Does survey non-response bias the association between occupational social class and health?

Surgeon Prioritization of Mental, Social, and Pathophysiological Aspects of Health Among People With Traumatic and Nontraumatic Musculoskeletal Conditions

BACKGROUND

There is mounting evidence that, among musculoskeletal patients, variation in capability has more notable associations with variations in mental and social health factors than with variation in pathophysiology severity. This study sought factors that could limit the integration of this evidence into more comprehensive care models.

METHODS

In two scenario-based experiments, surgeon participants in an international collaborative, the Science of Variation Group, reviewed scenarios of (a) nontraumatic (83 participants) and (b) trauma-related (130 participants) pathophysiologies for which tests and treatments were discretionary. The following demographic, mental, and social health elements were varied randomly: sex, age, race/ethnicity, mindsets, social health aspects, and specific pathophysiologies. For each scenario, participants rated their likelihood to offer surgery (continuous) and their sense of presence of an opportunity to address better mental or social health in treatment (yes or no). Factors associated with each rating were sought in multivariable analysis.

RESULTS

Greater likelihood to offer discretionary surgery for nontraumatic pathophysiologies was associated with greater pathophysiology severity, trapeziometacarpal arthritis, and greater distress and unhelpful thoughts regarding symptoms. Lateral elbow enthesopathy was associated with a lower likelihood. For trauma-related pathophysiologies, an ankle fracture with slight articular subluxation was associated with greater likelihood to offer surgery, and several other trauma-related pathophysiologies were associated with a lower likelihood. For both nontraumatic and trauma-related pathophysiologies, surgeons noticed unhelpful thinking, distress, and social issues as reasons to consider addressing mental and social health in treatment, relatively independent of pathophysiology.

CONCLUSION

Surgeons seem to recognize opportunities to address mental and social needs but ultimately base their decision to offer discretionary surgery on pathophysiological factors.

CLINICAL RELEVANCE

Comprehensive, whole-person care for musculoskeletal illness might be supported by strategies for ensuring that aspects of stress and distress that contribute to greater symptom intensity are not misinterpreted as a reflection of greater pathophysiology severity.

Unincreased mortality of patients with early rheumatoid arthritis compared to the general population in the past 17 years: Analyses from the IORRA cohort

OBJECTIVES

The aim of this article is to investigate the mortality rate of patients with early rheumatoid arthritis (RA) over the past 17 years.

METHODS

Japanese patients with early RA enrolled in the Institute of Rheumatology, Rheumatoid Arthritis cohort from 2001 to 2012 were classified into Groups A (2001-06) and B (2007-12). The standardized mortality ratio (SMR) and 5-year survival rate were calculated.

RESULTS

Groups A and B had 1609 and 1608 patients, of which 167 and 178 patients were lost during follow-up and 47 and 45 deaths were confirmed, respectively. The SMR (95% confidence intervals) for Groups A and B were 0.81 (0.59-1.08) and 0.78 (0.57-1.04), respectively, with the condition that all untraceable patients were alive. Assuming that the mortality rate of untraceable patients was twice as high as that of the general population, the SMR was 0.90 (0.68-1.19) for Group A and 0.92 (0.68-1.23) for Group B. The 5-year survival rates were 96.9% and 97.0% for Groups A and B, respectively.

CONCLUSIONS

The 5-year mortality of patients with early RA has been comparable to that of the general Japanese population. The 5-year survival rate has been stable over the past 17 years.

Can non-participants in a follow-up be used to draw conclusions about incidences and prevalences in the full population invited at baseline? An investigation based on the Swedish MDC cohort

BACKGROUND

Participants in epidemiological cohorts may not be representative of the full invited population, limiting the generalizability of prevalence and incidence estimates. We propose that this problem can be remedied by exploiting data on baseline participants who refused to participate in a re-examination, as such participants may be more similar to baseline non-participants than what baseline participants who agree to participate in the re-examination are.

METHODS

We compared background characteristics, mortality, and disease incidences across the full population invited to the Malmö Diet and Cancer (MDC) study, the baseline participants, the baseline non-participants, the baseline participants who participated in a re-examination, and the baseline participants who did not participate in the re-examination. We then considered two models for estimating characteristics and outcomes in the full population: one ("the substitution model") assuming that the baseline non-participants were similar to the baseline participants who refused to participate in the re-examination, and one ("the extrapolation model") assuming that differences between the full group of baseline participants and the baseline participants who participated in the re-examination could be extended to infer results in the full population. Finally, we compared prevalences of baseline risk factors including smoking, risky drinking, overweight, and obesity across baseline participants, baseline participants who participated in the re-examination, and baseline participants who did not participate in the re-examination, and used the above models to estimate the prevalences of these factors in the full invited population.

RESULTS

Compared to baseline non-participants, baseline participants were less likely to be immigrants, had higher socioeconomic status, and lower mortality and disease incidences. Baseline participants not participating in the re-examination generally resembled the full population. The extrapolation model often generated characteristics and incidences even more similar to the full population. The prevalences of risk factors, particularly smoking, were estimated to be substantially higher in the full population than among the baseline participants.

CONCLUSIONS

Participants in epidemiological cohorts such as the MDC study are unlikely to be representative of the full invited population. Exploiting data on baseline participants who did not participate in a re-examination can be a simple and useful way to improve the generalizability of prevalence and incidence estimates.

Racial/Ethnic Differences in Non-Discretionary Risk Factors for COVID-19 Among Patients in an Early COVID-19 Hotspot

BACKGROUND

Baseline disparities in non-discretionary risk factors, i.e., those not readily altered, like family size and work environment, appear to underlie the disproportionate COVID-19 infection rates seen among Hispanic persons and, at surge onsets, Black persons. No study has systematically compared such risk factors by race/ethnicity among infected individuals.

METHODS

Using a cross-sectional survey, we compared household, job, and socioeconomic characteristics among 260 Hispanic, non-Hispanic Black, and non-Hispanic White adults with confirmed or probable COVID-19 in New York from March to May 2020. We used logistic regression to identify independent relationships.

RESULTS

In bivariate analysis, we found significant differences by race/ethnicity in the following: (1) rates of household crowding (p < 0.001), which were highest for Hispanic patients (45.1%) and lowest for White patients (0.9%); (2) rates of non-healthcare frontline work (p < 0.001), which were highest for Hispanic patients (71.0% of those employed) and lowest for White patients (31.4%); (3) rates of working close to people (p < 0.001), which were highest for Black patients (69.4%) and lowest for Hispanic patients (32.3%); and (4) rates of frontline healthcare work (p = 0.004), which were higher for Black (44.9%) and White (44.3%) patients than Hispanic patients (19.4%). Adjusting for covariates eliminated most differences but not that for household crowding.

CONCLUSIONS

Non-discretionary COVID-19 risk factors among patients in the initial surge differed substantially by race/ethnicity. Socioeconomic factors explained most differences, but household crowding was independently associated with Hispanic ethnicity. Our findings highlight the ongoing need for universal safeguards for US frontline workers, including mandated paid sick leave and expanded affordable housing options.

Comparing the sociodemographic characteristics of participants and non-participants in the population-based Tromsø Study

BACKGROUND

Differences in the sociodemographic characteristics of participants and non-participants in population-based studies may introduce bias and reduce the generalizability of research findings. This study aimed to compare the sociodemographic characteristics of participants and non-participants of the seventh survey of the Tromsø Study (Tromsø7, 2015-16), a population-based health survey.

METHODS

A total of 32,591 individuals were invited to Tromsø7. We compared the sociodemographic characteristics of participants and non-participants by linking the Tromsø7 invitation file to Statistics Norway, and explored the association between these characteristics and participation using logistic regression. Furthermore, we created a geographical socioeconomic status (area SES) index (low-SES, medium-SES, and high-SES area) based on individual educational level, individual income, total household income, and residential ownership status. We then mapped the relationship between area SES and participation in Tromsø7.

RESULTS

Men, people aged 40-49 and 80-89 years, those who were unmarried, widowed, separated/divorced, born outside of Norway, had lower education, had lower income, were residential renters, and lived in a low-SES area had a lower probability of participation in Tromsø7.

CONCLUSIONS

Sociodemographic differences in participation must be considered to avoid biased estimates in research based on population-based studies, especially when the relationship between SES and health is being explored. Particular attention should be paid to the recruitment of groups with lower SES to population-based studies.

Adjustment for survey non-participation using record linkage and multiple imputation: A validity assessment exercise using the Health 2000 survey

AIMS

It is becoming increasingly possible to obtain additional information about health survey participants, though not usually non-participants, via record linkage. We aimed to assess the validity of an assumption underpinning a method developed to mitigate non-participation bias. We use a survey in Finland where it is possible to link both participants and non-participants to administrative registers. Survey-derived alcohol consumption is used as the exemplar outcome.

