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author:("bundorf, Alex")
1.  How needs and preferences of employees influence participation in health promotion programs: a six-month follow-up study 
BMC Public Health  2014;14(1):1277.
Low participation in health promotion programs (HPPs) might hamper their effectiveness. A potential reason for low participation is disagreement between needs and preferences of potential participants and the actual HPPs offered. This study aimed to investigate employees’ need and preferences for HPPs, whether these are matched by what their employers provide, and whether a higher agreement enhanced participation.
Employees of two organizations participated in a six-month follow-up study (n = 738). At baseline, information was collected on employees’ needs and preferences for the topic of the HPP (i.e. physical activity, healthy nutrition, smoking cessation, stress management, general health), whether they favored a HPP via their employer or at their own discretion, and their preferred HPP regarding three components with each two alternatives: mode of delivery (individual vs. group), intensity (single vs. multiple meetings), and content (assignments vs. information). Participation in HPPs was assessed at six-month follow-up. In consultation with occupational health managers (n = 2), information was gathered on the HPPs the employers provided. The level of agreement between preferred and provided HPPs was calculated (range: 0–1) and its influence on participation was studied using logistic regression analyses.
Most employees reported needing a HPP addressing physical activity (55%) and most employees preferred HPPs organized via their employer. The mean level of agreement between the preferred and offered HPPs ranged from 0.71 for mode of delivery to 0.84 for intensity, and was 0.47 for all three HPP components within a topic combined. Employees with a higher agreement on mode of delivery (OR: 1.72, 95% CI: 0.87-3.39) and all HPP components combined (OR: 2.36, 95% CI: 0.68-8.17) seemed to be more likely to participate in HPPs, but due to low participation these associations were not statistically significant.
HPPs aimed at physical activity were most needed by employees. The majority of employees favor HPPs organized via the employer above those at their own discretion, supporting the provision of HPPs at the workplace. This study provides some indications that a higher agreement between employees’ needs and preferences and HPPs made available by their employers will enhance participation.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-1277) contains supplementary material, which is available to authorized users.
PMCID: PMC4301819  PMID: 25512055
Workplace; Health promotion; Preferences; Health behavior; Participation
2.  Trends in overweight by educational level in 33 low- and middle-income countries: The role of parity, age at first birth and breastfeeding 
This study examined trends in overweight among women of reproductive age by educational level in 33 low- and middle income countries, and estimated the contribution of parity, age at first birth and breastfeeding to these trends. We used repeated cross-sectional demographic health surveys (DHS) of 255,828 women aged 25-49 years interviewed between 1992 and 2009. We applied logistic regression to model overweight (> 25 kg/m2) as a function of education, reproductive variables and time period by country and region. The prevalence of overweight ranged from 3.4% in South and Southeast Asia to 73.7% in North Africa West/Central Asia during the study period. The association between education and overweight differed across regions. In North Africa West/Central Asia and Latin American, lower education was associated with higher overweight prevalence, while the inverse was true in South/Southeast Asia and Sub-Saharan Africa. In all regions, there was a consistent pattern of increasing overweight trends across all educational groups. Older age at first birth, longer breastfeeding, and lower parity were associated with less overweight, but these variables did not account for the association or the increasing trends between education and overweight.
PMCID: PMC3804307  PMID: 23782957
overweight; education; parity; breastfeeding; developing countries
3.  Lifestyle factors, direct and indirect costs for a Brazilian airline company 
Revista de Saúde Pública  2014;48(6):949-957.
To analyze lifestyle risk factors related to direct healthcare costs and the indirect costs due to sick leave among workers of an airline company in Brazil.
In this longitudinal 12-month study of 2,201 employees of a Brazilian airline company, the costs of sick leave and healthcare were the primary outcomes of interest. Information on the independent variables, such as gender, age, educational level, type of work, stress, and lifestyle-related factors (body mass index, physical activity, and smoking), was collected using a questionnaire on enrolment in the study. Data on sick leave days were available from the company register, and data on healthcare costs were obtained from insurance records. Multivariate linear regression analysis was used to investigate the association between direct and indirect healthcare costs with sociodemographic, work, and lifestyle-related factors.
Over the 12-month study period, the average direct healthcare expenditure per worker was US$505.00 and the average indirect cost because of sick leave was US$249.00 per worker. Direct costs were more than twice the indirect costs and both were higher in women. Body mass index was a determinant of direct costs and smoking was a determinant of indirect costs.
Obesity and smoking among workers in a Brazilian airline company were associated with increased health costs. Therefore, promoting a healthy diet, physical activity, and anti-tobacco campaigns are important targets for health promotion in this study population.
PMCID: PMC4285830
Aviation, manpower; Absenteeism; Life Style; Occupational Health; Health Expenditures; Cohort Studies
4.  Evaluation of the Validity of Job Exposure Matrix for Psychosocial Factors at Work 
PLoS ONE  2014;9(9):e108987.
To study the performance of a developed job exposure matrix (JEM) for the assessment of psychosocial factors at work in terms of accuracy, possible misclassification bias and predictive ability to detect known associations with depression and low back pain (LBP).
