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1.  Socioeconomic and Psychosocial Adversity in Midlife and Depressive Symptoms Post Retirement: A 21-year Follow-up of the Whitehall II Study 
We examined whether socioeconomic and psychosocial adversity in midlife predicts post-retirement depressive symptoms.
Design and Setting
A prospective cohort study of British civil servants who responded to a self-administered questionnaire in middle-age and at older ages, 21 years later.
The study sample consisted of 3,939 Whitehall II Study participants (2,789 men, 1,150 women; mean age 67.6 years at follow-up) who were employed at baseline and retired at follow-up.
Midlife adversity was assessed by self-reported socioeconomic adversity (low occupational position; poor standard of living) and psychosocial adversity (high job strain; few close relationships). Symptoms of depression post-retirement were measured by the Center for Epidemiologic Studies Depression scale.
After adjustment for sociodemographic and health-related covariates at baseline and follow-up, there were strong associations between midlife adversities and post-retirement depressive symptoms: low occupational position (odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.15–2.51), poor standard of living (OR: 2.37, 95% CI: 1.66–3.39), high job strain (OR: 1.52, 95% CI: 1.09–2.14), and few close relationships (OR: 1.51, 95% CI: 1.12–2.03). The strength of the associations between socioeconomic, psychosocial, work-related, or non-work related exposures and depressive symptoms was similar.
Robust associations from observational data suggest that several socioeconomic and psychosocial risk factors for symptoms of depression post-retirement can be detected already in midlife.
PMCID: PMC4270962  PMID: 24816123
Depression; elderly; inequalities; life course; mood disorders; old age; prospective; stress
2.  Long working hours, socioeconomic status, and the risk of incident type 2 diabetes: a meta-analysis of published and unpublished data from 222 120 individuals 
Working long hours might have adverse health effects, but whether this is true for all socioeconomic status groups is unclear. In this meta-analysis stratified by socioeconomic status, we investigated the role of long working hours as a risk factor for type 2 diabetes.
We identified four published studies through a systematic literature search of PubMed and Embase up to April 30, 2014. Study inclusion criteria were English-language publication; prospective design (cohort study); investigation of the effect of working hours or overtime work; incident diabetes as an outcome; and relative risks, odds ratios, or hazard ratios (HRs) with 95% CIs, or sufficient information to calculate these estimates. Additionally, we used unpublished individual-level data from 19 cohort studies from the Individual-Participant-Data Meta-analysis in Working-Populations Consortium and international open-access data archives. Effect estimates from published and unpublished data from 222 120 men and women from the USA, Europe, Japan, and Australia were pooled with random-effects meta-analysis.
During 1·7 million person-years at risk, 4963 individuals developed diabetes (incidence 29 per 10 000 person-years). The minimally adjusted summary risk ratio for long (≥55 h per week) compared with standard working hours (35–40 h) was 1·07 (95% CI 0·89–1·27, difference in incidence three cases per 10 000 person-years) with significant heterogeneity in study-specific estimates (I2=53%, p=0·0016). In an analysis stratified by socioeconomic status, the association between long working hours and diabetes was evident in the low socioeconomic status group (risk ratio 1·29, 95% CI 1·06–1·57, difference in incidence 13 per 10 000 person-years, I2=0%, p=0·4662), but was null in the high socioeconomic status group (1·00, 95% CI 0·80–1·25, incidence difference zero per 10 000 person-years, I2=15%, p=0·2464). The association in the low socioeconomic status group was robust to adjustment for age, sex, obesity, and physical activity, and remained after exclusion of shift workers.
In this meta-analysis, the link between longer working hours and type 2 diabetes was apparent only in individuals in the low socioeconomic status groups.
Medical Research Council, European Union New and Emerging Risks in Occupational Safety and Health research programme, Finnish Work Environment Fund, Swedish Research Council for Working Life and Social Research, German Social Accident Insurance, Danish National Research Centre for the Working Environment, Academy of Finland, Ministry of Social Affairs and Employment (Netherlands), Economic and Social Research Council, US National Institutes of Health, and British Heart Foundation.
PMCID: PMC4286814  PMID: 25262544
3.  Adherence to antihypertensive therapy prior to the first presentation of stroke in hypertensive adults: population-based study 
European Heart Journal  2013;34(38):2933-2939.
Antihypertensive drug therapy is a major strategy of stroke prevention among hypertensive patients. The aim of this study was to estimate the excess risk of stroke associated with non-adherence to antihypertensive drug therapy among hypertensive patients.