METHODS

Data on participants (85.5%) and true non-participants of the Finnish Health 2000 survey (invited survey sample N=7167 aged 30-79 years) and a contemporaneous register-based population sample (N=496,079) were individually linked to alcohol-related hospitalisation and death records. Applying the methodology to create synthetic observations on non-participants, we created 'inferred samples' (participants and inferred non-participants). Relative differences (RDs) between the inferred sample and the invited survey sample were estimated overall and by education. Five per cent limits were used to define acceptable RDs.

RESULTS

Average weekly consumption estimates for men were 129 g and 131 g of alcohol in inferred and invited survey samples, respectively (RD -1.6%; 95% confidence interval (CI) -2.2 to -0.04%) and 35 g for women in both samples (RD -1.1%; 95% CI -2.4 to -0.8%). Estimates for men with secondary levels of education had the greatest RD (-2.4%; 95% CI -3.7 to -1.1%).

CONCLUSIONS

The sufficiently small RDs between inferred and invited survey samples support the assumption validity and use of our methodology for adjusting for non-participation. However, the presence of some significant differences means caution is required.

Organizational and psychosocial environmental work factors associated with self-rated exhaustion disorder among municipal employees in rural northern Sweden

BACKGROUND

Research indicates that good organizational and psychosocial environments are vital to well-functioning workplaces and employee health. Working in the municipal sector and in the rural context may contribute to more health problems, poorer organizational and psychosocial work environments, and higher sick-leave rates.

OBJECTIVE

The aim of this study was to explore organizational and psychosocial environmental work factors among municipal employees with or without self-rated exhaustion disorder (s-ED) in rural northern Sweden.

METHODS

The Modern Work Life Questionnaire and the Self-Rated Exhaustion Disorder Scale were used among 1093 municipal employees.

RESULTS

The results showed that there were significant differences between the s-ED and the non-s-ED group in all but one of the organizational and psychosocial environmental work factors. Various demands, i.e. quantitative, emotional, intellectual, and IT demands were some factors associated with the s-ED group. Social support, resources, and time for work and reflection were some factors associated with the non-s-ED group. Both the s-ED and the non-s-ED groups assessed significantly higher emotional demands and less resources compared to national reference values.

CONCLUSION

Findings from this study are relevant to a better understanding what organizational and psychosocial work environmental work factor the employer need to pay extra attention to. Addressing risk and protective factors in the work environment could tribute to promote occupational well-being, preventing exhaustion disorder and long-term sick leave among municipal employees in rural northern Sweden.

Childhood Socioeconomic Disadvantage and Pathways to Memory Performance in Mid to Late Adulthood: What Matters Most?

OBJECTIVES

Childhood socioeconomic disadvantage is consistently associated with lower cognitive function in later life. This study aims to distinguish the contribution of specific aspects of childhood socioeconomic disadvantage for memory performance in mid-to-late adulthood, with consideration for direct and indirect effects through education and occupation.

METHODS

Data were from adults aged 50-80 years who completed the life history module in the 2006/07 wave of the English Longitudinal Study of Ageing (n=4,553). The outcome, memory score, was based on word recall tests (range: 0-20 points). We used the g-formula to estimate direct and indirect effects of a composite variable for childhood socioeconomic disadvantage, and its four individual components: lower-skilled occupation of the primary breadwinner, having few books in the home, overcrowding in the home, and lack of water and heating facilities in the home.

RESULTS

Few books were the most consequential component of childhood socioeconomic disadvantage for later life memory (total effect: ⎼0.82 points for few books; 95% CI: ⎼1.04, ⎼0.60), with roughly half being a direct effect. The total effect of a breadwinner in lower-skilled occupations was smaller but not significantly different from few books (⎼0.67 points; 95% CI: ⎼0.88, ⎼0.46), while it was significantly smaller with overcrowding (⎼0.31 points; 95% CI: ⎼0.56, ⎼0.06). The latter two total effects were mostly mediated by education and occupation.

DISCUSSION

A literate environment in the childhood home may have lasting direct effects on memory function in mid-to-later life, while parental occupation and overcrowding appear to influence memory primarily through educational and occupational pathways.

Intimate partner violence during infancy and cognitive outcomes in middle childhood: Results from an Australian community-based mother and child cohort study

The cognitive functioning of children who experience intimate partner violence (IPV) has received less attention than their emotional-behavioral outcomes. Drawing upon data from 615 (48.4% female) 10-year-old Australian-born children and their mothers (9.6% of mothers born in non-English speaking countries) participating in a community-based longitudinal study between 2004 and 2016, this study examined the associations between IPV in infancy and cognition in middle childhood (at age 10). Results showed that IPV in the first 12 months of life was associated with lower general cognitive ability and poorer executive attention but not working memory skills. IPV in middle childhood (in the 10th year postpartum) was not associated with cognition. This study provides evidence for the long-term impact of early life exposure to IPV on children's cognition, and points to the importance of early intervention to optimize development.

Working Conditions and Long-Term Sickness Absence Due to Mental Disorders: A Prospective Record Linkage Cohort Study Among 19- to 39-Year-Old Female Municipal Employees

OBJECTIVE

We examined associations between working conditions and long-term sickness absence due to mental disorders (LTSA-MD) among younger female public sector employees from different employment sectors.

METHODS

Survey data collected in 2017 (n = 3048) among 19- to 39-year-old female employees of the City of Helsinki, Finland, were used to examine job demands, job control, physical workload, computer work, and covariates. Register data on LTSA-MD were used over 1-year follow-up. Negative binomial regression models were applied.

RESULTS

Adverse psychosocial and physical working conditions were associated with higher LTSA-MD during the follow-up. Health and social care workers had the highest number of days of LTSA-MD.

CONCLUSION

Working conditions are important factors when aiming to prevent LTSA-MD among younger employees, in the health and social care sector in particular.

Improving postal survey response using behavioural science: a nested randomised control trial

Background

Systematic reviews have identified effective strategies for increasing postal response rates to questionnaires; however, most studies have isolated single techniques, testing the effect of each one individually. Despite providing insight into explanatory mechanisms, this approach lacks ecological validity, given that multiple techniques are often combined in routine practice.

Methods

We used a two-armed parallel randomised controlled trial (n = 2702), nested within a cross-sectional health survey study, to evaluate whether using a pragmatic combination of behavioural science and evidenced-based techniques (e.g., personalisation, social norms messaging) in a study invitation letter increased response to the survey, when compared with a standard invitation letter. Participants and outcome assessors were blinded to group assignment. We tested this in a sample of women testing positive for human papillomavirus (HPV) at cervical cancer screening in England.

Results

Overall, 646 participants responded to the survey (response rate [RR] = 23.9%). Logistic regression revealed higher odds of response in the intervention arm (n = 357/1353, RR = 26.4%) compared with the control arm (n = 289/1349, RR = 21.4%), while adjusting for age, deprivation, clinical site, and clinical test result (aOR = 1.30, 95% CI: 1.09–1.55).

Conclusion

Applying easy-to-implement behavioural science and evidence-based methods to routine invitation letters improved postal response to a health-related survey, whilst adjusting for demographic characteristics. Our findings provide support for the pragmatic adoption of combined techniques in routine research to increase response to postal surveys.

Trial registration

ISRCTN, ISRCTN15113095. Registered 7 May 2019 – retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01476-7.

The impact of musculoskeletal pain and strenuous work on self-reported physical work ability: a cohort study of Swedish men and women

Objective

We investigated the separate and combined effects of musculoskeletal pain (MSP) and strenuous work (heavy physical workload (PWL)/low-decision authority) on poor physical work ability (WA).

Methods

This study uses baseline data from the 2010 Stockholm Public Health Questionnaire (SPHQ) including 9419 workers with good physical WA. Exposure to PWL and decision authority were estimated using sex-specific job-exposure matrices linked to occupations. Exposures (high/low) were combined with the presence of MSP. Follow-up data on physical WA were taken from the 2014 SPHQ and dichotomised (the responses: “moderate”, “rather poor” and “very poor” indicated poor WA). Logistic regression models calculated sex-specific odds ratios adjusting for age, education and health and lifestyle factors. Interaction between MSP and strenuous work was examined using the synergy index (SI). Analyses were conducted using SPSS.27.

Results

MSP, heavy PWL and low-decision authority were separately associated with poor WA. MSP was associated with higher odds of poor WA than strenuous work for women, the opposite for men. Combinations of MSP and strenuous work often resulted in higher risks of poor WA than when adding the effects of the single exposures (e.g., MSP and heavy PWL men: AOR 4.04 95% CI 2.00–8.15, women: AOR: 3.25 95% CI 1.81–5.83). The SI was non-significant for both sexes.

Conclusion

Workers with MSP and strenuous work often had higher risks of poor WA than would be expected from adding the effects of the single exposures. To decrease poor WA in this group, strenuous work should be lowered, and MSP addressed in workplaces.

Intimate partner violence and child outcomes at age 10: a pregnancy cohort

OBJECTIVE

Assess the mental health, physical health, cognitive and language development of 10-year old children in families where mothers have reported intimate partner violence (IPV) compared with children with no reported IPV exposure.

