Effectiveness of a mental health stepped-care programme for healthcare workers with psychological distress in crisis settings: a multicentre randomised controlled trial.

BACKGROUND: Evidence-based mental health interventions to support healthcare workers (HCWs) in crisis settings are scarce. OBJECTIVE: To evaluate the capacity of a mental health intervention in reducing anxiety and depression symptoms in HCWs, relative to enhanced care as usual (eCAU), amidst the COVID-19 pandemic. METHODS: We conducted an analyst-blind, parallel, multicentre, randomised controlled trial. We recruited HCWs with psychological distress from Madrid and Catalonia (Spain). The intervention arm received a stepped-care programme consisting of two WHO-developed interventions adapted for HCWs: Doing What Matters in Times of Stress (DWM) and Problem Management Plus (PM+). Each intervention lasted 5 weeks and was delivered remotely by non-specialist mental health providers. HCWs reporting psychological distress after DWM completion were invited to continue to PM+. The primary endpoint was self-reported anxiety/depression symptoms (Patient Health Questionnaire-Anxiety and Depression Scale) at week 21. FINDINGS: Between 3 November 2021 and 31 March 2022, 115 participants were randomised to stepped care and 117 to eCAU (86% women, mean age 37.5). The intervention showed a greater decrease in anxiety/depression symptoms compared with eCAU at the primary endpoint (baseline-adjusted difference 4.4, 95% CI 2.1 to 6.7; standardised effect size 0.8, 95% CI 0.4 to 1.2). No serious adverse events occurred. CONCLUSIONS: Brief stepped-care psychological interventions reduce anxiety and depression during a period of stress among HCWs. CLINICAL IMPLICATIONS: Our results can inform policies and actions to protect the mental health of HCWs during major health crises and are potentially rapidly replicable in other settings where workers are affected by global emergencies. TRIAL REGISTRATION NUMBER: NCT04980326.

The Impact of COVID-19 Lockdown on Adults with Major Depressive Disorder from Catalonia: A Decentralized Longitudinal Study.

The present study analyzes the effects of each containment phase of the first COVID-19 wave on depression levels in a cohort of 121 adults with a history of major depressive disorder (MDD) from Catalonia recruited from 1 November 2019, to 16 October 2020. This analysis is part of the Remote Assessment of Disease and Relapse-MDD (RADAR-MDD) study. Depression was evaluated with the Patient Health Questionnaire-8 (PHQ-8), and anxiety was evaluated with the Generalized Anxiety Disorder-7 (GAD-7). Depression's levels were explored across the phases (pre-lockdown, lockdown, and four post-lockdown phases) according to the restrictions of Spanish/Catalan governments. Then, a mixed model was fitted to estimate how depression varied over the phases. A significant rise in depression severity was found during the lockdown and phase 0 (early post-lockdown), compared with the pre-lockdown. Those with low pre-lockdown depression experienced an increase in depression severity during the "new normality", while those with high pre-lockdown depression decreased compared with the pre-lockdown. These findings suggest that COVID-19 restrictions affected the depression level depending on their pre-lockdown depression severity. Individuals with low levels of depression are more reactive to external stimuli than those with more severe depression, so the lockdown may have worse detrimental effects on them.

Government interventions and control policies to contain the first COVID-19 outbreak: An analysis of evidence.

BACKGROUND: The overarching aim of this study was to evaluate the effectiveness over time of government interventions and policy restrictions and the impact of determinants on spread and mortality during the first-wave of the COVID-19 pandemic, globally, regionally and by country-income level, up to 18 May 2020. METHODS: We created a global database merging World Health Organization daily case reports (from 218 countries/territories) with other socio-demographic and population health measures from 21 January to 18 May 2020. A four-level government policy interventions score (low to very high) was created based on the Oxford Stringency Index. RESULTS: Our results support the use of very high government interventions to suppress both COVID-19 spread and mortality effectively during wave one globally compared to other policy levels of control. Similar trends in virus propagation and mortality were observed in all country-income levels and specific regions. CONCLUSIONS: Rapid implementation of government interventions was needed to contain the first wave of the COVID-19 outbreak and to reduce COVID-19-related mortality.

The Association of Social Support and Loneliness with Symptoms of Depression, Anxiety, and Posttraumatic Stress during the COVID-19 Pandemic: A Meta-Analysis.