Materials and Methods
We utilized two large population surveys (the Health 2000 Study and the Finnish Work and Health Surveys), one to construct the JEM and another to test matrix performance. In the first study, information on job demands, job control, monotonous work and social support at work was collected via face-to-face interviews. Job strain was operationalized based on job demands and job control using quadrant approach. In the second study, the sensitivity and specificity were estimated applying a Bayesian approach. The magnitude of misclassification error was examined by calculating the biased odds ratios as a function of the sensitivity and specificity of the JEM and fixed true prevalence and odds ratios. Finally, we adjusted for misclassification error the observed associations between JEM measures and selected health outcomes.
The matrix showed a good accuracy for job control and job strain, while its performance for other exposures was relatively low. Without correction for exposure misclassification, the JEM was able to detect the association between job strain and depression in men and between monotonous work and LBP in both genders.
Our results suggest that JEM more accurately identifies occupations with low control and high strain than those with high demands or low social support. Overall, the present JEM is a useful source of job-level psychosocial exposures in epidemiological studies lacking individual-level exposure information. Furthermore, we showed the applicability of a Bayesian approach in the evaluation of the performance of the JEM in a situation where, in practice, no gold standard of exposure assessment exists.
PMCID: PMC4182611  PMID: 25268276
5.  Trends in overweight among women differ by occupational class: Results from 33 low and middle income countries in the period 1992–2009 
International journal of obesity (2005)  2013;38(1):10.1038/ijo.2013.50.
There has been an increase in overweight among women in low- and middle-income countries, but whether these trends differ for women in different occupations is unknown. We examined trends by occupational class among women from 33 low- and middle-income countries in four regions.
Cross-national study with repeated cross-sectional demographic health surveys (DHS).
Height and weight were assessed at least twice between 1992 and 2009 in 248,925 women aged 25–49 years. Interviews were conducted to assess occupational class, age, place of residence, educational level, household wealth index, parity, and age at first birth and breastfeeding. We used logistic and linear regression analyses to assess the annual percent change (APC) in overweight (BMI > 25 kg/m2) by occupational class.
The prevalence of overweight ranged from 2.2% in Nepal in 1992–1997 to 75% in Egypt in 2004–2009. In all four regions, women working in agriculture had consistently lower prevalence of overweight, while women from professional, technical, managerial as well as clerical occupational classes had higher prevalence. Although the prevalence of overweight increased in all occupational classes in most regions, women working in agriculture and production experienced the largest increase in overweight over the study period, while women in higher occupational classes experienced smaller increases. To illustrate, overweight increased annually by 0.5% in Latin America and the Caribbean and by 0.7% in Sub-Saharan Africa among women from professional, technical, and managerial classes, as compared to 2.8% and 3.7%, respectively, among women in agriculture.
The prevalence of overweight has increased in most low and middle income countries, but women working in agriculture and production have experienced larger increases than women in higher occupational classes.
PMCID: PMC3742714  PMID: 23649471
overweight; occupation; labour force; developing countries
6.  An Evidence-Based Multidisciplinary Practice Guideline to Reduce the Workload due to Lifting for Preventing Work-Related Low Back Pain 
We developed an evidence-based practice guideline to support occupational safety and health (OSH) professionals in assessing the risk due to lifting and in selecting effective preventive measures for low back pain (LBP) in the Netherlands. The guideline was developed at the request of the Dutch government by a project team of experts and OSH professionals in lifting and work-related LBP. The recommendations for risk assessment were based on the quality of instruments to assess the risk on LBP due to lifting. Recommendations for interventions were based on a systematic review of the effects of worker- and work directed interventions to reduce back load due to lifting. The quality of the evidence was rated as strong (A), moderate (B), limited (C) or based on consensus (D). Finally, eight experts and twenty-four OSH professionals commented on and evaluated the content and the feasibility of the preliminary guideline. For risk assessment we recommend loads heavier than 25 kg always to be considered a risk for LBP while loads less than 3 kg do not pose a risk. For loads between 3–25 kg, risk assessment shall be performed using the Manual handling Assessment Charts (MAC)-Tool or National Institute for Occupational Safety and Health (NIOSH) lifting equation. Effective work oriented interventions are patient lifting devices (Level A) and lifting devices for goods (Level C), optimizing working height (Level A) and reducing load mass (Level C). Ineffective work oriented preventive measures are regulations to ban lifting without proper alternatives (Level D). We do not recommend worker-oriented interventions but consider personal lift assist devices as promising (Level C). Ineffective worker-oriented preventive measures are training in lifting technique (Level A), use of back-belts (Level A) and pre-employment medical examinations (Level A). This multidisciplinary evidence-based practice guideline gives clear criteria whether an employee is at risk for LBP while lifting and provides an easy-reference for (in)effective risk reduction measures based on scientific evidence, experience, and consensus among OSH experts and practitioners.
PMCID: PMC4081511  PMID: 24999432
Back pain; Interventions; Occupational health care; Prevention; Surveillance; Practice guideline; Lifting
7.  Barriers and facilitators for participation in health promotion programs among employees: a six-month follow-up study 
BMC Public Health  2014;14:573.