DESIGN

Prospective pregnancy cohort. Maternal report of IPV (Composite Abuse Scale) at 1, 4 and 10 years. Maternal and direct assessment of child mental health (probable psychiatric diagnosis, anxiety and emotional/behavioural difficulties), cognition (IQ and executive function), language (general, pragmatic and receptive) and physical health at 10 years.

SETTING

A subsample of 615 mother-child dyads drawn from a pregnancy cohort of 1507 nulliparous women recruited from six public hospitals in Melbourne, Australia.

RESULTS

Any IPV exposure from infancy to age 10 was associated with poorer child outcomes at age 10. Specifically, twice the odds of a probable psychiatric diagnosis, emotional/behavioural difficulties, impaired language skills (general and pragmatic), and having consulted a health professional about asthma or sleep problems. IPV exposure at age 10 associated with two to three times higher odds of all mental health outcomes, elevated blood pressure and sleep problems. Early life exposure alone (at 1 and/or 4 years) associated with three times higher odds of a general language problem and asthma at age 10.

CONCLUSION

The high prevalence of IPV and increased risk of poorer health and development among children exposed highlights the burden of ill health carried by children in families experiencing IPV. Fewer difficulties where exposure was limited to the early years builds the case for better identification, understanding and resourcing of effective early intervention.

Physical workload and increased frequency of musculoskeletal pain: a cohort study of employed men and women with baseline occasional pain

OBJECTIVES

Musculoskeletal pain (MSP) is prevalent among the workforce. This study investigates the long-term association between physical workload (PWL) and increased frequency of MSP among male and female employees with pre-existing occasional MSP.

METHODS

This study uses the Stockholm Public Health cohort survey data from the baseline 2006. The sample includes 5715 employees with baseline occasional MSP (no more than a few days per month). Eight PWL exposures and overall PWL were estimated using a job-exposure matrix (JEM). The JEM was assigned to occupational titles from a national register in 2006. Follow-up survey data on frequent MSP (a few or more times a week) were collected from 2010. Logistic regressions produced sex-specific ORs with 95% CIs and were adjusted for education, health conditions, psychological distress, smoking, BMI, leisure-time physical activity and decision authority.

RESULTS

Associations were observed between several aspects of heavy PWL and frequent MSP for men (eg, OR 1.57, 95% CI 1.13 to 2.20, among those in the highest exposure quartile compared with those in the lowest quartile for heavy lifting) and women (eg, OR 1.76, 95% CI 1.35 to 2.29, among those in the highest exposure quartile compared with those in the the lowest quartile for physically strenuous work). Small changes were observed in the OR after adjustment, but most of the ORs for PWL exposures among the men were no longer statistically significantly increased.

CONCLUSION

A high level of exposure to heavy PWL was associated with increased frequency of MSP 4 years later for men and women with baseline occasional pain.

Lifetime Duration of Exposure to Biomechanical Factors at Work as a Mediator of the Relationship Between Socioeconomic Position and Walking Speed

The study aimed to assess the proportion mediated by the duration of exposure to ergonomic factors at work on the relationship between socioeconomic position (SEP) and low walking speed. This cross-sectional study was performed on data collected at baseline on 19,704 men and 20,273 women 45-70 years old, currently or previously employed, enrolled in the Constances cohort. SEP was assigned through current or last occupation, categorized in three classes, based on the European Socioeconomic Classification. Walking speed was assessed through one measurement of normal walking for 3 m and dichotomized at the lowest quintile of the sex- and age- (5-year) specific distribution. Self-reported workplace exposure throughout working life to repetitive work, intense physical work, and lifting/carrying heavy loads was used to assess the duration of exposure to each factor, categorized in four classes. Through Poisson regression models, adjusted for BMI, smoking, alcohol intake, hypertension, physical activity, diabetes, cardiovascular diseases, and a cognitive score, the attenuation in the prevalence ratio (PR) of low walking speed by SEP produced by the inclusion of duration of exposure to each factor was evaluated. The mediating effect of work ergonomic exposures on the relationship between SEP and low walking speed was assessed using the weighted method by Vanderweele. In the fully adjusted model without ergonomic exposures, both men and women in the middle and the lowest SEP had a significantly increased risk of low walking speed compared with those in the highest SEP (men: PR = 1.30 and PR = 1.46, respectively; women: PR = 1.24 and PR = 1.45, respectively). The inclusion in separate regression models of exposure duration to repetitive work, intense physical work, and handling of heavy loads produced modest risk attenuations in both men and women, all smaller or around 10%. Mediation analysis revealed in both sexes significant mediation effects for most ergonomic exposures considered, although also with low mediation effects. Significant differences in walking speed by SEP were observed in this large sample, but the proportion of such differences explained by the duration of exposure to ergonomic factors at work was low using either the risk attenuation or the mediation analysis methods.

Evaluation of Nonresponse Bias in a Case-Control Study of Pleural Mesothelioma

Nonparticipation limits the power of epidemiological studies, and can cause bias. In a case–control study on pleural malignant mesothelioma (MM), we found low participation in interviews (63%) among controls. Our goal was to characterize nonresponder controls and assess nonresponse bias in our study. We selected all nonresponder controls (204) and a random sample of responder controls (174). Data were obtained linking hospital admissions and town registrars, and concordance between sources was assessed. Nonresponse bias was evaluated using a logistic regression model applying the inverse probability weighting approach. The odds ratio (OR) for the status of the respondents was 0.61 (95% confidence interval (CI): 0.33–1.16) for controls aged 61–70, 0.37 (CI: 0.20–0.66) for those aged 71–80, and 0.40 (CI: 0.20–0.80) for those aged above 80 (reference group: ≤60 years). Controls with low education level had lower OR (0.47; CI: 0.26–0.84). After adjustment, the ORs for MM by categories of cumulative exposure to asbestos were similar to the unadjusted results, ranging from 4.6 (CI: 1.8–11.7) for cumulative exposures between 0.1 and 1 f/mL-y to 57.5 (CI: 20.2–163.9) above 10 f/mL-y. Responder controls were younger and had higher education level. Nevertheless, there was little evidence of bias from nonresponse in the risk estimates of MM.

Self-reports of Dutch dog owners on received professional advice, their opinions on castration and behavioural reasons for castrating male dogs

Male dogs are often castrated based on the thought that it facilitates well-behavedness. However, the causal evidence for this from prospective studies lacks and the existing associative studies present mixed results depending on the studied behaviours. We aimed to gain insight into possible factors driving an owner’s decision to castrate their male dog, through a quantitative survey based on a convenience sample. We determined the advice owners received from three types of dog professionals (veterinarian practitioners, behavioural trainers, behavioural therapists) and the owners’ assessments of castration’s behavioural effects. Data on 491 Dutch owners of castrated and intact male dogs were analysed with Chi-square tests. Results indicate that owners of both castrated and intact dogs received castration advice most often from veterinarian practitioners, with pro-castration at higher frequencies for owners of castrated dogs (Chi-square, P<0.001). Overall, most owners disagreed with or were neutral about statements on castration positively affecting male dog behaviour at a population level. Nevertheless, 58% (N = 145) of the owners of castrated dogs (N = 249) reported that correcting unwanted behaviour was a reason to castrate their own male dog. Unwanted behaviour involved aggression in 50% (N = 70) of the owner-dog dyads. Castrated dog’s aggression changes were reported on most as ‘no change’. The second most common answer indicated an aggression decrease in dogs castrated to correct unwanted behaviour and an increase in dogs castrated for other reasons (Chi-square, P<0.001). The increase in aggression in a subset of castrated dogs is concerning, as aggression can pose risks to the dog’s welfare. We acknowledge the limitations of our study which identifies associations rather than provides causal evidence. Still, we recommend professionals’ awareness of possible negative behavioural changes following castration, like increased aggression. Future research on behavioural consequences of castrating dogs needs to build a more solid knowledge base for balanced advice regarding castration.

Assessment of selection bias due to dropouts in the follow-up of the Scania Public Health Cohort

Aims: To investigate potential differences between participants and dropouts in the 2005 follow-up of the Scania Public Health Cohort Study regarding the prevalence of commonly studied health determinants and whether these factors had differential associations with three health outcomes: all-cause mortality and purchase of prescribed cardiovascular or psychotropic drugs during a 10-year follow-up period. Methods: The Scania Public Health Cohort was initiated in 1999/2000, with randomly invited participants aged 18–80 years from the general population (58% participation). Questionnaire data from 10,462 participants and 2576 dropouts in the 2005 follow-up (80% participation) were linked to public registers on mortality and purchase of prescribed drugs. Results: Age, male gender, being born abroad, low educational level, low self-rated mental and general health and daily smoking were all related to dropping out. The 10-year mortality was higher among dropouts (13.4% versus 11.9%; age-adjusted hazard ratio 1.6, 95% confidence interval: 1.4–1.8). In 13 out of 18 analyses, similar associations between health determinants and outcomes were found across participants and dropouts. However, being born outside of Sweden was associated with higher risks for all three poor health outcomes among participants, but not so among dropouts. Conclusions: Despite selective participation at follow-up, there was little evidence of selection bias, insofar as estimated associations were generally similar across participants, dropouts and the whole cohort. This finding is important for the assessment of the validity of prospective findings from this cohort and similar ones, where the loss of individuals at consecutive follow-ups of exposure is non-negligible.