Methods and results
We conducted a population-based study using records from Finnish national registers for 1 January 1995 to 31 December 2007. Of the 73 527 hypertensive patients aged 30 years or older and without pre-existing stroke or cardiovascular disease, 2144 died from stroke and 24 560 were hospitalized due to stroke during the follow-up. At the 2- and 10-year follow-up after the start of continuous antihypertensive medication, non-adherent patients had 3.81 [95% confidence interval (CI) 2.85–5.10] and 3.01 (95% CI: 2.37–3.83) times higher odds of stroke death when compared with the adherent patients. The corresponding odds ratio (OR) for stroke hospitalization was 2.74 (95% CI: 2.35–3.20) at Year 2 and 1.71 (95% CI: 1.49–1.96) at Year 10. In the stroke-event year, the ORs were higher, 5.68 (95% CI: 5.05–6.39) for stroke death and 1.87 (95% CI: 1.72–2.03) for hospitalization. Among those using agents acting on the renin–angiotensin system combined with diuretics or β-blockers, these ORs were 7.49 (95% CI: 5.62–9.98) and 3.91 (95% CI: 3.23–4.75), respectively. The associations between non-adherence and stroke followed a dose–response pattern—the poorer the adherence, the greater the risk of death and hospitalization due to stroke.
These data suggest that poor adherence to antihypertensive therapy substantially increases near- and long-term risk of stroke among hypertensive patients.
PMCID: PMC3791393  PMID: 23861328
Adherence; Antihypertensive therapy; Stroke; Hypertension; Mortality
4.  Self-Rated Health in the Last 12 Years of Life Compared to Matched Surviving Controls: The Health and Retirement Study 
PLoS ONE  2014;9(9):e107879.
Self-rated health (SRH) is a valid measure of health status and associated with mortality. Based on individual-level biannual repeat data on SRH we sought to characterize the natural history of poor SRH during the 12 years prior to death in men and women in different age groups. We conducted a retrospective analysis of the Health and Retirement Study participants who died between 1998 and 2010 and had at least two SRH measurements in the 12 years prior to death. We used a nested case-control design to compare SRH trajectories of deceased men and women aged 30–64, 65–79 and 80 years versus surviving participants. The cases comprised 3,350 deceased participants who were matched to surviving controls (n = 8,127). SRH was dichotomized into good vs. poor health. Men and women dying at age 65–79 and ≥80 years had 1.5 to 3 times higher prevalence of poor SRH already 11–12 years prior to death compared to surviving controls. The risk estimates remained statistically significant even after adjusting for life-style related risk factors and diagnosed diseases. Prevalence of poor SRH before death was lowest among those aged ≥80 years and highest in 30–64 year-olds. In conclusion, men and women who subsequently die perceive their health worse already 11–12 years prior to death compared to their surviving controls.
PMCID: PMC4169624  PMID: 25237814
5.  Increased risk of coronary heart disease among individuals reporting adverse impact of stress on their health: the Whitehall II prospective cohort study 
European Heart Journal  2013;34(34):2697-2705.
Response to stress can vary greatly between individuals. However, it remains unknown whether perceived impact of stress on health is associated with adverse health outcomes. We examined whether individuals who report that stress adversely affects their health are at increased risk of coronary heart disease (CHD) compared with those who report that stress has no adverse health impact.
Methods and results
Analyses are based on 7268 men and women (mean age: 49.5 years, interquartile range: 11 years) from the British Whitehall II cohort study. Over 18 years of follow-up, there were 352 coronary deaths or first non-fatal myocardial infarction (MI) events. After adjustment for sociodemographic characteristics, participants who reported at baseline that stress has affected their health ‘a lot or extremely’ had a 2.12 times higher (95% CI 1.52–2.98) risk of coronary death or incident non-fatal MI when compared with those who reported no effect of stress on their health. This association was attenuated but remained statistically significant after adjustment for biological, behavioural, and other psychological risk factors including perceived stress levels, and measures of social support; fully adjusted hazard ratio: 1.49 (95% CI 1.01–2.22).
In this prospective cohort study, the perception that stress affects health, different from perceived stress levels, was associated with an increased risk of coronary heart disease. Randomized controlled trials are needed to determine whether disease risk can be reduced by increasing clinical attention to those who complain that stress greatly affects their health.
PMCID: PMC3766148  PMID: 23804585
Epidemiology; Stress; Coronary heart disease; Prospective studies
6.  Vertical and Horizontal Trust at Work as Predictors of Retirement Intentions: The Finnish Public Sector Study 
PLoS ONE  2014;9(9):e106956.
This prospective cohort study aimed to examine the associations of trust towards the supervisor (vertical trust) and trust towards co-workers (horizontal trust) with retirement intentions. The participants were 14 840 women and men working in the municipal sector in 2000–12 (Finnish Public Sector Study). Trust (vertical trust towards the supervisor and horizontal trust towards co-workers) and retirement intentions were assessed in repeated surveys. Multivariable multinomial logistic regression analyses were conducted to assess the association between baseline trust and retirement intentions at 3.7 years of follow-up. Demographic characteristics, health, psychological distress, health risk behaviors, personality factors, and psychosocial factors were included as covariates. Of the participants, 67.0% trusted their supervisor and 54.9% trusted their co-workers. Employees who trusted their supervisor (odds ratio (OR) 0.60, 95% confidence interval (CI) 0.53–0.67) and employees who trusted their co-workers (odds ratio 0.62, 95% confidence interval 0.55–0.70) at baseline were less likely to have strong retirement intentions at follow-up compared to those who did not trust. These associations largely persisted after adjusting for all covariates and taking into account baseline retirement intentions. In conclusion, trust in the supervisor and co-workers predicted retirement intentions. These observational findings suggest that increasing trust in the workplace may contribute to lengthening working careers and preventing early retirement.
