Racial and ethnic variations in office-based medical care for work-related injuries and illnesses

OBJECTIVES

This exploratory study uses nationally representative data to evaluate the extent to which ambulatory care for work-related conditions varies by patients' race and ethnicity.

METHODS

Using the National Ambulatory Medical Care Survey (NAMCS) for 1997 and 1998, we describe medical care for work-related conditions, stratifying by whether the patient self-identified as African-American, white, Hispanic and/or non-Hispanic. Multivariate regression analyses were conducted to evaluate the impact of patient race and ethnicity on care, controlling for age, gender, geographical region and MSA (urban/rural) status.

RESULTS

Compared to white patients, African-American patients were more likely to receive mental health counseling and physical therapy and less likely to see a nurse, after controlling for age, gender, geographical region and MSA status. Hispanic patients were more likely to receive x-rays and need insurer authorization for care and less likely to receive a prescription drug or to see a physician, compared to non-Hispanics.

CONCLUSIONS

This is the nation's first study to describe socially based differences in medical care provided for patients with work-related injuries and illnesses. Identifying areas in which these variations in care exist is a critical first step in ensuring that equitable care is afforded to all injured workers.

Disability management practices in education, hotel/motel, and health care workplaces

BACKGROUND

The high costs and the impact of work disability have become a growing concern for workplaces. As a result, workplace disability management approaches have been developed to lower disability costs, protect the employability of workers, and promote early return to work.

METHODS

A stratified random sample of 455 employers in education (n = 157), hotel/motel (n = 110), and health care (n = 188) sectors who completed a mailed Organizational Policies and Practices (OPP) questionnaire is reported. The OPP questionnaire asked questions about eight workplace disability management practices. The article examined the multi-dimensionality, internal consistency, and discriminant validity of the OPP and compares disability management practices across the three sectors.

RESULTS

The OPP questionnaire showed good internal consistency (Cronbach's alpha = 0.95) and discriminant validity. A one-way analysis of variance (ANOVA) for each of the eight subscales demonstrated that there were statistically significant differences between the sectors in ergonomic practices (F (2,452) = 15.8, P < 0.001), disability case management (F (2,452) = 4.6, P < 0.01), return to work (F (2,452) = 10.3, P < 0.001), and people-oriented culture (F (2,452) = 4.5, P < 0.01).

CONCLUSIONS

On examining disability management practices in education, hotel/motel, and health care sectors, the OPP seems to be a promising instrument that can be used to assess and monitor how employers are managing disability.

Management and employee agreement on reports of organizational policies and practices important in return to work following carpal tunnel surgery

This study's purpose was to assess the agreement between management and employee ratings of organizational policies and practices (OPP) involved in the return to work process following carpal tunnel surgery. As a part of the prospective community-based Maine Carpal Tunnel II Study, 65 manager and employee pairs completed a questionnaire tapping four OPP dimensions. people oriented culture, safety climate, ergonomic practices, and disability management. It was hypothesized that managers and employees would agree on their assessment of the four OPPs and a composite organizational support index. Agreement was assessed using Lin's concordance correlation coefficient. Employee and manager ratings were similar for the organizational support index (rho(c) = 0.14, p = 0.08), and people oriented culture (rho(c) = 0.25, p = 0.01) but not the other three OPPs. In larger companies (>450 employees), ratings were also similar for safety climate (rho(c) = 0.24, p = 0.09), disability management (rho(c) = 0.22, p = 0.07) and ergonomic practices (rho(c) = 0.35, p = 0.02). In unionized companies there was agreement for safety climate (rho = 0.44, p = 0.02), disability management (rho(c) = 0.41, p = 0.01) and ergonomic practices (rho(c) = 0.40, p = 0.06). These preliminary results suggest employees can report on certain OPPs and that an employee questionnaire can be used to assess organizational support. Given recent evidence that employee ratings of OPPs are predictive of injury/illness incidence, work disability and return-to-work outcomes, further research is needed to confirm these findings.

Determinants of work absence following surgery for carpal tunnel syndrome

BACKGROUND

The objective was to identify factors across multiple domains associated with return to work in a community-based cohort of workers with carpal tunnel syndrome.

METHODS

Workers scheduled for carpal tunnel release were recruited into this prospective study. Subjects completed questionnaires preoperatively and at 2, 6, and 12 months postoperatively. The questionnaires contained demographic, clinical, and psychosocial factors and physical and psychosocial workplace stressors. Predictors of work absence at 6 and 12 months were examined in bivariate and multivariate logistic regression analyses.

RESULTS

Six months following surgery of 181 subjects, 29 (19%) were out of work. Twelve months postoperatively 33 subjects (22%) were out of work. In bivariate analyses, the factors associated with work absence at 6 months, at P < or = 0.01, included preoperative physical functional status, change in self-efficacy between preoperative assessment and 2 months, lower income, workers' compensation, representation by an attorney, work exposure to force and repetition, higher psychological job demands and lower control, lower social support by coworkers, lower job security and more supportive organizational policies and practices. The factors associated with work absence at 12 months in bivariate analyses included preoperative physical functional status, lower self-efficacy at 2 months, workers' compensation, and less supportive organizational policies and practices. Multivariate analyses documented a multidimensional model, with predictors from multiple domains.

CONCLUSIONS

Clinical, demographic, economic, and workplace factors were associated with work absence. Strategies to reduce work absence following carpal tunnel release should address multiple dimensions of the worker and workplace.