Body Mass Index Trajectory-Specific Changes in Economic Circumstances: A Person-Oriented Approach Among Midlife and Ageing Finns

Economic disadvantage is related to a higher risk of adulthood obesity, but few studies have considered whether changes in economic circumstances depend on a person's body mass index (BMI) trajectory. We identified latent BMI trajectories among midlife and ageing Finns and captured individual-level changes in economic circumstances within the BMI trajectories utilizing sequence analysis. We used the Helsinki Health Study cohort data of initially 40-60-year-old Finnish municipal employees, with four survey questionnaire phases (2000-2017). Each survey included identical questions on height and weight, and on economic circumstances incorporating household income and current economic difficulties. Based on computed BMI, we identified participants' (n = 7105; 82% women) BMI trajectories over the follow-up using group-based trajectory modeling. Four BMI trajectories were identified: stable healthy weight (34% of the participants), stable overweight (42%), overweight to class I obesity (20%), and stable class II obesity (5%). Lower household income level and having economic difficulties became more common and persistent when moving from lower- to higher-level BMI trajectories. Differences in household income widened over the follow-up between the trajectory groups, whereas economic difficulties decreased equally in all trajectory groups over time. Our study provides novel information on the dynamic interplay between long-term BMI changes and economic circumstances.

Risk for unemployment at 10 years following cancer diagnosis among very long-term survivors: a population based study

PURPOSE

To clarify the association between cancer diagnosis and subsequent risk of being unemployed at 10 years after diagnosis among very long-term survivors.

METHODS

A historical cohort study using prospectively collected data was done which included baseline measurements from the Israeli national census. Only patients who were 50 years old or younger at the time of diagnosis were included in the current study. Binary logistic regression analyses were used to assess odds ratios for unemployment at 10 years following diagnosis, while controlling for socioeconomic measurements and employment status at 2 years prior to diagnosis.

RESULTS

The final study population included 2493 patients who were diagnosed with cancer and 7360 persons without a history of cancer, after excluding individuals who died before the end of 2015. After controlling for confounders, positive associations were found between cancer and increased risk for unemployment at 10 years (OR = 1.31, 95% CI 1.17-1.47). Analysis by cancer type revealed that patients who were diagnosed with CNS malignancies (OR = 2.71, 95% CI 1.80-4.07), followed by patients who were diagnosed with lymphoma (OR = 1.66, 95% CI 1.16-1.28) showed the greatest magnitude of effect, while the association between unemployment at 10 years following diagnosis and breast cancer was found to weaken and actually lose significance (adjusted OR = 1.22, 95% CI 0.99-1.50).

CONCLUSIONS

Cancer survivors have an increased risk for long-term unemployment among very long-term survivors, mainly among patients diagnosed with CNS malignancies and lymphoma.

IMPLICATIONS FOR CANCER SURVIVORS

The current study emphasizes the need for tailored intervention in order to mitigate the long-term risk of unemployment.

Who maintains good health functioning? The contribution of social, work-related and behavioural factors to mental and physical health functioning trajectories in ageing employees

OBJECTIVES

The determinants of poor functioning and subsequent early exit from work are well established but very little is known about the positive determinants of maintaining good functioning among the ageing workforce. We investigated modifiable determinants of maintaining good mental and physical health functioning.

METHODS

We used prospective survey data collected across four waves among the midlife employees of the City of Helsinki, Finland, 2000-2017 (n=3342). Health functioning was repeatedly measured using the Short Form 36 (SF-36) inventory. Trajectories of mental and physical health functioning were separately examined using group-based trajectory analysis. Multinomial logistic regression models were fitted to examine determinants of each trajectory.

RESULTS

Four trajectory solutions for the developmental patterns in health functioning during the follow-up period were selected, with a slightly different shape of the first trajectory for mental and physical functioning: (1) continuously low (mental), low and decreasing (physical), (2) increasing, (3) decreasing and (4) continuously high functioning. After adjustments, the employees in the continuously high mental health functioning group were more likely to have optimal job demands, high job control, no sleep problems and no binge drinking behaviour. Employees in the continuously high physical functioning group had more likely low levels of physically strenuous work and hazardous working environment and no sleep problems and normal weight.

CONCLUSION

High job control, good sleep and avoiding binge drinking may help maintain good mental health functioning. Low levels of physical or environmental work exposures, good sleep and recommended healthy weight may support maintenance of good physical health functioning among ageing employees.

Factors associated with health survey response among young employees: a register-based study using online, mailed and telephone interview data collection methods

Background

Declining response rates are a common challenge to epidemiological research. Response rates further are particularly low among young people. We thus aimed to identify factors associated with health survey response among young employees using different data collection methods.

Methods

We included fully register-based data to identify key socioeconomic, workplace and health-related factors associated with response to a health survey collected via online and mailed questionnaires. Additionally, telephone interviews were conducted for those who had not responded via online or to the mailed survey. The survey data collection was done in autumn 2017 among young employees of the City of Helsinki, Finland (18–39 years, target population n = 11,459).

Results

The overall response to the survey was 51.5% (n = 5898). The overall findings suggest that differences in the distributions of socioeconomic, workplace and health-related factors between respondents in the online or mailed surveys, or telephone interviews, are relatively minor. Telephone interview respondents were of lower socioeconomic position, which helped improve representativeness of the entire cohort. Despite the general broad representativeness of the data, some socioeconomic and health-related factors contributed to response. Thus, non-respondents were more often men, manual workers, from the lowest income quartile, had part-time jobs, and had more long sickness absence spells. In turn, job contract (permanent or temporary) and employment sector did not affect survey response.

Conclusions

Despite a general representativeness of data of the target population, socioeconomically more disadvantaged and those with long sickness absence, are slightly overrepresented among non-respondents. This suggests that when studying the associations between social factors and health, the associations can be weaker than if complete data were available representing all socioeconomic groups.

Recurrent pain and work disability: a record linkage study

Purpose

We examined the associations between recurrent single- and multisite pain and incident sickness absence (SA) of different lengths and the risk of disability pension (DP).

Methods

The data were derived from the Finnish Helsinki Health Study. Pain measures were recorded for panel 1 in 2000/2 and 2007, and for panel 2 in 2007 and 2012 (altogether 3191 employees). SA data were obtained from the employer’s personnel register and DP events from the Finnish Centre for Pensions. Negative binomial regression models with generalized estimation equations were used to model the incidence of self-certified short- (1–3 days), and medically certified medium- (4–14 days) and long-term (more than 14 days) SA episodes. Cox regression models were fitted for the associations between pain and all-cause DP and competing risk models for DP by diagnostic groups. Social and health-related covariates were adjusted for.

Results

Recurrent pain was associated with short-, medium- and long-term SA. Additionally, recurrent single- and multisite pain increased the risk of long-term SA. Recurrent single or multisite pain was further associated with an increased risk of DP, while a single instance of pain did not increase the risk.

Conclusions

These results suggest that recurrent pain is a robust determinant of subsequent SA and DP risk. Improved understanding of determinants of recurrent pain is needed to inform the development of targeted measures to reduce SA and premature exit from employment.

Electronic supplementary material

The online version of this article (10.1007/s00420-019-01494-5) contains supplementary material, which is available to authorized users.

Underestimated Health Inequalities Among Older People-A Consequence of Excluding the Most Disabled and Disadvantaged

OBJECTIVES

The present study analyzed whether estimates of health inequalities in old age are sensitive to the exclusion of people living in institutions and nonuse of proxy interviews.

METHOD

Pooled data from the 2004 wave (n = 1,180, aged 69-100, primarily interviewed over the phone) and the 2011 wave (n = 931, aged 76-101, primarily interviewed face-to-face) of the Swedish Panel Study of Living Conditions of the Oldest Old were used to compare absolute and relative differences in disability and mortality between people with compulsory education and people with more than compulsory education.

RESULTS

Both absolute and relative health inequalities would have been underestimated in a survey that excluded institutionalized people and proxy-interviewed community dwellers. The same patterns were found in men and women and regardless of the mode of data collection (telephone or face-to-face interview). The degree of underestimation was lower in those 85 years and older than in those 69 to 84 years.

DISCUSSION

A survey that only includes people who live in the community and can participate without the help of a proxy might give the impression that those with low levels of education have less extensive health disadvantages than they actually have.