Health promotion programs (HPPs) are thought to improve health behavior and health, and their effectiveness is increasingly being studied. However, participation in HPPs is usually modest and effect sizes are often small. This study aims to (1) gain insight into the degree of participation of employees in HPPs, and (2) identify factors among employees that are associated with both their intention to participate and actual participation in HPPs.
Employees of two organizations were invited to participate in a six-month follow-up study (n = 744). Using questionnaires, information on participation in HPPs was collected in two categories: employees’ intention at baseline to participate and their actual participation in a HPP during the follow-up period. The following potential determinants were assessed at baseline: social-cognitive factors, perceived barriers and facilitators, beliefs about health at work, health behaviors, and self-perceived health. Logistic regression analyses, adjusted for demographics and organization, were used to examine associations between potential determinants and intention to participate, and to examine the effect of these determinants on actual participation during follow-up.
At baseline, 195 employees (26%) expressed a positive intention towards participation in a HPP. During six months of follow-up, 83 employees (11%) actually participated. Participants positively inclined at baseline to participate in a HPP were more likely to actually participate (OR = 3.02, 95% CI: 1.88-4.83). Privacy-related barriers, facilitators, beliefs about health at work, social-cognitive factors, and poor self-perceived health status were significantly associated with intention to participate. The odds of employees actually participating in a HPP were higher among participants who at baseline perceived participation to be expected by their colleagues and supervisor (OR = 2.87, 95% CI: 1.17-7.02) and among those who said they found participation important (OR = 2.81, 95% CI: 1.76-4.49).
Participation in HPPs among employees is limited. Intention to participate predicted actual participation in a HPP after six months of follow-up. However, only 21% of employees with a positive intention actually participated during follow-up. Barriers, facilitators, beliefs about health at work, social-cognitive factors, and a poor self-perceived health status were associated with intention to participate, but hardly influenced actual participation during follow-up.
PMCID: PMC4066706  PMID: 24909151
Workplace health promotion; Participation; Barriers; Facilitators; Health behavior
8.  Risky Music Listening, Permanent Tinnitus and Depression, Anxiety, Thoughts about Suicide and Adverse General Health 
PLoS ONE  2014;9(6):e98912.
To estimate the extent to which exposure to music through earphones or headphones with MP3 players or at discotheques and pop/rock concerts exceeded current occupational safety standards for noise exposure, to examine the extent to which temporary and permanent hearing-related symptoms were reported, and to examine whether the experience of permanent symptoms was associated with adverse perceived general and mental health, symptoms of depression, and thoughts about suicide.
A total of 943 students in Dutch inner-city senior-secondary vocational schools completed questionnaires about their sociodemographics, music listening behaviors and health. Multiple logistic regression analyses were used to examine associations.
About 60% exceeded safety standards for occupational noise exposure; about one third as a result of listening to MP3 players. About 10% of the participants experienced permanent hearing-related symptoms. Temporary hearing symptoms that occurred after using an MP3 player or going to a discotheque or pop/rock concert were associated with exposure to high-volume music. However, compared to participants not experiencing permanent hearing-related symptoms, those experiencing permanent symptoms were less often exposed to high volume music. Furthermore, they reported at least two times more often symptoms of depression, thoughts about suicide and adverse self-assessed general and mental health.
Risky music-listening behaviors continue up to at least the age of 25 years. Permanent hearing-related symptoms are associated with people’s health and wellbeing. Participants experiencing such symptoms appeared to have changed their behavior to be less risky. In order to induce behavior change before permanent and irreversible hearing-related symptoms occur, preventive measurements concerning hearing health are needed.
PMCID: PMC4045887  PMID: 24897078
9.  The influence of lifestyle and gender on sickness absence in Brazilian workers 
BMC Public Health  2014;14:317.
Despite an increasing body of knowledge concerning gender and lifestyle factors as determinants of sickness absence in well-developed countries, the relationship between these variables has not been elucidated in emerging economic power countries, where the burden of non-communicable diseases is particularly high. This study aimed to analyze the relationships among lifestyle-related factors and sick leave and to examine whether gender differences in sickness absence can be explained by differences in socio-demographic, work and lifestyle-related factors among Brazilian workers.
In this longitudinal study with a one year follow-up among 2.150 employees of a Brazilian airline company, sick leave was the primary outcome of interest. Independent variables collected by interview at enrolment in the study were gender, age, educational level, type of work, stress, and lifestyle-related factors (body mass index, physical activity and smoking). In addition, the risk for coronary heart disease was determined based on measurement of blood pressure, total cholesterol and glucose levels. The total number of days on sick leave during 12 months follow-up was available from the company register. Logistic regression analysis was used to determine the influence of socio-demographic, type of work and lifestyle-related factors on sick leave.