The cross-cultural adaptation of the Work Role Functioning Questionnaire in Canadian French

The Work Role Functioning Questionnaire (WRFQ) is a new work disability measurement tool assessing the perceived impact of a health problem on the worker's ability to perform his job. The objective of this study was to make the cross-cultural adaptation of the WRFQ for the French Canadian population. The methodology was composed of five steps: forward translation, synthesis of the translations, back translation, revision by an expert committee and test of the pre-final version. The psychometric properties of the translated version were evaluated by administering the questionnaire to forty workers with a musculoskeletal disorder (MSD). Results indicated good content validity and internal consistency (Cronbach alpha > 0.80 for each scale). Construct validity was tested and confirmed through three hypotheses: (1) subjects with MSD scored higher for the Physical, Work Scheduling and Output demands scales than for the Mental and Social demands scales, (2) subjects having back pain had lower scores than subjects having pain at other body sites and (3) subjects with an MSD had lower scores than healthy workers working full time. This study confirmed that the process used for the adaptation of the Canadian French version of the WRFQ was successful and that this version had good psychometric properties.

Distribution of sickness absence in the European Union countries

AIMS

To determine the sickness absence frequency in European Union (EU) countries.

METHODS

Sickness absence was measured by questionnaire using the Third European Survey on Working Conditions. Employees were considered to have sickness absence if they reported to be absent at least one day in the past 12 months because of an accident at work, work related problems, or by other health problems.

RESULTS

Sickness absence percentages were lower in Southern European countries compared with Central and Northern European countries, and, in general, slightly higher in men than in women.

CONCLUSION

This is the first description of sickness absence in each of the 15 EU countries. Examination of the sickness absence patterning between EU countries could indicate countries where important lessons to reduce sickness absence are to be learned and diffused across the EU.

Psychosocial factors and work related sickness absence among permanent and non-permanent employees

STUDY OBJECTIVE

To examine the association between psychosocial work factors and work related sickness absence among permanent and non-permanent employees by sex.

DESIGN

A cross sectional survey conducted in 2000 of a representative sample of the European Union total active population, aged 15 years and older. The independent variables were psychological job demands and job control as measures of psychosocial work environment, and work related sickness absence as the main outcome. Poisson regression models were used to compute sickness absence days' rate ratios.

SETTING

15 countries of the European Union.

PARTICIPANTS

A sample of permanent (n = 12 875) and non-permanent (n = 1203) workers from the Third European Survey on Working Conditions.

RESULTS

High psychological job demands, low job control, and high strain and passive work were associated with higher work related sickness absence. The risks were more pronounced in non-permanent compared with permanent employees and men compared with women.

CONCLUSIONS

This work extends previous research on employment contracts and sickness absence, suggesting different effects depending on psychosocial working conditions and sex.

Predictors of Successful Work Role Functioning After Carpal Tunnel Release Surgery

This study identified the clinical, individual, and workplace predictors of successful work role functioning (WRF) after carpal tunnel release surgery (CTRS). A community-based cohort (n = 197) was followed for 6 months post-CTRS. Predictors of successful WRF were analyzed prospectively using ordinal logistic regression. Baseline WRF predicted successful WRF at 2 months, whereas being depressed and a workers' compensation claimant predicted being out of work. Baseline WRF, improved self-efficacy, and a supportive organization predicted 6-month successful WRF. Supportive organizations have an impact on the effectiveness of medical interventions for CTS. The significance of improved self-efficacy at 6 months and depression at 2 months postsurgery highlights the importance of psychosocial management of musculoskeletal disorders.

Smoking behavior in a low-income multiethnic HIV/AIDS population

The aim of this study was to describe smoking prevalence and smoking behavior in a multiethnic low-income HIV/AIDS population. A cross-sectional survey design was used. The study site was Thomas Street Clinic, an HIV/AIDS care facility serving a medically indigent and ethnically diverse population. Demographic, disease status, behavioral, and psychosocial variables were assessed by participant self-report. Surveys were collected from 348 study participants. Demographic composition of the sample was 78% male, 25% White, 44% Black, and 29% Hispanic. Study participants had a mean age of 40.2 years (SD=7.8). The HIV exposure profile of the sample was diverse: 46% men who have sex with men, 35% heterosexual contact, and 11% injection drug use. Prevalence of current cigarette smoking in the sample was 46.9%. Among participants with a lifetime history of smoking 100 or more cigarettes (62.8%), only 26.6% were currently abstinent, lower than the 48.8% rate seen in the general population. Multiple logistic regression analysis indicated that race/ethnicity, education level, age, and heavy drinking were significantly associated with smoking status. Hispanics were less likely than Whites were to smoke, younger participants were less likely than older participants were to be current smokers, and heavy drinkers were more likely to be current smokers than were those who were not heavy drinkers. As education level increased, the likelihood of smoking decreased and the likelihood of quitting increased. The high smoking prevalence in this HIV/AIDS population demonstrates the need for smoking cessation interventions targeted to the special needs of this patient group.

Upper extremity musculoskeletal symptoms and functional impairment associated with computer use among college students

PURPOSE

Occupational computer use has been associated with upper extremity musculoskeletal disorders among working-age adults, but little is known about computer-related musculoskeletal problems among college students. We carried out a descriptive epidemiological study of computer use-associated symptoms, functional limitations, and medication and health care utilization in this population.

SUBJECTS AND METHODS

Cross-sectional survey of 240 undergraduates in the second through fourth years at a residential dormitory at a four-year college with random housing assignments.

RESULTS

194 students returned useable surveys (81% response rate). 42% reported upper extremity pain or discomfort when using a computer in the preceding two weeks. 41% said this pain or discomfort caused functional limitation and 9% said that these symptoms hindered academic or extracurricular performance. 23% reported taking medications for upper extremity pain related to computing (4% regularly) and 16% had seen a health care provider for computer-related symptoms. Female students, students of racial/ethnic minority groups, and students who experienced symptoms with < or = 1 hour of computer use were more likely to report symptom-related functional limitation than others.

