Global-, regional- and country-level estimates of the work-related burden of diseases and accidents in 2019.

OBJECTIVE: This study provides the global-, regional- and country-level estimates on the work-related burden of diseases and accidents for 2019, including deaths, disability adjusted life years (DALY) and economic losses. METHODS: Data on occupational illnesses and injuries from international organizations, institutions, and public websites were used. Risk ratios (RR) and population attributable fractions (PAF) for the risk factor-outcome pairs were derived from the literature. Estimated mortality and DALY for a group of seven major diseases covering 120 risk-outcome pairs attributable to work were calculated for 181 countries. RESULTS: Globally, 2.9 million deaths were attributed to work, with 2.58 million deaths due to work-related diseases and 0.32 million related to occupational injuries. Globally, work-related diseases with a long latency period are increasing, while the number of occupational injuries has decreased. Work-related circulatory diseases were the major cause of 912 000 deaths globally, followed by 843 000 work-related malignant neoplasms. In high-income, American, Eastern European and Western Pacific World Health Organization (WHO) regions, however, work-related malignant neoplasms comprised the biggest disease group. DALY attributable to work were estimated to be 180 million in 2019, with an associated economic loss of 5.8% of global GDP. New estimates of psychosocial factors increased the global loss. CONCLUSIONS: The burden of work-related diseases and injuries increased by 26% from 2.3 million annual deaths in 2014 to 2.9 million in 2019. The DALY attributable to work have also substantially increased from 123 million in 2014 to 180 million in 2019 (47% increase). We found large regional and country variations.

Global, regional and national burdens of non-melanoma skin cancer attributable to occupational exposure to solar ultraviolet radiation for 183 countries, 2000-2019: A systematic analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury.

BACKGROUND: A World Health Organization (WHO) and International Labour Organization (ILO) systematic review reported sufficient evidence for higher risk of non-melanoma skin cancer (NMSC) amongst people occupationally exposed to solar ultraviolet radiation (UVR). This article presents WHO/ILO Joint Estimates of global, regional, national and subnational occupational exposures to UVR for 195 countries/areas and the global, regional and national attributable burdens of NMSC for 183 countries, by sex and age group, for the years 2000, 2010 and 2019. METHODS: We calculated population-attributable fractions (PAFs) from estimates of the population occupationally exposed to UVR and the risk ratio for NMSC from the WHO/ILO systematic review. Occupational exposure to UVR was modelled via proxy of occupation with outdoor work, using 166 million observations from 763 cross-sectional surveys for 96 countries/areas. Attributable NMSC burden was estimated by applying the PAFs to WHO's estimates of the total NMSC burden. Measures of inequality were calculated. RESULTS: Globally in 2019, 1.6 billion workers (95 % uncertainty range [UR] 1.6-1.6) were occupationally exposed to UVR, or 28.4 % (UR 27.9-28.8) of the working-age population. The PAFs were 29.0 % (UR 24.7-35.0) for NMSC deaths and 30.4 % (UR 29.0-31.7) for disability-adjusted life years (DALYs). Attributable NMSC burdens were 18,960 deaths (UR 18,180-19,740) and 0.5 million DALYs (UR 0.4-0.5). Men and older age groups carried larger burden. Over 2000-2019, attributable deaths and DALYs almost doubled. CONCLUSIONS: WHO and the ILO estimate that occupational exposure to UVR is common and causes substantial, inequitable and growing attributable burden of NMSC. Governments must protect outdoor workers from hazardous exposure to UVR and attributable NMSC burden and inequalities.

Estimating the population exposed to a risk factor over a time window: A microsimulation modelling approach from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury.

OBJECTIVES: Burden of disease estimation commonly requires estimates of the population exposed to a risk factor over a time window (yeart to yeart+n). We present a microsimulation modelling approach for producing such estimates and apply it to calculate the population exposed to long working hours for one country (Italy). METHODS: We developed a three-model approach: Model 1, a multilevel model, estimates exposure to the risk factor at the first year of the time window (yeart). Model 2, a regression model, estimates transition probabilities between exposure categories during the time window (yeart to yeart+n). Model 3, a microsimulation model, estimates the exposed population over the time window, using the Monte Carlo method. The microsimulation is carried out in three steps: (a) a representative synthetic population is initiated in the first year of the time window using prevalence estimates from Model 1, (b) the exposed population is simulated over the time window using the transition probabilities from Model 2; and (c) the population is censored for deaths during the time window. RESULTS: We estimated the population exposed to long working hours (i.e. 41-48, 49-54 and ≥55 hours/week) over a 10-year time window (2002-11) in Italy. We populated all three models with official data from Labour Force Surveys, United Nations population estimates and World Health Organization life tables. Estimates were produced of populations exposed over the time window, disaggregated by sex and 5-year age group. CONCLUSIONS: Our modelling approach for estimating the population exposed to a risk factor over a time window is simple, versatile, and flexible. It however requires longitudinal exposure data and Model 3 (the microsimulation model) is stochastic. The approach can improve accuracy and transparency in exposure and burden of disease estimations. To improve the approach, a logical next step is changing Model 3 to a deterministic microsimulation method, such as modelling of microflows.