BACKGROUND: Research suggests that changes in social support and loneliness have affected mental disorder symptoms during the COVID-19 pandemic. However, there are a lack of studies comparing the robustness of these associations. AIMS: The aims were to estimate the strength of the associations of loneliness and social support with symptoms of depression, anxiety, and posttraumatic stress during the COVID-19 pandemic (2020-2022) in the general population. METHOD: The method entailed a systematic review and random-effects meta-analysis of quantitative studies. RESULTS: Seventy-three studies were included in the meta-analysis. The pooled correlations of the effect size of the association of loneliness with symptoms of depression, anxiety, and posttraumatic stress were 0.49, 0.40, and 0.38, respectively. The corresponding figures for social support were 0.29, 0.19, and 0.18, respectively. Subgroup analyses revealed that the strength of some associations could be influenced by the sociodemographic characteristics of the study samples, such as age, gender, region, and COVID-19 stringency index, and by methodological moderators, such as sample size, collection date, methodological quality, and the measurement scales. CONCLUSIONS: Social support had a weak association with mental disorder symptoms during the COVID-19 pandemic while the association with loneliness was moderate. Strategies to address loneliness could be highly effective in reducing the impact of the pandemic on social relationships and mental health.

Factors Associated with Depression and Anxiety Symptoms among Migrant Population in Spain during the COVID-19 Pandemic.

Migrants are likely to experience mental health conditions, being one of the most vulnerable groups during the COVID-19 pandemic. The present study aims to: (1) estimate the prevalence of depressive and anxious symptoms and (2) examine the impact of risk and protective factors on this symptomatology. A sample of 129 migrants living in Spain during the COVID-19 pandemic completed an anonymous online survey, including information on sociodemographic and individual characteristics, migration, basic needs, social environment and perceived health domains. Multiple Poisson regression models analysed the effects of risk and protective factors on depression and anxiety symptoms. The prevalence of depressive and anxiety symptoms was 22.3% and 21.4%, respectively. Risk factors such as living in a rented house and previous mental health conditions were associated with higher depression symptoms, whereas unemployment was related to anxiety symptoms. Conversely, older age, better self-esteem, and higher levels of social support were associated with fewer depression symptoms. Older age and better quality of life were related to fewer anxiety symptoms. These findings addressing risk and protective factors (e.g., social support, self-esteem) help to design culturally effective programs, particularly in migrants with pre-existing mental health conditions, adjusting the organisation of mental healthcare services in difficult times in Spain.

Biopsychosocial Response to the COVID-19 Lockdown in People with Major Depressive Disorder and Multiple Sclerosis.

BACKGROUND: Changes in lifestyle, finances and work status during COVID-19 lockdowns may have led to biopsychosocial changes in people with pre-existing vulnerabilities such as Major Depressive Disorders (MDDs) and Multiple Sclerosis (MS). METHODS: Data were collected as a part of the RADAR-CNS (Remote Assessment of Disease and Relapse-Central Nervous System) program. We analyzed the following data from long-term participants in a decentralized multinational study: symptoms of depression, heart rate (HR) during the day and night; social activity; sedentary state, steps and physical activity of varying intensity. Linear mixed-effects regression analyses with repeated measures were fitted to assess the changes among three time periods (pre, during and post-lockdown) across the groups, adjusting for depression severity before the pandemic and gender. RESULTS: Participants with MDDs (N = 255) and MS (N = 214) were included in the analyses. Overall, depressive symptoms remained stable across the three periods in both groups. A lower mean HR and HR variation were observed between pre and during lockdown during the day for MDDs and during the night for MS. HR variation during rest periods also decreased between pre- and post-lockdown in both clinical conditions. We observed a reduction in physical activity for MDDs and MS upon the introduction of lockdowns. The group with MDDs exhibited a net increase in social interaction via social network apps over the three periods. CONCLUSIONS: Behavioral responses to the lockdown measured by social activity, physical activity and HR may reflect changes in stress in people with MDDs and MS. Remote technology monitoring might promptly activate an early warning of physical and social alterations in these stressful situations. Future studies must explore how stress does or does not impact depression severity.

Global, regional, and national burden of aortic aneurysm, 1990-2017: a systematic analysis of the Global Burden of Disease Study 2017.