PMCID: PMC4156392  PMID: 25191745
7.  Lifestyle factors as predictors of nonadherence to statin therapy among patients with and without cardiovascular comorbidities 
Easily detectable predictors of nonadherence to long-term drug treatment are lacking. We investigated the association between lifestyle factors and nonadherence to statin therapy among patients with and without cardiovascular comorbidities.
We included 9285 participants from the Finnish Public Sector Study who began statin therapy after completing the survey. We linked their survey data with data in national health registers. We used prescription dispensing data to determine participants’ nonadherence to statin therapy during the first year of treatment (defined as < 80% of days covered by filled prescriptions). We used logistic regression to estimate the association of several lifestyle factors with nonadherence, after adjusting for sex, age and year of statin initiation.
Of the participants without cardiovascular comorbidities (n = 6458), 3171 (49.1%) were nonadherent with their statin therapy. Obesity (adjusted odds ratio [OR] 0.86, 95% confidence interval [CI] 0.74–0.99), overweight (adjusted OR 0.88, 95% CI 0.79–0.98) and former smoking (adjusted OR 0.82, 95% CI 0.74–0.92) predicted a reduced risk of nonadherence in this group after adjustment for sex, age and year of statin initiation. Of the participants with cardiovascular comorbidities (n = 2827), 1155 (40.9%) were nonadherent. In this group, high alcohol consumption (adjusted OR 1.55, 95% CI 1.12–2.15), extreme drinking occasions (adjusted OR 1.48, 95% CI 1.11–1.97) and a cluster of 3–4 lifestyle risks (adjusted OR 1.61, 95% CI 1.15–2.27) predicted increased odds of nonadherence after adjustment for sex, age and year of statin initiation.
People with cardiovascular comorbidities who had risky drinking behaviours or a cluster of lifestyle risks were at increased risk of nonadherence. Among individuals without cardiovascular comorbidities, information on lifestyle factors was unhelpful in identifying those at increased risk of nonadherence; that overweight, obesity and former smoking were predictors of better adherence in this group provides insight into mechanisms of adherence to preventive medication that deserve further study.
PMCID: PMC4150731  PMID: 24958839
8.  Proximity of off-premise alcohol outlets and heavy alcohol consumption: A cohort study* 
Drug and alcohol dependence  2013;132(0):295-300.
Availability of alcohol has been associated with alcohol consumption in cross-sectional studies. We examined longitudinally whether change in proximity to off-premise (i.e., no consumption on the premises) beer and liquor outlets is associated with heavy alcohol consumption.
Distances from 54,778 Finnish Public Sector study participants' homes to the nearest off-premise beer and liquor outlets were calculated using Global Positioning System-coordinates. Between-individual analyses were used to study the effects of distance to the nearest outlet on heavy alcohol use, and within-individual analyses to study the effects of a change in distance on change in heavy use.
Mean follow-up time in 2000–2009 was 6.8 (standard deviation 2.0) years. In a between-individual analysis, decrease from ≥500m to <500m (vs. remained ≥500m) in the distance to the nearest beer outlet increased the likelihood of incident heavy alcohol use in women (odds ratio 1.23, 95% CI 1.05–1.44), but not in men. In a within-individual analysis decrease from 500m to 0m in log-transformed continuous distance to the nearest beer outlet increased the odds of heavy alcohol consumption in women by 13% (odds ratio 1.13, 95% CI 1.01–1.27). For the corresponding change in distance to liquor outlet the increase was 3% (odds ratio 1.03, 95% CI 0.97–1.09).
Change in distance from home to the nearest off-premise alcohol outlet affects the risk of heavy alcohol consumption in women. This evidence supports policies that restrict physical availability of alcohol.
PMCID: PMC3709004  PMID: 23499055
alcohol consumption; alcohol policy; availability; distance; longitudinal; Finnish Public Sector Study
9.  Genome-wide scan of job-related exhaustion with three replication studies implicate a susceptibility variant at the UST gene locus 
Human Molecular Genetics  2013;22(16):3363-3372.
Job-related exhaustion is the core dimension of burnout, a work-related stress syndrome that has several negative health consequences. In this study, we explored the molecular genetic background of job-related exhaustion. A genome-wide analysis of job-related exhaustion was performed in the GENMETS subcohort (n = 1256) of the Finnish population-based Health 2000 study. Replication analyses included an analysis of the strongest associations in the rest of the Health 2000 sample (n = 1660 workers) and in three independent populations (the FINRISK population cohort, n = 10 753; two occupational cohorts, total n = 1451). Job-related exhaustion was ascertained using a standard self-administered questionnaire (the Maslach Burnout Inventory (MBI)-GS exhaustion scale in the Health 2000 sample and the occupational cohorts) or a single question (FINRISK). A variant located in an intron of UST, uronyl-2-sulfotransferase (rs13219957), gave the strongest statistical evidence in the initial genome-wide study (P = 1.55 × 10−7), and was associated with job-related exhaustion in all the replication sets (P < 0.05; P = 6.75 × 10−7 from the meta-analysis). Consistent with studies of mood disorders, individual common genetic variants did not have any strong effect on job-related exhaustion. However, the nominally significant signals from the allelic variant of UST in four separate samples suggest that this variant might be a weak risk factor for job-related exhaustion. Together with the previously reported associations of other dermatan/chondroitin sulfate genes with mood disorders, these results indicate a potential molecular pathway for stress-related traits and mark a candidate region for further studies of job-related and general exhaustion.
