anxiety disorder (OR=1.56, 95% CI 1.14–2.12). Manual occupational class was modestly associated with risk for alcohol use disorder (OR=1.44, 95% CI 1.06–1.95). Low income was the only socio-economic component associated with psychiatric comorbidity, that is, a combination of various disorders within the same individual (OR 2.26, 95% CI 1.52–3.37 for any combination). Conclusion: Low income seems to be a more important correlate of mental disorders than education or occupation in a high-income country such as Finland.
PMCID: PMC3358631  PMID: 21953062
9.  Correction: Diabetes Care Provision in UK Primary Care Practices 
PLoS ONE  2012;7(8):10.1371/annotation/1957ad3b-e192-4faa-bf4c-5dce22c5560e.
PMCID: PMC3414526
10.  Diabetes Care Provision in UK Primary Care Practices 
PLoS ONE  2012;7(7):e41562.
Although most people with Type 2 diabetes receive their diabetes care in primary care, only a limited amount is known about the quality of diabetes care in this setting. We investigated the provision and receipt of diabetes care delivered in UK primary care.
Postal surveys with all healthcare professionals and a random sample of 100 patients with Type 2 diabetes from 99 UK primary care practices.
326/361 (90.3%) doctors, 163/186 (87.6%) nurses and 3591 patients (41.8%) returned a questionnaire. Clinicians reported giving advice about lifestyle behaviours (e.g. 88% would routinely advise about calorie restriction; 99.6% about increasing exercise) more often than patients reported having received it (43% and 42%) and correlations between clinician and patient report were low. Patients’ reported levels of confidence about managing their diabetes were moderately high; a median (range) of 21% (3% to 39%) of patients reporting being not confident about various areas of diabetes self-management.
Primary care practices have organisational structures in place and are, as judged by routine quality indicators, delivering high quality care. There remain evidence-practice gaps in the care provided and in the self confidence that patients have for key aspects of self management and further research is needed to address these issues. Future research should use robust designs and appropriately designed studies to investigate how best to improve this situation.
PMCID: PMC3408463  PMID: 22859997
11.  Natural Course of Recurrent Psychological Distress in Adulthood 
Journal of affective disorders  2010;130(3):454-461.
The course of major depressive disorder is often characterized by progressing chronicity, but whether this applies to the course of self-reported psychological distress remains unclear. We examined whether the risk of self-reported psychological distress becomes progressively higher the longer the history of distress and whether prolonged history of distress modifies associations between risk markers and future distress.
Participants were British civil servants from the prospective Whitehall II cohort study (n=7934; 31.5% women, mean age 44.5 years at baseline) followed from 1985 to 2006 with repeat data collected in 7 study phases. Psychological distress was assessed with the 30-item General Health Questionnaire (GHQ). Sex, socioeconomic status, marital status, ethnicity, physical activity, alcohol consumption, smoking, and obesity were assessed as risk markers.
Recurrent history of psychological distress was associated with a progressively increasing risk of future distress in a dose-response manner. Common risk markers, such as low socioeconomic status, non-White ethnicity, being single, and alcohol abstinence were stronger predictors of subsequent distress in participants with a longer history of psychological distress. Sex differences in psychological distress attenuated with prolonged distress history.
The participants were already adults in the beginning of the study, so we could not assess the progressive chronicity of psychological distress from adolescence onwards.
These data suggest that self-reported psychological distress becomes more persistent over time and that a longer prior exposure to psychological distress increases sensitivity to the stressful effects of certain risk markers.
PMCID: PMC3062710  PMID: 21106248
Chronic distress; Kindling hypothesis; Longitudinal; Recurrence
12.  Obesity, unexplained weight loss and suicide: The original Whitehall study 
Journal of Affective Disorders  2008;116(3):218-221.
Evidence on the association between obesity and suicide is mixed. However, the strength of obesity as a predictor of suicide may be reduced, because of the role of weight changes associated with mental disorders. We tested the hypothesis that both obesity and unexplained weight loss are related to elevated suicide risk.
A clinical examination with measurements of height, weight and self-reported unexplained weight loss was conducted at baseline for 18,784 men aged 40 to 69. Based on national mortality register, 61 suicides were identified during the 38-year follow-up.