CONCLUSION

College students report high rates of computer use-associated upper extremity musculoskeletal symptoms and symptom-related functional limitation. Future studies should more closely examine exposure, demographic, and ergonomic correlates of these symptoms and outcomes.

Effect of office ergonomics intervention on reducing musculoskeletal symptoms

STUDY DESIGN

Office workers invited and agreeing to participate were assigned to one of three study groups: a group receiving a highly adjustable chair with office ergonomics training, a training-only group, and a control group receiving the training at the end of the study.

OBJECTIVE

To examine the effect of office ergonomics intervention in reducing musculoskeletal symptom growth over the workday and, secondarily, pain levels throughout the day.

MATERIALS AND METHODS

Data collection occurred 2 months and 1 month before the intervention and 2, 6, and 12 months postintervention. During each round, a short daily symptom survey was completed at the beginning, middle, and end of the workday for 5 days during a workweek to measure total bodily pain growth over the workday. Multilevel statistical models were used to test hypotheses.

RESULTS

The chair-with-training intervention lowered symptom growth over the workday (P = 0.012) after 12 months of follow-up. No evidence suggested that training alone lowered symptom growth over the workday (P = 0.461); however, average pain levels in both intervention groups were reduced over the workday.

CONCLUSION

Workers who received a highly adjustable chair and office ergonomics training had reduced symptom growth over the workday. The lack of a training-only group effect supports implementing training in conjunction with highly adjustable office furniture and equipment to reduce symptom growth. The ability to reduce symptom growth has implications for understanding how to prevent musculoskeletal injuries in knowledge workers.

Relationship of employee-reported work limitations to work productivity

BACKGROUND

Work limitation rates are crucial indicators of the health status of working people. If related to work productivity, work limitation rates may also supply important information about the economic burden of illness.

OBJECTIVE

Our objective was to assess the productivity impact of on-the-job work limitations due to employees' physical or mental health problems.

RESEARCH DESIGN

Subjects were asked to complete a self-administered survey on the job during 3 consecutive months. Using robust regression analysis, we tested the relationship of objectively-measured work productivity to employee-reported work limitations.

SUBJECTS

We attempted to survey employees of a large firm within 3 different jobs. The survey response rate was 2245 (85.9%). Full survey and productivity data were available for 1827 respondents.

MEASURES

Each survey included a validated self-report instrument, the Work Limitations Questionnaire (WLQ). The firm provided objective, employee-level work productivity data.

RESULTS

In adjusted regression analyses (n = 1827), employee work productivity (measured as the log of units produced/hour) was significantly associated with 3 dimensions of work limitations: limitations handling the job's time and scheduling demands (P = 0.003), physical job demands (P = 0.001), and output demands (P = 0.006). For every 10% increase in on-the-job work limitations reported on each of the 3 WLQ scales, work productivity declined approximately 4 to 5%.

CONCLUSION

Employee work limitations have a negative impact on work productivity. Employee assessments of their work limitations supply important proxies for the economic burden of health problems.

Functional status and overall quality of life in a multiethnic HIV-positive population

The objective of this study was to examine the sociodemographic and behavioral variables associated with quality of life (QOL) among multiethnic, economically disadvantaged patients with HIV/AIDS. A cross-sectional survey was conducted in a large inner-city HIV/AIDS clinic serving medically indigent residents of Houston, Texas, and the surrounding area. On arrival at the clinic, patients were systematically approached and asked to complete a questionnaire, offered in both English and Spanish. Demographic characteristics, stage of disease, and behavioral variables were assessed in addition to work-role functioning and overall health-related QOL. Multiple regression analysis was conducted to assess the relationships between the variables of interest. Of 617 patients approached and asked to participate in the study, 385 (62.4%) consented to complete the questionnaire. Demographic composition of the sample was as follows: 78% male, 25% white, 44% black, and 29% Hispanic. Forty-five percent of the participants were infected through men having sex with men (MSM), 35% through heterosexual contact, and 11% through injection drug use. Racial/ethnic minorities reported significantly (p < 0.05) poorer physical functioning and work-role functioning. Participants with higher nadir CD4 cell counts (> 500 per cubic millimeter), MSM HIV exposure, and more education (beyond high school) reported better physical functioning and work-role functioning. Overall QOL and work-related functioning were significantly impaired in this patient population. The impaired functional status findings hold for every social, demographic, and behavioral subgroup examined. Findings suggest that the influence of social inequality persist even among a universally disadvantaged population.

Evaluation of an upper extremity student-role functioning scale using item response theory

Millions of workers suffer from upper extremity (musculoskeletal) disorders. Many of these workers are predisposed to upper extremity musculoskeletal disorders because of early exposure to ergonomic risks as students. Computer usage for four or more hours remains the greatest risk for upper extremity musculoskeletal disorders for workers and students alike. Developing preventative methods to reduce student exposure, and thus protect future workers from upper extremity musculoskeletal disorders later in life, requires an appropriate measure for upper extremity musculoskeletal disorder prevalence and related limitations for student functioning. Item response theory analysis was used to evaluate and further develop a upper extremity functioning scale for the student role.

An invisible disability: Qualitative research on upper extremity disorders in a university community

OBJECTIVES

To understand how upper extremity disorders related to computer use affect graduate and undergraduate university students; and, to develop hypotheses for prevention and management of these disorders.

METHODS

Focus group discussions concerning upper extremity disorders were conducted among sixteen symptomatic undergraduate and graduate students at a private university in the US. Discussions were tape recorded, transcribed, coded for themes, and analyzed qualitatively.

RESULTS

The findings point to four main themes: 1). the essential role of computers in academic, social, and personal activities; 2). the negative impact of upper extremity disorders on students' physical and emotional well-being, including their career aspirations; 3). students' expectations and perceptions of medical care providers; and 4). recommendations for interventions.