Younger employees, those with lower educational level, those who worked as air crew members and those with higher levels of stress were more likely to have sick leave. Body mass index and level of physical activity were not associated with sick leave. After adjustment by socio-demographic variables, increased odds for 10 or more days of sick leave were found in smokers (OR = 1.51, CI = 1.05-2.17), and ex-smokers (OR = 1.45, CI = 1.01-2.10). Women were more likely to have 10 or more days of sick leave. Gender differences were reduced mainly when adjusted for type of work (15%) and educational level (7%).
The higher occurrence of sick leave among women than among men was partly explained by type of work and educational level. Our results suggest that type of work, a stressful life, and smoking are important targets for health promotion in this study population.
PMCID: PMC3983852  PMID: 24708760
Sick leave; Gender; Health behavior
10.  Characteristics of residential areas and transportational walking among frail and non-frail Dutch elderly: does the size of the area matter? 
A residential area supportive for walking may facilitate elderly to live longer independently. However, current evidence on area characteristics potentially important for walking among older persons is mixed. This study hypothesized that the importance of area characteristics for transportational walking depends on the size of the area characteristics measured, and older person’s frailty level.
The study population consisted of 408 Dutch community-dwelling persons aged 65 years and older participating in the Elderly And their Neighborhood (ELANE) study in 2011–2012. Characteristics (aesthetics, functional features, safety, and destinations) of areas surrounding participants’ residences ranging from a buffer of 400 meters up to 1600 meters (based on walking path networks) were linked with self-reported transportational walking using linear regression analyses. In addition, interaction effects between frailty level and area characteristics were tested.
An increase in functional features (e.g. presence of sidewalks and benches) within a 400 meter buffer, in aesthetics (e.g. absence of litter and graffiti) within 800 and 1200 meter buffers, and an increase of one destination per buffer of 400 and 800 meters were associated with more transportational walking, up to 2.89 minutes per two weeks (CI 1.07-7.32; p < 0.05). No differences were found between frail and non-frail elderly.
Better functional and aesthetic features, and more destinations in the residential area of community-dwelling older persons were associated with more transportational walking. The importance of area characteristics for transportational walking differs by area size, but not by frailty level. Neighbourhood improvements may increase transportational walking among older persons, thereby contributing to living longer independently.
PMCID: PMC4015736  PMID: 24588848
Physical environment; Neighbourhood; Elderly; Walking; Transport-related PA
11.  The Impact of Increasing Health Insurance Coverage on Disparities in Mortality: Health Care Reform in Colombia, 1998–2007 
American journal of public health  2013;103(3):e100-e106.
We examined the impact of expanding health insurance coverage on socioeconomic disparities in total and cardiovascular disease mortality from 1998 to 2007 in Colombia.
We used Poisson regression to analyze data from mortality registries (633 905 deaths) linked to population census data. We used the relative index of inequality to compare disparities in mortality by education between periods of moderate increase (1998–2002) and accelerated increase (2003–2007) in health insurance coverage.
Disparities in mortality by education widened over time. Among men, the relative index of inequality increased from2.59 (95% confidence interval [CI] = 2.52, 2.67) in 1998–2002 to 3.07 (95% CI = 2.99, 3.15) in 2003–2007, and among women, from 2.86 (95% CI = 2.77, 2.95) to 3.12 (95% CI = 3.03, 3.21), respectively. Disparities increased yearly by 11% in men and 4% in women in 1998–2002, whereas they increased by 1% in men per year and remained stable among women in 2003–2007.
Mortality disparities widened significantly less during the period of increased health insurance coverage than the period of no coverage change. Although expanding coverage did not eliminate disparities, it may contribute to curbing future widening of disparities.
PMCID: PMC3673514  PMID: 23327277
12.  How Work Impairments and Reduced Work Ability are Associated with Health Care Use in Workers with Musculoskeletal Disorders, Cardiovascular Disorders or Mental Disorders 
Purpose the aim of this study was to explore how work impairments and work ability are associated with health care use by workers with musculoskeletal disorders (MSD), cardiovascular disorders (CVD), or mental disorders (MD). Methods in this cross-sectional study, subjects with MSD (n = 2,074), CVD (n = 714), and MD (n = 443) were selected among health care workers in 12 Dutch organizations. Using an online questionnaire, data were collected on individual characteristics, health behaviors, work impairments, work ability, and consultation of a general practitioner (GP), physiotherapist, specialist, or psychologist in the past year. Univariate and multivariate logistic regression analyses were performed to explore the associations of work impairments and work ability with health care use. Results lower work ability was associated with a higher likelihood of consulting any health care provider among workers with common disorders (OR 1.05–1.45). Among workers with MSD work impairments increased the likelihood of consulting a GP (OR 1.55), specialist (OR 2.05), and physical therapist (OR 1.98). Among workers with CVD work impairments increased the likelihood of consulting a specialist (OR 1.94) and physical therapist (OR 2.73). Among workers with MD work impairments increased the likelihood of consulting a specialist (OR 1.79) and psychologist (OR 1.82). Conclusion work impairments and reduced work ability were associated with health care use among workers with MSD, CVD, or MD. These findings suggest that addressing work-related problems in workers with common disorders may contribute in reducing health care needs.