PMCID: PMC3723313  PMID: 23620144
10.  Study protocol for examining job strain as a risk factor for severe unipolar depression in an individual participant meta-analysis of 14 European cohorts 
F1000Research  2014;2:233.
Background: Previous studies have shown that gainfully employed individuals with high work demands and low control at work (denoted “job strain”) are at increased risk of common mental disorders, including depression. Most existing studies have, however, measured depression using self-rated symptom scales that do not necessarily correspond to clinically diagnosed depression. In addition, a meta-analysis from 2008 indicated publication bias in the field.
Methods: This study protocol describes the planned design and analyses of an individual participant data meta-analysis, to examine whether job strain is associated with an increased risk of clinically diagnosed unipolar depression based on hospital treatment registers.  The study will be based on data from approximately 120,000 individuals who participated in 14 studies on work environment and health in 4 European countries. The self-reported working conditions data will be merged with national registers on psychiatric hospital treatment, primarily hospital admissions. Study-specific risk estimates for the association between job strain and depression will be calculated using Cox regressions. The study-specific risk estimates will be pooled using random effects meta-analysis.
Discussion: The planned analyses will help clarify whether job strain is associated with an increased risk of clinically diagnosed unipolar depression. As the analysis is based on pre-planned study protocols and an individual participant data meta-analysis, the pooled risk estimates will not be influenced by selective reporting and publication bias. However, the results of the planned study may only pertain to severe cases of unipolar depression, because of the outcome measure applied.
PMCID: PMC3938244  PMID: 24627793
11.  Extending Employment beyond the Pensionable Age: A Cohort Study of the Influence of Chronic Diseases, Health Risk Factors, and Working Conditions 
PLoS ONE  2014;9(2):e88695.
In response to the economic consequences of ageing of the population, governments are seeking ways with which people might work into older age. We examined the association of working conditions and health with extended employment (defined as >6 months beyond the pensionable age) in a cohort of older, non-disabled employees who have reached old-age retirement.
A total of 4,677 Finnish employees who reached their old-age pensionable date between 2005 and 2011 (mean age 59.8 years in 2005, 73% women) had their survey responses before pensionable age linked to national health and pension registers, resulting in a prospective cohort study.
In all, 832 participants (17.8%) extended their employment by more than 6 months beyond the pensionable date. After multivariable adjustment, the following factors were associated with extended employment: absence of diagnosed mental disorder (OR 1.25, 95% confidence interval = 1.01–1.54) and psychological distress (OR 1.68; 1.35–2.08) and of the work characteristics, high work time control (OR 2.31; 1.88–2.84). The projected probability of extended employment was 21.3% (19.5–23.1) among those free of psychiatric morbidity and with high work time control, while the corresponding probability was only 9.2% (7.4–11.4) among those with both psychiatric morbidity and poor work time control. The contribution of chronic somatic diseases was modest.
In the present study, good mental health in combination with the opportunity to control work time seem to be key factors in extended employment into older age. In addition, high work time control might promote work life participation irrespective of employees' somatic disease status.
PMCID: PMC3929527  PMID: 24586372
12.  Job Strain and the Risk of Inflammatory Bowel Diseases: Individual-Participant Meta-Analysis of 95 000 Men and Women 
PLoS ONE  2014;9(2):e88711.
Background and Aims
Many clinicians, patients and patient advocacy groups believe stress to have a causal role in inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis. However, this is not corroborated by clear epidemiological research evidence. We investigated the association between work-related stress and incident Crohn's disease and ulcerative colitis using individual-level data from 95 000 European adults.
We conducted individual-participant data meta-analyses in a set of pooled data from 11 prospective European studies. All studies are a part of the IPD-Work Consortium. Work-related psychosocial stress was operationalised as job strain (a combination of high demands and low control at work) and was self-reported at baseline. Crohn's disease and ulcerative colitis were ascertained from national hospitalisation and drug reimbursement registers. The associations between job strain and inflammatory bowel disease outcomes were modelled using Cox proportional hazards regression. The study-specific results were combined in random effects meta-analyses.
Of the 95 379 participants who were free of inflammatory bowel disease at baseline, 111 men and women developed Crohn's disease and 414 developed ulcerative colitis during follow-up. Job strain at baseline was not associated with incident Crohn's disease (multivariable-adjusted random effects hazard ratio: 0.83, 95% confidence interval: 0.48, 1.43) or ulcerative colitis (hazard ratio: 1.06, 95% CI: 0.76, 1.48). There was negligible heterogeneity among the study-specific associations.