Risk and protective factors for pre- and postnatal bonding

Since disturbances in the mother-child bond increase the risk of negative consequences for child development, it is important to identify risk and protective factors for bonding as well as longitudinal associations. Previous research has used different bonding instruments during pregnancy and the postnatal phase, leading to inconsistent results. In the current study, the same instrument was used during the various phases. In a large, community-based sample (N = 793), general information, feelings of pre- and postnatal bonding (Pre- and Postnatal Bonding Scale), depressive symptoms (Edinburgh Postnatal Depression Scale), and partner support (subscale Tilburg Pregnancy/Postnatal Distress Scale) were measured at both 32 weeks of pregnancy and 8 months postnatally. Partner support was found to be a protective factor for suboptimal pre- and postnatal bonding, as was the engagement with fetal movements for prenatal bonding. High maternal educational level was a risk factor for suboptimal prenatal bonding, as were depressive symptoms for suboptimal postnatal bonding. The associations between most prenatal determinants and postnatal bonding were mediated by prenatal bonding, which underlines the importance of promoting prenatal bonding. Professionals in clinical practice should be aware of partner support, engagement with fetal movements, and postnatal depressive symptoms: All these factors offer opportunities for improving the bonding processes.

Job type and other socio-demographic factors associated with participation in a national, cross-sectional study of Danish employees

OBJECTIVES

Participation in population-based surveys and epidemiological studies has been declining over the years in many countries. The aim of this study was to examine the association between job type and participation in the work environment and health in Denmark survey with/without taking into account other socio-demographic factors.

DESIGN

Cross-sectional survey using questionnaire data on working environment and registry data on job type, industry and socio-economic variables.

SETTING

The work environment and health study.

PARTICIPANTS

A total of 50 806 employees (15 767 in a stratified workplace sample; 35 039 in a random sample) working at least 35 hours/month and earning at least 3000 Danish Krones.

OUTCOME MEASURES

The outcome was participation (yes/no) and logistic regression was used to estimate the OR for participation with 95% CI.

RESULTS

In the random sample, women were more likely to participate than men, and married/non-married couples were more likely to participate than persons living alone or more families living together. Participation increased with higher age, higher annual personal income, higher education and Danish origin, and there were marked differences in participation between job types and geographical regions. For armed forces, craft and related trade workers, and skilled agricultural, forestry and fishery workers, the association between job type and participation was strongly attenuated after adjustment for sex and age. Additional adjustment for annual income, education, cohabitation, country of origin and geographical region generally attenuated the association between job type and participation. Similar results were found in the stratified workplace sample.

CONCLUSION

In this population of Danish employees, participation varied across types of jobs. Some but not all the variation between job types was explained by other socio-demographic factors. Future studies using questionnaires may consider targeting efforts to (sub-)populations, defined by job type and other factors, where response probability is particularly important.

Analysis of non-respondent pregnant women who were registered in the Japan Environment and Children's Study: a longitudinal cohort study

OBJECTIVES

Non-response to questionnaires in a longitudinal study reduces the effective sample size and introduces bias. We identified the characteristics of non-respondent pregnant women, and compared them with respondents in the Japan Environment and Children's Study (JECS) during the gestational period.

DESIGN

This was a questionnaire-based, longitudinal cohort study.

SETTING

Questionnaires were provided by research coordinators to mothers at prenatal examinations (at obstetrics clinics) or by mail. Mothers were measured twice: during the first trimester and during the second/third trimester.

PARTICIPANTS

Data were collected from the 10 129 participating mothers of the 10 288 children surveyed in the 2011 baseline JECS. We excluded responses from mothers who had a miscarriage or stillbirth; therefore, we analysed data from 9649 participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data concerning demographics, medical history, health characteristics, health-related behaviour and environmental exposure were collected via self-administered questionnaires. The response status of participants' partners and contact with their obstetrician were also examined. Multivariate logistic regression analysis was used to examine factors related to non-response.

RESULTS

Response was associated with living with one's mother-in-law (ORs: 0.47, 95% CIs: 0.24 to 0.85), positive participation of participants' partner (OR: 0.25, 95% CI: 0.17 to 0.35) and multiple visits to the obstetrician (OR: 0.02, 95% CI: 0.02 to 0.03). Participants who had a medical history of allergic rhinitis, had body pain or drank alcohol had higher odds of responding (ORs: 0.68, 0.96 and 0.36, 95% CIs: 0.48 to 0.95 and 0.95 to 0.98 and 0.16 to 0.72, respectively); those exposed to secondary smoke had lower odds of responding (OR: 1.59, 95% CI: 1.12 to 2.23).

CONCLUSIONS

The non-response rate decreased when participants reported health-related behaviour or characteristics. Obtaining the understanding of people around each participant might help increase response rates.

Non-response and external validity in a school-based quasi-experimental study 'The Healthy Primary School of the Future': A cross-sectional assessment

Limited evidence is available about (non)-representativeness of participants in health-promoting interventions. The Dutch Healthy Primary School of the Future (HPSF)-study is a school-based study aiming to improve health through altering physical activity and dietary behaviour, that started in 2015 (registered in ClinicalTrials.gov on 14-06-2016, NCT02800616). The study has a response rate of 60%. A comprehensive non-responder analysis was carried out, and responders were compared with schoolchildren from the region and the Netherlands using a cross-sectional design. External sources were consulted to collect non-responder, regional, and national data regarding relevant characteristics including sex, demographics, health, and lifestyle. The Chi-square test, Mann-Whitney U test, or Student's t-test were used to analyse differences. The analyses showed that responders (n = 494) were comparable with non-responders (n = 348) and regional data (n = 6172) with regard to sex and health. Responders did not significantly differ from regional data with regard to lifestyle. Responders had significantly higher educated parents compared to non-responders and were more often of autochthonous ethnicity compared to regional data. Major differences were observed between responders and schoolchildren in the Netherlands, regarding, among others sex, ethnicity, and parental employment rates. We conclude that a potential healthy-volunteer effect in the HPSF-sample is limited. External validity is high when compared to the regional population but low when compared to the national sample. For future intervention studies, we advise to evaluate outcome measures according to regional/national standards and to cooperate with external parties in early stages of research to be able to assess and enhance generalisability.

Work cessation after cancer diagnosis: a population-based study

BACKGROUND

Long-term work maintenance among cancer survivors is important for patients, their families and society.

AIMS

To assess the risk of work cessation among workers at baseline in cancer survivors at 2 and 4 years after diagnosis compared with a matched cancer-free control group.

METHODS

Baseline measurements for this historical prospective study were drawn from the Israeli Central Bureau of Statistics 1995 National Census, followed up until 2011. Patients who died before the end of 2011 were excluded from the study. Adjusted odds ratios (ORs) for the study outcome were assessed by binary logistic regression analyses, controlled for age, sex, ethnicity, years of education and socioeconomic position.

RESULTS

Cancer was associated with not working at 2 years after diagnosis (adjusted OR = 1.71, 95% confidence interval [CI] 1.59-1.84, P < 0.001), while only mild attenuation was seen at 4 years after diagnosis (adjusted OR = 1.57, 95% CI 1.46-1.68, P < 0.001). Analysis by cancer type revealed that patients diagnosed with central nervous system (adjusted OR = 3.42, 95% CI 2.41-4.86, P < 0.001), renal (adjusted OR = 2.10, 95% CI 1.38-3.16, P < 0.001), breast (adjusted OR = 2.05, 95% CI 1.76-2.38, P < 0.001) and haematologic malignancies (adjusted OR = 2.04, 95% CI 1.59-2.61, P < 0.001) showed the greatest magnitude effect at 2 years.

CONCLUSIONS

These results emphasize the need for tailored interventions in order to enhance work maintenance, even among patients who are working at baseline and with very long-term survivors.

The association between bullying victimization in childhood and fibromyalgia. Data from the nationwide Finnish health and social support (HeSSup) study based on a sample of 64,797 individuals

BACKGROUND

Fibromyalgia is a functional pain syndrome presenting with various psychological symptoms. Several studies have shown that adverse life events are associated with fibromyalgia. The aim of the current study is to explore the association between self-reported bullying victimization in childhood and self-reported fibromyalgia in adulthood.

METHODS

The basic study setting is cross-sectional - with focused use of retrospective data - derived from a large on-going postal follow up survey (sample N = 64,797) initiated in Finland in 1998. Only respondents having answered the questions on fibromyalgia in both follow ups in 2003 and 2012 were included (N = 11,924). Severity of bullying was divided into three groups starting from no bullying followed by minor and severe bullying. Covariates having shown statistically significant associations with fibromyalgia in cross tabulation using Pearson's chi-squared test were included in the final multiple logistic regression analyses.

RESULTS

In our study, 50.6% of the respondents reported victimization of minor and 19.6% of severe bullying in childhood. Participants reporting fibromyalgia in adulthood reported more bullying, and in females alone this association was statistically significant (p = .027). In multiple logistic regression analysis statistically significant associations between bullying victimization in childhood (reference: no bullying) and fibromyalgia were found: adjusted odds ratio (OR) for minor bullying was 1.35 (95% CI 1.09-1.67) and for severe bullying 1.58 (95% CI 1.21-2.06). However, in log-linear and logistic regression interaction models the association between bullying and fibromyalgia was not statistically significant when depression was included in the models.