PMCID: PMC4229647  PMID: 24390780
Work ability; Work impairments; Health care utilization; Musculoskeletal disease; Cardiovascular disease; Mental disorders
13.  Is retirement good for your health? A systematic review of longitudinal studies 
BMC Public Health  2013;13:1180.
Several studies regarding the effect of retirement on physical as well as mental health have been performed, but the results thereof remain inconclusive. The aim of this review is to systematically summarise the literature on the health effects of retirement, describing differences in terms of voluntary, involuntary and regulatory retirement and between blue-collar and white-collar workers.
A search for longitudinal studies using keywords that referred to the exposure (retirement), outcome (health-related) and study design (longitudinal) was performed using several electronic databases. Articles were then selected for full text analysis and the reference lists of the selected studies were checked for relevant studies. The quality of the studies was rated based on predefined criteria. Data was analysed qualitatively by using a best evidence synthesis. When possible, pooled mean differences and effect sizes were calculated to estimate the effect of retirement on health.
Twenty-two longitudinal studies were included, of which eleven were deemed to be of high quality. Strong evidence was found for retirement having a beneficial effect on mental health, and contradictory evidence was found for retirement having an effect on perceived general health and physical health. Few studies examined the differences between blue- and white-collar workers and between voluntary, involuntary and regulatory retirement with regards to the effect of retirement on health outcomes.
More longitudinal research on the health effects of retirement is needed, including research into potentially influencing factors such as work characteristics and the characteristics of retirement.
PMCID: PMC4029767  PMID: 24330730
Retirement; Physical health; Mental health; Perceived health; Systematic review; Meta-analysis
14.  Comparing health outcomes in SHARE with other European surveys 
BMC Proceedings  2013;7(Suppl 4):S2.
PMCID: PMC3892725  PMID: 24819884
15.  Determinants of Participation in a Web-Based Health Risk Assessment and Consequences for Health Promotion Programs 
The health risk assessment (HRA) is a type of health promotion program frequently offered at the workplace. Insight into the underlying determinants of participation is needed to evaluate and implement these interventions.
To analyze whether individual characteristics including demographics, health behavior, self-rated health, and work-related factors are associated with participation and nonparticipation in a Web-based HRA.
Determinants of participation and nonparticipation were investigated in a cross-sectional study among individuals employed at five Dutch organizations. Multivariate logistic regression was performed to identify determinants of participation and nonparticipation in the HRA after controlling for organization and all other variables.
Of the 8431 employees who were invited, 31.9% (2686/8431) enrolled in the HRA. The online questionnaire was completed by 27.2% (1564/5745) of the nonparticipants. Determinants of participation were some periods of stress at home or work in the preceding year (OR 1.62, 95% CI 1.08-2.42), a decreasing number of weekdays on which at least 30 minutes were spent on moderate to vigorous physical activity (ORdayPA0.84, 95% CI 0.79-0.90), and increasing alcohol consumption. Determinants of nonparticipation were less-than-positive self-rated health (poor/very poor vs very good, OR 0.25, 95% CI 0.08-0.81) and tobacco use (at least weekly vs none, OR 0.65, 95% CI 0.46-0.90).
This study showed that with regard to isolated health behaviors (insufficient physical activity, excess alcohol consumption, and stress), those who could benefit most from the HRA were more likely to participate. However, tobacco users and those who rated their overall health as less than positive were less likely to participate. A strong communication strategy, with recruitment messages that take reasons for nonparticipation into account, could prove to be an essential tool for organizations trying to reach employees who are less likely to participate.
PMCID: PMC3742395  PMID: 23933650
participation; Internet; workplace; health promotion; health risk assessment; reach
16.  The influence of re-employment on quality of life and self-rated health, a longitudinal study among unemployed persons in the Netherlands 
BMC Public Health  2013;13:503.
Unemployed persons have a poorer health compared with employed persons and unemployment may cause ill health. The aim of this study was to investigate the effect of re-employment on quality of life and health among unemployed persons on social benefits.
A prospective study with 18 months follow-up was conducted among unemployed persons (n=4,308) in the Netherlands, receiving either unemployment benefits or social security benefits. Quality of life, self-rated health, and employment status were measured at baseline and every 6 months of follow up with questionnaires. Generalized estimating equations (GEE) modeling was performed to study the influence of re-employment on change in self-rated health and quality of life over time.
In the study population 29% had a less than good quality of life and 17% had a poor self-rated health. Persons who started with paid employment during the follow-up period were more likely to improve towards a good quality of life (OR 1.76) and a good self-rated health (OR 2.88) compared with those persons who remained unemployed. Up to 6 months after re-employment, every month with paid employment, the likelihood of a good quality of life increased (OR 1.12).
Starting with paid employment improves quality of life and self-rated health. This suggests that labour force participation should be considered as an important measure to improve health of unemployed persons. Improving possibilities for unemployed persons to find paid employment will reduce socioeconomic inequalities in health.
PMCID: PMC3680011  PMID: 23706106
General health; Quality of life; Re-employment; Unemployment; Longitudinal study
17.  Pathways through which health influences early retirement: a qualitative study 
BMC Public Health  2013;13:292.