Our findings suggest that job strain, an indicator of work-related stress, is not a major risk factor for Crohn's disease or ulcerative colitis.
PMCID: PMC3928274  PMID: 24558416
13.  Association of physical activity with future mental health in older, mid-life and younger women 
Background: Mental ill-health, particularly depression and anxiety, is a leading and increasing cause of disability worldwide, especially for women. Methods: We examined the prospective association between physical activity and symptoms of mental ill-health in younger, mid-life and older working women. Participants were 26 913 women from the ongoing cohort Finnish Public Sector Study with complete data at two phases, excluding those who screened positive for mental ill-health at baseline. Mental health was assessed using the 12-item General Health Questionnaire. Self-reported physical activity was expressed in metabolic equivalent task (MET) hours per week. Logistic regression models were used to analyse associations between physical activity levels and subsequent mental health. Results: There was an inverse dose–response relationship between physical activity and future symptoms of mental ill-health. This association is consistent with a protective effect of physical activity and remained after adjustments for socio-demographic, work-related and lifestyle factors, health and body mass index. Furthermore, those mid-life and older women who reported increased physical activity by more than 2 MET hours per week demonstrated a reduced risk of later mental ill-health in comparison with those who did not increase physical activity. This protective effect of increased physical activity did not hold for younger women. Conclusions: This study adds to the evidence for the protective effect of physical activity for later mental health in women. It also suggests that increasing physical activity levels may be beneficial in terms of mental health among mid-life and older women. The alleviation of menopausal symptoms may partly explain age effects but further research is required.
PMCID: PMC4168042  PMID: 24532567
14.  Living in proximity of a bar and risky alcohol behaviours: A longitudinal study 
Addiction (Abingdon, England)  2012;108(2):320-328.
We examined whether distance from home to the nearest bar, i.e. alcohol outlet permitting consumption on the premises, is associated with risky alcohol behaviours.
Cross-sectional and longitudinal study.
Setting and Participants
The cross-sectional data consisted of 78 858 and the longitudinal data of 54 778 Finnish Public Sector Study participants in between 2000 and 2009 [mean follow-up 6.8 years (SD=2.0)].
Distances from home to the nearest bar were calculated using Global Positioning System-coordinates. The outcome variables were heavy alcohol use (drinking above the weekly guidelines) and extreme drinking occasions (passing out due to alcohol use). We used binomial logistic regression in cross-sectional analyses and in longitudinal mixed effects (between-individual) analyses. Conditional logistic regression was used in longitudinal fixed effects (within-individual) analyses.
Cross-sectionally, the likelihood of an extreme drinking occasion and heavy use was higher among those who resided <1 vs. ≥1 km from a bar. Longitudinally, between individuals, a decrease from >1 km to ≤1 km in distance was weakly associated with an extreme drinking occasion (1.18, 95% CI 0.98–1.41), and heavy use (1.12, 95% CI 0.97–1.29). Within-individual, the odds ratio for becoming a heavy user was 1.17 (95% CI, 1.02–1.34), per 1 km decrease in log-transformed continuous distance, the corresponding odds ratio for an extreme drinking occasion was 1.03 (95% CI, 0.89–1.18).
Moving place of residence close to or far from a bar appears to be associated with a small corresponding increase or decrease in risky alcohol behaviour.
PMCID: PMC3529803  PMID: 22897634
15.  Depression-Related Work Disability: Socioeconomic Inequalities in Onset, Duration and Recurrence 
PLoS ONE  2013;8(11):e79855.
Depression is a major cause of disability in working populations and the reduction of socioeconomic inequalities in disability is an important public health challenge. We examined work disability due to depression with four indicators of socioeconomic status.
A prospective cohort study of 125 355 Finnish public sector employees was linked to national register data on work disability (>9 days) due to depressive disorders (International Classification of Diseases, codes F32–F34) from January 2005 to December 2011. Primary outcomes were the onset of work disability due to depressive disorders and, among those with such disability, return to work after and recurrent episodes of work disability due to depression.
We found a consistent inverse socioeconomic gradient in work disability due to depression. Lower occupational position, lower educational level, smaller residence size, and rented (vs. owner-occupied) residence were all associated with an increased risk of work disability. Return to work was slower for employees with basic education (cumulative odds ratio = 1.21, 95% CI: 1.05–1.39) compared to those with higher education. Recurrent work disability episodes due to depression were less common among upper-grade non-manual workers (the highest occupational group) than among lower-grade non-manual (hazard ratio = 1.16, 95% CI: 1.07–1.25) and manual (hazard ratio = 1.14, 95% CI: 1.02–1.26) workers.
These data from Finnish public sector employees show persistent socioeconomic inequalities in work disability due to depression from 2005 to 2011 in terms of onset, recovery and recurrence.
