Bi-directional associations between gender-based harassment at work, psychological treatment and depressive symptoms.

Introduction: The objective of this study was to investigate the bi-directional associations between experienced and witnessed gender-based harassment (GBH) on the one hand, and depressive symptoms and psychological treatment on the other, in an occupational setting. GBH are behaviors that derogate, demean, or humiliate an individual based on his or her gender. Methods: The analyses were based on data from the Swedish Longitudinal Occupational Survey of Health at 2018 (T1) and 2020 (T2), including 6,679 working participants (60.3% women) with a majority in the age range of 45-64. Using cross-lagged structural equational models, we analyzed experienced and witnessed GBH in relation to depressive symptoms and having received psychological treatment (talked to a counselor or psychological professional) over time. Results: Our results showed that neither experienced nor witnessed GBH was prospectively associated with depressive symptoms or psychological treatment over two years. Both higher levels of depressive symptoms (ß = 0.002, p ≤ 0.001) and having received psychological treatment (ß = 0.013, p = 0.027) weakly predicted experiences of GBH over time. Having received psychological treatment was furthermore weakly associated with witnessed GBH (ß = 0.019, p = 0.012). Discussion: In conclusion, the hypothesized associations between exposure to GBH and mental health outcomes were not statistically significant, while a weak reverse association was noted. More research addressing bidirectional associations between GBH and mental health outcomes are needed.

Healthcare in distress: A survey of mental health problems and the role of gender among nurses and physicians in Sweden.

INTRODUCTION: The present article aimed to investigate 1) if mental health problems (depression and burnout including the dimensions; emotional exhaustion, mental distance and cognitive and emotional impairment) differed between nurses and physicians in Sweden, 2) if any differences were explained by differences in sex compositions, and 3) if any sex differences were larger within either of the two professions. METHOD: Data were derived from a representative sample of nurses (n = 2903) and physicians (n = 2712) in 2022. Two scales were used to assess burnout (KEDS and BAT) and one to assess depression (SCL-6). The BAT scale has four sub-dimensions. Descriptive statistics and logistic regression were used to analyse each scale and dimension separately. RESULTS: Results showed that 16-28 % of nurses and physicians reported moderate to severe symptoms of burnout. The prevalence differed between occupations across the scales and dimensions used. Nurses reported higher scores on KEDS while physicians reported higher scores on BAT including the four dimensions. Also, 7 % of nurses' and 6 % of physicians' scores were above the cut-off for major depression. The inclusion of sex in the models changed the odds ratios of differences between doctors and nurses in all mental health dimensions except mental distance and cognitive impairment. LIMITATIONS: This study was based on cross-sectional survey data which has some limitations. CONCLUSION: Our study suggests that the prevalence of mental health problems is prominent among nurses and physicians in Sweden. Sex plays an important role in the difference in the prevalence of mental health problems between the two professions.

Gender-based harassment in Swedish workplaces and alcohol-related morbidity and mortality: A prospective cohort study.

OBJECTIVE: The study investigated experiences of different types of work-related gender-based harassment (GBH), specifically sexual and gender harassment, as risk factors for alcohol-related morbidity and mortality (ARMM). METHODS: Information about experiences of (i) sexual harassment (SH-I) and (ii) gender harassment (GH-I) from inside the organization and (iii) sexual harassment from a person external to the organization (SH-E) were obtained from the Swedish Work Environment Survey 1995-2013, a biannual cross-sectional survey, administered to a representative sample of the Swedish working population. The survey responses from 86 033 individuals were connected to multiple registers containing information about alcohol-related diagnoses, treatment, or cause of death. Cox proportional hazard models were fitted to assess hazard ratios (HR) of incident ARMM during a mean follow-up of eight (SH-I and GH-I) and ten (SH-E) years. RESULTS: A higher prospective risk estimate of ARMM was found among participants who reported experiences of SH-E [HR 2.01, 95% confidence interval (CI) 1.61-2.52], GH-I (HR 1.33, CI 1.03-1.70), or SH-I (HR 2.37, CI 1.42-3.00). Additional analyses, distinguishing one-time from reoccurring harassment experiences, indicated a dose-response relationship for all three harassment types. Gender did not modify the associations. Under the assumption of causality, 9.3% (95% CI 5.4-13.1) of the risk of ARMM among Swedish women and 2.1% (95% CI 0.6-3.6) among Swedish men would be attributable to any of the three types of GBH included in this study. CONCLUSIONS: Experiences of GBH in the work context may be a highly relevant factor in the etiology of ARMM.

