Attrition is a noted feature of eHealth interventions and trials. In 2005, Eysenbach published a landmark paper calling for a “science of attrition,” suggesting that the 2 forms of attrition—nonusage attrition (low adherence to the intervention) and dropout attrition (poor retention to follow-up)—may be related and that this potential relationship deserved further study.
The aim of this paper was to use data from an online alcohol trial to explore Eysenbach’s hypothesis, and to answer 3 research questions: (1) Are adherence and retention related? If so, how, and under which circumstances? (2) Do adherence and retention have similar predictors? Can these predictors adequately explain any relationship between adherence and retention or are there additional, unmeasured predictors impacting on the relationship? (3) If there are additional unmeasured predictors impacting on the relationship, are there data to support Eysenbach’s hypothesis that these are related to overall levels of interest?
Secondary analysis of data from an online trial of an online intervention to reduce alcohol consumption among heavy drinkers. The 2 outcomes were adherence to the intervention measured by number of log-ins, and retention to the trial measured by provision of follow-up data at 3 months (the primary outcome point). Dependent variables were demographic and alcohol-related data collected at baseline. Predictors of adherence and retention were modeled using logistic regression models.
Data were available on 7932 participants. Adherence and retention were related in a complex fashion. Participants in the intervention group were more likely than those in the control group to log in more than once (42% vs 28%, P<.001) and less likely than those in the control group to respond at 3 months (40% vs 49%, P<.001). Within each randomized group, participants who logged in more frequently were more likely to respond than those who logged in less frequently. Response rates in the intervention group for those who logged in once, twice, or ≥3 times were 34%, 46%, and 51%, respectively (P<.001); response rates in the control group for those who logged in once, twice, or ≥3 times were 44%, 60%, and 67%, respectively (P<.001). Relationships between baseline characteristics and adherence and retention were also complex. Where demographic characteristics predicted adherence, they tended also to predict retention. However, characteristics related to alcohol consumption and intention or confidence in reducing alcohol consumption tended to have opposite effects on adherence and retention, with factors that predicted improved adherence tending to predict reduced retention. The complexity of these relationships suggested the existence of an unmeasured confounder.
In this dataset, adherence and retention were related in a complex fashion. We propose a possible explanatory model for these data.
International Standard Randomized Controlled Trial Number (ISRCTN): 31070347; http://www.controlled-trials.com/ISRCTN31070347 (Archived by WebCite at http://www.webcitation.org/6IEmNnlCn).
Internet; eHealth; attrition; adherence; retention; follow-up
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.
participation; Internet; workplace; health promotion; health risk assessment; reach
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.
General health; Quality of life; Re-employment; Unemployment; Longitudinal study
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.
Early retirement; Health; Qualitative study; Dialogue
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.
birth weight; bisphenol A; fetal growth; head circumference; pregnancy; urine
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.
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.
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.
Socioeconomic; Inequalities; Physical activity; Systematic review; Europe
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.
Productivity loss at work; Sick leave; Education; Inequalities
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.
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.
Participation; Retention; Internet; Physical activity; Nutrition; Workplace; Health promotion
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.
Developmental diseases, such as birth defects, growth restriction and preterm delivery, account for >25% of infant mortality and morbidity. Several studies have shown that exposure to chemicals during pregnancy is associated with adverse birth outcomes. The aim of this study was to identify whether occupational exposure to various chemicals might adversely influence intrauterine growth patterns and placental weight.
Associations between maternal occupational exposure to various chemicals and fetal growth were studied in 4680 pregnant women participating in a population-based prospective cohort study from early pregnancy onwards in the Netherlands (2002–2006), the Generation R Study. Mothers who filled out a questionnaire during mid-pregnancy (response: 77% of enrolment) were included if they conducted paid employment during pregnancy and had a spontaneously conceived singleton live born pregnancy (n = 4680). A job exposure matrix was used, linking job titles to expert judgement on exposure to chemicals in the workplace. Fetal growth characteristics were repeatedly measured by ultrasound and were used in combination with measurements at birth. Placental weight was obtained from medical records and hospital registries. Linear regression models for repeated measurements were used to study the associations between maternal occupational exposure to chemicals and intrauterine growth.