PMCID: PMC3835932  PMID: 24278194
16.  Influence of retirement on nonadherence to medication for hypertension and diabetes 
The extent to which common life transitions influence medication adherence among patients remains unknown. We examined whether retirement is associated with a change in adherence to medication in patients with hypertension or type 2 diabetes.
Participants in the Finnish Public Sector study were linked to national registers. We included data for the years 1994–2011. We identified and followed 3468 adult patients with hypertension and 412 adult patients with type 2 diabetes for medication adherence for the 3 years before their retirement and the 4 years after their retirement (mean follow-up 6.8 yr). Our primary outcome was proportion of patients with poor adherence to medication, which we defined as less than 40% of days covered by treatment. We determined these proportions before and after retirement using data from filled prescriptions.
The preretirement prevalence of poor adherence to medication was 6% in men and women with hypertension, 2% in men with diabetes and 4% in women with diabetes. Among men, retirement was associated with an increased risk of poor adherence to both antihypertensive agents (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.03–1.68) and antidiabetic drugs (OR 2.40, 95% CI 1.37–4.20). Among women, an increased risk of poor adherence was seen only for antihypertensive agents (OR 1.25, 95% CI 1.07–1.46). Similar results were apparent for alternative definitions of poor adherence. Our results did not differ across strata of age, socioeconomic status or comorbidity.
We found a decline in adherence to medication after retirement among men and women with hypertension and men with type 2 diabetes. If these findings can be confirmed, we need randomized controlled trials to determine whether interventions to reduce poor adherence after retirement could improve clinical outcomes of treatments for hypertension and diabetes.
PMCID: PMC3832579  PMID: 24082018
17.  Study protocol for examining job strain as a risk factor for severe unipolar depression in an individual participant meta-analysis of 14 European cohorts 
F1000Research  2013;2:233.
Background: Previous studies have shown that gainfully employed individuals with high work demands and low control at work (denoted “job strain”) are at increased risk of common mental disorders, including depression. Most existing studies have, however, measured depression using self-rated symptom scales that do not necessarily correspond to clinically diagnosed depression. In addition, a meta-analysis from 2008 indicated publication bias in the field.
Methods: This study protocol describes the planned design and analyses of an individual participant data meta-analysis, to examine whether job strain is associated with an increased risk of clinically diagnosed unipolar depression based on hospital treatment registers.  The study will be based on data from approximately 120,000 individuals who participated in 14 studies on work environment and health in 4 European countries. The self-reported working conditions data will be merged with national registers on psychiatric hospital treatment, primarily hospital admissions. Study-specific risk estimates for the association between job strain and depression will be calculated using Cox regressions. The study-specific risk estimates will be pooled using random effects meta-analysis.
Discussion: The planned analyses will help clarify whether job strain is associated with an increased risk of clinically diagnosed unipolar depression. As the analysis is based on pre-planned study protocols and an individual participant data meta-analysis, the pooled risk estimates will not be influenced by selective reporting and publication bias. However, the results of the planned study may only pertain to severe cases of unipolar depression, because of the outcome measure applied.
PMCID: PMC3938244  PMID: 24627793
18.  Obesity and Occupational Injury: A Prospective Cohort Study of 69,515 Public Sector Employees 
PLoS ONE  2013;8(10):e77178.
Obesity and overweight are suggested to increase the risk of occupational injury but longitudinal evidence to confirm this is rare. We sought to evaluate obesity and overweight as risk factors for occupational injuries.
Methodology/Principal Findings
A total of 69,515 public sector employees (80% women) responded to a survey in 2000–2002, 2004 or 2008. Body mass index (kg/m2) was derived from self-reported height and weight and was linked to records of subsequent occupational injuries obtained from national registers. Different injury types, locations and events or exposures (the manner in which the injury was produced or inflicted) were analyzed by body mass index category adjusting for baseline socio-demographic characteristics, work characteristics, health-risk behaviors, physical and mental health, insomnia symptoms, and sleep duration. During the mean follow-up of 7.8 years (SD = 3.2), 18% of the employees (N = 12,204) recorded at least one occupational injury. Obesity was associated with a higher overall risk of occupational injury; multivariable adjusted hazard ratio (HR) 1.21 (95% CI 1.14–1.27). A relationship was observed for bone fractures (HR = 1.37; 95% CI: 1.10–1.70), dislocations, sprains and strains (HR = 1.36; 95% CI: 1.25–1.49), concussions and internal injuries (HR = 1.26; 95% CI: 1.11–1.44), injuries to lower extremities (HR = 1.62; 95%: 1.46–1.79) and injuries to whole body or multiple sites (HR = 1.37; 95%: 1.10–1.70). Furthermore, obesity was associated with a higher risk of injuries caused by slipping, tripping, stumbling and falling (HR = 1.55; 95% CI: 1.40–1.73), sudden body movement with or without physical stress (HR = 1.24; 95% CI: 1.10–1.41) and shock, fright, violence, aggression, threat or unexpected presence (HR = 1.33; 95% CI: 1.03–1.72). The magnitude of the associations between overweight and injuries was smaller, but the associations were generally in the same direction as those of obesity.