CONCLUSION

Students with upper extremity disorders experience numerous adverse consequences on a college campus. Effective strategies for prevention, and treatment of upper extremity disorders in young adults in universities are needed. Based on this research, an educational and skills development intervention would appear to be appropriate for preventing disability due to upper extremity disorders.

Effects of a participatory ergonomics intervention computer workshop for university students: a pilot intervention to prevent disability in tomorrow's workers

A participatory approach was used to create a computer ergonomics workshop for college students, incorporating an instructional systems design process and adult learning inquiry perspectives. The primary objective of this participatory ergonomic pilot intervention was to involve students throughout the training design process in solving computer workstation ergonomic problems and adopting healthy computing behaviors. Students' level of participation included becoming part of the training design team, a co-facilitator, or a student trainee. A second objective was to examine the translation of an industrial office ergonomics training program into a college computer ergonomics training program. The long term goal was to reduce upper extremity symptoms and disability. The program was piloted at one private university. The three student trainees significantly increased their knowledge of computer ergonomics from 69% of test items answered correctly pre-training to 82% post-training. Trainees were also successful in conducting computer ergonomic evaluations of students' computing work areas. They achieved 100% accuracy in identifying ergonomic problems and proposing solutions in five ergonomic workstation assessments in the field. This approach was successful in creating a sense of ownership among the student developers and facilitators as reflected in their self-reports during a post-intervention debriefing. The results of this pilot study justify formal controlled trials of this intervention in university students, who will become tomorrow's workers.

Evidence-based care for depression in Maine: dissemination of the Kaiser Permanente Nurse Telecare Program

This paper describes the program model, implementation and preliminary results from a dissemination of a nurse case management program for treating depression in primary care. The program design was modeled after the Kaiser Permanente Nurse TeleCare program, which in a randomized clinical trial had previously demonstrated significant improvement in depression outcomes and patient satisfaction over usual care. As illustrated in this pilot by patient outcomes measured using the Hamilton Depression Rating Scale, the SF-12 Mental Health Composite Score, and the Work Role, Household and Leisure Time Functioning, the authors believe that it is possible to implement successful interventions in smaller primary care practices in community-based settings.

Employer, physical therapist, and employee outcomes in the management of work-related upper extremity disorders

The purpose of this study was to investigate the relationship among employer, provider, and patient outcome measures and how they are related to clinical factors and other occupation-related factors. Data were obtained from a New England workplace physical therapy (PT) clinic. Successful outcomes were defined as remaining-on/returning-to preinjury job (employer); achieving PT goals (provider); and increases in the SF-36 scale scores (patient). Variation in outcomes was explored across injury regions (shoulder, elbow, wrist/hand), work categories, number of visits, and length of PT care. Employer and provider outcomes are moderately correlated (phi coefficient = 0.51). Subjects demonstrated significant improvements in the SF-36 physical functioning and bodily pain scores after physical therapy intervention. Patients with elbow disorders needed more PT care and did not improve in the SF-36 role physical domain compared to shoulder and wrist/hand groups (p < 0.05). Our results describe the relationship between outcome measures from different perspectives and the influence from other contributing factors. The impact of workplace injury management and the selection of outcome measures warrant continued study.

Office-based medical care for work-related conditions: findings from the National Ambulatory Medical Care Survey, 1997-1998

Data from the 1997 and 1998 National Ambulatory Medical Care Surveys were analyzed to describe nationally representative patterns of office-based ambulatory medical care for work-related injuries and illnesses. Key dimensions of care included patient demographics, diagnoses, utilization of services, provider and payer information, and characteristics of the clinical setting in which care was delivered. Multivariate analyses revealed that compared to visits for nonwork related conditions, ambulatory care visits for work-related conditions are more likely to involve x-rays, injury prevention counseling, and physiotherapy. Surgical procedures, mental health counseling, prescription drug medication, and the taking of blood pressure were found to be relatively less common. Additionally, authorization for care was required considerably more often at visits for work-related conditions, and the provider for patients with work-related conditions was less likely to be the patient's regular primary care physician.

Relationship between all-cause mortality and cumulative working life course psychosocial and physical exposures in the United States labor market from 1968 to 1992

OBJECTIVE

To examine the relationship between cumulative exposures to psychosocial and physical work conditions and mortality in a nationally representative sample.

METHODS

A working cohort was created using the U.S. Panel Study of Income Dynamics. Information on psychosocial and physical work conditions were imputed using the Job Characteristics Scoring System exposure matrix for the period 1968 through 1991 to construct working life courses. Deaths were ascertained from 1970 through 1992.

RESULTS

Working in low-control jobs for a working life was associated with a 43% increase in the chance of death (OR, 1.43, 1.13-1.81) assuming a 10-year time lag. No significant effect was found for high-strain work (ie, high psychosocial job demands and low job control), but a relationship was found between passive work (ie, low psychosocial job demands and low job control) and mortality (OR, 1.35, 1.06-1.72). No significant risk of death was found for psychosocial or physical job demands, job security, or work-related social support. Retirement (OR, 2.85, 1.59-5.11) and unemployment (OR, 2.26, 1.65-3.10) transitions and baseline disability (OR, 1.38, 1.06-1.79) predicted mortality.

CONCLUSIONS

The results support the importance of job control to health. The passive work effect suggests that job content may be important in shaping a worker's health over the life course. Future research should focus on modeling stressors over the life course to capture the dynamic interplay of life transitions, stressor intensity and duration and the role of health in the interplay.