We observed that maternal occupational exposure to polycyclic aromatic hydrocarbons, phthalates, alkylphenolic compounds and pesticides adversely influenced several domains of fetal growth (fetal weight, fetal head circumference and fetal length). We found a significant association between pesticide and phthalate exposure with a decreased placental weight.
Our results suggest that maternal occupational exposure to several chemicals is associated with impaired fetal growth during pregnancy and a decreased placental weight. Further studies are needed to confirm these findings and to assess post-natal consequences.
chemical exposure; occupational exposure; phthalates; pesticides; fetal growth
Background: Asbestos is a well-recognized cause of lung cancer, but there is considerable between-study heterogeneity in the slope of the exposure–response relationship.
Objective: We considered the role of quality of the exposure assessment to potentially explain heterogeneity in exposure–response slope estimates.
Data sources: We searched PubMed MEDLINE (1950–2009) for studies with quantitative estimates of cumulative asbestos exposure and lung cancer mortality and identified 19 original epidemiological studies. One was a population-based case–control study, and the others were industry-based cohort studies.
Data extraction: Cumulative exposure categories and corresponding risks were abstracted. Exposure–response slopes [KL (lung cancer potency factor of asbestos)] were calculated using linear relative risk regression models.
Data synthesis: We assessed the quality of five exposure assessment aspects of each study and conducted random effects univariate and multivariate meta-regressions. Heterogeneity in exposure–response relationships was greater than expected by chance (I2 = 64%). Stratification by exposure assessment characteristics revealed that studies with well-documented exposure assessment, larger contrast in exposure, greater coverage of the exposure history by exposure measurement data, and more complete job histories had higher meta-KL values than did studies without these characteristics. The latter two covariates were most strongly associated with the KL value. Meta-KL values increased when we incrementally restricted analyses to higher-quality studies.
Conclusions: This meta-analysis indicates that studies with higher-quality asbestos exposure assessment yield higher meta-estimates of the lung cancer risk per unit of exposure. Potency differences for predominantly chrysotile versus amphibole asbestos-exposed cohorts become difficult to ascertain when meta-analyses are restricted to studies with fewer exposure assessment limitations.
amphiboles; asbestos; chrysotile; lung cancer; meta-analysis
After publication of this work [Beenackers et al: Int J Behav Nutr Phys Act 2011, 8:76] it was realized that formula 3 and formula 4 in the Statistical Analysis section of the Methods were incorrectly listed. Since the formulas were correctly used in the analysis, this correction does not affect the results or conclusions of the paper.
Little is known about the interaction between individual and environmental determinants of physical activity, although this may be important information for the development of effective interventions. The goal of this paper is to investigate whether perceived neighborhood safety modifies associations between individual cognitions and sports participation.
Cross-sectional data were obtained from residents (age 25-75) of 87 neighborhoods in the city of Eindhoven, who participated in the Dutch GLOBE study in 2004 (N = 2474). We used multilevel logistic regression to analyze the interactions between perceived neighborhood safety and individual cognitions (attitude, self-efficacy, social influence, and intention) on sports participation (yes/no).
In its association with sports participation, perceived neighborhood safety interacted significantly with self-efficacy and attitude (p < 0.05). Among persons who perceived their neighborhood as safe, a positive attitude was strongly associated with sports participation (OR = 2.00, 95%CI = 1.48-2.71). In contrast, attitude was not associated with sports participation in persons who perceived their neighborhood as unsafe (OR = 0.65, 95%CI = 0.34-1.24). Further, self-efficacy was significantly stronger associated with sports participation in persons who perceived their neighborhood as unsafe (OR = 1.85, 95%CI = 1.31-2.60) than in those who perceived their neighborhood as safe (OR = 1.19, 95%CI = 1.05-1.36). Social influence and intention did not interact with perceived neighborhood safety.
Associations between individual cognitions and sports participation depend on neighborhood circumstances, such as perceived neighborhood safety. Interventions to promote sports participation in adults should take the interaction between environmental and individual characteristics into account. More research is needed to find out the causal pathways in individual-environment interactions.
physical activity; sport; safety; moderator variable; environment
There is debate to what extent employers are entitled to interfere with the lifestyle and health of their workers. In this context, little information is available on the opinion of employees. Within the framework of a workplace health promotion (WHP) program, moral considerations among workers were investigated.