Obese employees record more occupational injuries than those with recommended healthy weight.
PMCID: PMC3797744  PMID: 24146966
19.  Workplace Determinants of Social Capital: Cross-Sectional and Longitudinal Evidence from a Finnish Cohort Study 
PLoS ONE  2013;8(6):e65846.
To examine which contextual features of the workplace are associated with social capital.
This is a cohort study of 43,167 employees in 3090 Finnish public sector workplaces who responded to a survey of individual workplace social capital in 2000–02 (response rate 68%). We used ecometrics approach to estimate social capital of work units. Features of the workplace were work unit's demographic and employment patterns and size, obtained from employers' administrative records. We used multilevel-multinomial logistic regression models to examine cross-sectionally whether these features were associated with social capital between individuals and work units. Fixed effects models were used for longitudinal analyses in a subsample of 12,108 individuals to examine the effects of changes in workplace characteristics on changes in social capital between 2000 and 2004.
After adjustment for individual characteristics, an increase in work unit size reduced the odds of high levels of individual workplace social capital (odds ratio 0.94, 95% confidence interval 0.91–0.98 per 30-person-year increase). A 20% increase in the proportion of manual and male employees reduced the odds of high levels of social capital by 8% and 23%, respectively. A 30% increase in temporary employees and a 20% increase in employee turnover were associated with 11% (95% confidence interval 1.04–1.17) and 24% (95% confidence interval 1.18–1.30) higher odds of having high levels of social capital respectively). Results from fixed effects models within individuals, adjusted for time-varying covariates, and from social capital of the work units yielded consistent results.
These findings suggest that workplace social capital is contextually patterned. Workplace demographic and employment patterns as well as the size of the work unit are important in understanding variations in workplace social capital between individuals and workplaces.
PMCID: PMC3679109  PMID: 23776555
20.  Associations of job strain and lifestyle risk factors with risk of coronary artery disease: a meta-analysis of individual participant data 
It is unclear whether a healthy lifestyle mitigates the adverse effects of job strain on coronary artery disease. We examined the associations of job strain and lifestyle risk factors with the risk of coronary artery disease.
We pooled individual-level data from 7 cohort studies comprising 102 128 men and women who were free of existing coronary artery disease at baseline (1985–2000). Questionnaires were used to measure job strain (yes v. no) and 4 lifestyle risk factors: current smoking, physical inactivity, heavy drinking and obesity. We grouped participants into 3 lifestyle categories: healthy (no lifestyle risk factors), moderately unhealthy (1 risk factor) and unhealthy (2–4 risk factors). The primary outcome was incident coronary artery disease (defined as first nonfatal myocardial infarction or cardiac-related death).
There were 1086 incident events in 743 948 person-years at risk during a mean follow-up of 7.3 years. The risk of coronary artery disease among people who had an unhealthy lifestyle compared with those who had a healthy lifestyle (hazard ratio [HR] 2.55, 95% confidence interval [CI] 2.18–2.98; population attributable risk 26.4%) was higher than the risk among participants who had job strain compared with those who had no job strain (HR 1.25, 95% CI 1.06–1.47; population attributable risk 3.8%). The 10-year incidence of coronary artery disease among participants with job strain and a healthy lifestyle (14.7 per 1000) was 53% lower than the incidence among those with job strain and an unhealthy lifestyle (31.2 per 1000).
The risk of coronary artery disease was highest among participants who reported job strain and an unhealthy lifestyle; those with job strain and a healthy lifestyle had half the rate of disease. A healthy lifestyle may substantially reduce disease risk among people with job strain.
PMCID: PMC3680555  PMID: 23670152
22.  Persistent asthma, co-morbid conditions and the risk of work disability: a prospective cohort study 
Allergy  2011;66(12):1598-1603.
This study examined whether asthma alone or together with chronic co-morbidity is associated with increased risk of long-term work disability.
We examined data from 2,332 asthmatic and 66,354 non-asthmatic public sector employees in Finland who responded to a survey between 1997 and 2004. Respondents were coded as persistent asthmatics based on the special reimbursement for continuous asthma medication by the Social Insurance Institution. Data on long-term work disability (sickness absences or disability pensions >90 days) were obtained from national registers. The risk of work disability was examined by Cox proportional hazard models adjusted for age, gender, socioeconomic status, type of employment contract and type of employer.
Asthma increased the risk of all-cause long-term work disability, hazard ratio (HR) 1.8 (95 % CI 1.62–2.09) compared to controls (no asthma). Asthma and one other chronic co-morbidity increased the risk for long-term all-cause work disability with HR 2.2 (95% CI 1.78–2.83). Asthma together with two or more other chronic conditions increased the risk with HR 4.5 (95% CI 2.98–6.78). Asthma and depression increased the risk with HR 3.6 and the risk was especially high for permanent work-disability (HR 6.8). Among those with asthma there were more women, obesity (BMI ≥30), ex-smokers and lower-grade non-manual workers.
Asthma is associated with increased risk of long-term all-cause work disability. The risk increases further with chronic co-morbidities, and is especially high in patients with asthma and depression.