Assessing the quality of evidence in studies estimating prevalence of exposure to occupational risk factors: The QoE-SPEO approach applied in the systematic reviews from the WHO/ILO Joint Estimates of the Work-related burden of disease and Injury.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) have produced the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury (WHO/ILO Joint Estimates). For these, systematic reviews of studies estimating the prevalence of exposure to selected occupational risk factors have been conducted to provide input data for estimations of the number of exposed workers. A critical part of systematic review methodology is to assess the quality of evidence across studies. In this article, we present the approach applied in these WHO/ILO systematic reviews for performing such assessments on studies of prevalence of exposure. It is called the Quality of Evidence in Studies estimating Prevalence of Exposure to Occupational risk factors (QoE-SPEO) approach. We describe QoE-SPEO's development to date, demonstrate its feasibility reporting results from pilot testing and case studies, note its strengths and limitations, and suggest how QoE-SPEO should be tested and developed further. METHODS: Following a comprehensive literature review, and using expert opinion, selected existing quality of evidence assessment approaches used in environmental and occupational health were reviewed and analysed for their relevance to prevalence studies. Relevant steps and components from the existing approaches were adopted or adapted for QoE-SPEO. New steps and components were developed. We elicited feedback from other systematic review methodologists and exposure scientists and reached consensus on the QoE-SPEO approach. Ten individual experts pilot-tested QoE-SPEO. To assess inter-rater agreement, we counted ratings of expected (actual and non-spurious) heterogeneity and quality of evidence and calculated a raw measure of agreement (Pi) between individual raters and rater teams for the downgrade domains. Pi ranged between 0.00 (no two pilot testers selected the same rating) and 1.00 (all pilot testers selected the same rating). Case studies were conducted of experiences of QoE-SPEO's use in two WHO/ILO systematic reviews. RESULTS: We found no existing quality of evidence assessment approach for occupational exposure prevalence studies. We identified three relevant, existing approaches for environmental and occupational health studies of the effect of exposures. Assessments using QoE-SPEO comprise three steps: (1) judge the level of expected heterogeneity (defined as non-spurious variability that can be expected in exposure prevalence, within or between individual persons, because exposure may change over space and/or time), (2) assess downgrade domains, and (3) reach a final rating on the quality of evidence. Assessments are conducted using the same five downgrade domains as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach: (a) risk of bias, (b) indirectness, (c) inconsistency, (d) imprecision, and (e) publication bias. For downgrade domains (c) and (d), the assessment varies depending on the level of expected heterogeneity. There are no upgrade domains. The QoE-SPEO's ratings are "very low", "low", "moderate", and "high". To arrive at a final decision on the overall quality of evidence, the assessor starts at "high" quality of evidence and for each domain downgrades by one or two levels for serious concerns or very serious concerns, respectively. In pilot tests, there was reasonable agreement in ratings for expected heterogeneity; 70% of raters selected the same rating. Inter-rater agreement ranged considerably between downgrade domains, both for individual rater pairs (range Pi: 0.36-1.00) and rater teams (0.20-1.00). Sparse data prevented rigorous assessment of inter-rater agreement in quality of evidence ratings. CONCLUSIONS: We present QoE-SPEO as an approach for assessing quality of evidence in prevalence studies of exposure to occupational risk factors. It has been developed to its current version (as presented here), has undergone pilot testing, and was applied in the systematic reviews for the WHO/ILO Joint Estimates. While the approach requires further testing and development, it makes steps towards filling an identified gap, and progress made so far can be used to inform future work in this area.