Employees from five companies were invited to participate in a WHP program. Both participants (n = 513) and non-participants (n = 205) in the program filled in a questionnaire on individual characteristics, lifestyle, health, and opinions regarding WHP.
Nineteen percent of the non-participants did not participate in the WHP program because they prefer to arrange it themselves, and 13% (also) preferred to keep private life and work separate. More participants (87%) than non-participants (77%) agreed with the statement that it is good that employers try to improve employees’ health (χ2 = 12.78, p = 0.002), and 26% of the non-participants and 21% of the participants think employer interference with their health is a violation of their privacy. Employees aged 50 year and older were more likely to agree with the latter statement than younger workers (OR = 1.56, 95% CI 1.02–2.39).
This study showed that most employees support the importance of WHP, but in a modest group of employees, moral considerations may play a role in their decision whether or not to participate in WHP. Older workers were more likely to resist employer interference with their health. Therefore, special attention on such moral considerations may be needed in the communication, design, and implementation of workplace health promotion programs.
Ethics; Participation; Workplace; Health promotion; Lifestyle
Introduction Most workers with musculoskeletal disorders on sick leave often consult with regular health care before entering a specific work rehabilitation program. However, it remains unclear to what extent regular healthcare contributes to the timely return to work (RTW). Moreover, several studies have indicated that it might postpone RTW. There is a need to establish the influence of regular healthcare on RTW as outcome; “Does visiting a regular healthcare provider influence the duration of sickness absence and recurrent sick leave due to musculoskeletal disorders?”. Methods A cohort of workers on sick leave for 2–6 weeks due to a-specific musculoskeletal disorders was followed for 12 months. The main outcomes for the present analysis were: duration of sickness absence till 100% return to work and recurrent sick leave after initial RTW. Cox regression analyses were conducted with visiting a general health practitioner, physical therapist, or medical specialist during the sick leave period as independent variables. Each regression model was adjusted for variables known to influence health care utilization like age, sex, diagnostic group, pain intensity, functional disability, general health perception, severity of complaints, job control, and physical load at work. Results Patients visiting a medical specialist reported higher pain intensity and more functional limitations and also had a worse health perception at start of the sick leave period compared with those not visiting a specialist. Visiting a medical specialist delayed return to work significantly (HR = 2.10; 95%CI 1.43–3.07). After approximately 8 weeks on sick leave workers visiting a physical therapist returned to work faster than other workers. A recurrent episode of sick leave during the follow up quick was initiated by higher pain intensity and more functional limitations at the moment of fully return to work. Visiting a primary healthcare provider during the sickness absence period did not influence the occurrence of a new sick leave period. Conclusion Despite the adjustment for severity of the musculoskeletal disorder, visiting a medical specialist was associated with a delayed full return to work. More attention to the factor ‘labor’ in the regular healthcare is warranted, especially for those patients experiencing substantial functional limitations due to musculoskeletal disorders.
Return to work; Work disability; Health care services; Musculoskeletal disorders
Workers with decreased work ability are at greater risk of reduced productivity at work. We hypothesized that work-related characteristics play an important role in supporting workers to remain productive despite decreased work ability.
The study population consisted of 10,542 workers in 49 different companies in the Netherlands in 2005–2009. Productivity loss at work was defined on a 10-point scale by asking how much work was actually performed during regular hours on the last regular workday when compared with normal. Independent variables in the logistic regression analysis were individual characteristics, work-related factors, and the work ability index. Additive interactions between work-related factors and decreased work ability were evaluated by the relative excess risk due to interaction (RERI).
The odds ratios and 95% confidence intervals (CI) for the likelihood of productivity loss at work were 2.03 (1.85–2.22), 3.50 (3.10–3.95), and 5.54 (4.37–7.03) for a good, moderate, and poor work ability, compared with an excellent work ability (reference group). Productivity loss at work was associated with lack of job control, poor skill discretion, and high work demands. There was a significant interaction between decreased work ability and lack of job control (RERI = 0.63 95% CI 0.11–1.16) with productivity loss at work.
The negative effects on work performance of decreased work ability may be partly counterbalanced by increased job control. This suggests that interventions among workers with (chronic) disease that cause a decreased work ability should include enlargement of possibilities to plan and pace their own activities at work.