The age-adjusted hazard ratio for suicide among obese versus normal weight men was 2.22 (95% CI 0.94 to 5.28). Additional adjustment for unexplained weight loss raised this ratio to 2.48 (95% CI 1.04 to 5.92). Unexplained weight loss was associated with a substantial excess risk of suicide irrespective of obesity (age-adjusted hazard ratio 5.38, 95% CI 2.31 to 12.50; age- and obesity-adjusted hazard ratio 5.58, 95% CI 2.37 to 13.13).
Inability to take into account the effect of depression as a potential mediating mechanism.
This study provides evidence that both obesity and unexplained weight loss may be important predictors of suicide. Lack of adjustment for weight loss may suppress the observed association between obesity and suicide.
PMCID: PMC3319297  PMID: 19097646
BMI; overweight; public sector; suicide; weight loss; work
13.  Lipid trajectories as predictors of depressive symptoms: The Young Finns Study 
Health Psychology  2010;29(3):237-245.
The aim of this study was to identify common trajectories of lipid levels across childhood and early adulthood life span.
The sample was a subpopulation of 824 young adults (3 – 9 years at baseline in 1980) of the on-going population-based prospective Cardiovascular Risk in Young Finns Study. Lipid levels were determined in 1980, 1983, 1986 and 2001.
Main outcome measures
Depressive symptoms were assessed using a modified version of Beck’s Depression Inventory in 1992 and 2001.
The two triglycerides trajectories (steeply vs moderately increasing) were differently related to depressive symptoms in adulthood. The trajectory showing steep increase over time was associated with higher level of depressive symptoms (mean 2.18, 95% CI 2.08 - 2.28 vs 1.99, 95% CI 1.95–2.04). This relationship persisted after adjustments for various risk factors. These triglycerides trajectories accounted for part of the association between high BMI and depressive symptoms.
A pattern of steeply increasing triglyceride levels throughout childhood and adulthood may be associated with increased the risk of depressive symptoms in adulthood. This pattern may also be one link between obesity and depressive symptoms.
PMCID: PMC3319303  PMID: 20496976
depression; CHD; psychosocial factors; lipids
14.  Living alone and antidepressant medication use: a prospective study in a working-age population 
BMC Public Health  2012;12:236.
An increasing proportion of the population lives in one-person households. The authors examined whether living alone predicts the use of antidepressant medication and whether socioeconomic, psychosocial, or behavioral factors explain this association.
The participants were a nationally representative sample of working-age Finns from the Health 2000 Study, totaling 1695 men and 1776 women with a mean age of 44.6 years. In the baseline survey in 2000, living arrangements (living alone vs. not) and potential explanatory factors, including psychosocial factors (social support, work climate, hostility), sociodemographic factors (occupational grade, education, income, unemployment, urbanicity, rental living, housing conditions), and health behaviors (smoking, alcohol use, physical activity, obesity), were measured. Antidepressant medication use was followed up from 2000 to 2008 through linkage to national prescription registers.
Participants living alone had a 1.81-fold (CI = 1.46-2.23) higher purchase rate of antidepressants during the follow-up period than those who did not live alone. Adjustment for sociodemographic factors attenuated this association by 21% (adjusted OR = 1.64, CI = 1.32-2.05). The corresponding attenuation was 12% after adjustment for psychosocial factors (adjusted OR = 1.71, CI = 1.38-2.11) and 9% after adjustment for health behaviors (adjusted OR = 1.74, CI = 1.41-2.14). Gender-stratified analyses showed that in women the greatest attenuation was related to sociodemographic factors and in men to psychosocial factors.
These data suggest that people living alone may be at increased risk of developing mental health problems. The public health value is in recognizing that people who live alone are more likely to have material and psychosocial problems that may contribute to excess mental health problems in this population group.
PMCID: PMC3338384  PMID: 22443226
Mental health; Antidepressant medication; Living arrangement; Psychosocial factors; Socioeconomic
15.  Association of CRP and IL-6 with lung function in a middle-aged population initially free from self-reported respiratory problems: the Whitehall II study 
European journal of epidemiology  2011;26(2):135-144.