Do illegitimate tasks matter for registered nurses' work motivation? A cross-sectional study based on a nationally representative sample of Swedish nurses.

Background: A challenge in Western countries is the growing need for registered nurses (RNs') in hospitals, primary care and home healthcare. Decreasing illegitimate tasks and strengthening RNs' work motivation are some strategies to address this challenge. Objective: Our overall aim was to explore the association between RNs' experiences of illegitimate tasks and work motivation operationalised as four dimensions: work engagement, opportunities to provide high-quality care, employer satisfaction and intention to remain at the workplace. To address this aim, three specific research questions were asked: (1) Is there an association between illegitimate tasks and work motivation? (2) Do the levels of reported illegitimate tasks differ between RNs working in hospitals and those working in primary care or home healthcare settings? (3) Do associations between illegitimate work tasks and work motivation differ with type of workplace? Design: A cross-sectional design. Methods: We used responses from a stratified population of RNs in Sweden, n = 2,333, working either in hospitals, primary care or home healthcare. Calibrating weights were applied in all analyses to ascertain the generalisability of the findings. Illegitimate tasks were measured with the Bern Illegitimate Tasks Scale. Data were analysed using chi-squared tests and linear or logistic regression analysis. Interaction was measured on the multiplicative scale by adding an interaction term to the fully adjusted models. Results: Overall, approximately 25 % of RNs reported frequently experiencing illegitimate tasks. There were statistically significant associations between higher perceptions of illegitimate tasks and lower ratings in the four dimensions of work motivation: work engagement [beta coefficient [beta] = -0.14, confidence interval [CI] 95 % = -0.18; -0.10], opportunities to provide high-quality care [beta = -0.46, CI 95 % = -0.51; -40] and employer satisfaction [beta = -0.60, CI 95 % = -0.67; -0.54]. Experiencing higher levels of illegitimate tasks also related to a decreased intention to remain at the workplace [illegitimate tasks: odds ratio = 0.32, CI 95 % = 0.27; 0.29]. RNs who worked in home healthcare reported higher levels of illegitimate tasks than RNs who worked in hospitals. Conclusions: Reducing the amount of illegitimate tasks may contribute to counteracting the shortage of RNs by increasing work motivation and willingness to remain at the workplace.

Workplace gender harassment, illegitimate tasks, and poor mental health: Hypothesized associations in a Swedish cohort.

Workers exposed to gender harassment and illegitimate tasks may experience adverse mental health outcomes such as depression and burnout. However, the longitudinal effects and the complex interrelationships between these variables remain largely unexplored. We investigated the cross-lagged relationships between gender harassment, illegitimate tasks, and mental health outcomes among working adults in Sweden over a period of two years, as well as the gender differences in the cross-lagged effects. Additionally, the study examined whether illegitimate tasks mediated the relationship between gender harassment and negative mental health outcomes over time. Data were drawn from the Swedish Longitudinal Occupational Survey of Health (SLOSH), covering 2796 working men and 4110 working women in a two-wave analysis from 2018 to 2020. We employed a structural equation model to examine the cross-lagged effects and the mediating effect between gender harassment, illegitimate tasks, and mental health outcomes over time. Furthermore, we applied a multigroup analysis to determine gender differences in the cross-lagged effects. The results showed statistically significant cross-lagged relationships (forward, reverse, and reciprocal) between gender harassment, illegitimate tasks, and mental ill-health. There were statistically significant gender differences in these cross-lagged relationships (burnout: △χ2(47)=106.21, p < 0.01; depression: △χ2(47)=80.5, p < 0.01). Initial illegitimate tasks mediated the relationship between gender harassment and mental ill-health outcomes over time. The gender differences in the interrelationships between gender harassment, illegitimate tasks, and mental ill-health outcomes among workers in Sweden indicate that policies, regulations, and interventions that address these exposures in organisations must be tailored to benefit both men and women.

Effects of a co-created occupational health intervention on stress and psychosocial working conditions within the construction industry: A controlled trial.