CONCLUSIONS

Our results suggest that peer bullying victimization might be associated with fibromyalgia. However, in logistic log linear and logistic interaction models there was no statistically significant association when depression was included. As a result, there is need for further, preferably prospective cohort studies. The findings also emphasize the importance of actions to prevent childhood bullying.

Higher incidence of screening-related cancers in the employed population

Background

Employment may confound the risk of a cancer diagnosis in both directions. We hypothesized that a higher baseline rate of employment among cancer patients may explain the lack of association between a cancer diagnosis and later unemployment in many studies.

Aims

To assess the unemployment rate among cancer patients before diagnosis compared with a matched cancer-free control group.

Methods

Using data from the Israeli National Central Bureau of Statistics 1995 census (persons aged between 15 and 60 years old), the Israeli Tax Authority database and the Israel Cancer Registry, cancer patients (diagnosed between the years 2000 and 2007 and alive at 2011) were compared with matched cancer-free controls.

Results

There were 8797 cancer patients and 26166 cancer-free controls. We found that, in general, cancer was not associated with unemployment 2 years before diagnosis (adjusted odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.90-1.009, P = NS) after adjustment for age, gender, ethnicity, educational years and residential socioeconomic position. However, the diagnoses associated with screening (breast, prostate, colorectal and cervix cancers) were inversely associated with unemployment 2 years before diagnosis (adjusted OR = 0.90, 95% CI 0.84-0.97, P < 0.01).

Conclusions

The results from the current study suggest that a higher baseline rate of employment among cancer patients, mainly those who were diagnosed with screening-associated cancers, explains false negative results in previous studies assessing cancer survivors' work issues.

The Third French Individual and National Food Consumption (INCA3) Survey 2014-2015: method, design and participation rate in the framework of a European harmonization process

OBJECTIVE

Assessing dietary exposure or nutrient intakes requires detailed dietary data. These data are collected in France by the cross-sectional Individual and National Studies on Food Consumption (INCA). In 2014-2015, the third survey (INCA3) was launched in the framework of the European harmonization process which introduced major methodological changes. The present paper describes the design of the INCA3 survey, its participation rate and the quality of its dietary data, and discusses the lessons learned from the methodological adaptations.

DESIGN

Two representative samples of adults (18-79 years old) and children (0-17 years old) living in mainland France were selected following a three-stage stratified random sampling method using the national census database.

SETTING

Food consumption was collected through three non-consecutive 24 h recalls (15-79 years old) or records (0-14 years old), supplemented by an FFQ. Information on food supplement use, eating habits, physical activity and sedentary behaviours, health status and sociodemographic characteristics were gathered by questionnaires. Height and body weight were measured.ParticipantsIn total, 4114 individuals (2121 adults, 1993 children) completed the whole protocol.

RESULTS

Participation rate was 41·5% for adults and 49·8% for children. Mean energy intake was estimated as 8795 kJ/d (2102 kcal/d) in adults and 7222 kJ/d (1726 kcal/d) in children and the rate of energy intake under-reporters was 17·8 and 13·9%, respectively.

CONCLUSIONS

Following the European guidelines, the INCA3 survey collected detailed dietary data useful for food-related and nutritional risk assessments at national and European level. The impact of the methodological changes on the participation rate should be further studied.

Understanding the public, the visitors, and the participants in science communication activities

Despite the promotion of public engagement in science, there has been little empirical research on the sociocultural and attitudinal characteristics of participants in science communication activities and the extent to which such individuals are representative of the general population. We statistically investigated the distinctiveness of visitors to a scientific research institution by contrasting samples from visitor surveys and nationally representative surveys. The visitors had more cultural capital (science and technology/art and literature) and believed more in the value of science than the general public, but there was no difference regarding assessment of the levels of national science or of the national economy. A deeper examination of the variations in the visitors' exhibit-viewing behaviors revealed that individuals with more scientific and technical cultural capital viewed more exhibits and stayed longer at the events. This trend in exhibit-viewing behaviors remained consistent among the different questionnaire items and smart-card records.

Social determinants affecting the use of complementary and alternative medicine in Japan: An analysis using the conceptual framework of social determinants of health

This study aims to use the conceptual framework of social determinants of health (SDH) to elucidate the social determinants that affect the use of complementary and alternative medicine (CAM) from the perspectives of both intermediary and structural determinants. Data were derived from a survey mailed to 1,500 randomly selected residents (20–69 years old; May–July 2009) of Sendai city in Japan. A generalized linear model was used in the analysis, with CAM use over the past one month as the dependent variable, SDH structural and intermediary determinants as independent variables, and demographic characteristics, indicators of health status, and the evaluation of health or healthcare systems as control variables. The prevalence of CAM usage was 62.1%. The generalized linear model showed that middle subjective social status (OR = 1.47; 95% CI: 1.04–2.07) as structural determinants was significantly associated with CAM usage. Adding the intermediary determinants, the same effect was observed. When demographic characteristics, indicators of health status, and the evaluation of health or healthcare systems were introduced as control variables, the associations of the structural determinants disappeared, revealing that hope (OR = 1.25; 95%CI: 1.04–1.50) as intermediary determinants was associated with the use of CAM. Female sex (OR = 1.47; 95% CI: 1.02–2.12) and health anxiety (OR = 1.68; 95% CI: 1.20–2.34) were associated with CAM usage. We found that intermediary rather than structural determinants were associated with CAM usage. Hope as an intermediary determinant was particularly associated with CAM usage.

Are estimates of intergenerational mobility biased by non-response? Evidence from the Netherlands

Intergenerational mobility is often studied using survey data. In such settings, selective unit or item non-response may bias estimates. Linking Dutch survey data to administrative income data allows us to examine whether selective responses bias the estimated relationship between parental income and children's mathematics and language test scores in grades 6 and 9. We find that the estimates of these relationships are biased downward due to parental unit non-response, while they are biased upwards due to item non-response. In the analyses of both unit and item non-response, the point estimates for language and mathematics test scores point in the same direction but only one of the two relationships is significant. These findings suggest that estimates of intergenerational mobility based on survey data need to be interpreted with caution because they may be biased by selective non-response. The direction of such bias is difficult to predict a priori. Bias due to unit and item non-response may work in opposing directions and may differ across outcomes.

Collecting standardised urban health indicator data at an individual level for adults living in urban areas: methodology from EURO-URHIS 2

Background

An aim of the EURO-URHIS 2 project was to collect standardised data on urban health indicators (UHIs) relevant to the health of adults resident in European urban areas. This article details development of the survey instruments and methodologies to meet this aim. 32 urban areas from 11 countries conducted the adult surveys. Using a participatory approach, a standardised adult UHI survey questionnaire was developed mainly comprised of previously validated questions, followed by translation and back-translation. An evidence-based survey methodology with extensive training was employed to ensure standardised data collection. Comprehensive UK piloting ensured face validity and investigated the potential for response bias in the surveys. Each urban area distributed 800 questionnaires to age-sex stratified random samples of adults following the survey protocols. Piloting revealed lower response rates in younger males from more deprived areas. Almost 19500 adult UHI questionnaires were returned and entered from participating urban areas. Response rates were generally low but varied across Europe. The participatory approach in development of survey questionnaires and methods using an evidence-based approach and extensive training of partners has ensured comparable UHI data across heterogeneous European contexts. The data provide unique information on health and determinants of health in adults living in European urban areas that could be used to inform urban health policymaking. However, piloting has revealed a concern that non-response bias could lead to under-representation of younger males from more deprived areas. This could affect the generalisability of findings from the adult surveys given the low response rates.

Nutrition "fat facts" are not common knowledge

ISSUE ADDRESSED

Individuals who are knowledgeable about nutrition are more likely to eat healthily. Yet, few studies have investigated levels of nutrition knowledge using a validated tool. The present study measured nutrition knowledge using the Re-examined General Nutrition Knowledge Questionnaire (R-GNKQ) to confirm influencing demographic characteristics.

METHODS

Adults aged 18-60 years were recruited. Nutrition knowledge was assessed using the R-GNKQ, examining four domains (dietary guidelines, sources of nutrients, choosing everyday foods, and diet-disease relationships) with 96 questions.

RESULTS

Of 606 respondents (mean age 38.8 ± 11.8 years), 506 completed all questions. R-GNKQ score was positively associated with education (p<0.001) and age (p<0.001). Those with the highest education levels scored higher across 89% of the R-GNKQ and the oldest (≥50 years) respondents scored higher than younger respondents. Other characteristics that were associated with higher levels of knowledge were being female, and having a healthy BMI. Lowest knowledge pertained to questions about diet-disease relationships and fatty acids in foods.

CONCLUSIONS

The majority of individuals had a good understanding about the Australian Dietary Guidelines, however the health benefits of adhering to the dietary guidelines was less well understood. Gaps in knowledge pertained to the specific details of how to adhere to the guidelines, particularly knowledge about the types of beneficial fats and their everyday food sources. SO WHAT?: Those with lower educational attainment, younger, males and those with higher BMI's would benefit from nutrition communications that identify foods with beneficial fatty acids to assist with adherence to the Australian Dietary Guidelines.