The effect of occupational exposure to ergonomic risk factors on osteoarthritis of hip or knee and selected other musculoskeletal diseases: A systematic review and meta-analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing joint estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates), with contributions from a large network of experts. Evidence from mechanistic data suggests that occupational exposure to ergonomic risk factors may cause selected other musculoskeletal diseases, other than back or neck pain (MSD) or osteoarthritis of hip or knee (OA). In this paper, we present a systematic review and meta-analysis of parameters for estimating the number of disability-adjusted life years from MSD or OA that are attributable to occupational exposure to ergonomic risk factors, for the development of the WHO/ILO Joint Estimates. OBJECTIVES: We aimed to systematically review and meta-analyse estimates of the effect of occupational exposure to ergonomic risk factors (force exertion, demanding posture, repetitiveness, hand-arm vibration, lifting, kneeling and/or squatting, and climbing) on MSD and OA (two outcomes: prevalence and incidence). DATA SOURCES: We developed and published a protocol, applying the Navigation Guide as an organizing systematic review framework where feasible. We searched electronic academic databases for potentially relevant records from published and unpublished studies, including the International Trials Register, Ovid Medline, EMBASE, and CISDOC. We also searched electronic grey literature databases, Internet search engines and organizational websites; hand-searched reference list of previous systematic reviews and included study records; and consulted additional experts. STUDY ELIGIBILITY AND CRITERIA: We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (<15 years) and unpaid domestic workers. We included randomized controlled trials, cohort studies, case-control studies and other non-randomized intervention studies with an estimate of the effect of occupational exposure to ergonomic risk factors (any exposure to force exertion, demanding posture, repetitiveness, hand-arm vibration, lifting, kneeling and/or squatting, and climbing ≥ 2 h/day) compared with no or low exposure to the theoretical minimum risk exposure level (<2 h/day) on the prevalence or incidence of MSD or OA. STUDY APPRAISAL AND SYNTHESIS METHODS: At least two review authors independently screened titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. Missing data were requested from principal study authors. We combined odds ratios using random-effect meta-analysis. Two or more review authors assessed the risk of bias and the quality of evidence, using Navigation Guide tools adapted to this project. RESULTS: In total eight studies (4 cohort studies and 4 case control studies) met the inclusion criteria, comprising a total of 2,378,729 participants (1,157,943 females and 1,220,786 males) in 6 countries in 3 WHO regions (Europe, Eastern Mediterranean and Western Pacific). The exposure was measured using self-reports in most studies and with a job exposure matrix in one study and outcome was generally assessed with physician diagnostic records or administrative health data. Across included studies, risk of bias was generally moderate. Compared with no or low exposure (<2 h per day), any occupational exposure to ergonomic risk factors increased the risk of acquiring MSD (odds ratio (OR) 1.76, 95% confidence interval [CI] 1.14 to 2.72, 4 studies, 2,376,592 participants, I2 70%); and increased the risk of acquiring OA of knee or hip (OR 2.20, 95% CI 1.42 to 3.40, 3 studies, 1,354 participants, I2 13%); Subgroup analysis for MSD found evidence for differences by sex, but indicated a difference in study type, where OR was higher among study participants in a case control study compared to study participants in cohort studies. CONCLUSIONS: Overall, for both outcomes, the main body of evidence was assessed as being of low quality. Occupational exposure to ergonomic risk factors increased the risk of acquiring MSD and of acquiring OA of knee or hip. We judged the body of human evidence on the relationship between exposure to occupational ergonomic factors and MSD as "limited evidence of harmfulness" and the relationship between exposure to occupational ergonomic factors and OA also as "limited evidence of harmfulness". These relative risks might perhaps be suitable as input data for WHO/ILO modelling of work-related burden of disease and injury. Protocol identifier: https://doi.org/10.1016/j.envint.2018.09.053 PROSPERO registration number: CRD42018102631.