Socioeconomic status and mortality among the elderly: findings from four US communities

The effect of socioeconomic status (SES) on mortality was examined in the community-dwelling elderly. Data were obtained from four population-based studies that enrolled elderly residents of four US communities (East Boston, Massachusetts; New Haven, Connecticut; east-central Iowa; and the Piedmont region of North Carolina) and followed them for 9 years, starting in 1982 or 1986. Higher SES, whether measured by education, by household income, or by occupational prestige, was generally associated with lower mortality. However, the pattern of findings varied by gender and by community. For men, all three SES indicators were associated with mortality in the majority of cohorts. For women, this was true only for income. SES-mortality associations were attenuated but not eliminated after adjustment for behavior and health status. SES-mortality associations were stronger in New Haven and North Carolina than in East Boston and Iowa. The latter communities are more homogeneous with respect to ethnicity, urbanization, and occupational history than the former. Future research should investigate the relative validity of traditional SES measures for men and women and develop more balanced assessment methods. These findings also suggest that it is important to consider not only individual characteristics but also community attributes that mediate or modify the pathways through which socioeconomic conditions may influence health.

Longer distal motor latency predicts better outcomes of carpal tunnel release

The association of preoperative median nerve distal latencies with surgical outcomes of carpal tunnel release is unclear. A total of 109 surgically treated workers with carpal tunnel syndrome across the state of Maine completed questionnaires assessing preoperative levels of symptom and functional limitations and general physical health (SF-12). A second questionnaire assessed the 6-month postoperative outcomes of symptom severity, functional limitations, and satisfaction with surgery. Univariate analyses indicated that longer preoperative distal motor and sensory latencies were associated with less postoperative levels of symptom, less postoperative functional limitations, and more satisfaction with surgery. The associations persisted in multiple linear regression analysis; however, better general health preoperatively was a better predictor of favorable outcomes. The results suggest that workers with prolonged preoperative distal motor latencies and who are in good general health preoperatively have a higher rate of successful carpal tunnel release surgery.

Assessment of upper extremity role functioning in students

BACKGROUND

Upper extremity symptoms associated with use of computers and other upper extremity activities are common in students. Research on these disorders requires psychometrically sound measures of health-related student role function; no such measure is available currently.

METHODS

Based upon input from students and clinicians, we developed a 10-item scale to measure student health-related role function. The measure was administered as part of a survey of 193 undergraduates at one university. A follow-up survey was administered 1 month later. The student health-related role function questionnaire was assessed for internal consistency, ceiling effects, convergent and discriminant validity, and responsiveness to self-reported change in functional status.

RESULTS

Eighty-two percent of students who were given the survey completed it and 65% completed a follow-up survey 1 month later. The new measure was reliable (Cronbach's alpha 0.87). Forty-six percent of respondents reported "no difficulty" on all items of the health-related student role function measure while 64% reported "no difficulty" on all items of a generic upper extremity functional status measure. This finding indicates that the new measure was better able to detect functional limitations; it had a less prominent ceiling effect. The new measure had moderately high correlations with measures of symptom severity and pain, documenting convergent validity. It distinguished students who utilized clinician services, medications, or academic accommodation from students who did not utilize these resources, documenting discriminant validity. The measure was responsive to self-perceived change, as demonstrated by a highly significant association (P < 0.0001) between changes in score over a 1-month follow-up and students' perceptions of whether they had improved in functional abilities after the month, deteriorated or remained stable.

CONCLUSIONS

The student health-related role functioning measure is reliable, valid and responsive to change. It is an appropriate measure for research on upper extremity symptoms in students.

Career paths in diagnostic radiology: scope and effect of part-time work

PURPOSE

To determine the extent and consequences of part-time work in radiology.

MATERIALS AND METHODS

A survey was mailed to 1,500 male and 1,500 female radiologists. Questions assessed part-time work and its effect on professional and family issues. The effects of education, radiology practice characteristics, organizational support, human resource practices, and family responsibilities on career and professional satisfaction were studied.

RESULTS

Ten and a half percent of the radiologists surveyed--7.4% of the men and 30.2% of the women--were working part-time. The part-time radiologists reported earning 56.3% of the income earned by full-time radiologists and working 56.9% of the hours worked by their full-time counterparts, with disproportionately fewer benefits. Part-time private practice radiologists were significantly less likely to be partners. For academic radiologists, having worked part-time at any time was significantly associated with lower academic rank.

CONCLUSION

The motivation for working part-time differed significantly according to gender and age. Benefits were disproportionate, and radiologists who had worked part-time were less likely to be partners or full professors.

The social context of health selection: a longitudinal study of health and employment

Health selection out of the labour force has received considerable attention by analysts attempting to disentangle the "true" biological dimensions of ill-health from its social meaning. Rejecting this dualistic separation, we argue that the effect of health on labour force participation is an inherently social process reflecting differential access to material and symbolic rewards that are structured by social position. Using longitudinal data from the US-based Panel Study of Income Dynamics, we examine the extent to which structural arrangements, including those designated by gender, race, education and age, differentially affect the risk of a labour market exit when health is compromised. Individuals employed at entry into the study (from 1984-1990) were followed for the duration of the study or until they left the labour force. Analyses were stratified by gender and age (25-39 and 40-61 years at baseline). We found suggestive evidence that the hazard of labour market exit in the context of perceived ill-health depended on gender, race and education, but in ways that were not constant across each of these social positions. For example, men may be more vulnerable to the labour market effects of poor health, but only in the younger group, black men were less likely to leave the labour force than white men, and education mattered, but only among younger women and older men. While these patterns may reflect differential access to disability pensions or other work-related benefits, we suggest that a more detailed analysis of trajectories of health and employment. as well as the meaning of health states would be useful in further elucidating the social dimensions of health selection.

The Work Limitations Questionnaire

OBJECTIVE

The objective of this work was to develop a psychometrically sound questionnaire for measuring the on-the-job impact of chronic health problems and/or treatment ("work limitations").