Current nut recommendation practices differ between health professionals in New Zealand

OBJECTIVE

Despite evidence linking regular nut consumption with reduced chronic disease risk, population-level intakes remain low. Research suggests nut-promoting advice from doctors facilitates regular nut consumption. However, there is no information on current nut recommendation practices of health professionals. The aim of the present study was to examine the advice provided by health professionals regarding nut consumption.

DESIGN

In this cross-sectional study, participants were invited to complete a survey including questions about their nut recommendation practices.

SETTING

New Zealand (NZ).

SUBJECTS

The NZ Electoral Roll was used to identify dietitians, general practitioners and practice nurses.

RESULTS

In total 318 dietitians, 292 general practitioners and 149 practice nurses responded. Dietitians were more likely (82·7 %) to recommend patients increase consumption of nuts than general practitioners (55·5 %) and practice nurses (63·1 %; both P<0·001). The most popular nuts recommended were almonds, Brazil nuts and walnuts, with most health professionals recommending raw nuts. The most common recommendation for frequency of consumption by dietitians and practice nurses was to eat nuts every day, while general practitioners most frequently recommended 2-4 times weekly, although not statistically significantly different between professions. Dietitians recommended a significantly greater amount of nuts (median 30 g/d) than both general practitioners and practice nurses (20 g/d; both P<0·001).

CONCLUSIONS

Dietitians were most likely to recommend consumption of nuts in accordance with current guidelines, but there are opportunities to improve the adoption of nut consumption recommendations for all professions. This may be a viable strategy for increasing population-level nut intakes to reduce chronic disease.

Current asthma and asthma-like symptoms among workers at a Veterans Administration Medical Center

INTRODUCTION

Healthcare workers are at increased risk for respiratory disorders. The purpose of our respiratory health survey was to estimate the prevalence of current asthma and asthma-like symptoms and their association with workplace exposures and tasks among healthcare workers at a Veterans Administration (VA) Medical Center.

MATERIAL AND METHODS

Information on respiratory health and work characteristics, including tasks performed, products used, and exposures, were collected by questionnaire from a convenience sample of workers employed at the VA Medical Center during 2012-2014. Associations of asthma and asthma-like symptoms with cleaning and disinfecting tasks and products as well as exposure to dampness and molds, and construction dust were evaluated using log-binomial regression.

RESULTS

The prevalence of current asthma was 17.6% and almost half of all workers reported asthma-like symptoms. We observed elevated prevalence of current asthma among the VA healthcare workers compared to the U.S. general and working adult populations. Asthma and asthma-like symptoms were significantly associated with mold, dampness, and construction material exposures; cleaning and disinfecting products; and cleaning or disinfecting tasks.

CONCLUSIONS

Workplace exposures and tasks associated with current asthma and asthma-like symptoms were identified but further research is needed to investigate the temporal association between workplace exposures and current asthma and asthma-like symptoms.

Participation in a US community-based cardiovascular health study: investigating nonrandom selection effects related to employment, perceived stress, work-related stress, and family caregiving

PURPOSE

Participation in health studies may be inversely associated with employment and stress. We investigated whether employment, perceived stress, work-related stress, and family caregiving were related to participation in a longitudinal US community-based health study of black and white men and women aged ≥45 years.

METHODS

Prevalence ratios and confidence intervals were estimated for completion of the second stage (S2) of a two-stage enrollment process by employment (status, type), and stress (perceived stress, work-related stress, caregiving), adjusting for age, sex, race, region, income, and education. Eligibility and consent for a follow-up occupational survey were similarly evaluated.

RESULTS

Wage- but not self-employed participants were less likely than the unemployed to complete S2. Among the employed, S2 completion did not vary by stress; however, family caregivers with a short time burden of care (<2 hour/d) were more likely to complete S2, compared to noncaregivers. Eligibility and participation in the follow-up occupational survey were higher among those employed (vs. unemployed) at enrollment but were not associated with enrollment stress levels.

CONCLUSIONS

Limited evidence of selection bias was seen by employment and stress within a large US community-based cohort, but findings suggest the need for enrollment procedures to consider possible barriers to participation among wage-employed individuals.

The relationship between childhood adversities and fibromyalgia in the general population

BACKGROUND

Fibromyalgia is a syndrome characterized by widespread pain and a variety of somatic symptoms. The international prevalence of fibromyalgia is 2-5%, but its current prevalence in Finland is unclear. Various adversities are linked to the onset of fibromyalgia. However, there is need for more data regarding the association between childhood physical abuse and fibromyalgia. Further, the association of childhood emotional stressors and fibromyalgia is disputed. The aim of the current study is to produce more information about that relationship using data from the Health and Social Support (HeSSup) Study.

METHODS

HeSSup is a postal study consisting of a random sample of the Finnish population. The study setting is cross-sectional. Participants in the study were asked if they have been diagnosed with fibromyalgia. Those responding affirmatively were classified as fibromyalgia patients. Six childhood adversities were enquired, and the relationship between fibromyalgia and these events were analysed by cross tabulation and logistic regression.

RESULTS

There were associations between examined adversities and fibromyalgia before and after adjustments for demographic features and depression (being afraid of a family member: odds ratio after adjustment 1.60, 95% CI 1.28-2.01; long-lasting financial difficulties 1.45, 1.18-1.77; serious conflicts in the family 1.40, 1.14-1.72; parental divorce 1.34, 1.05-1.72; serious or chronic illnesses in the family 1.27, 1.05-1.55; alcohol problems in the family 1.25, 1.02-1.53).

CONCLUSION

All six enquired adversities were associated with fibromyalgia after adjustments. These findings emphasize the importance of preventing adverse childhood experiences.

Quality of life following trauma before and after implementation of a physician-staffed helicopter

Background

Implementation of a physician‐staffed helicopter emergency medical service (PS‐HEMS) in Denmark was associated with lower 30‐day mortality in severely injured trauma patients and less time on social subsidy. However, the reduced 30‐day mortality in severely injured patients might be at the expense of a worse functional outcome and quality of life (QoL) in those who survive. The aim of this study was to investigate the effect of a physician‐staffed helicopter on long‐term QoL in trauma patients.

Methods

Prospective, observational study including trauma patients who survived at least 3 years after injury. A 5‐month period prior to PS‐HEMS implementation was compared with the first 12 months after PS‐HEMS implementation. QoL was assessed 4.5 years after trauma by the SF‐36 questionnaire. Primary endpoint was the Physical Component Summary score.

Results

Of the 1994 patients assessed by a trauma team, 1521 were eligible for inclusion in the study. Of these, 566 (37%) gave consent to participate and received a questionnaire by mail, and 402 (71%) of them returned the questionnaire (n = 114 before PS‐HEMS; n = 288 after PS‐HEMS implementation). Older patients, women and patients with trauma in the after PS‐HEMS period were more likely to return the questionnaire. No significant association between QoL and period (before vs. after PS‐HEMS) was found; the Physical Component Summary scores were 50.0 and 50.9 in the before and after PS‐HEMS periods, respectively (P = 0.47). We also found no difference on multivariable analysis with adjustment for sex, age and injury severity score.

Conclusion

No significant difference in QoL among trauma patients was found after implementation of a PS‐HEMS.

Perceptions and Knowledge of Nuts amongst Health Professionals in New Zealand

Despite their nutritional value, population-level nut consumption remains low. Studies suggest that individuals would eat more nuts on their doctor’s advice, making health professionals potentially important for promoting nut consumption. This cross-sectional study aimed to examine the perceptions and knowledge of nuts and the predictors of nut promotion among health professionals in New Zealand. Dietitians, general practitioners (GPs), and practice nurses were identified from the Electoral Roll and invited to complete a questionnaire (n = 318, 292, and 149 respondents respectively). Over one-fifth of GPs and practice nurses believed that eating nuts could increase blood cholesterol concentrations and cause weight gain. The most common perceptions overall were that nuts are healthy; high in protein, fat, and calories; and are satiating. Nut consumption was recommended for reasons relating to these perceptions and because of nuts’ selenium content. Conversely, reasons for suggesting the consumption of fewer nuts included that they were high in calories and fat, would cause weight gain, and concerns regarding allergies and cost. All groups of health professionals were more likely to promote nut consumption if they perceived nuts to reduce the risk of diabetes (all p ≤ 0.034). Education could improve health professionals’ knowledge regarding the effects of nut consumption on blood cholesterol and body weight, alongside other health benefits, which should improve the advice given to patients and may thereby increase nut consumption.

Physical and mental health functioning after all-cause and diagnosis-specific sickness absence: a register-linkage follow-up study among ageing employees

Background

Sickness absence has been shown to be a risk marker for severe future health outcomes, such as disability retirement and premature death. However, it is poorly understood how all-cause and diagnosis-specific sickness absence is reflected in subsequent physical and mental health functioning over time. The aim of this study was to examine the association of all-cause and diagnosis-specific sickness absence with subsequent changes in physical and mental health functioning among ageing municipal employees.