AIMS: This study aimed at evaluating the age, sex, and country-income patterns in aortic aneurysm disease burden, analysing trends in mortality and years of life lost (YLLs), as well as their causal drivers and risk factors, using the 2017 Global Burden of Diseases, Injuries, and Risk Factors Study (GBD 2017). METHODS AND RESULTS: We described the temporal, global, and regional (195 countries) patterns of aortic aneurysm (thoracic and abdominal) mortality, YLLs, their drivers [sociodemographic index (SDI), healthcare access and quality index (HAQ index)] and risk factors using the GBD 1990-2017. Correlation and mixed multilevel modelling between aortic aneurysm mortality, YLLs, HAQ index and other variables were applied. From 1990 to 2017, a global declining trend in age-standardized aortic aneurysm mortality was found [2.88 deaths/100 000 (95% uncertainty intervals, UI 2.79 to 3.03) in 1990 and 2.19 deaths/100 000 (95% UI 2.09 to 2.28) in 2017]. Among high-income countries (HICs) a consistent declining Spearman's correlation between age-standardised aortic aneurysm mortality, SDI (HICs; 1990 rho: 0.57, P ≤ 0.001; 2017 rho: 0.41, P = 0.001) and HAQ index was observed (HICs; 1990 rho: 0.50, P <0.001; 2016 rho: 0.35, P = 0.006); in comparison with low- and middle-income countries where correlation trends were weak and mixed. At a global level, higher HAQ index was related with lower aortic aneurysm mortality and YLLs [mortality, coef: -0.05, 95% confidence interval (CI): -0.06, -0.04; YLLs, coef: -0.94, 95% CI: -1.17, -0.71]. CONCLUSIONS: Age-standardized aortic aneurysm mortality declined globally between 1990 and 2017. Globally, age-standardized aortic aneurysm mortality and YLLs were related to changes in SDI and HAQ index levels, while country-level income-related variations were also observed.

Changes in Health Behaviors, Mental and Physical Health among Older Adults under Severe Lockdown Restrictions during the COVID-19 Pandemic in Spain.

We used data from 3041 participants in four cohorts of community-dwelling individuals aged ≥65 years in Spain collected through a pre-pandemic face-to-face interview and a telephone interview conducted between weeks 7 to 15 after the beginning of the COVID-19 lockdown. On average, the confinement was not associated with a deterioration in lifestyle risk factors (smoking, alcohol intake, diet, or weight), except for a decreased physical activity and increased sedentary time, which reversed with the end of confinement. However, chronic pain worsened, and moderate declines in mental health, that did not seem to reverse after restrictions were lifted, were observed. Males, older adults with greater social isolation or greater feelings of loneliness, those with poorer housing conditions, as well as those with a higher prevalence of chronic morbidities were at increased risk of developing unhealthier lifestyles or mental health declines with confinement. On the other hand, previously having a greater adherence to the Mediterranean diet and doing more physical activity protected older adults from developing unhealthier lifestyles with confinement. If another lockdown were imposed during this or future pandemics, public health programs should specially address the needs of older individuals with male sex, greater social isolation, sub-optimal housing conditions, and chronic morbidities because of their greater vulnerability to the enacted movement restrictions.

Estimating the COVID-19 Spread Through Real-time Population Mobility Patterns: Surveillance in Low- and Middle-Income Countries.

BACKGROUND: On January 21, 2020, the World Health Organization reported the first case of severe acute respiratory syndrome coronavirus 2, which rapidly evolved to the COVID-19 pandemic. Since then, the virus has also rapidly spread among Latin American, Caribbean, and African countries. OBJECTIVE: The first aim of this study is to identify new emerging COVID-19 clusters over time and space (from January 21 to mid-May 2020) in Latin American, Caribbean, and African regions, using a prospective space-time scan measurement approach. The second aim is to assess the impact of real-time population mobility patterns between January 21 and May 18, 2020, under the implemented government interventions, measurements, and policy restrictions on COVID-19 spread among those regions and worldwide. METHODS: We created a global COVID-19 database, of 218 countries and territories, merging the World Health Organization daily case reports with other measures such as population density and country income levels for January 21 to May 18, 2020. A score of government policy interventions was created for low, intermediate, high, and very high interventions. The population's mobility patterns at the country level were obtained from Google community mobility reports. The prospective space-time scan statistic method was applied in five time periods between January and May 2020, and a regression mixed model analysis was used. RESULTS: We found that COVID-19 emerging clusters within these five periods of time increased from 7 emerging clusters to 28 by mid-May 2020. We also detected various increasing and decreasing relative risk estimates of COVID-19 spread among Latin American, Caribbean, and African countries within the period of analysis. Globally, population mobility to parks and similar leisure areas during at least a minimum of implemented intermediate-level control policies (when compared to low-level control policies) was related to accelerated COVID-19 spread. Results were almost consistent when regional stratified analysis was applied. In addition, worldwide population mobility due to working during high implemented control policies and very high implemented control policies, when compared to low-level control policies, was related to positive COVID-19 spread. CONCLUSIONS: The prospective space-time scan is an approach that low-income and middle-income countries could use to detect emerging clusters in a timely manner and implement specific control policies and interventions to slow down COVID-19 transmission. In addition, real-time population mobility obtained from crowdsourced digital data could be useful for current and future targeted public health and mitigation policies at a global and regional level.