The prevalence of occupational exposure to ergonomic risk factors: A systematic review and meta-analysis from the WHO/ILO Joint Estimates of the Work-related Burden of Disease and Injury.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing joint estimates of the work-related burden of disease and injury (WHO/ILO Joint Estimates), with contributions from a large network of experts. Evidence from mechanistic and human data suggests that occupational exposure to ergonomic (or physical) risk factors may cause osteoarthritis and other musculoskeletal diseases (excluding rheumatoid arthritis, gout, and back and neck pain). In this paper, we present a systematic review and meta-analysis of the prevalence of occupational exposure to physical ergonomic risk factors for estimating the number of disability-adjusted life years from these diseases that are attributable to exposure to this risk factor, for the development of the WHO/ILO Joint Estimates. OBJECTIVES: We aimed to systematically review and meta-analyse estimates of the prevalence of occupational exposure to ergonomic risk factors for osteoarthritis and other musculoskeletal diseases. DATA SOURCES: We searched electronic bibliographic databases for potentially relevant records from published and unpublished studies, including Ovid Medline, EMBASE, and CISDOC. We also searched electronic grey literature databases, Internet search engines and organizational websites; hand-searched reference list of previous systematic reviews and included study records; and consulted additional experts. STUDY ELIGIBILITY AND CRITERIA: We included working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State but excluded children (<15 years) and unpaid domestic workers. The exposure was defined as any occupational exposure to one or more of: force exertion, demanding posture, repetitive movement, hand-arm vibration, kneeling or squatting, lifting, and/or climbing. We included all study types with an estimate of the prevalence of occupational exposure to ergonomic risk factors. STUDY APPRAISAL AND SYNTHESIS METHODS: At least two review authors independently screened titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. We combined prevalence estimates using random-effect meta-analysis. Two or more review authors assessed the risk of bias and the quality of evidence, using the ROB-SPEO tool and QoE-SPEO approach developed specifically for the WHO/ILO Joint Estimates. RESULTS: Five studies (three cross-sectional studies and two cohort studies) met the inclusion criteria, comprising 150,895 participants (81,613 females) in 36 countries in two WHO regions (Africa, Europe). The exposure was generally assessed with questionnaire data about self-reported exposure. Estimates of the prevalence of occupational exposure to ergonomic risk factors are presented for all five included studies, disaggregated by country, sex, 5-year age group, industrial sector or occupational group where feasible. The pooled prevalence of any occupational exposure to ergonomic risk factors was 0.76 (95% confidence interval 0.69 to 0.84, 3 studies, 148,433 participants, 35 countries in the WHO Europe region, I2 100%, low quality of evidence). Subgroup analyses found no statistically significant differences in exposure by sex but differences by age group, occupation and country. No evidence was found for publication bias. We assessed this body evidence to be of low quality, based on serious concerns for risk of bias due to exposure assessment only being based on self-report and for indirectness due to evidence from two WHO regions only. CONCLUSIONS: Our systematic review and meta-analysis found that occupational exposure to ergonomic risk factors is highly prevalent. The current body of evidence is, however, limited, especially by risk of bias and indirectness. Producing estimates for the burden of disease attributable to occupational exposure to ergonomic risk factors appears evidence-based, and the pooled effect estimates presented in this systematic review may perhaps be used as input data for the WHO/ILO Joint Estimates. Protocol identifier:https://doi.org/10.1016/j.envint.2018.09.053. PROSPERO registration number: CRD42018102631.

Educational Differences in Decline in Maximum Gait Speed in Older Adults Over an 11-Year Follow-up.

BACKGROUND: This study examined educational differences in decline in maximum gait speed over an 11-year follow-up in the general Finnish population aged 55 years and older and assessed the contribution of lifestyle factors, body mass index, physical workload, and chronic conditions on the association. METHOD: Data from the nationally representative Health 2000 Survey and its 11-year follow-up were used. Participants aged 55 years and older with maximum gait speed measured at both time points were included (n = 1128). Information on education, age, sex, lifestyle factors, body mass index, physical workload, and chronic conditions was collected at baseline. General linear model was used to examine differences in decline in maximum gait speed between education groups. Mediation analyses using the product method was conducted to partition the total effect of education on decline in maximum gait speed into direct effect and indirect effect acting through mediators. RESULTS: Decline in maximum gait speed was greater in low and intermediate education groups in comparison to the high education group (0.24 m/s [95% confidence interval 0.21-0.26], 0.24 m/s [0.21-0.28], 0.10 m/s [0.07-0.14], respectively]. The most important mediators were higher body mass index and lifetime exposure to physical workload among the less educated, accounting for 10% and 11% of the total effect, respectively. CONCLUSIONS: Education-based disparities in objectively measured mobility increase with age as lower education is associated with greater decline in gait speed. Higher body mass index and physical workload among less educated contributed most to the educational disparities in age-related decline in maximum gait speed.

Alcohol-related mortality and all-cause mortality following bereavement in two successive generations.

BACKGROUND AND AIM: Bereavement affects the health of the bereaved both emotionally and physically. Bereavement resulting from alcohol-related death of the previous generation (parents-first generation) may increase the risk of alcohol abuse and consequently alcohol-related mortality as well as all-cause mortality in the next generation (offspring-second generation). Furthermore, these associations can be bi-directional. However, there is no conclusive evidence of these effects, and studies exploring these intergenerational effects are rare. This study investigates these associations. METHODS: A longitudinal data were constructed by linking participants from the Adolescent Health and Lifestyle Surveys (AHLS) from 1979 to 1997 with census and registry-based data from Statistics Finland containing the socioeconomic status of the survey participants and their parents (N = 78610) to investigate these associations. Multivariate Cox proportional hazards models were used to calculate hazard ratios with 95% confidence intervals to determine the effect of bereavement with alcohol-related mortality and all-cause mortality. RESULTS: The findings suggest that bereavement following the death of an offspring increases the risk of both alcohol-related and all-cause mortality among both parents. The magnitude of the risk of mortality following the death of an offspring is higher for mothers than for fathers. There were no clear associations of a parent's death with an offspring's alcohol-related or all-cause mortality. However, generally, a father's death seems to be protective of the risk of mortality among the offspring while a mother's alcohol-related death slightly increased the risk of alcohol-related mortality among their offspring. CONCLUSIONS: These findings emphasise the role of bereavement, particularly resulting from the death of an offspring, on alcohol-related and all-cause mortality and therefore inequalities in mortality. Furthermore, the findings highlighting the need for alcohol abuse intervention and emotional support for bereaved persons following the death of an offspring.