Due to the aeging of the population, there is a societal need for workers to prolong their working lives. In the Netherlands, many employees still leave the workforce before the official retirement age of 65. Previous quantitative research showed that poor self-perceived health is a risk factor of (non-disability) early retirement. However, little is known on how poor health may lead to early retirement, and why poor health leads to early retirement in some employees, but not in others. Therefore, the present qualitative study aims to identify in which ways health influences early retirement.
Face-to-face semi-structured interviews were conducted with 30 employees (60–64 years) who retired before the official retirement age of 65. Participants were selected from the Study on Transitions in Employment, Ability and Motivation. The interviews were transcribed verbatim, a summary was made including a timeline, and the interviews were open coded.
In 15 of the 30 persons, health played a role in early retirement. Both poor and good health influenced early retirement. For poor health, four pathways were identified. First, employees felt unable to work at all due to health problems. Second, health problems resulted in a self-perceived (future) decline in the ability to work, and employees chose to retire early. Third, employees with health problems were afraid of a further decline in health, and chose to retire early. Fourth, employees with poor health retired early because they felt pushed out by their employer, although they themselves did not experience a reduced work ability. A good health influenced early retirement, since persons wanted to enjoy life while their health still allowed to do so. The financial opportunity to retire sometimes triggered the influence of poor health on early retirement, and often triggered the influence of good health. Employees and employers barely discussed opportunities to prolong working life.
Poor and good health influence early retirement via several different pathways. To prolong working life, a dialogue between employers and employees and tailored work-related interventions may be helpful.
PMCID: PMC3621068  PMID: 23551994
Early retirement; Health; Qualitative study; Dialogue
18.  Fetal Growth and Prenatal Exposure to Bisphenol A: The Generation R Study 
Environmental Health Perspectives  2013;121(3):393-398.
Background: Prenatal exposure to bisphenol A (BPA) has been associated with adverse birth outcomes, but findings of previous studies have been inconsistent.
Objective: We investigated the relation of prenatal BPA exposure with intrauterine growth and evaluated the effect of the number of measurements per subject on observed associations.
Methods: This study was embedded in a Dutch population-based prospective cohort study, with urine samples collected during early, mid-, and late pregnancy. The study comprised 219 women, of whom 99 had one measurement, 40 had two measurements, and 80 had three measurements of urinary BPA. Fetal growth characteristics were repeatedly measured by ultrasound during pregnancy and combined with measurements at birth. Linear regression models for repeated measurements of both BPA and fetal growth were used to estimate associations between urinary concentrations of creatinine-based BPA (BPACB) and intrauterine growth.
Results: The relationship between BPACB and fetal growth was sensitive to the number of BPA measurements per woman. Among 80 women with three BPA measurements, women with BPACB > 4.22 μg/g crea (creatinine) had lower growth rates for fetal weight and head circumference than did women with BPACB < 1.54 μg/g crea, with estimated differences in mean values at birth of –683 g (20.3% of mean) and –3.9 cm (11.5% of mean), respectively. When fewer measurements were available per woman, the exposure–response relationship became progressively attenuated and statistically nonsignificant.
Conclusion: Our findings suggest that maternal urinary BPA may impair fetal growth. Because previous studies have shown contradictory findings, further evidence is needed to corroborate these findings in the general population.
PMCID: PMC3621207  PMID: 23459363
birth weight; bisphenol A; fetal growth; head circumference; pregnancy; urine
19.  Development and Validation of a Job Exposure Matrix for Physical Risk Factors in Low Back Pain 
PLoS ONE  2012;7(11):e48680.
The aim was to construct and validate a gender-specific job exposure matrix (JEM) for physical exposures to be used in epidemiological studies of low back pain (LBP).
Materials and Methods
We utilized two large Finnish population surveys, one to construct the JEM and another to test matrix validity. The exposure axis of the matrix included exposures relevant to LBP (heavy physical work, heavy lifting, awkward trunk posture and whole body vibration) and exposures that increase the biomechanical load on the low back (arm elevation) or those that in combination with other known risk factors could be related to LBP (kneeling or squatting). Job titles with similar work tasks and exposures were grouped. Exposure information was based on face-to-face interviews. Validity of the matrix was explored by comparing the JEM (group-based) binary measures with individual-based measures. The predictive validity of the matrix against LBP was evaluated by comparing the associations of the group-based (JEM) exposures with those of individual-based exposures.
The matrix includes 348 job titles, representing 81% of all Finnish job titles in the early 2000s. The specificity of the constructed matrix was good, especially in women. The validity measured with kappa-statistic ranged from good to poor, being fair for most exposures. In men, all group-based (JEM) exposures were statistically significantly associated with one-month prevalence of LBP. In women, four out of six group-based exposures showed an association with LBP.
The gender-specific JEM for physical exposures showed relatively high specificity without compromising sensitivity. The matrix can therefore be considered as a valid instrument for exposure assessment in large-scale epidemiological studies, when more precise but more labour-intensive methods are not feasible. Although the matrix was based on Finnish data we foresee that it could be applicable, with some modifications, in other countries with a similar level of technology.