PMCID: PMC3203316  PMID: 21958351
Asthma; co-morbidity; sickness absence; work disability
23.  Job Strain as a Risk Factor for Leisure-Time Physical Inactivity: An Individual-Participant Meta-Analysis of Up to 170,000 Men and Women 
American Journal of Epidemiology  2012;176(12):1078-1089.
Unfavorable work characteristics, such as low job control and too high or too low job demands, have been suggested to increase the likelihood of physical inactivity during leisure time, but this has not been verified in large-scale studies. The authors combined individual-level data from 14 European cohort studies (baseline years from 1985–1988 to 2006–2008) to examine the association between unfavorable work characteristics and leisure-time physical inactivity in a total of 170,162 employees (50% women; mean age, 43.5 years). Of these employees, 56,735 were reexamined after 2–9 years. In cross-sectional analyses, the odds for physical inactivity were 26% higher (odds ratio = 1.26, 95% confidence interval: 1.15, 1.38) for employees with high-strain jobs (low control/high demands) and 21% higher (odds ratio = 1.21, 95% confidence interval: 1.11, 1.31) for those with passive jobs (low control/low demands) compared with employees in low-strain jobs (high control/low demands). In prospective analyses restricted to physically active participants, the odds of becoming physically inactive during follow-up were 21% and 20% higher for those with high-strain (odds ratio = 1.21, 95% confidence interval: 1.11, 1.32) and passive (odds ratio = 1.20, 95% confidence interval: 1.11, 1.30) jobs at baseline. These data suggest that unfavorable work characteristics may have a spillover effect on leisure-time physical activity.
PMCID: PMC3521479  PMID: 23144364
cohort studies; exercise; physical activity; psychosocial factors; working population
24.  Childhood adversities and adult-onset asthma: a cohort study 
BMJ Open  2012;2(5):e001625.
Childhood adversities may be important determinants of later illnesses and poor health behaviour. However, large-scale prospective studies on the associations between childhood adversities and the onset of asthma in adulthood are lacking.
Prospective cohort study with 7-year follow-up.
Nationally representative study. Data were collected from the Health and Social Support (HeSSup) survey and national registers.
The participants represent the Finnish population from the following age groups: 20–24, 30–34, 40–44, and 50–54 years at baseline in 1998 (24 057 survey participants formed the final cohort of this study). The occurrence of childhood adversities was assessed at baseline with a six-item survey scale. The analyses were adjusted for sociodemographic characteristics, behavioural health risks and common mental disorders.
Primary and secondary outcomes
The survey data were linked to data from national health registers on incident asthma during a 7-year follow-up to define new-onset asthma cases with verified diagnoses.
A total of 12 126 (59%) participants reported that they encountered a childhood adversity. Of them 3677 (18% of all) endured three to six adversities. During a follow-up of 7 years, 593 (2.9%) participants were diagnosed with incident asthma. Those who reported three or more childhood adversities had a 1.6-fold (95% CI 1.31 to 2.01) greater risk of asthma compared to those without childhood adversities. This hazard attenuated but remained statistically significant after adjustment for conventional risk factors (HR 1.33; 95% CI 1.06 to 1.67).
Adults who report having encountered adversities in childhood may have an increased risk of developing asthma.
PMCID: PMC3488721  PMID: 23069774
Psychiatry; Epidemiology
25.  Differences in the association between sickness absence and long-term sub-optimal health by occupational position: a 14-year follow-up in the GAZEL cohort 
Although sickness absence is a strong predictor of health, little work has examined whether this association varies by occupational position. The aim of this study was to investigate overall and diagnosis-specific sickness absence as a predictor of future long-term sub-optimal health by occupational position.
Prospective occupational cohort study; 15,320 employees (73% men) aged 37–51. Sickness absences (1990–1992), including 13 diagnostic categories, were examined by occupational position, based on employment grade, in relation to self-rated health measured annually 1993–2006.
60% of employees in higher grade and 22% in lower grade occupations had no sickness absence. Conversely, 40% of employees in lower grade and 9.5% in higher grade occupations had over 30 sick-leave days. Repeated-measures logistic regression analyses adjusted for age, sex, and chronic disease showed employees with over 30 days absence, compared to those with no absence, had approximately double the risk of suboptimal health over the 14-year follow-up in all occupational positions. However, 1–30 days sick-leave was associated with greater odds of suboptimal health in the high; odds ratio 1.48, 95% confidence intervals (1.27–1.72) and intermediate 1.29 (1.15–1.45), but not lower grade occupations 1.06 (0.82–1.38). Differences by occupational position in the association between sickness absence in 13 specific diagnostic categories and sub-optimal health over the ensuing 14 years were limited to stronger associations observed with cancer and mental disorders in the higher grades.
The association between sickness absence of over 30 days a year and future long-term self-rated health appears to differ little by occupational position.
PMCID: PMC3186885  PMID: 21242277
Sickness absence; sick leave; self-rated health; longitudinal; multi-level; occupational position

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