Background: Work-related stress problems, i.e., burnout, depression, and anxiety, is a rising global health challenge. Poor mental health also appears to be a challenge for the construction industry, even though the occupational health focus has traditionally been on the physical work environment and musculoskeletal disorders. Yet, studies targeting the organisational level (i.e., work environment, policy) to enhance mental health within the construction industry are scant. Therefore, our first objective was to evaluate the effectiveness of a co-created occupational health intervention on stress and psychosocial working conditions within the construction industry in Sweden. The second objective was to evaluate whether the intervention was implemented as intended, i.e., implementation fidelity. The trial is registered in the ISRCTN clinical trial registry (ISRCTN16548039, http://isrctn.com/). Methods: This is a controlled trial with one intervention and one matched control group. We co-created the program logic with stakeholders from the intervention group. The essence of the chosen intervention components, duties clarification, and structured roundmaking was enhanced planning and role clarification. We assessed adherence to the intervention and dose delivered (i.e., fidelity). We collected data on the outcomes (role clarity, team effectiveness, planning, staffing, quantitative demands, and the psychosocial safety climate) with online questionnaires at baseline, 12, and 24 months. Marginal means models adjusting for missing data patterns were applied to estimate potential differences in outcomes between groups over time. Results: Fidelity was considered reasonably high. Yet, we found no intervention effects on the primary outcome stress. All outcomes, except role clarity deteriorated during the trial in the intervention and control group. However, the results indicate a positive effect of the intervention components on professionals' role clarity. The pandemic appears to have negatively affected stress and psychosocial working conditions. Conclusion: The study's results suggest that co-creating occupational health interventions could be one solution for improved implementation fidelity. More studies are needed to evaluate these intervention components. Also, we recommend researchers of future intervention studies consider using missing not at random, sensitivity analysis.

The Work Environment during Coronavirus Epidemics and Pandemics: A Systematic Review of Studies Using Quantitative, Qualitative, and Mixed-Methods Designs.

We aimed to provide an overview of how work environment and occupational health are affected, and describe interventions designed to improve the work environment during epidemics and pandemics. The guidelines on Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) were followed. The databases Cinahl, Medline, PsycInfo, and Web of Science were searched for population: working population; exposure: coronavirus epidemic or pandemic; and outcome: work environment, in articles published until October 2020. Quality assessment was based on a modified version of the Mixed Methods Appraisal Tool (MMAT). After deduplication 3711 articles remained, of which 530 were selected for full-text screening and 119 for quality assessment. After the exclusion of studies that were low quality, 95 remained, of which 85 focused on healthcare personnel and 10 on employees in other industries; 73 used quantitative methods and 22 used qualitative or mixed methods; the majority were based on cross-sectional data. Healthcare staff experienced increased job demands, poor leadership, and lack of resources (personal protective equipment, personnel, and competence). High demands and work with infected patients were associated with negative mental health outcomes. There was a lack of studies assessing interventions, studies from industries other than healthcare, and studies of high quality.

Job demands, job resources, and health outcomes among nursing professionals in private and public healthcare sectors in Sweden - a prospective study.

BACKGROUND: Nursing professionals exhibit high prevalence of stress-related health problems. Job demands and job resources are parallel drivers of health and well-being among employees. Better job resources associate with better job satisfaction, job motivation and engagement even when job demands are high. To date, there is limited research which explores the association between job demands, job resources and health outcomes among nursing professionals in the Swedish context. The aim of this study was therefore to investigate Swedish nursing professionals' job demands and job resources in relation to health outcomes, with comparisons between the private and public healthcare sectors. The specific research questions were as follows: (1) Are there differences between private and public healthcare regarding job demands, job resources, and health outcomes? and (2) Are there prospective associations between job demands and job resources in relation to health outcomes? METHODS: Data were drawn from the Swedish Longitudinal Occupational Survey of Health (SLOSH) 2016 and 2018, including 520 nurses and 544 assistant nurses working in the private and public healthcare sectors from 2016 (baseline). Data were analyzed using binary logistic regression. RESULTS: Nursing professionals reported higher threats, lower bullying, lower control, lower social support, and lower cohesion in the public healthcare units compared to the private healthcare units. The prospective analyses showed that job resources in terms of social support and rewards were associated with higher self-rated health and lower burnout. Cohesion was associated with higher self-rated health. Job demands in terms of psychological demands and job efforts were associated with lower self-rated health, higher burnout, and higher sickness absence, while emotional demands were associated with higher burnout. CONCLUSIONS: Nursing professionals' job resources are deficient in public healthcare units. Job resources are associated with positive health outcomes, whereas job demands are associated with negative health outcomes, among nursing professionals. Strengthening job resources among nursing professionals in the private and public healthcare sectors can promote and sustain their work-related health.