To assess whether two inflammatory markers, C-reactive protein (CRP) and interleukin-6 (IL-6), and change in their concentrations over 12 years, are associated with lung function (FVC and FEV1) 12 years after baseline. Data are from over 1,500 participants free from self-reported respiratory problems in a large-scale prospective cohort study of white-collar male and female civil servants. CRP and IL-6 measured at baseline (1991–1993) and follow-up (2002–2004) and FVC and FEV1, measured at follow-up. Results adjusted for sociodemographic and anthropometric characteristics, health behaviours, biological factors, chronic conditions and medications, and corrected for short-term variability in CRP and IL-6 concentrations. Higher baseline levels of CRP and IL-6 were strongly associated with lower FVC and FEV1, independent of potential confounders. A 10% increase serum CRP from baseline to follow-up was associated with lower values of FVC and FEV1 at follow-up, 4.7 and 3.0 ml, respectively. The corresponding values for a 10% increase in IL-6 were 12.6 ml for FVC and 7.3 ml for FEV1. Systemic low-grade inflammation is associated with only slightly poorer pulmonary function in a population free from self-reported respiratory problems 12 years earlier. These data provide evidence linking inflammation to adverse outcomes beyond cardiovascular disease. Interventions targeting inflammation may prevent lung function impairment.
PMCID: PMC3199309  PMID: 21293970
Inflammation; Pulmonary function; Cohort study; Epidemiology
16.  Do Passive Jobs Contribute to Low Levels of Leisure-Time Physical Activity? The Whitehall II Cohort Study 
There is mixed evidence on the association between psychosocial work exposures (i.e., passive jobs) and physical activity, but previous studies did not take into account the effect of cumulative exposures nor did they examine different trajectories in exposure. We investigated whether exposure to passive jobs, measured three times over an average of five years, is associated with leisure-time physical activity (LTPA).
Data were from working men (n=4291) and women (n=1794) aged 35 to 55 who participated in the first three phases of the Whitehall II prospective cohort. Exposure to passive jobs was measured at each phase and LTPA at phases 1 and 3. Participants were categorized according to whether or not they worked in a passive job at each phase, leading to a scale ranging from 0 (non-passive job at all three phases) to 3 (passive job at all three phases). Poisson regression with robust variance estimates were used to assess the prevalence ratios of low LTPA.
An association was found in men between exposure to passive jobs over 5 years and low LTPA at follow-up, independently of other relevant risk factors. The prevalence ratio for low LTPA in men was 1.16 (95% confidence interval 1.01 to 1.33) times greater for employees with three reports of passive job than for those who had never worked in passive jobs. No association was observed in women.
This study provides evidence that working in passive jobs may encourage a passive lifestyle in men.
PMCID: PMC3226945  PMID: 19528047
longitudinal; occupational; physical exercise; sedentarism
17.  Justice at Work and Metabolic Syndrome: the Whitehall II Study 
Growing evidence shows that high levels of justice are beneficial for employee health, although biological mechanisms underlying this association are yet to be clarified. We aim to test whether high justice at work protects against metabolic syndrome.
A prospective cohort study of 20 civil service departments in London (the Whitehall II study) including 6123 male and female British civil servants aged 35 to 55 years without prevalent CHD at baseline (1985-1990). Perceived justice at work was determined by means of questionnaire on two occasions between 1985 and 1990. Follow-up for metabolic syndrome and its components occurring from 1990 through 2004 was based on clinical assessments on three occasions over more than 18 years.
Cox proportional hazard models adjusted for age, ethnicity and employment grade showed that men who experienced a high level of justice at work had a lower risk of incident metabolic syndrome than employees with a low level of justice (hazard ratio 0.75; 95% confidence interval: 0.63-0.89). There was little evidence of an association between organizational justice and metabolic syndrome or its components in women (hazard ratio 0.88; 95%CI: 0.67-1.17).
Our prospective findings provide evidence of an association between high levels of justice at work and the development of metabolic syndrome in men.
PMCID: PMC3226946  PMID: 19819861
Coronary heart disease; Psychosocial factors; Risk factors; Epidemiology; Cohort; Work organization
18.  The association of cognitive performance with mental health and physical functioning strengthens with age: The Whitehall II cohort study 
Psychological medicine  2009;40(5):837-845.
Cognitive performance has been associated with mental and physical health, but it is unknown whether the strength of these associations changes with ageing and with age-related social transitions, such as retirement. We examined whether cognitive performance predicted mental and physical health from midlife to early old age.
