Work as a social determinant of health in high-income countries: past, present, and future.

This paper, the first in a three-part Series on work and health, provides a narrative review of research into work as a social determinant of health over the past 25 years, the key emerging challenges in this field, and the implications of these challenges for future research. By use of a conceptual framework for work as a social determinant of health, we identified six emerging challenges: (1) the influence of technology on the nature of work in high-income countries, culminating in the sudden shift to telework during the COVID-19 pandemic; (2) the intersectionality of work with gender, sexual orientation, age, race, ethnicity, migrant status, and socioeconomic status as codeterminants of health disparities; (3) the arrival in many Organisation for Economic Co-operation and Development countries of large migrant labour workforces, who are often subject to adverse working conditions and social exclusion; (4) the development of precarious employment as a feature of many national labour markets; (5) the phenomenon of working long and irregular hours with potential health consequences; and (6) the looming threat of climate change's effects on work. We conclude that profound changes in the nature and availability of work over the past few decades have led to widespread new psychosocial and physical exposures that are associated with adverse health outcomes and contribute to increasing disparities in health. These new exposures at work will require novel and creative methods of data collection for monitoring of their potential health impacts to protect the workforce, and for new research into better means of occupational health promotion and protection. There is also an urgent need for a better integration of occupational health within public health, medicine, the life sciences, and the social sciences, with the work environment explicitly conceptualised as a major social determinant of health.

Health and inclusive labour force participation.

The future of work is rapidly changing, with higher flexibility of the labour market and increasing informal employment in many countries worldwide. There is also an increased pressure to extend working careers until older age. We introduce the concept of working life expectancy as a useful metric, capturing the expected numer of years in paid employment across the working age individuals, in particular among different groups. We describe factors that determine working life expectancy. Macro-level factors focus on the socioeconomic and political context that influences labour force participation, primarily policies and legislation in specific countries. At the meso level, employment contracts and working conditions are important. The micro level shows that individual characteristics, such as education, gender, and age, influence working careers. There are three important groups with a disadvantaged position in the labour market-workers with chronic diseases, workers with impairing disabilities, and workers aged 50 years or more. Within each of these disadvantaged groups, macro-level, meso-level, and micro-level factors that influence entering and exiting paid employment are discussed. To assure that paid employment is available for everyone of working age and that work contributes to better health, specific challenges need to be addressed at the macro, meso, and micro levels. To reach inclusive labour force participation, national policies, company practices, and workplace improvements need to be aligned to ensure safe and healthy workplaces that contribute to the health and wellbeing of workers and their communities.

Sleep quality, sleep duration, and sleep disturbances among hospital night workers: a prospective cohort study.

PURPOSE: This study aimed to assess among hospital night workers (i) to what extent sleep quality, sleep duration and sleep disturbances overlap, and (ii) associations between sociodemographic factors, lifestyle factors and work characteristics and sleep components. METHODS: Data were used from 467 hospital night workers participating in the Klokwerk + study, a prospective cohort study with two measurements. Sleep quality was measured by the Pittsburgh Sleep Quality Index, sleep duration and sleep disturbances were measured by the Medical Outcomes Study Sleep Scale. The overlap between the three sleep measures was visualized with a Venn diagram and the proportions of overlap was calculated. Associations between independent variables (sociodemographic factors, lifestyle factors and work characteristics) and the three sleep outcomes were estimated using between-within Poisson regression models. RESULTS: About 50% of the hospital night workers had at least one poor sleep outcome. Overlap in poor sleep outcomes was apparent for 36.8% of these workers, while the majority had a poor outcome in one of the sleep components only (63.1%). Former smoking had a significant association with poor sleep quality. For most independent variables no associations with poor sleep outcomes were observed. CONCLUSION: Our findings suggest that sleep quality, sleep duration and sleep disturbances are separate entities and should be studied separately. Lifestyle factors and work characteristics were generally not associated with poor sleep. Since these factors can have an acute effect on sleep, future research should consider ecological momentary assessment to examine how exposure and outcomes (co)vary within-persons, over time, and across contexts. Trial registration Netherlands Trial Register trial number NL56022.041.16.

Changing smoking habits and the occurrence of lung cancer in Sweden-a population analysis.

BACKGROUND: The objective is to estimate the importance of the decrease of smoking habits in Sweden for the occurrence of lung cancer. METHODS: The change in smoking habits in the general population was retrieved from surveys and on taxation of sale of cigarettes. We used data from the Swedish Cancer Register on incidence of lung cancer between 1970 and 2021, stratified for sex, age and cell type, and compared the occurrence overtime in ages between 40 and 84 years. RESULTS: The sale of cigarettes peaked in 1980 to 1800 cigarettes per person and decreased to 600 per person in 2021. The change in incidence rates of squamous cell cancer and other cell types varied over time, sex, and age in a pattern that partly seems to be explained by change in the prevalence of daily smokers. The incidence of adenocarcinoma was similar in men and women 1970-2021 and increased, e.g. for women and men 75-79 years of age from around 20 cases in early 1970s to around 120 cases per 100 000 person-years in the 2020s. CONCLUSIONS: Our data indicate that the risk of lung cancer several years after smoking cessation is less favourable than previously studies have indicated. There is a similar increase in the incidence of adenocarcinoma in men and women which is hard to explain only with changing smoking habits. The change from non-filter to filter cigarettes in the 1960s-1970s may be a contributing factor.

Impact of the COVID-19 pandemic on psychosocial work factors and emotional exhaustion among workers in the healthcare sector: a longitudinal study among 1915 Dutch workers.