Prevalence of and factors associated with under-5 mortality in South Asia.

BACKGROUND: This study investigated the prevalence of and the factors associated with under-5 mortality across five South Asian countries. METHODS: Cross-sectional pooled data from 1999 through 2014 collected from the Demographic and Health Survey (DHS) in five South Asian countries (Bangladesh, India, Maldives, Nepal and Pakistan) were used. Associations of under-5 mortality with sociodemographic characteristics and maternal and child factors were studied using the Cox proportional-hazard method. The estimates were presented as hazard ratios (HR) and their 95% CIs. Kaplan-Meier survival curves were used to describe time-to-event of under-5 survival patterns. RESULTS: Overall, 15-year prevalence of under-5 mortality in South Asian countries was 10%, with Nepal having the highest prevalence (11.1%) and the Maldives the lowest (5%). In a multivariable model in pooled data, older age of mother (HR 0.70, 95% CI 0.68-0.72), being employed (HR 1.09, 95% CI 1.07-1.12), having a higher level of education (HR 0.36, 95%, CI 0.32-0.40) and having a husband with higher level of education (HR 0.74, 95% CI 0.70-0.78) were significantly associated with under-5 mortality. Factors associated with under-5 mortality were mostly common across countries. CONCLUSION: The prevalence of under-5 mortality is still high in South Asia. Most of the studied sociodemographic factors were associated with under-5 mortality and were common across South Asian countries.

WHO/ILO work-related burden of disease and injury: Protocol for systematic reviews of exposure to occupational ergonomic risk factors and of the effect of exposure to occupational ergonomic risk factors on osteoarthritis of hip or knee and selected other musculoskeletal diseases.

BACKGROUND: The World Health Organization (WHO) and the International Labour Organization (ILO) are developing a joint methodology for estimating the national and global work-related burden of disease and injury (WHO/ILO joint methodology), with contributions from a large network of experts. In this paper, we present the protocol for two systematic reviews of parameters for estimating the number of disability-adjusted life years from osteoarthritis of hip or knee, and selected other musculoskeletal diseases respectively, attributable to exposure to occupational ergonomic risk factors to inform the development of the WHO/ILO joint methodology. OBJECTIVES: We aim to systematically review studies on exposure to occupational ergonomic risk factors (Systematic Review 1) and systematically review and meta-analyze estimates of the effect of exposure to occupational ergonomic risk factors on osteoarthritis of the hip or knee, and selected other musculoskeletal diseases respectively (Systematic Review 2), applying the Navigation Guide systematic review methodology as an organizing framework, conducting both systematic reviews in tandem and in a harmonized way. DATA SOURCES: Separately for Systematic Reviews 1 and 2, we will search electronic academic databases for potentially relevant records from published and unpublished studies, including Medline, EMBASE, Web of Science and CISDOC. We will also search electronic grey literature databases, Internet search engines and organizational websites; hand-search reference lists of previous systematic reviews and included study records; and consult additional experts. STUDY ELIGIBILITY AND CRITERIA: We will include working-age (≥15 years) workers in the formal and informal economy in any WHO and/or ILO Member State, but exclude children (<15 years) and unpaid domestic workers. The included occupational ergonomic risk factors will be any exposure to one or more of: force exertion; demanding posture; repetitiveness; hand-arm vibration; lifting; kneeling and/or squatting; and climbing. Included outcomes will be (i) osteoarthritis and (ii) other musculoskeletal diseases (i.e., one or more of: rotator cuff syndrome; bicipital tendinitis; calcific tendinitis; shoulder impingement; bursitis shoulder; epicondylitis medialis; epicondylitis lateralis; bursitis elbow; bursitis hip; chondromalacia patellae; meniscus disorders; and/or bursitis knee). For Systematic Review 1, we will include quantitative prevalence studies of any exposure to occupational ergonomic risk factors stratified by country, gender, age and industrial sector or occupation. For Systematic Review 2, we will include randomized controlled trials, cohort studies, case-control-studies and other non-randomized intervention studies with an estimate of the relative effect of any exposure with occupational ergonomic risk factors on the prevalence or incidence of osteoarthritis and/or selected musculoskeletal diseases, compared with the theoretical minimum risk exposure level (i.e., no exposure). STUDY APPRAISAL AND SYNTHESIS METHODS: At least two review authors will independently screen titles and abstracts against the eligibility criteria at a first stage and full texts of potentially eligible records at a second stage, followed by extraction of data from qualifying studies. At least two review authors will assess risk of bias and the quality of evidence, using the most suited tools currently available. For Systematic Review 2, if feasible, we will combine relative risks using meta-analysis. We will report results using the guidelines for accurate and transparent health estimates reporting (GATHER) for Systematic Review 1 and the preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA) for Systematic Review 2. PROSPERO registration number: CRD42018102631.