RESEARCH DESIGN

Three pilot studies (focus groups, cognitive interviews, and an alternate forms test) generated candidate items, dimensions, and response scales. Two field trials tested the psychometric performance of the questionnaire (studies 1 and 2). To test recall error, study 1 subjects were randomly assigned to 2 different questionnaire groups, a questionnaire with a 4-week reporting period completed once or a 2-week version completed twice. Responses were compared with data from concurrent work limitation diaries (the gold standard). To test construct validity, we compared questionnaire scores of patients with those of healthy job-matched control subjects. Study 2 was a cross-sectional mail survey testing scale reliability and construct validity.

SUBJECTS

The study subjects were employed individuals (18-64 years of age) from several chronic condition groups (study 1, n = 48; study 2, n = 121) and, in study 1, 17 healthy matched control subjects.

MEASURES

Study 1 included the assigned questionnaires and weekly diaries. Study 2 included the new questionnaire, SF-36, and work productivity loss items.

RESULTS

In study 1, questionnaire responses were consistent with diary data but were most highly correlated with the most recent week. Patients had significantly higher (worse) limitation scores than control subjects. In study 2, 4 scales from a 25-item questionnaire achieved Cronbach alphas of > or = 0.90 and correlated with health status and self-reported work productivity in the hypothesized manner (P < or = 0.05).

CONCLUSIONS

With 25 items, 4 dimensions (limitations handling time, physical, mental-interpersonal, and output demands), and a 2-week reporting period, the Work Limitations Questionnaire demonstrated high reliability and validity.

Predictors of outcomes of carpal tunnel release

OBJECTIVE

To identify factors that are predictive of the outcomes of greatest importance to patients-i.e., symptom relief, functional improvement, and satisfaction with the outcomes of surgery-following carpal tunnel release.

METHODS

We analyzed data from the Maine Carpal Tunnel Study, a community-based study of the outcomes of treatment for carpal tunnel syndrome. In a cohort of patients who underwent carpal tunnel release, a preoperative physical examination was performed and questionnaires were completed preoperatively and at 6, 18, and 30 months postoperatively. The questionnaires assessed symptom severity, upper extremity functional limitations, mental health, general physical health status, the relative severity of individual symptoms, satisfaction with the results of surgery, sociodemographic factors, and for those subjects who were in the workforce, aspects of the work environment. The associations between preoperative factors and the 3 principal outcomes (symptom severity, upper extremity functional limitations, and satisfaction with the results of surgery, all evaluated at 18 months postoperatively) were assessed with bivariate and multivariate linear regression and logistic regression analyses.

RESULTS

Two hundred forty-one subjects were enrolled and 188 (78%) completed followup surveys 18 months postoperatively. Two-thirds of the patients reported being completely or very satisfied with the outcomes of surgery at 6, 18, and 30 months postoperatively. A range of clinical and work-related variables were associated with outcomes. In multivariate analyses, greater preoperative upper extremity functional limitation was predictive of greater functional limitations postoperatively. Worse mental health status was significantly associated with more severe symptoms and lower satisfaction. Alcohol use was also associated with more severe symptoms and lower satisfaction. Among workers, involvement of an attorney was significantly associated with greater functional limitation, more severe symptoms, and lower satisfaction. Recipients of worker's compensation who did not hire an attorney had generally good outcomes. Of note, physical examination parameters were not predictive of the outcomes of surgery.

CONCLUSION

The outcomes of carpal tunnel release in community-based practices are excellent. Predictors of the outcomes of surgery are disease-specific and generic clinical factors as well as work-related factors. The strongest predictors of less favorable outcomes are worse scores on patient-reported measures of upper extremity functional limitation and mental health status, alcohol use, and the involvement of an attorney. Clinicians should carefully evaluate patients' functional status, mental health status, health habits, and attorney involvement prior to performing carpal tunnel release, and discuss with patients the prognostic implications of these parameters.

Adolescents' understanding of social class: a comparison of white upper middle class and working class youth

PURPOSE

Social class is increasingly being recognized as an important factor in the development of population-based variation in health among teens. However, little consensus exists regarding its measurement or conceptualization.

METHODS

This study examined beliefs about social class of 48 working class and 50 upper middle class 16-year-old, white teens.

RESULTS

Working class teens were more likely to misclassify themselves with regard to social class position. Significant class differences were present in beliefs regarding social mobility, parents' equity, equality of opportunity within society, and financial status as adults. How this conceptualization of social class translates into population-based variation in health remains an important area for further inquiry.

A national survey of health-related work limitations among employed persons in the United States

PURPOSE

To estimate the total prevalence of health-related work limitations among working people in the United States (US) as well as their condition-specific prevalence.

METHODS

A new questionnaire measuring limitations in ability to perform specific work demands was administered to 940 employed people in a national household survey. The prevalence of specific work limitations is reported as are condition-specific risk estimates (odds ratios) based on logistic regression.

RESULTS

In the US, 19.3% of working people (CI = 14.0, 24.6) were limited in their abilities to perform physical work demands; 24.1% (CI = 18.9, 29.2) were limited in performing psychosocial work demands; and 13.8% (CI = 8.3, 19.3) were limited in their abilities to function without difficulty within the ambient work environment. With successive increments in the number of conditions, the odds of having a limitation increased significantly.

CONCLUSIONS

This study contributes new information concerning the implications of chronic health problems for working people and the significant risks for workers with multiple chronic conditions.