PMCID: PMC3495969  PMID: 23152793
20.  Occupational Activities Associated with a Reported History of Malaria among Women Working in Small-Scale Agriculture in South Africa 
Malaria-endemic agricultural communities are at risk for this disease because of crop and agricultural activities. A cross-sectional survey among women in small-scale agriculture on irrigated and dryland areas in Makhatini Flats, KwaZulu-Natal South Africa explored associations with self-reported history of malaria, including demographics, crop production, and specific agricultural activities. Ninety-eight (15.2%) of 644 women reported malaria while working in agriculture. More women working in drylands than women working in irrigation scheme reported disease (18.4% versus 10.9%; P < 0.05). Working self or family-owned farms (prevalence ratio [PR] = 2.6, 95% confidence interval [CI] = 1.3–5.2), spraying pesticides (PR = 2.3; 95% CI = 1.4–3.8), cultivating sugar cane (PR = 1.6, 95% CI = 1.1–2.3), and cultivating cotton and mangoes (PR = 1.7, 95% CI = 1.1–2.6) were positively associated with a history of malaria while working in agriculture. This study suggests that certain agricultural activities and types of crop production may increase the risk for malaria among women working in small-scale agriculture.
PMCID: PMC3205622  PMID: 22049030
21.  Socioeconomic inequalities in occupational, leisure-time, and transport related physical activity among European adults: A systematic review 
This study systematically reviewed the evidence pertaining to socioeconomic inequalities in different domains of physical activity (PA) by European region.
Studies conducted between January 2000 and December 2010 were identified by a systematic search in Pubmed, Embase, Web of Science, Psychinfo, Sportdiscus, Sociological Abstracts, and Social Service Abstracts. English-language peer-reviewed studies undertaken in the general population of adults (18–65 years) were classified by domain of PA (total, leisure-time including sport, occupational, active transport), indicator of socioeconomic position (education, income, occupation), and European region. Distributions of reported positive, negative, and null associations were evaluated.
A total of 131 studies met the inclusion criteria. Most studies were conducted in Scandinavia (n = 47). Leisure-time PA was the most frequently studied PA outcome (n = 112). Considerable differences in the direction of inequalities were seen for the different domains of PA. Most studies reported that those with high socioeconomic position were more physically active during leisure-time compared to those with low socioeconomic position (68% positive associations for total leisure-time PA, 76% for vigorous leisure-time PA). Occupational PA was more prevalent among the lower socioeconomic groups (63% negative associations). Socioeconomic differences in total PA and active transport PA did not show a consistent pattern (40% and 38% positive associations respectively). Some inequalities differed by European region or socioeconomic indicator, however these differences were not very pronounced.
The direction of socioeconomic inequalities in PA in Europe differed considerably by domain of PA. The contradictory results for total PA may partly be explained by contrasting socioeconomic patterns for leisure-time PA and occupational PA.
PMCID: PMC3491027  PMID: 22992350
Socioeconomic; Inequalities; Physical activity; Systematic review; Europe
22.  The role of lifestyle, health, and work in educational inequalities in sick leave and productivity loss at work 
To investigate the influence of lifestyle, health, and work conditions in the association between education and productivity loss at work and sick leave.
Employees of six companies filled out a questionnaire on demographics, lifestyle-related, health, and work-related factors, and productivity loss at work and sick leave at baseline (n = 915) and after 1-year (n = 647).
Employees with a low education were more likely to report productivity loss at work (OR = 1.49, 95 % CI 0.98–2.26) and sick leave (OR = 1.81, 95 % CI 1.15–2.85). After adjustment for lifestyle, health, and work conditions, the association between education and productivity loss at work did not attenuate. Work conditions attenuated the association between low education and sick leave (OR = 1.62, 95 % CI 1.01–2.61), and additional adjustment for health and lifestyle-related factors further reduced the strength of the association (OR = 1.42, 95 % CI 0.86–2.34).
Work conditions and lifestyle-related factors partly explained the association between education and sick leave, but did not influence the association between education and productivity loss at work. The educational differences in sick leave prompt for interventions that address behavioral aspects as well as work-related and lifestyle-related factors.
PMCID: PMC3722458  PMID: 22772397
Productivity loss at work; Sick leave; Education; Inequalities
23.  Work-Related Maternal Risk Factors and the Risk of Pregnancy Induced Hypertension and Preeclampsia during Pregnancy. The Generation R Study 
PLoS ONE  2012;7(6):e39263.
To study the associations between physically demanding work and occupational exposure to chemicals and hypertensive disorders during pregnancy within a large birth cohort study, the Generation R Study.
Associations between occupational characteristics and hypertensive disorders during pregnancy were studied in 4465 pregnant woman participating in a population-based prospective cohort study from early pregnancy onwards in the Netherlands (2002–2006). Mothers who filled out a questionnaire during mid-pregnancy (response 77% of enrolment), were included if they conducted paid employment, had a spontaneously conceived singleton live born pregnancy, and did not suffer from pre-existing hypertension (n = 4465). Questions on physical demanding work were obtained from the Dutch Musculoskeletal Questionnaire and concerned questions on manually handling loads of 25 kg or more, long periods of standing or walking, night shifts, and working hours. To assess occupational exposure to chemicals, job titles and task descriptions were linked to a job-exposure-matrix (JEM), an expert judgment on exposure to chemicals at the workplace. Information on hypertensive disorders during pregnancy was obtained from medical records.