Prevalence and factors associated with abortion and unsafe abortion in Nepal: a nationwide cross-sectional study.

BACKGROUND: Abortion is one of the leading causes of maternal death in low- and middle-income countries. In Nepal, abortion is reported to be the third leading cause of maternal death. We aimed to investigate the prevalence and factors associated with abortion and unsafe abortion in Nepal. METHODS: This study is based on a nationally representative sample of the Nepal Demographic and Health Survey 2011. Women who had ever had a terminated pregnancy (n = 2395) were studied. The survey elicited information on the most recent abortion. Unsafe abortion was defined according to the providers of abortion services. Binary logistic regression was used to calculate odds ratios (ORs) and 95% Confidence Intervals (CIs) of abortions and unsafe abortions due to demographic, socio-economic and lifestyle-related characteristics. The interaction of the reason for abortion with age and educational status in predicting unsafe abortion was calculated using the predictive margins and their 95% CI. RESULTS: The five-year prevalence of abortion was 21.1% among women of reproductive age who ever had a terminated pregnancy and 16.0% of total abortions were unsafe. Women of Buddhist religion (OR 2.15; 95% CI 1.04, 4.44), those who were literate (secondary level education OR 1.69; 95% CI 1.22, 2.34), those who knew about legal abortion (OR 1.88; 95% CI 1.41, 2.52) and those who were aware of safe places for abortion services (OR 4.96; 95% CI 3.04, 8.09) were more likely to undergo an abortion. Likewise, women in age group 25-34 years (OR 0.43; 95% CI 0.19, 0.97) and those who were in the richest wealth quintile (OR 0.10; 95% CI 0.04, 0.25) were less likely to undergo an unsafe abortion. Educated women of 25-34 years reporting "health risk" as the reason for abortion had a decidedly lower probability (< 10.0%) than the others of going through the unsafe abortion. CONCLUSIONS: The prevalence of abortion in Nepal remains high. Education, religion, age, knowledge about legal abortion and safe places to undergo abortion were the major decisive factors associated with abortion. Young, poorest and uneducated women were more likely to undergo unsafe abortions. Therefore, intervention studies among these target groups are warranted.

An effort to assess the relation between productivity loss costs and presenteeism at work.

PURPOSE: This study assesses potential presenteeism costs and the association of these with a company's business figures. MATERIALS AND METHODS: We conducted the questionnaire surveys in alternate years between 2003 and 2007 and linked them to sickness absence register data. Perceived work ability levels were assessed and converted into presenteeism days using the Presenteeism Scale tool. Sickness absence and presenteeism days were converted into monetary figures using median monthly salary information. RESULTS: The share of presenteeism costs was constant at about 1% of annual turnover and about 3.7% of personnel costs. The lowest annual presenteeism cost per employee was EUR 986 and the highest was EUR 1302. The lowest number of presenteeism days per employee in a year was 8.7 days and the highest number was 10.4 days. Estimated losses to a company due to sickness absences and presenteeism ranged from EUR 4.6 million to EUR 5.6 million annually. The potential presenteeism costs to the company and to Finnish society were vast. CONCLUSIONS: Presenteeism is a costly problem but more research is needed to reveal the connections between presenteeism and a company's turnover, personnel costs and profit.

National economic and development indicators and international variation in prostate cancer incidence and mortality: an ecological analysis.