The migraine work and productivity loss questionnaire: concepts and design

Our objectives were to: (1) develop a self-report questionnaire for measuring the impact of migraine headache on work; and (2) qualitatively assess aspects of its performance. Two samples of migraine sufferers provided the data. Sample 1 (n = 18) participated in a structured discussion group designed to elicit examples of migraine's on-the-job impact. Sample 2 (n = 11) completed a mail survey and participated in in-depth phone interviews. Interviews addressed item comprehensibility, consistency of interpretation, the cognitive processes by which certain answers were generated and response burden. The participants were currently employed men and women, at least 18 years of age, who met the International Headache Society (IHS) criteria for migraine headache [1]. Discussion group participants indicated that migraine attacks substantially diminished their job performance. Pain, photophobia, phonophobia, mental impairment and fatigue were perceived as interfering with even routine or relatively simple job tasks. The Migraine Work and Productivity Loss Questionnaire, Version 1.0 (MWPLQ) was written. Next, it was assessed in the context of the in-depth interviews. Result indicated that the MWPLQ was comprehended without difficulty, interpreted consistently and easy to complete. Thus, qualitative results provide initial support for the new questionnaire.

Racial/ethnic disparities in health: the interplay between discrimination and socioeconomic status

In the past decade, racial/ethnic discrepancy in health status has drawn increased attention from academicians, policy makers and planners, service providers, and community advocates. While the field has witnessed a growth in research projects and intervention programs, the gap in health status among racial/ethnic groups persists, which suggests that future research should incorporate a focus on one neglected area, ie, the health implications of discrimination. Using the National Survey of Functional Health (N=1,659), a nationally representative sample of English-speaking persons 18 years of age and older living in non-institutional arrangements within the United States, we analyzed how self-perceived unfairness (discrimination due to racial identity or to low socioeconomic status [SES]) was linked to self-assessed health status. The study found that racial and class discrimination were rather pervasive in the United States. Experiences of discrimination tended to have a strong negative association with health and accounted for some racial/ethnic differences in health status. The study also revealed a complex relationship between experiences of discrimination and social class, suggesting that future research should focus on specifying the social distribution of discrimination and assessing its subsequent association with health.

Office technology and musculoskeletal disorders: building an ecological model

Symptoms drive health care utilization. Therefore, health care costs are reduced by reducing musculoskeletal injuries through job redesign, ergonomics, or changes in work scheduling.

Relationship of job strain and iso-strain to health status in a cohort of women in the United States

OBJECTIVE

This study examined the relationships of job strain and iso-strain psychosocial work-environment exposures to health status in a cohort of working women in the United States.

METHODS

In a cross-sectional survey, 33689 women responded to the Karasek job content and the MOS SF-36 health status questionnaires. The psychosocial work-environment exposures were characterized using the job strain and iso-strain frameworks. Health status was assessed with the following 6 scales: physical functioning, vitality, freedom from pain, mental health, role limitations due to physical health, and role limitations due to emotional health.

RESULTS

When compared with active work, high-strain work (high job demands and low job control) was associated with lower vitality, mental health, higher pain, and increased risks of both physical and emotional role limitations. Iso-strain work (high strain and low work-related social support) increased the risks further. Job insecurity was also associated with lower health status.

CONCLUSIONS

The analyses supported the hypothesis that the psychosocial work environment is an important determinant of health status among working women. The findings suggest that incorporating social conditions at work into the measurement of psychosocial work-environment exposure improves the identification of high-risk work arrangements.

The Angina-related Limitations at Work Questionnaire

This report describes initial experience with a new self-report questionnaire, the 17 item Angina-related Limitations at Work Questionnaire. Forty employed individuals with chronic stable angina pectoris completed the questionnaire which retrospectively examined the subjects' difficulty in performing specific work activities during the preceding 4 week period. The questionnaire performed well in this study and there was initial evidence of its validity and reliability. More than one-half of the respondents (52.5%) indicated at least some difficulty in performing one or more of the 17 work items due to angina during the preceding 4 weeks, with the greatest difficulty experienced in physically exerting tasks, handling stressful situations and feeling a sense of accomplishment. In contrast, only one-quarter of the sample missed any work time. In tests of convergent validity, the degree of work limitation correlated significantly with SF-36 physical and mental health component scores and with self-reports of angina symptoms. The questionnaire had internal reliability, with item to total score correlations of 0.75 or higher for 14 of the 17 items. In summary, the Angina-related Limitations at Work Questionnaire offers promise for quantifying work limitations among individuals with chronic stable angina.

Influences of gender and social class on adolescents' perceptions of health

OBJECTIVE

To explore how gender and social class affect perceptions of health status among 16-year-old adolescents.

DESIGN

Cross-sectional survey.

SETTING

University psychology laboratory. PARTICIPANS: Fifty upper-middle-class and 48 working-class adolescents stratified by gender.

MAIN OUTCOME MEASURES

The general health perceptions (GHP) scale of the Medical Outcomes Survey 36-Item Short Form Health Survey (SF-36). The other self-reported health status domains and 3 measures of different aspects of psychological well-being were included as covariates in analysis of variance models.

RESULTS

Upper-middle-class females reported the lowest and upper-middle-class males the highest GHP (76.7 vs 88.4, P=.003). A multivariate regression model (adjusted R2=0.08) revealed significant gender (P=.03) differences in GHP, but not a social class effect, and an interaction effect between gender and class (P=.01). With addition of psychological well-being covariates (P<.001), gender remained significant (P=.04) and a significant portion of the interaction effect (P=.13) was explained. When the self-reported physical health status scales (P<.001) were added to the model (adjusted R2=0.51), gender remained significant (P=.03) and the interaction effect was partially explained (P=.07).

CONCLUSIONS

Gender is a crucial factor in understanding the complex relationships between sociostructural inequalities and health differentials. These data suggest that psychological well-being and self-reported physical health status mediate the effects of gender and the gender and social class interaction in explaining variation in GHP. Contrary to the social class gradient hypothesis, upper-middle-class females reported the lowest GHP. These results suggest that the paradigms applicable to early childhood and adulthood may not be appropriate to understand the complex dynamics of adolescence.