Presentism; Productivity loss at work; Work ability; Job control
Internet-delivered behavior change programs have the potential to reach a large population. However, low participation levels and high levels of attrition are often observed. The worksite could be a setting suitable for reaching and retaining large numbers of people, but little is known about reach and use of Internet-delivered health promotion programs in the worksite setting.
This study aimed (1) to gain more insight in the use of the website component of a worksite behavior change intervention and (2) to identify demographic, behavioral, and psychosocial factors associated with website use.
The study was an observational study among participants from 5 workplaces in a cluster randomized controlled trial. At baseline, all participants visited a study website to fill out the baseline questionnaire. Then a physical health check was done followed by face-to-face advice. After this contact, all participants received an email to promote visiting the website to view their health check results and the personal advice based on the baseline questionnaire. In the subsequent period, only participants in the intervention group received monthly email messages to promote website visits and were offered additional Web-based tools (self-monitors and a food frequency questionnaire [FFQ] assessing saturated fat intake) to support their behavior change. Website use was monitored by website statistics registering website access. Complete data were available for 726 employees. Logistic regression analyses were conducted to identify characteristics of employees who visited and used the website.
In total, 43% of the participants visited the website after the email to promote website visits. Participants who were insufficiently physically active were less likely to visit the website (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.45-0.88), whereas individuals with an elevated total cholesterol level visited the website more often (OR 1.44, 95% CI 1.05-1.98). The monthly emails in the intervention group resulted in higher website use during a 3-month period (18% versus 5% in the reference group, OR 3.96, 95% CI 2.30-6.82). Participants with a positive attitude toward increasing physical activity were less likely to visit the website (OR 0.54, 95% CI 0.31-0.93) or to use the self-monitor and FFQ (OR 0.50, 95% CI 0.25-0.99). Female workers visited the website more often to monitor their behavior and to receive advice on fat intake (OR 2.36, 95% CI 1.14-4.90).
Almost half of the participants used the website component of a worksite behavior change program. Monthly emails were a prompt to visit the website, but website use remained low. More women than men used the website to obtain personalized advice for behavior change. No consistently higher participation was found among those with healthier behaviors. This health promotion program did not provide an indication that healthier subjects are more susceptible to health promotion.
ISRCTN52854353; http://www.controlled-trials.com/ISRCTN52854353 (Archived by WebCite at http://www.webcitation.org/5smxIncB1)
Internet; physical activity; nutrition; behavior change; selective retention; workplace
Concern about potential health impacts of low level exposures to organophosphorus (OP) pesticides, bisphenol A (BPA), and phthalates among the general population is increasing. We measured levels of six dialkyl phosphate (DAP) metabolites of OP pesticides, a chlorpyrifos-specific metabolite (3,5,6-trichloro-2-pyridinol, TCPy), BPA, and fourteen phthalate metabolites in urine samples of 100 pregnant women from the Generation R study, the Netherlands. The unadjusted and creatinine-adjusted concentrations were reported, and compared to National Health and Nutrition Examination Survey and other studies. In general, these metabolites were detectable in the urine of the women from the Generation R study and compared with other groups, they had relatively high level exposures to OP pesticides and several phthalates but similar exposure to BPA. The median concentrations of total dimethyl (DM) metabolites was 264.0 nmol/g creatinine (Cr) and of total DAP was 316.0 nmol/g Cr. The median concentration of mono-ethyl phthalate (MEP) was 222.0 µg/g Cr; the median concentrations of mono-isobutyl phthalate (MiBP) and mono-n-butyl phthalate (MnBP) were above 50 µg/g Cr. The median concentrations of the three secondary metabolites of di-2-ethylhexyl phthalate (DEHP) were greater than 20 µg/g Cr. The data indicate that the Generation R study population provides a wide distribution of selected environmental exposures. Reasons for the relatively high levels and possible health effects need investigation.
Organophosphorus (OP) pesticides; Bisphenol A (BPA); Phthalates; Prenatal exposure; Biological monitoring
The aim of the study is to evaluate whether health inequalities associated with unemployment are comparable across different ethnic groups.
A random sample of inhabitants of the city of Rotterdam filled out a questionnaire on health and its determinants, with a response of 55.4% (n = 2,057). In a cross-sectional design the associations of unemployment, ethnicity, and individual characteristics with a perceived poor health were investigated with logistic regression analysis. The associations of these determinants with physical and mental health, measured by the Short Form 36 Health Survey, were evaluated with linear regression analyses. Interactions between ethnicity and unemployment were investigated to determine whether associations of unemployment and health differed across ethnic groups.