Participants were 5414 men and 2278 women from the Whitehall II cohort study followed for 15 years between 1991 and 2006. The age range included over the follow-up was from 40 to 75 years. Mental health and physical functioning were measured six times using SF-36 subscales. Cognitive performance was assessed three times using five cognitive tests assessing verbal and numerical reasoning, verbal memory, and phonemic and semantic fluency. Socioeconomic status and retirement were included as covariates.
High cognitive performance was associated with better mental health and physical functioning. Mental health differences associated with cognitive performance widened with age from 39 to 76 years of age, while physical functioning differences widened only between 39 and 60 years but not after 60 years of age. Socioeconomic status explained part of the widening differences in mental health and physical functioning before the age of 60. Cognitive performance was more strongly associated with mental health in retired than non-retired participants, which contributed to the widening differences after 60 years of age.
The strength of cognitive performance in predicting mental and physical health may increase from midlife to early old age, and these changes may be related to socioeconomic status and age-related transitions, such as retirement.
PMCID: PMC3178658  PMID: 19719898
19.  Depressive Symptoms and the Metabolic Syndrome in Childhood and Adulthood 
To examine the reciprocal associations between depressive symptoms and clinical definitions of the metabolic syndrome in childhood and adulthood.
Population-based prospective cohort study of 921 participants (538 women and 383 men) in Finland. The components of the metabolic syndrome were measured in childhood (mean age 12 years) and again in adulthood (mean age 33 years). A revised version of the Beck Depression Inventory was used to assess depressive symptoms at the mean ages of 24 and 33.
Main Outcome Measures
Metabolic syndrome defined by the National Cholesterol Education Program Adult Treatment Panel III (NCEP), the European Group for the Study of Insulin Resistance, and the International Diabetes Federation criteria.
In women, depressive symptoms were associated with increased risk of the metabolic syndrome in adulthood (odds ratio for NCEP metabolic syndrome per 1 SD increase in depressive symptoms 1.40, 95% confidence interval 1.05-1.85). The metabolic syndrome in childhood, in turn, predicted higher levels of depressive symptoms in adulthood (p= 0.03). In men, no associations were found between depressive symptoms and the clinical definitions of the metabolic syndrome.
The process linking depressive symptoms with the metabolic syndrome may go into both directions and may begin early in life.
PMCID: PMC3166561  PMID: 19210024
metabolic syndrome; depressive symptoms; obesity; cardiovascular disease; childhood
20.  Socioeconomic Differences in Cardiometabolic Factors: Social Causation or Health-related Selection? Evidence From the Whitehall II Cohort Study, 1991–2004 
American Journal of Epidemiology  2011;174(7):779-789.
In this study, the health-related selection hypothesis (that health predicts social mobility) and the social causation hypothesis (that socioeconomic status influences health) were tested in relation to cardiometabolic factors. The authors screened 8,312 United Kingdom men and women 3 times over 10 years between 1991 and 2004 for waist circumference, body mass index, systolic and diastolic blood pressure, fasting glucose, fasting insulin, serum lipids, C-reactive protein, and interleukin-6; identified participants with the metabolic syndrome; and measured childhood health retrospectively. Health-related selection was examined in 2 ways: 1) childhood health problems as predictors of adult occupational position and 2) adult cardiometabolic factors as predictors of subsequent promotion at work. Social causation was assessed using adult occupational position as a predictor of subsequent change in cardiometabolic factors. Hospitalization during childhood and lower birth weight were associated with lower occupational position (both P’s ≤ 0.002). Cardiometabolic factors in adulthood did not consistently predict promotion. In contrast, lower adult occupational position predicted adverse changes in several cardiometabolic factors (waist circumference, body mass index, fasting glucose, and fasting insulin) and an increased risk of new-onset metabolic syndrome (all P’s ≤ 0.008). These findings suggest that health-related selection operates at younger ages and that social causation contributes to socioeconomic differences in cardiometabolic health in midlife.
PMCID: PMC3176829  PMID: 21813793
cardiovascular diseases; health status disparities; longitudinal studies; metabolic syndrome X; public health; social class
21.  Are skin disorders related to work strain in hospital workers? A cross-sectional study 
BMC Public Health  2011;11:600.
To evaluate whether occupational stress factors (high demands, low control, low social support, strain, and iso-strain) are associated with skin disorders in hospital workers and whether psychological problems, such as anxiety and depression, act as potential mechanisms through which occupational stress factors are associated with skin disorders.