Racial and ethnic disparities in self-assessed health status: evidence from the National Survey of Families and Households

We examined racial and ethnic disparities in global health assessment and functional limitations of daily activities among whites, blacks and Hispanics, and within the Hispanic origin among Mexicans, Puerto Ricans, Cubans, and 'Others'. Logistic regression were employed to estimate the log odds of reporting 'poor health' and 'having functional limitations' among 12,814 respondents from the 1987-1988 National Survey of Families and Households. Compared with whites, blacks had an increased risk of reporting poor health and functional limitations. Hispanics had even a higher risk of reporting poor health, but did not have an increased risk of reporting functional limitations. Among Hispanics, Mexicans were more likely than whites to report poor health, whereas Puerto Ricans were more likely than whites to experience functional limitations. Both race and ethnicity remain important factors in explaining the disparities in self-assessed health status independent of socioeconomic status (SES). Meanwhile, the way self-assessed health status varies with ethnicity is importantly stratified by SES as measured by income and education. These results suggest that future research should analyze the interplay between ethnicity and SES rather than assuming measuring either captures all the important variation.

Race and self assessed health status: the role of socioeconomic factors in the USA

STUDY OBJECTIVE

To estimate relative odds ratios and to ascertain the relative contribution of each socioeconomic covariate in explaining racial disparities in self assessed health status (for example, global health perceptions and functional limitations of daily activities).

DESIGN

National representative data from the 1987-88 national survey of families and households, a multistage, stratified probability sample of non-institutionalised American adults age 19 and older, were used. Logistic regression models enabled a multistage building strategy to be used in the analyses.

PARTICIPANTS AND SETTING

The study included three racial groups: whites (n = 9419), blacks (n = 2391), and Hispanics (n = 1004). While face to face interviews were carried out with each respondent, some portions of the interview were self administered to collect sensitive information.

MAIN RESULTS

Compared with whites, blacks and Hispanics were more likely to assess health as poor and report having functional limitations of daily activities. Socioeconomic factors tended to play a different role in explaining racial disparities in self assessed health status. In global health, education tended to play a significant role in accounting for health disparities between whites and Hispanics. In functional limitations, none of the covariates explained racial differences for blacks, whereas for Hispanics, education and marital status explained racial differences.

CONCLUSIONS

The debate over whether race is a proxy for socioeconomic conditions or race influences health independent of socioeconomic factors depends on the measure of health and racial group included in the study. Future studies should examine separately the differential impacts of various socioeconomic factors on varying domains of health.

A three-year longitudinal assessment of changes in office activities following the introduction of microcomputers into a multinational bank

A longitudinal assessment of the introduction of new office technologies into a multinational bank was conducted using both task diaries and semi-structured interviews. Task diaries were administered prior to the introduction of microcomputers, several months after the introduction and several years later. Semi-structured interviews were completed after the second task diary. The assessment provides evidence of how offices adapt to changing electronic tookits. The assessment provides ergonomists with a usable list of task activities and the effects on task variability of the adoption of microcomputers into the work routine. It shows that when support staff are asked to use a new computer they must choose what other tasks to cut back on, which has consequences for the overall work process. Overtime increased 170% after the introduction of the computer. In a culture where professional staff have high expectations of support staff this has consequences for working relationships in terms of perceptions of the computer's utility. Support staff and professional staff differ in perceptions of control, time-saving and ability to make corrections. The assessment demonstrates the importance of multiple measurement instruments in tracking the effects of technological change on the work process. In conclusion, it is noted that the introduction of new technologies into the office must be considered in the broader office context to avoid the unintended consequences often reported in other case studies.

Stress, computer-based work monitoring and measurement systems: a conceptual overview

The design and implementation of computer-based work monitoring systems can result in changes in the organization, job and task. Electronic performance monitoring (EPM) systems are one type of change based on principles of work simplification and work rationalization. In this new work arrangement, control and coordination functions are allocated to the computer. The supervisor becomes a monitor of information and primarily provides negative performance feedback to the employee. The employee is constrained in his/her ability to use either job resources or social resources to meet the greater demands resulting from the system controlling the pace of work. It is proposed that these work arrangements provoke stress responses in employees that can result in short-term illness and potentially long-term changes in health status. Information enriched work environments are proposed as an alternative. These new work arrangements could improve job resources and social resources to manage job demands and reduce the potentially damaging stress responses. To provide a frame of reference we focus on the impact of EPM systems on the organizational and job elements involved in provoking individual stress responses. The impact of EPM systems on individual health is described using a psychosocial stress framework. Ergonomics interventions discussed include: participation in the design process; allocation of control and coordination functions between the computer and the employee; development of feedback systems; and work measurement and the development of performance appraisal systems.

Factors influencing the diagnosis of mental disorder among primary care patients

Understanding the role primary care physicians play in the recognition and management of mental disorder among their patients is a research topic that has assumed considerable importance because of the high prevalence combined with low recognition of mental morbidity in primary care settings. Patient characteristics that influence diagnostic patterns have been one important focus of this research. This paper presents data from a study in two primary care departments in a large comprehensive health care clinic in central Wisconsin. During a 3-month period, 1,452 attenders at these clinics were assessed using a brief psychiatric screening scale, and special study forms were completed by the primary care clinicians. Consistent with previous research, reason for visit, psychiatric symptoms, and prior knowledge of the patient are significant predictors of physician diagnosis of mental disorder. Additionally, pattern of physician practice, as represented by differences between the two types of clinics, was a strong predictor of both diagnosis and treatment. The lack of significant effects of sex and previous medical utilization is contrary to previous research. Key words: mental disorders; diagnosis; primary care.