The Swedish HealthPhys Study: Study Description and Prevalence of Clinical Burnout and Major Depression among Physicians.

Objectives: The study purpose was to describe the Swedish HealthPhys cohort. Using data from the HealthPhys study, we aimed to describe the prevalence of clinical burnout and major depression in a representative sample of Swedish physicians across gender, age, worksite, hierarchical position, and speciality in spring of 2021, during the third wave of the Covid-19 pandemic. Method: The HealthPhys questionnaire was sent to a representative sample of practising physicians (n = 6699) in Sweden in February to May of 2021 with a 41.3% response rate. The questionnaire included validated instruments measuring psychosocial work environment and health including measurements for major depression and clinical burnout. Results: Data from the HealthPhys study showed that among practising physicians in Sweden the prevalence of major depression was 4.8% and clinical burnout was 4.7%. However, the variations across sub-groups of physicians regarding major depression ranged from 0% to 10.1%. For clinical burnout estimates ranged from 1.3% to 14.5%. Emergency physicians had the highest levels of clinical burnout while they had 0% prevalence of major depression. Prevalence of exhaustion was high across all groups of physicians with physicians working in emergency departments, at the highest (28.6%) and anaesthesiologist at the lowest (5.6%). Junior physicians had high levels across all measurements. Conclusions: In conclusion, the first data collection from the HealthPhys study showed that the prevalence of major depression and clinical burnout varies across genders, age, hierarchical position, worksite, and specialty. Moreover, many practising physicians in Sweden experienced exhaustion and were at high risk of burnout.

Sexual and gender harassment and use of psychotropic medication among Swedish workers: a prospective cohort study.

OBJECTIVE: To estimate the prospective association between the exposure to three types of gender-based violence and harassment (GBVH) and psychotropic medication. METHODS: Information on three measures of workplace GBVH-sexual harassment (1) from superiors or colleagues, (2) from others (eg, clients) and (3) gender harassment from superiors or colleagues-were retrieved from the biannual Swedish Work Environment Survey 2007-2013 (N=23 449), a representative sample of working 16-64 years old registered in Sweden. The survey answers were merged with data on antidepressants, hypnotics/sedatives and anxiolytics from the Swedish Prescribed Drug Register. Cox proportional hazards analyses with days to purchase as time scale and first instance of medicine purchase as failure event were fitted, adjusted for demographic and workplace factors. RESULTS: Workers who reported exposure to gender harassment only (HR 1.2, 95% CI 1.07 to 1.36), to sexual but not gender harassment (HR 1.21, 95% CI 1.04 to 1.40), or to gender and sexual harassment (HR 1.31, 95% CI 1.08 to 1.60) had an excess risk of psychotropics use in comparison to workers who reported neither of the exposures in the past 12 months. We found no interaction between the exposures and gender in the association with psychotropics use. CONCLUSIONS: Exposure to sexual or gender harassment at the workplace may contribute to the development of mental disorders.

How consistently does sleep quality improve at retirement? Prospective analyses with group-based trajectory models.

Growing evidence indicates that retiring from paid work is associated, at least in the short-term, with dramatic reductions in sleep difficulties and more restorative sleep. However, much is still not known, in particular how universal these improvements are, how long they last, and whether they relate to the work environment. A methodological challenge concerns how to model time when studying abrupt changes such as retirement. Using data from Swedish Longitudinal Occupational Survey of Health (n = 2,148), we studied difficulties falling asleep, difficulties maintaining sleep, premature awakening, restless sleep, a composite scale of these items, and non-restorative sleep. We compared polynomial and B-spline functions to model time in group-based trajectory modelling. We estimated variations in the individual development of sleep difficulties around retirement, relating these to the pre-retirement work environment. Reductions in sleep difficulties at retirement were sudden for all outcomes and were sustained for up to 11 years for non-restorative sleep, premature awakening, and restless sleep. Average patterns masked distinct patterns of change: groups of retirees experiencing greatest pre-retirement sleep difficulties benefitted most from retiring. Higher job demands, lower work time control, lower job control, and working full-time were work factors that accounted membership in these groups. Compared to polynomials, B-spline models more appropriately estimated time around retirement, providing trajectories that were closer to the observed shapes. The study highlights the need to exercise care in modelling time over a sudden transition because using polynomials can generate artefactual uplifts or omit abrupt changes entirely, findings that would have fallacious implications.