We observed no consistent associations between any of the work related risk factors, such as long periods of standing or walking, heavy lifting, night shifts, and working hours, nor exposure to chemicals with hypertensive disorders during pregnancy.
This prospective birth cohort study suggests that there is no association of hypertensive disorders during pregnancy with physically demanding work or exposure to chemicals. However, the low prevalence of PIH and PE, combined with the low prevalence of occupational risk factors limit the power for inference and larger studies are needed to corroborate or refute these findings.
PMCID: PMC3376127  PMID: 22720087
24.  Initial and Sustained Participation in an Internet-delivered Long-term Worksite Health Promotion Program on Physical Activity and Nutrition 
Determinants of participation in health promotion programs are largely unknown. To evaluate and implement interventions, information is needed regarding their reach as well as regarding the characteristics of program users and non-users.
In this study, individual, lifestyle, and health indicators were investigated in relation to initial, and sustained participation in an Internet-delivered physical activity and healthy nutrition program in the workplace setting. In addition, determinants of program website use were studied.
Determinants of participation were investigated in a longitudinal study among employees from six workplaces participating in a two-year cluster randomized controlled trial. The employees were invited by email to participate. At baseline, all participants visited a website to fill out the questionnaire on lifestyle, work, and health factors. Subsequently, a physical health check was offered, followed by face-to-face advice. Throughout the study period, all participants had access to a website with information on lifestyle and health, and to fully automated personalized feedback on the questionnaire results. Only participants in the intervention received monthly email messages to promote website visits during the first year and had access to additional Web-based tools (self-monitors, a food frequency questionnaire assessing saturated fat intake, and the possibility to ask questions) to support behavior change. Website use was monitored by website statistics measuring access. Logistic regression analyses were conducted to identify characteristics of employees who participated in the program and used the website.
Complete baseline data were available for 924 employees (intervention: n=456, reference: n=468). Lifestyle and health factors were not associated with initial participation. Employees aged 30 years and older were more likely to start using the program and to sustain their participation. Workers with a low intention to increase their physical activity level were less likely to participate (Odds Ratio (OR)=0.60, 95% Confidence interval (95%CI), 0.43-0.85) but more likely to sustain participation throughout the study period (ORs ranging from 1.40 to 2.06). Furthermore, it was found that smokers were less likely to sustain their participation in the first and second year (OR=0.54, 95%CI 0.35-0.82) and to visit the website (OR=0.72, 95%CI 0.54-0.96). Website use was highest in the periods immediately after the baseline (73%) and follow-up questionnaires (71% and 87%). Employees in the intervention were more likely to visit the website in the period they received monthly emails (OR=5.88, 95%CI 3.75-9.20) but less likely to visit the website in the subsequent period (OR=0.62, 95%CI 0.45-0.85).
Modest initial participation and high attrition in program use were found. Workers with a low intention to change their behavior were less likely to participate, but once enrolled they were more likely to sustain their participation. Lifestyle and health indicators were not related to initial participation, but those with an unhealthy lifestyle were less likely to sustain. This might influence program effectiveness. Regular email messages prompted website use, but the use of important Web-based tools was modest. There is a need for more appealing techniques to enhance retention and to keep those individuals who need it most attracted to the program.
Trial Registration
PMCID: PMC3376517  PMID: 22390886
Participation; Retention; Internet; Physical activity; Nutrition; Workplace; Health promotion
25.  Cost-effectiveness of a long-term Internet-delivered worksite health promotion programme on physical activity and nutrition: a cluster randomized controlled trial 
Health Education Research  2012;27(3):399-410.
This study aims to evaluate the cost-effectiveness of a long-term workplace health promotion programme on physical activity (PA) and nutrition. In total, 924 participants enrolled in a 2-year cluster randomized controlled trial, with departments (n = 74) within companies (n = 6) as the unit of randomization. The intervention was compared with a standard programme consisting of a physical health check with face-to-face advice and personal feedback on a website. The intervention consisted of several additional website functionalities: action-oriented feedback, self-monitoring, possibility to ask questions and monthly e-mail messages. Primary outcomes were meeting the guidelines for PA and fruit and vegetable intake. Secondary outcomes were self-perceived health, obesity, elevated blood pressure, elevated cholesterol level and maximum oxygen uptake. Direct and indirect costs were calculated from a societal perspective, and a process evaluation was performed. Of the 924 participants, 72% participated in the first and 60% in the second follow-up. No statistically significant differences were found on primary and secondary outcomes, nor on costs. Average direct costs per participant over the 2-year period were €376, and average indirect costs were €9476. In conclusion, no additional benefits were found in effects or cost savings. Therefore, the programme in its current form cannot be recommended for implementation.
PMCID: PMC3337425  PMID: 22350194

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