1,744 hospital workers were invited to answer a questionnaire concerning the occurrence of skin disorders and psychosocial factors at work. The abbreviated Italian version of the Demand/Control model (Karasek) was used to assess perceived work strain, while the Goldberg scales were used to assess anxiety and depression. Analyses were adjusted for age, gender, occupation, latex glove use and history of atopy.
Of the participants, 25% reported hand dermatitis in the previous 12 months and 35% had been affected by skin disorders in other parts of the body. High job demands (OR = 1.09 CI95% 1.05-1.14), low social support (OR = 0.90, CI95% 0.87-0.93), high strain (OR = 1.54 CI95% 1.20-1.98) and high iso-strain (1.66 CI95% 1.27-2.19) were all associated with a higher prevalence of reported hand skin disorders. Both depression (OR = 2.50 CI95% 1.99-3.14) and anxiety (OR = 2.29 CI95% 1.81-2.89) were associated with higher risk of hand skin disorders. The same pattern was observed for dermatological complaints in other parts of the body. Only a slight reduction in the association between occupational stress variables and skin disorders was observed after including depression and anxiety in the model.
Job stress plays a significant role in triggering skin disorders among hospital workers and psychological problems do not appear to be the mechanism behind this association. Occupational health education and training should focus on reducing job demands and occupational stress in order to prevent skin problems among hospital workers.
PMCID: PMC3160993  PMID: 21798019
hospital workers; skin disorders; occupational stress factors; psychological problems; anxiety; depression; demand; control; social support; strain; isostrain
22.  Psychosocial Work Environment as a Risk Factor for Absence With a Psychiatric Diagnosis: An Instrumental-Variables Analysis 
American Journal of Epidemiology  2010;172(2):167-172.
Recent reviews show that self-reported psychosocial factors related to work, such as job demands and job control, are associated with employee mental health, but it is not known whether this association is attributable to reporting bias. The authors examined this question using objectively measured hospital ward overcrowding as an instrument. The extent of overcrowding provided a strong instrument for self-reported job demands but not for job control, and it was used to examine unbiased associations between self-reported job demands and sickness absence with a psychiatric diagnosis among 2,784 female nurses working in somatic illness wards in Finland. During the 12-month follow-up period (2004–2005), 102 nurses had an absence with a psychiatric diagnosis, 33 with a diagnosis of depressive disorder. Both greater extent of overcrowding and higher self-reported job demands were associated with increased risk of psychiatric absence. The latter association was stronger but less precisely estimated in an instrumental-variables analysis which took into account only the variation in self-reported job demands that was explained by overcrowding. Repeating these analyses with absence due to depressive disorders as the outcome led to similar results. Findings from this instrumental-variables analysis support the status of high self-reported job demands as a risk factor for absence with a psychiatric diagnosis.
PMCID: PMC2915486  PMID: 20534822
absenteeism; behavior; depression; employment; mental disorders; psychology; risk factors; sick leave
23.  Instrument development, data collection, and characteristics of practices, staff, and measures in the Improving Quality of Care in Diabetes (iQuaD) Study 
Type 2 diabetes is an increasingly prevalent chronic illness and an important cause of avoidable mortality. Patients are managed by the integrated activities of clinical and non-clinical members of primary care teams. This study aimed to: investigate theoretically-based organisational, team, and individual factors determining the multiple behaviours needed to manage diabetes; and identify multilevel determinants of different diabetes management behaviours and potential interventions to improve them. This paper describes the instrument development, study recruitment, characteristics of the study participating practices and their constituent healthcare professionals and administrative staff and reports descriptive analyses of the data collected.
The study was a predictive study over a 12-month period. Practices (N = 99) were recruited from within the UK Medical Research Council General Practice Research Framework. We identified six behaviours chosen to cover a range of clinical activities (prescribing, non-prescribing), reflect decisions that were not necessarily straightforward (controlling blood pressure that was above target despite other drug treatment), and reflect recommended best practice as described by national guidelines. Practice attributes and a wide range of individually reported measures were assessed at baseline; measures of clinical outcome were collected over the ensuing 12 months, and a number of proxy measures of behaviour were collected at baseline and at 12 months. Data were collected by telephone interview, postal questionnaire (organisational and clinical) to practice staff, postal questionnaire to patients, and by computer data extraction query.