Are environmental pollution and biodiversity levels associated to the spread and mortality of COVID-19? A four-month global analysis.

On March 12th, 2020, the WHO declared COVID-19 as a pandemic. The collective impact of environmental and ecosystem factors, as well as biodiversity, on the spread of COVID-19 and its mortality evolution remain empirically unknown, particularly in regions with a wide ecosystem range. The aim of our study is to assess how those factors impact on the COVID-19 spread and mortality by country. This study compiled a global database merging WHO daily case reports with other publicly available measures from January 21st to May 18th, 2020. We applied spatio-temporal models to identify the influence of biodiversity, temperature, and precipitation and fitted generalized linear mixed models to identify the effects of environmental variables. Additionally, we used count time series to characterize the association between COVID-19 spread and air quality factors. All analyses were adjusted by social demographic, country-income level, and government policy intervention confounders, among 160 countries, globally. Our results reveal a statistically meaningful association between COVID-19 infection and several factors of interest at country and city levels such as the national biodiversity index, air quality, and pollutants elements (PM10, PM2.5, and O3). Particularly, there is a significant relationship of loss of biodiversity, high level of air pollutants, and diminished air quality with COVID-19 infection spread and mortality. Our findings provide an empirical foundation for future studies on the relationship between air quality variables, a country's biodiversity, and COVID-19 transmission and mortality. The relationships measured in this study can be valuable when governments plan environmental and health policies, as alternative strategy to respond to new COVID-19 outbreaks and prevent future crises.

Development of a common scale for measuring healthy ageing across the world: results from the ATHLOS consortium.

BACKGROUND: Research efforts to measure the concept of healthy ageing have been diverse and limited to specific populations. This diversity limits the potential to compare healthy ageing across countries and/or populations. In this study, we developed a novel measurement scale of healthy ageing using worldwide cohorts. METHODS: In the Ageing Trajectories of Health-Longitudinal Opportunities and Synergies (ATHLOS) project, data from 16 international cohorts were harmonized. Using ATHLOS data, an item response theory (IRT) model was used to develop a scale with 41 items related to health and functioning. Measurement heterogeneity due to intra-dataset specificities was detected, applying differential item functioning via a logistic regression framework. The model accounted for specificities in model parameters by introducing cohort-specific parameters that rescaled scores to the main scale, using an equating procedure. Final scores were estimated for all individuals and converted to T-scores with a mean of 50 and a standard deviation of 10. RESULTS: A common scale was created for 343 915 individuals above 18 years of age from 16 studies. The scale showed solid evidence of concurrent validity regarding various sociodemographic, life and health factors, and convergent validity with healthy life expectancy (r = 0.81) and gross domestic product (r = 0.58). Survival curves showed that the scale could also be predictive of mortality. CONCLUSIONS: The ATHLOS scale, due to its reliability and global representativeness, has the potential to contribute to worldwide research on healthy ageing.

Factors related with sarcopenia and sarcopenic obesity among low- and middle-income settings: the 10/66 DRG study.