Methods

Prospective survey and register data from the Finnish Helsinki Health Study and the Social Insurance Institution of Finland were used. Register based records for medically certified all-cause and diagnostic-specific sickness absence spells (>14 consecutive calendar days) in 2004–2007 were examined in relation to subsequent physical and mental health functioning measured by Short-Form 36 questionnaire in 2007 and 2012. In total, 3079 respondents who were continuously employed over the sickness absence follow-up were included in the analyses. Repeated-measures analysis was used to examine the associations.

Results

During the 3-year follow-up, 30% of the participants had at least one spell of medically certified sickness absence. All-cause sickness absence was associated with lower subsequent physical and mental health functioning in a stepwise manner: the more absence days, the poorer the subsequent physical and mental health functioning. These differences remained but narrowed slightly during the follow-up. Furthermore, the adverse association for physical health functioning was strongest among those with sickness absence due to diseases of musculoskeletal or respiratory systems, and on mental functioning among those with sickness absence due to mental disorders.

Conclusions

Sickness absence showed a persistent adverse stepwise association with subsequent physical and mental health functioning. Evidence on health-related outcomes after long-term sickness absence may provide useful information for targeted interventions to promote health and workability.

The joint contribution of cardiovascular disease and socioeconomic status to disability retirement: A register linkage study

BACKGROUND

Whether low occupational class amplifies the risk of disability retirement among employees with cardiovascular disease (CVD) is unknown. We examined this issue in two prospective cohort studies.

METHODS

In the Finnish Public Sector Study and the Helsinki Health Study (n=50.799 employees), prevalent CVD (coronary heart disease or stroke, n=1269) was ascertained using records from national health registers, self-reported doctor-diagnosed diseases, and Rose Angina Questionnaire. Data linkage to national pension registers allowed the follow up of disability retirement among the participants for a mean of six years. We analysed the associations of occupational class and CVD with disability retirement using Cox regression, tested interactions between occupational class and prevalent CVD in predicting disability retirement by calculating the Synergy Index, and pooled the results from the two studies using fixed-effect meta-analysis.

RESULTS

Compared with the participants from high occupational class and no CVD, the participants from the low occupational class without CVD had a 2.13-fold (95% CI 1.97-2.30), those with high occupational class and CVD a 2.18-fold (1.73-2.74); and those with both low occupational class and CVD a 4.49-fold (3.83-5.26) risk of disability retirement. A Synergy Index of 1.55 (1.16-2.06) suggested a greater than additive effect for low occupational class and CVD in combination.

CONCLUSIONS

Individuals with both low occupational class and CVD are at a particularly high risk of premature exit from the labour market due to work disability. These findings suggest that better preventive strategies are needed to improve prognosis in this risk group.

Unemployment risk at 2 and 4 years following colorectal cancer diagnosis: a population based study

BACKGROUND

About half of colorectal patients are diagnosed less than 65 years of age and they have a relatively high cure rate. However, little is known about their employment and related risk factors. The aim of the current study was to clarify the association between colorectal cancer (CRC) and subsequent risk of being unemployed.

METHODS

A historical prospective cohort study included baseline socio-demographic measurements of age, sex, ethnicity, residential socio-economic position and education from the 1995 Israeli National Census, cancer incidence between 2000 and 2007 and employment data between 1998 and 2011. Binary logistic regression analyses were used to assess odds ratios for unemployment, while controlling for socio-economic measurements and employment status at 2 years prior to diagnosis.

RESULTS

The final study population included 885 colorectal patients and 2646 healthy controls. After controlling for confounders, positive associations were found between stages II (odds ratio [OR] = 1.91, 95% confidence interval [CI]: 1.31-2.76 or III (OR = 1.70, 95% CI: 1.13-2.54) and increased risk for unemployment at 2 years. At 4 years follow-up, stages I (OR = 1.56, 95% CI: 1.11-2.19), II (OR = 1.57, 95% CI: 1.09-2.26) and III (OR = 2.28, 95% CI: 1.55-3.37) were associated with increased risk for unemployment. Higher risk was seen among rectal cancer patients and among patients aged ≤50 years old at the time of cancer diagnosis.

CONCLUSIONS

CRC patients are at increased long-term risk for unemployment, especially among rectal cancer and younger patients. The clinical ramifications of our findings emphasise the importance of an accurate evaluation and attention to unemployment status during the care of these patients.

Asthma and sleep disturbance in adolescents and young adults: A cohort study

AIMS

A longitudinal birth cohort provides an opportunity to study the impact of childhood conditions persisting into adulthood. This study examines the cross-sectional association of asthma with sleep quality and snoring in the adolescent and young adult population and the extent to which asthma, sleep quality and snoring at 14 years independently predict themselves or each other at 21 years.

METHODS

Data from a 21-year follow-up of mothers and their children recruited into the Mater-University of Queensland Study of Pregnancy (n = 7223). Complete asthma and sleep information (questionnaire data) was available for 5015 participants at 14 years and 3527 at 21 years, with 3237 participants at both 14 and 21 years.

RESULTS

Poor sleep quality and snoring were independently associated with asthma at 14 years and 21 years, with stronger associations evident in women. At 21 years, associations were mediated by asthma symptom severity. Asthma, sleep quality and snoring at 14 years each strongly and independently predicted themselves at 21 years. Asthma at 14 years predicted snoring at 21 years, while poor sleep quality and snoring in women predicted asthma at 21 years, the latter partially mediated by body mass index.

CONCLUSIONS

The relationship between asthma, sleep quality and snoring varied by gender. Sleep quality and snoring should be considered in the assessment and holistic management of asthma. The predictive relationship seen between 14 and 21 years provides an opportunity to address these issues at a younger age.

Registry-based analysis of participator representativeness: a source of concern for sickness absence research?

OBJECTIVES

Selective participation can bias results in epidemiological surveys. The importance of health status is often suggested as a possible explanation for non-participation but few empirical studies exist. In a population-based study, explicitly focused on sickness absence, health and work, we examined whether a history of high levels of sickness absence was associated with non-participation.

DESIGN

The study is based on data from official sickness absence registers from participants, non-participants and the total target population of the baseline survey of the Health Assets Project (HAP).

SETTING

HAP is a population-based cohort study in the Västra Götaland region in South Western Sweden.

PARTICIPANTS

HAP included a random population cohort (n=7984) and 2 cohorts with recent sickness absence (employees (n=6140) and non-employees (n=990)), extracted from the same overall general working-age population.

PRIMARY OUTCOME MEASURES

We examined differences in participation rates between cohorts (2008), and differences in previous sickness absence (2001-2008) between participants (individual-level data) and non-participants or the target population (group-level data) within cohorts.

RESULTS

Participants had statistically significant less registered sickness absence in the past than non-participants and the target population for some, but not all, of the years analysed. Yet these differences were not of substantial size. Other factors than sickness absence were more important in explaining differences in participation, whereby participants were more likely to be women, older, born in Nordic countries, married and have higher incomes than non-participants.

CONCLUSIONS

Although specifically addressing sickness absence, having such experience did not add any substantial layer to selective participation in the present survey. Detailed measures are needed to gain a better understanding for health selection in health-related surveys such as those addressing sickness absence, for instance in order to discriminate between selection due to ability or motivation for participation.

Comparing healthcare utilization among health survey respondents with the total population - are respondents representative?

Background

Surveys are often used for analysis of health status and healthcare utilization in different socioeconomic groups. However, differential non-response rates may bias results. The aim of this study was to compare register data on outpatient healthcare utilization among respondents to a health survey to that of the total population and to investigate whether socioeconomic differences in outpatient healthcare utilization differ between survey respondents and the total population.

Method

Data from the Stockholm Public Health Survey 2010 (n = 30,767 aged 18 + years) were linked to register data on outpatient healthcare utilization in order to investigate differentials by socioeconomic groups, country of birth and residential areas among respondents, using logistic regression and negative binomial regression. These results were compared to analyses of register data on outpatient healthcare utilization for the total population (n = 1.6 million aged 18 + years) of Stockholm County.

Results

Outpatient healthcare utilization was generally higher among survey respondents than in the total population, especially among men. The proportion of individuals having made at least one visit was significantly higher among survey respondents than in the total population but the differences were smaller regarding the average number of visits. Socioeconomic differences in outpatient healthcare utilization between subgroups were largely similar among survey respondents and in the total population. However, individuals born outside Sweden responding to the survey had significantly higher outpatient healthcare utilisation than individuals born outside Sweden in the total population.

Conclusion

Compared to the total population, a greater proportion of survey respondents had made at least one outpatient visit to the doctor. However, the mean number of registered visits did not differ significantly between survey respondents and the total population. Hence, depending on the outcome measure used survey-based estimates may result in slightly biased prevalence estimates, however, relative differences among survey respondents were to a large degree comparable to relative differences in the total population.

In contrast, survey respondents born outside Sweden differed from persons born outside Sweden in the total population to a degree where they may not be representative and comparisons between this group and other subgroups, using survey data, may be biased.