The role of managerial leadership in sickness absence in health and social care: antecedent or moderator in the association between psychosocial working conditions and register-based sickness absence? A longitudinal study based on a swedish cohort.

BACKGROUND: The prevalence of sickness absence is particularly high among employees in health and social care, where psychosocial work stressors are pertinent. Managerial leadership is known to affect sickness absence rates, but the role leadership plays in relation to sickness absence is not fully understood; that is, whether poor leadership (i) is associated with sickness absence directly, (ii) is associated with sickness absence indirectly through the establishment of poor psychosocial working conditions, or (iii) whether good leadership rather has a buffering role in the association between work stressors and sickness absence. METHODS: Four biennial waves from the Swedish Longitudinal Occupational Survey of Health (SLOSH, 2010-2016, N=2333) were used. Autoregressive cross-lagged analyses within a multilevel structural equation modelling (MSEM) framework were conducted to test hypotheses i)-iii), targeting managerial leadership, register-based sickness absence and psychosocial work stressors (high psychological demands, poor decision authority and exposure to workplace violence). RESULTS: A direct association was found between poor leadership and sickness absence two years later, but no associations were found between leadership and the psychosocial work stressors. Finally, only in cases of poor leadership was there a statistically significant association between workplace violence and sickness absence. CONCLUSIONS: Poor managerial leadership may increase the risk of sickness absence among health and social care workers in two ways: first, directly and, second, by increasing the link between workplace violence and sickness absence.

Co-Creating an Occupational Health Intervention within the Construction Industry in Sweden: Stakeholder Perceptions of the Process and Output.

One way to prevent work-related stress, is to implement primary occupational health interventions aimed at improving the psychosocial work environment. However, such interventions have shown a limited effect, often due to implementation failure and poor contextual fit. Co-creation, where researchers, together with end-users and other relevant stakeholders, develop the intervention is increasingly encouraged. However, few studies have evaluated the effects of co-created interventions, and participants' experience of the co-creation process. This is one of the first studies evaluating stakeholder perceptions of co-creating an occupational health intervention. We applied a thematic analysis, with data from 12 semi-structured interviews with stakeholders involved in the co-creation. Our results show that the respondents, in general, were satisfied with engaging in the co-creation, and they reported an increased awareness regarding risk factors of stress and how these should be handled. Additionally, the respondents described trust in the intervention activities and a good fit into the context. The study indicates that co-creating occupational health interventions can enhance the implementation and the contextual fit.

A Theoretical Development of the Gender Embodiment of Enrichment: A Study of Gender Norms in Enrichment and Factors Related to Enrichment in a Sample of the Swedish Working Population.

Enrichment is a phenomenon described as the synergistic and beneficial effects of participating in both work and private life. Far too few studies have acknowledged the role of gender in enrichment. By applying a gender theoretical approach, this article has two aims; first, we aim to study the role of gender in enrichment by examining the factorial structure of enrichment in men and women; secondly, we aim to study the relationship between enrichment and work and private life factors in an approximately representative sample of the Swedish working population. A multigroup confirmatory factor analysis with measurement in variance was performed and this resulted in a two-factor solution for enrichment for both men and women, representing the two directions of enrichment: work-to-life enrichment (WLE) and life-to-work enrichment (LWE). Factor loadings differ across genders, indicating that men and women construct and value items of enrichment differently. Next, linear mixed models were used to answer the second aim. Results show that gendered cultural norms in work and private life manifest in the relationship between factors in the work and home sphere and enrichment. Factors in work and private life with more or less masculine or feminine epithets relate differently to WLE and LWE for men and women. The main conclusion is that masculine and feminine norms are embodied in the values and experiences of enrichment and factors related to enrichment.

Sexual and gender harassment in Swedish workplaces: A prospective cohort study on implications for long-term sickness absence.