All 99 practices completed a telephone interview and responded to baseline questionnaires. The organisational questionnaire was completed by 931/1236 (75.3%) administrative staff, 423/529 (80.0%) primary care doctors, and 255/314 (81.2%) nurses. Clinical questionnaires were completed by 326/361 (90.3%) primary care doctors and 163/186 (87.6%) nurses. At a practice level, we achieved response rates of 100% from clinicians in 40 practices and > 80% from clinicians in 67 practices. All measures had satisfactory internal consistency (alpha coefficient range from 0.61 to 0.97; Pearson correlation coefficient (two item measures) 0.32 to 0.81); scores were generally consistent with good practice. Measures of behaviour showed relatively high rates of performance of the six behaviours, but with considerable variability within and across the behaviours and measures.
We have assembled an unparalleled data set from clinicians reporting on their cognitions in relation to the performance of six clinical behaviours involved in the management of people with one chronic disease (diabetes mellitus), using a range of organisational and individual level measures as well as information on the structure of the practice teams and across a large number of UK primary care practices. We would welcome approaches from other researchers to collaborate on the analysis of this data.
PMCID: PMC3130687  PMID: 21658211
24.  Effort‐reward imbalance, procedural injustice and relational injustice as psychosocial predictors of health: complementary or redundant models? 
Effort‐reward imbalance at work is an established psychosocial risk factor but there are also newer conceptualisations, such as procedural injustice (decisions at work lack consistency, openness and input from all affected parties) and relational injustice (problems in considerate and fair treatment of employees by supervisors). The authors examined whether procedural injustice and relational injustice are associated with employee health in addition to, and in combination with, effort‐reward imbalance.
Prospective survey data from two cohorts related to public‐sector employees: the 10‐Town study (n = 18 066 (78% women, age range 19–62) and the Finnish Hospital Personnel study (n = 4833, 89% women, age range 20–60). Self‐rated poor health, minor psychiatric morbidity and doctor‐diagnosed depression were assessed at baseline (2000–2) and at follow‐up (2004). To determine incident morbidity, baseline cases were excluded.
In multivariate models including age, sex, occupational status and all three psychosocial factors as predictors, high effort‐reward imbalance and either high procedural injustice or high relational injustice were associated with increased morbidity at follow‐up in both cohorts. After combining procedural and relational injustice into a single measure of organisational injustice, high effort‐reward imbalance and high injustice were both independently associated with health. For all outcome measures, a combination of high effort‐reward imbalance and high organisational injustice was related to a greater health risk than high effort‐reward imbalance or injustice alone.
Evidence from two independent occupational cohorts suggests that procedural and relational components of injustice, as a combined index, and effort‐reward imbalance are complementary risk factors.
PMCID: PMC2078405  PMID: 17259167
25.  Socioeconomic position, psychosocial work environment and cerebrovascular disease among women: the Finnish public sector study 
Background The excess risk of fatal and non-fatal cerebrovascular disease in people from low socioeconomic positions is only partially explained by conventional cerebrovascular risk factors. This has led to the suggestion that poor psychosocial work environments provide important additional explanatory power. However, little evidence is available for women.
Methods We examined whether job demands or job control contributed to the socioeconomic gradient in cerebrovascular disease among 48 361 women aged 18–65 years. Job demands, job control and behavioural risk factors were self-reported in 2000–2002; socioeconomic position (as indexed by occupational class) and all of the health measures were obtained from registers. The outcome was recorded hospitalization or death from cerebrovascular disease.
Results During a mean follow-up of 3.4 years, 124 women had a new cerebrovascular disease event. The risk was 2.3 (95% CI 1.3–3.9) times higher among women in low vs high socioeconomic positions. Adjustment for conventional risk factors, such as prevalent hypertension, coronary heart disease, diabetes, smoking, heavy alcohol consumption, physical inactivity and obesity, attenuated this excess risk by 23%. In contrast, adjustment for job demands and job control actually amplified the gradient by 36% suggesting a suppression effect.
Conclusions In this contemporary cohort of employed women, job demands—alone and in combination with job control—suppressed rather than explained socioeconomic differences in cerebrovascular disease.
PMCID: PMC3159152  PMID: 19155280
Socioeconomic status; psychosocial factors; risk factors; cerebrovascular disorders; cohort studies; stroke

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