BACKGROUND: Macroeconomic indicators are likely associated with prostate cancer (PCa) incidence and mortality globally, but have rarely been assessed. METHODS: Data on PCa incidence in 2003-2007 for 49 countries with either nationwide cancer registry or at least two regional registries were obtained from Cancer Incidence in Five Continents Vol X and national PCa mortality for 2012 from GLOBOCAN 2012. We compared PCa incidence and mortality rates with various population-level indicators of health, economy and development in 2000. Poisson and linear regression methods were used to quantify the associations. RESULTS: PCa incidence varied more than 15-fold, being highest in high-income countries. PCa mortality exhibited less variation, with higher rates in many low- and middle-income countries. Healthcare expenditure (rate ratio, RR 1.46, 95 % CI 1.45-1.47) and population growth (RR 1.15, 95 % CI 1.14-1.16), as well as computer and mobile phone density, were associated with a higher PCa incidence, while gross domestic product, GDP (RR 0.94, 95 % CI 0.93-0.95) and overall mortality (RR 0.72, 95 % CI 0.71-0.73) were associated with a low incidence. GDP (RR 0.55, 95 % CI 0.46-0.66) was also associated with a low PCa mortality, while life expectancy (RR 3.93, 95 % CI 3.22-4.79) and healthcare expenditure (RR 1.20, 95 % CI 1.09-1.32) were associated with an elevated mortality. CONCLUSIONS: Our results show that healthcare expenditure and, thus, the availability of medical resources are an important contributor to the patterns of international variation in PCa incidence. This suggests that there is an iatrogenic component in the current global epidemic of PCa. On the other hand, higher healthcare expenditure is associated with lower PCa death rates.

Changes in work behavior during pregnancy in rural Anhui, China from 2001-03 to 2009: a population based cross-sectional study.

BACKGROUND: In low- and middle-income countries, many women continue working later into pregnancy. In our recent study on some areas in rural China, most women stopped working already during the first trimester (≤3 months) of pregnancy. In this paper we aimed to explore whether stopping work during early pregnancy has changed over an 8 year period (between 2001-03 and 2009); we also studied whether the reasons for stopping work early were the same in the two time periods. METHODS: A population-based cross-sectional survey with a representative sample of new mothers was carried out in one rural county in Anhui Province in 2001-03 (N = 1479 respondents) and in two other rural counties in 2009 (N = 1574 respondents). Both surveys were used to evaluate prenatal care interventions not related to work behavior. The surveys targeted all women who had recently given birth. Multilevel logistic regression analysis was used to examine the determinants of work behavior in the two time periods. RESULTS: There was a big change in the working behavior between the two survey years: in the period 2001-03 6 % and in 2009, 53 % of pregnant women stopped working at ≤3 months (percentage change 839, 95 % CI -15.90 to 1694.49). In 2001-03, 30 % and in 2009, 23 % of pregnant women worked the same as before pregnancy (percentage change -22.30, 95 % CI -90.28 to 45.68). In both time periods women with two children were less likely to stop work at ≤3 months of pregnancy. Non-farmers were more likely in 2001-03 but less likely in 2009 to stop work at ≤3 months of pregnancy. Women with medium township-level income were more likely to maintain the same level of work as before pregnancy in 2001-03, while in 2009 women with high township-level income were less likely to work the same. CONCLUSION: Stopping work very early during pregnancy appeared to have become very common from 2001-3 to 2009 in rural Anhui, China and was not explained by women's background characteristics.

Work-related determinants of multi-site musculoskeletal pain among employees in the health care sector.

BACKGROUND: Work-related musculoskeletal pain is a major occupational problem. Those with pain in multiple sites usually report worse health outcomes than those with pain in one site. OBJECTIVE: This study explored prevalence and associated predictors of multi-site pain in health care sector employees. METHOD: Survey responses from 1348 health care sector employees across three organisations (37% response rate) collected data on job satisfaction, work life balance, psychosocial and physical hazards, general health and work ability. Musculoskeletal discomfort was measured across 5 body regions with pain in ≥ 2 sites defined as multi-site pain. Generalized linear models were used to identify relationships between work-related factors and multi-site pain. RESULTS: Over 52% of the employees reported pain in multiple body sites and 19% reported pain in one site. Poor work life balance (PRR = 2.33, 95% CI = 1.06-5.14). physical (PRR = 7.58, 95% CI = 4.89-11.77) and psychosocial (PRR = 1.59, 95% CI = 1.00-2.57) hazard variables were related to multi-site pain (after controlling for age, gender, health and work ability. Older employees and females were more likely to report multi-site pain. CONCLUSION: Effective risk management of work related multi-site pain must include identification and control of psychosocial and physical hazards.

Women's Autonomy and Skilled Attendance During Pregnancy and Delivery in Nepal.