OBJECTIVES: This prospective cohort study aimed to investigate gender harassment and sexual harassment as risk factors for prospective long-term sickness absence (LTSA, ≥21 days). Furthermore, support from colleagues was investigated as a moderating factor of this association. METHODS: Information on gender harassment, sexual harassment and support by colleagues were derived from the biannual Swedish Work Environment Survey 1999-2013, a representative sample of the Swedish working population (N=64 297). Information on LTSA as well as demographic and workplace variables were added from register data. Relative rates of LTSA the year following the exposure were determined using modified Poisson regression. RESULTS: Monthly to daily exposure to gender harassment was a risk factor for prospective LTSA among women [rate ratio (RR) 1.04, 95% confidence interval (CI) 1.02-1.05] and men (RR 1.07, 95% CI 1.04-1.10). Monthly to daily exposure to sexual harassment was also a risk factor for LTSA among women (RR 1.05, 95% CI 1.01-1.10) and men (RR 1.07, 95% CI 1.02-1.13). Exposure to sexual or gender harassment once in the last 12 months was not associated with LTSA. There was no support for an interaction between either of the exposures and support from colleagues in relation to LTSA. CONCLUSIONS: Sexual harassment and gender harassment appear to contribute to a small excess risk for LTSA among women and men. For both kinds of offensive behaviors, the pervasiveness appears to be important for the outcome. The role of support by colleagues was inconclusive and needs further investigation.

A Participatory Intervention to Improve the Psychosocial Work Environment and Mental Health in Human Service Organisations. A Mixed Methods Evaluation Study.

Work-related stress is a global problem causing suffering and economic costs. In Sweden, employees in human service occupations are overrepresented among persons on sick leave due to mental health problems such as stress-related disorders. The psychosocial work environment is one contributing factor for this problem, making it urgent to identify effective methods to decrease stress at the workplace. The aim of the study is to evaluate a participatory intervention to improve the psychosocial work environment and mental health using an embedded mixed methods design. The study is a controlled trial with a parallel process evaluation exploring fidelity and participants' reactions to the intervention activities, experiences of learning and changes in behaviours and work routines. We collected data through documentation, interviews and three waves of questionnaires. Our results show small changes in behaviours and work routines and no positive effects of the intervention on the psychosocial work environment nor health outcomes. One explanation is end-users' perceived lack of involvement over the process causing the intervention to be seen as a burden. Another explanation is that the intervention activities were perceived targeting the wrong organisational level. A representative participation over both content and process can be an effective strategy to change psychosocial working conditions and mental health.

The relationship between onset of workplace violence and onset of sleep disturbances in the Swedish working population.

The study investigated the association between onset of workplace violence and onset of sleep disturbances. We used self-reported data from the Swedish Longitudinal Occupational Survey of Health (SLOSH) collected in 2014, 2016, and 2018. A two-wave design was based on participants who had no exposure to workplace violence or sleep disturbances at baseline (n = 6,928). A three-wave design was based on participants who in addition were unexposed to sleep disturbances in the second wave (n = 6,150). Four items of the Karolinska Sleep Questionnaire were used to measure sleep disturbances and one question was used to measure the occurrence of workplace violence or threats of violence. Multivariate logistic regression analyses were performed. In the two-wave approach, onset of workplace violence was associated with onset of sleep disturbances after adjustment for sex, age, occupational position, education, and civil status (adjusted odds ratio 1.41, 95% confidence interval 1.02-1.96). The association was no longer statistically significant after further adjustment for night/evening work, demands, control, and social support at work. In the three-wave approach, results were only suggestive of an association between onset of workplace violence and subsequent onset of sleep disturbances after adjustment for sex, age, occupational position, education, and civil status. Onset of frequent exposure to workplace violence was associated with subsequent onset of sleep disturbances in the adjusted analyses, but these analyses were based on few individuals (13 exposed versus 5,907 unexposed). The results did not conclusively demonstrate that onset of workplace violence predicts development of sleep disturbances. Further research could elucidate the role of other working conditions.

Barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections: A qualitative study with general practitioners in Malta.