Ill health was more common among unemployed persons [odds ratio (OR) 2.6; 95% CI 1.7–3.8] than workers in paid employment. Health inequalities between employed and unemployed persons were largest among native Dutch persons (OR = 3.2) and Surinamese/Antillean persons (OR = 2.6), and smaller in Turkish/Moroccan persons (OR = 1.6) and overseas refugees (OR = 1.6). The proportions of persons with poor health that could be attributed to unemployment were 14, 26, 14, and 13%, respectively.
Differences in ill health between employed and unemployed persons were less profound in ethnic groups compared to the majority population, but the prevalence of unemployment was much higher in ethnic groups. The population attributable fractions varied between 14 and 28%, supporting the argument that policies for health equity should pay more attention to measures that include persons in the labour market and that prevent workers with ill health from dropping out of the workforce.
Ethnicity; Inequalities; Unemployment; Perceived health
The relationship between poor health and unemployment is well established. Health promotion among unemployed persons may improve their health. The aims of this study were to investigate characteristics of non-participants and drop-outs in a multidisciplinary health promotion programme for long-term unemployed persons with health complaints, to evaluate changes in physical health among participants, and to investigate determinants of improvement in physical health.
A longitudinal, non-controlled design was used. The programme consisted of two weekly exercise sessions and one weekly cognitive session during 12 weeks. The main outcome measures were body mass index, blood pressure, cardiorespiratory fitness, abdominal muscle strength, and low back and hamstring flexibility. Potential determinants of change in physical health were demographic variables, psychological variables (self-esteem, mastery, and kinesiophobia), and self-perceived health.
The initial response was 73% and 252 persons had complete data collection at baseline. In total, 36 subjects were lost during follow-up. Participants were predominantly low educated, long-term unemployed, and in poor health. Participation in the programme was not influenced by demographic and psychological factors or by self-reported health. Drop-outs were younger and had a lower body mass index at baseline than subjects who completed the programme. At post-test, participants' cardiorespiratory fitness, abdominal muscle strength, and flexibility had increased by 6.8%–51.0%, whereas diastolic and systolic blood pressures had decreased by 2.2%–2.5%. The effect sizes ranges from 0.17–0.68.
Participants with the poorest physical health benefited most from the programme and gender differences in improvement were observed. Physical health of unemployed persons with health complaints improved after participation in this health promotion programme, but not sufficiently, considering their poor physical health at baseline.
The workplace has been identified as a promising setting for health promotion, and many worksite health promotion programmes have been implemented in the past years. Research has mainly focused on the effectiveness of these interventions. For implementation of interventions at a large scale however, information about (determinants of) participation in these programmes is essential. This systematic review investigates initial participation in worksite health promotion programmes, the underlying determinants of participation, and programme characteristics influencing participation levels.
Studies on characteristics of participants and non-participants in worksite health promotion programmes aimed at physical activity and/or nutrition published from 1988 to 2007 were identified through a structured search in PubMed and Web of Science. Studies were included if a primary preventive worksite health promotion programme on PA and/or nutrition was described, and if quantitative information was present on determinants of participation.
In total, 23 studies were included with 10 studies on educational or counselling programmes, 6 fitness centre interventions, and 7 studies examining determinants of participation in multi-component programmes. Participation levels varied from 10% to 64%, with a median of 33% (95% CI 25–42%). In general, female workers had a higher participation than men (OR = 1.67; 95% CI 1.25–2.27]), but this difference was not observed for interventions consisting of access to fitness centre programmes. For the other demographic, health- and work-related characteristics no consistent effect on participation was found. Pooling of studies showed a higher participation level when an incentive was offered, when the programme consisted of multiple components, or when the programme was aimed at multiple behaviours.
In this systematic review, participation levels in health promotion interventions at the workplace were typically below 50%. Few studies evaluated the influence of health, lifestyle and work-related factors on participation, which hampers the insight in the underlying determinants of initial participation in worksite health promotion. Nevertheless, the present review does provide some strategies that can be adopted in order to increase participation levels. In addition, the review highlights that further insight is essential to develop intervention programmes with the ability to reach many employees, including those who need it most and to increase the generalizability across all workers.