Objectives This study aims to explore the association between women's autonomy and skilled attendance during pregnancy and delivery in Nepal. Methods We adopt data from the Nepal Demographic and Health Survey (NDHS, 2011). We include only married women who gave birth in the 5 years preceding the survey (N = 4148). Women's autonomy was assessed on the basis of four indicators of decision making: healthcare, visiting friends or relatives, household purchases and spending earned money. Each indicator was dichotomized (yes/no) and then summarized into a single variable to measure overall autonomy. Next, we measured health attendance (skilled vs. unskilled) during antenatal and delivery care. The association between women's autonomy and skilled attendance was analysed using a logistic regression model. Results Most women had a medium (40 %) and high (35 %) level of overall autonomy. The proportion of women accessing skilled providers during antenatal and delivery care was 51 and 36 %. Women with autonomy in healthcare, visiting friends or relatives, making household purchases and spending money earned were associated with a higher likelihood of receiving care from skilled providers during antenatal care and delivery. An elevated probability of access to skilled attendance during antenatal (aOR 1.33; 95 % CI 1.10-1.59) and delivery care (aOR 1.38; 95 % CI 1.12-1.70) was reported among women with higher levels of overall autonomy. Conclusion Women's autonomy was significantly associated with the maternal health care utilization by skilled attendants. This study will provide insights for policy makers to develop strategies in improving maternal health.

Cesarean deliveries among Nepalese mothers: changes over time 2001-2011 and determinants.

OBJECTIVES: To examine the most recent trends of cesarean delivery in Nepal and the association with socio-demographic characteristics of mothers. METHODS: Nationally representative cross-sectional data was used from three Demographic and Health Surveys conducted in Nepal in 2001 (N = 4,745), 2006 (N = 4,066) and 2011 (N = 4,148). Cesarean section delivery was measured in two categories with yes and no responses for the delivery in their latest pregnancy. Data on socio-demographic variables was obtained by interviewing the participants. The data was analysed using logistic regression models. RESULTS: The prevalence of cesarean section delivery was increased by more than 4 times from 2001 to 2011 both among rural and urban residents. After adjusting for mother's age, number of births in last 5 years and mother's education the prevalence of cesarean section delivery among all mothers was 1.71 times higher in 2006 (OR = 1.71, 95 % CI 1.23-2.37) and increased further in 2011 (OR = 2.42, 95 % CI 1.78-3.30) compared with year 2001. When adjusted for all the variables simultaneously, all variables except births in last 5 years remained significantly associated with cesarean section delivery of the mother. Older age, urban resident, being educated, having educated partners and being rich according to wealth index were associated with cesarean section delivery. CONCLUSIONS: The prevalence of cesarean section delivery continues to rise but still lower than the World Health Organization recommended rates. More studies are needed to examine the non-medical reason of increasing rates of cesarean section deliveries and their effect in maternal and infant morbidity and mortality in Nepal.

Utilization of postnatal care among Nepalese women.

This study investigated risk factors associated with the type of birth attendants and timing of postnatal care among a nationally representative sample of Nepalese women. The 2006 Nepalese Demographic and Health Survey on women age 15-49 years old who had delivered within 3 years prior to the survey (N = 4,136) was used. Multivariate logistic regression was employed to study the association between socio-demographic variables and type of birth attendants and timing of postnatal care. Only 23 % deliveries were assisted by skilled attendants. A majority of Nepalese women did not have postnatal check-ups. Education (OR = 1.46, 95 % CI = 1.11-1.92), wealth (OR = 2.57, 95 % CI = 1.59-4.15) and sufficiency of advice during pregnancy (OR = 3.09, 95 % CI = 2.16-4.41), were all independently associated with having postnatal check-ups. Similarly, maternal age, education, parity, wealth, sufficiency of advice and place of delivery were associated with having delivery assisted by a skilled attendant. The utilization of postnatal services is still very low in Nepal. Public health interventions are needed to increase the utilization of postnatal care as well as delivery assisted by skilled attendants. Such interventions should target poor women, the less educated and those in rural areas in Nepal.

Determinants of time of start of prenatal care and number of prenatal care visits during pregnancy among Nepalese women.

This study is aimed at investigating the factors determining the timing of first prenatal care (PNC) visit and the number of PNC visits among a national representative sample of Nepali women. Data was drawn from the 2006 Nepal Demographic and Health Survey on women age 15-49 years old who had delivery within three years prior to the survey (N = 4,136). Multinomial logistic regression was used to study the association between socio-demographic variables and two outcome variables--the timing of first PNC and number of PNC visits. Most of the women (45%) started prenatal care after 3 months of pregnancy while 28% had no care. About 43% of women had 1-3 PNC visits, 29% had more than 3 visits. Age, education, parity and wealth were associated with both the timing of PNC and the number of PNC visits such that older women and those socioeconomically disadvantaged had late and fewer PNC visits compared to the younger ones and those with socioeconomic advantage, respectively. Women with higher parity and those in rural residencies were more likely to delay PNC, have fewer PNC or have no care at all. Majority of Nepali women do not attend prenatal care during the first trimester of pregnancy contrary to the WHO recommendation for women in developing countries. Programmes aimed at improving maternal health in general and participation in PNC in particular should target all Nepali women, especially those: in rural residencies, with no education, with high parity; older women and those from poor households.