BACKGROUND: Antibiotic resistance is a leading global public health concern and antibiotic use is a key driver. Effective interventions are needed to target key stakeholders, including general practitioners (GPs). In Malta, little is known about factors that influence GPs' antibiotic prescribing, making it challenging to implement targeted interventions. We therefore aimed to explore GPs' understanding of antibiotic use and resistance, and describe their perceived barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections in Malta. METHODS: Face-to-face individual semi-structured interviews were held with a quota sample of 20 GPs in 2014. Interviews were audio recorded and transcribed verbatim, and later analysed iteratively using manifest and latent content analysis. Findings were collated in a socioecological model to depict how GPs as individuals are embedded within larger social systems and contexts, and how each component within this system impacts their prescribing behaviour. FINDINGS: We found that GPs' antibiotic prescribing decisions are complex and impacted by numerous barriers and facilitators at the individual, interpersonal, organisational, community, and public policy level. Predominant factors found to impact GPs' antibiotic prescribing included not only intrinsic GP factors such as knowledge, awareness, experience, and misconceptions, but also several external factors. At the interpersonal level, GPs' perceived patient demand and behaviour to be a persistent issue that impacts their prescribing decisions. Similarly, some GPs found pressure from drug reps to be concerning despite being considered an important source of information. Organisational and public policy-level issues such as lack of access to relevant antibiotic prescribing guidelines and current antibiotic resistance data from the community, were also considered major barriers to appropriate antibiotic prescribing. Utilisation of diagnostic testing was found to be low and GPs' perceptions on the introduction of rapid point-of-care tests to support antibiotic prescription decisions, were mixed. CONCLUSION: This study revealed the complexity of the antibiotic prescribing decision and the numerous barriers and facilitators that impact it, visualised through a socioecological model. Addressing GPs' antibiotic prescribing practices will require targeted and coordinated implementation activities at all levels to change behaviour and address misconceptions, whilst also improving the physical and social environment. TRIAL REGISTRATION NUMBER: NCT03218930; https://clinicaltrials.gov/ct2/show/NCT03218930.

Does Exposure to High Job Demands, Low Decision Authority, or Workplace Violence Mediate the Association between Employment in the Health and Social Care Industry and Register-Based Sickness Absence? A Longitudinal Study of a Swedish Cohort.

BACKGROUND: The aim of this paper was to investigate if job demands, decision authority, and workplace violence mediate the association between employment in the health and social care industry and register-based sickness absence. METHODS: Participants from the Swedish Longitudinal Occupational Survey of Health who responded to questionnaires in 2006-2016 (n = 3951) were included. Multilevel autoregressive cross-lagged mediation models were fitted to the data. Employment in the health and social care industry at one time point was used as the predictor variable and register-based sickness absence >14 days as the outcome variable. Self-reported levels of job demands, decision authority, and exposure to workplace violence from the first time point were used as mediating variables. RESULTS: The direct path between employment in the health and social care industry and sickness absence >14 days was, while adjusting for the reverse path, 0.032, p = 0.002. The indirect effect mediated by low decision authority was 0.002, p = 0.006 and the one mediated by exposure to workplace violence was 0.008, p = 0.002. High job demands were not found to mediate the association. CONCLUSION: Workplace violence and low decision authority may, to a small extent, mediate the association between employment in the health and social care industry and sickness absence.

Workplace violence and health in human service industries: a systematic review of prospective and longitudinal studies.

OBJECTIVES: To provide systematically evaluated evidence of prospective associations between exposure to physical, psychological and gender-based violence and health among healthcare, social care and education workers. METHODS: The guidelines on Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. Medline, Cinahl, Web of Science and PsycInfo were searched for population: human service workers; exposure: workplace violence; and study type: prospective or longitudinal in articles published 1990-August 2019. Quality assessment was performed based on a modified version of the Cochrane's 'Tool to Assess Risk of Bias in Cohort Studies'. RESULTS: After deduplication, 3566 studies remained, of which 132 articles were selected for full-text screening and 28 were included in the systematic review. A majority of the studies focused on healthcare personnel, were from the Nordic countries and were assessed to have medium quality. Nine of 11 associations between physical violence and poor mental health were statistically significant, and 3 of 4 associations between physical violence and sickness absence. Ten of 13 associations between psychological violence and poor mental health were statistically significant and 6 of 6 associations between psychological violence and sickness absence. The only study on gender-based violence and health reported a statistically non-significant association. CONCLUSION: There is consistent evidence mainly in medium quality studies of prospective associations between psychological violence and poor mental health and sickness absence, and between physical violence and poor mental health in human service workers. More research using objective outcomes, improved exposure assessment and that focus on gender-based violence is needed.