Sarcopenia and sarcopenic obesity research in low- and middle- income countries (LMICs) is limited. We investigated sarcopenia and sarcopenic obesity prevalence and sociodemographic, bio-clinical and lifestyle factors in LMICs settings. For the purposes of this study, the 10/66 Dementia Research Group follow-up wave information from individuals aged 65 and over in Cuba, Dominican Republic, Peru, Mexico, Puerto Rico, China, was employed and analysed (n = 8.694). Based on indirect population formulas, we calculated body fat percentage (%BF) and skeletal muscle mass index (SMI). Sarcopenia prevalence ranged from 12.4% (Dominican Republic) to 24.6% (rural Peru); sarcopenic obesity prevalence ranged from 3.0% (rural China) to 10.2% (rural Peru). Odds ratios (OR) with 95% confidence intervals (CI) for sarcopenia were higher for men 2.82 (2.22-3.57) and those with higher %BF 1.08 (1.07-1.09), whereas higher number of assets was associated with a decreased likelihood 0.93 (0.87-1.00). OR of sarcopenic obesity were higher for men 2.17 (1.70-2.76), those reporting moderate alcohol drinking 1.76 (1.21-2.57), and those with increased number of limiting impairments 1.54 (1.11-2.14). We observed heterogeneity in the prevalence of sarcopenia and sarcopenic obesity in the 10/66 settings. We also found a variety of factors to be associated with those. Our results reveal the need for more research among the older population of LMICs.

Ageing trajectories of health-longitudinal opportunities and synergies (ATHLOS) Healthy Ageing Scale in adults from 16 international cohorts representing 38 countries worldwide.

BACKGROUND: Uniform international measurement tools for assessing healthy ageing are currently lacking. OBJECTIVES: The study assessed the novel comprehensive global Ageing Trajectories of Health: Longitudinal Opportunities and Synergies (ATHLOS) Healthy Ageing Scale, using an Item Response Theory approach, for evaluating healthy ageing across populations. DESIGN: Pooled analysis of 16 international longitudinal studies. SETTING: 38 countries in five continents. SUBJECTS: International cohort (n=355 314), including 44.4% (n=153 597) males, aged (mean±SD) 61.7±11.5 years old. METHODS: The ATHLOS Healthy Ageing Scale (including 41 items related to intrinsic capacity and functional ability) was evaluated in a pooled international cohort (n=355 314 from 16 studies) according to gender, country of residence and age group. It was also assessed in a subset of eight cohorts with ≥3 waves of follow-up assessment. The independent samples t-test and Mann-Whitney test were applied for comparing normally and skewed continuous variables between groups, respectively. RESULTS: The ATHLOS Scale (range: 12.49-68.84) had a mean (±SD) value of 50.2±10.0, with males and individuals >65 years old exhibiting higher and lower mean scores, respectively. Highest mean scores were detected in Switzerland, Japan and Denmark, while lowest in Ghana, India and Russia. When the ATHLOS Scale was evaluated in a subset of cohorts with ≥3 study waves, mean scores were significantly higher than those of the baseline cohort (mean scores in ≥3 study waves vs baseline: 51.6±9.4 vs 50.2±10.0; p<0.01). CONCLUSIONS: The ATHLOS Healthy Ageing Scale may be adequately applied for assessing healthy ageing across populations.

Mental Disorders, Musculoskeletal Disorders and Income-Driven Patterns: Evidence from the Global Burden of Disease Study 2017.

BACKGROUND: The aim of the present study was to use the extensive Global Burden ofDiseases, Injuries, and Risk Factors Study (GBD) database from 1990-2017 to evaluate the levels andtemporal correlation trends between disability adjusted life years (DALYs) attributed tomusculoskeletal (MSK) disorders, all mental disorders collectively and by mental disorder subcategory. METHODS: We utilized results of the GBD 2017 to describe the correlation patterns betweenDALYs due to MSK disorders, mental disorders and other diseases among 195 countries. Mixedmodel analysis was also applied. RESULTS: A consistent relation was reported between age-adjustedDALYs attributed to MSK and mental disorders (in total) among the 195 countries, in both sexes,for 1990 to 2017 (1990 Rho = 0.487; 2017 Rho =0.439 p < 0.05). Distinct regional and gender correlationpatterns between age-adjusted DALYs due to MSK and mental disorders were reported. Nocorrelation was reported between DALYs due to MSK and all mental disorders collectively, amongLow- or Middle-income countries. However, in High-income countries (HICs), the correlation wasstrong and consistent between 1990 and 2017 (1990 Rho = 0.735; 2017 Rho = 0.727, p < 0.05). CONCLUSIONS: The reported correlation patterns call for targeted preventive strategies andintervention policies for mental and MSK disorders internationally. Special attention is neededamong HICs.

Alcohol Drinking and Health in Ageing: A Global Scale Analysis of Older Individual Data through the Harmonised Dataset of ATHLOS.

We investigated the relation between alcohol drinking and healthy ageing by means of a validated health status metric, using individual data from the Ageing Trajectories of Health: Longitudinal Opportunities and Synergies (ATHLOS) project. For the purposes of this study, the ATHLOS harmonised dataset, which includes information from individuals aged 65+ in 38 countries, was analysed (n = 135,440). Alcohol drinking was reflected by means of three harmonised variables: alcohol drinking frequency, current and past alcohol drinker. A set of 41 self-reported health items and measured tests were used to generate a specific health metric. In the harmonised dataset, the prevalence of current drinking was 47.5% while of past drinking was 26.5%. In the pooled sample, current alcohol drinking was positively associated with better health status among older adults ((b-coef (95% CI): 1.32(0.45 to 2.19)) and past alcohol drinking was inversely related (b-coef (95% CI): -0.83 (-1.51 to -0.16)) with health status. Often alcohol consumption appeared to be beneficial only for females in all super-regions except Africa, both age group categories (65-80 years old and 80+), both age group categories, as well as among all the financial status categories (all p < 0.05). Regional analysis pictured diverse patterns in the association for current and past alcohol drinkers. Our results report the need for specific alcohol intake recommendations among older adults that will help them maintain a better health status throughout the ageing process.

Pain rates in general population for the period 1991-2015 and 10-years prediction: results from a multi-continent age-period-cohort analysis.

BACKGROUND: Pain is a common symptom, often associated with neurological and musculoskeletal conditions, and experienced especially by females and by older people. The aims of this study are to evaluate the temporal variations of pain rates among general populations for the period 1991-2015 and to project 10-year pain rates. METHODS: We used the harmonized dataset of ATHLOS project, which included 660,028 valid observations in the period 1990-2015 and we applied Bayesian age-period-cohort modeling to perform projections up to 2025. The harmonized Pain variable covers the content "self-reported pain experienced at the time of the interview", with a dichotomous (yes or no) modality. RESULTS: Pain rates were higher among females, older subjects, in recent periods, and among observations referred to cohorts of subjects born between the 20s and the 60s. The 10-year projections indicate a noteworthy increase in pain rates in both genders and particularly among subjects aged 66 or over, for whom a 10-20% increase in pain rate is foreseen; among females only, a 10-15% increase in pain rates is foreseen for those aged 36-50. CONCLUSIONS: Projected increase in pain rates will require specific interventions by health and welfare systems, as pain is responsible for limited quality of subjective well-being, reduced employment rates and hampered work performance. Worksite and lifestyle interventions will therefore be needed to limit the impact of projected higher pain rates.

Predictors of pain in general ageing populations: results from a multi-country analysis based on ATHLOS harmonized database.

BACKGROUND: Pain is a common symptom, often associated with neurological and musculoskeletal conditions, and experienced especially by females and by older people, and with increasing trends in general populations. Different risk factors for pain have been identified, but generally from studies with limited samples and a limited number of candidate predictors. The aim of this study is to evaluate the predictors of pain from a large set of variables and respondents. METHODS: We used part of the harmonized dataset of ATHLOS project, selecting studies and waves with a longitudinal course, and in which pain was absent at baseline and with no missing at follow-up. Predictors were selected based on missing distribution and univariable association with pain, and were selected from the following domains: Socio-demographic and economic characteristics, Lifestyle and health behaviours, Health status and functional limitations, Diseases, Physical measures, Cognition, personality and other psychological measures, and Social environment. Hierarchical logistic regression models were then applied to identify significant predictors. RESULTS: A total of 13,545 subjects were included of whom 5348 (39.5%) developed pain between baseline and the average 5.2 years' follow-up. Baseline risk factors for pain were female gender (OR 1.34), engaging in vigorous exercise (OR 2.51), being obese (OR 1.36) and suffering from the loss of a close person (OR 1.88) whereas follow-up risk factors were low energy levels/fatigue (1.93), difficulties with walking (1.69), self-rated health referred as poor (OR 2.20) or average to moderate (OR 1.57) and presence of sleep problems (1.80). CONCLUSIONS: Our results showed that 39.5% of respondents developed pain over a five-year follow-up period, that there are proximal and distal risk factors for pain, and that part of them are directly modifiable. Actions aimed at improving sleep, reducing weight among obese people and treating fatigue would positively impact on pain onset, and avoiding vigorous exercise should be advised to people aged 60 or over, in particular if female or obese.