OBJECTIVES: This study aims to investigate across subgroups of healthcare workers (1) the changes in psychosocial working conditions and emotional exhaustion during the pandemic compared with the situation before, and (2) the impact of different stages of the COVID-19 pandemic in terms of hospital pressure on psychosocial working conditions and emotional exhaustion. METHODS: Five questionnaire measurements during 2 years from 1915 healthcare workers in the longitudinal study 'the Netherlands Working Conditions Survey-COVID-19' were used. At each measurement, three subgroups were defined: working with patients with COVID-19, working with other patients and not working with patients. For each measurement, hospital pressure was determined by number of hospitalisations per day. Linear mixed models were fitted to analyse differences across subgroups of healthcare workers. RESULTS: During COVID-19, psychosocial working conditions deteriorated among healthcare workers working with patients, in particular with patients with COVID-19, compared with healthcare workers not working with patients after correcting for the situation before COVID-19. No changes were observed for emotional exhaustion in any of the subgroups. An increasing hospital pressure improved job autonomy and reduced emotional demands among healthcare workers in COVID-19 wards, but had no influence on other psychosocial working conditions and emotional exhaustion. CONCLUSION: Psychosocial working conditions deteriorated for healthcare workers working with (COVID-19) patients during the pandemic, while emotional exhaustion did not change among all groups of healthcare workers.

The relationship between having a job and the outcome of brief therapy in patients with common mental disorders.

BACKGROUND: Previous studies have shown that being employed is associated not only with patients' health but also with the outcome of their treatment for severe mental illness. This study examined what influence employment had on improvements in mental health and functioning among patients with common mental disorders who received brief treatment and how patients' diagnosis, environmental and individual factors moderated the association between being employed and treatment outcome. METHODS: The study used naturalistic data from a cohort of patients in a large mental health franchise in the Netherlands. The data were obtained from electronic registration systems, intake questionnaires and Routine Outcome Monitoring (ROM). The International Classification of Functioning, Disability and Health (ICF) framework was used to identify potential subgroups of patients. Logistic regression models were used to analyze the relationship between employment status and treatment outcome and to determine how the relationship differed among ICF subgroups of patients. RESULTS: A strong relationship was found between employment status and the outcome of brief therapy for patients with common mental disorders. After potential confounding variables had been controlled, patients who were employed were 54% more likely to recover compared to unemployed patients. Two significant interactions were identified. Among patients who were 60 years of age or younger, being employed was positively related to recovery, but this relationship disappeared in patients older than 60 years. Second, among patients in all living situations there was a positive effect of being employed on recovery, but this effect did not occur among children (18+) who were living with a single parent. CONCLUSIONS: Being employed was positively associated with treatment outcome among both people with a severe mental illness and those with a common mental disorder (CMD). The main strength of this study was its use of a large dataset from a nationwide franchised company. Attention to work is important not only for people with a severe mental illness, but also for people with a CMD. This means that in addition to re-integration methods that focus on people with a severe mental illness, more interventions are needed for people with a CMD.

Reach and effectiveness of a worksite health promotion program combining a preventive medical examination with motivational interviewing; a quasi-experimental study among workers in low socioeconomic position.

BACKGROUND: This study aimed to evaluate individual characteristics associated with participation and effectiveness of a worksite health promotion program with motivational interviewing targeting health and health behaviour among Dutch workers in low socioeconomic position. METHODS: In a production company and a hospital, 838 workers were invited for a Preventive Medical Examination and subsequent coaching with motivational interviewing up to 7 sessions within 6 months. Follow-up information was collected after 6 months. Characteristics associated with participation in coaching were assessed with logistic regression models. The effectiveness of coaching on body mass index (BMI), bodyweight, self-rated health, vigorous physical activity, smoking, alcohol intake, fruit- and vegetable consumption, work ability, and sickness absence was evaluated with linear regression models and on participation in health promotion activities with logistic regression analysis. The analyses on effectiveness were performed without and with propensity score adjustment. RESULTS: Of the 838 invited workers, 313 workers participated in the Preventive Medical Examination and follow-up data were available for 176 workers, of whom 100 workers with increased cardiovascular risk attended coaching. The majority of workers with obesity (73%), overweight (60%), and unhealthy behaviours (58%-69%) at baseline participated in motivational interviewing. Males, workers with overweight or obesity, workers at the production company, workers with insufficient vigorous physical activity, and workers with a low educational level were most likely to participate in coaching. Coaching with motivational interviewing after the Preventive Medical Examination was associated with a 4.74 times higher likelihood [95% confidence interval (CI): 1.99;11.32] to participate in health promotion activities and 10.9% (95%CI: 0.6;21.3) more persons who quit smoking compared to workers without coaching. No statistically significant effects were observed on BMI, bodyweight, health, health behaviour, work ability and sickness absence. CONCLUSIONS: The program combining a Preventive Medical Examination with follow-up coaching reached - as intended - workers with obesity or overweight, those with a low education and with unhealthy behaviours. Adding coaching with motivational interviewing to a Preventive Medical Examination contributed to higher participation in health promotion activities and an increase in smoking cessation after 6 months among workers with a lower socioeconomic position, but was not effective on other outcomes. TRIAL REGISTRATION: The study was registered retrospectively in the Netherlands Trial Register as NL8178 on 22/11/2019.

Exposure to hand-arm vibrations in the workplace and the occurrence of hand-arm vibration syndrome, Dupuytren's contracture, and hypothenar hammer syndrome: a systematic review and meta-analysis.

This study provides an overview of the relationships between exposure to work-related hand-arm vibration and the occurrence of pre-defined disorders of the hands. We searched Medline, Embase, Web of Science, Cochrane Central, and PsycINFO for cross-sectional and longitudinal studies on the association between work-related vibration exposure and the occurrence of hand-arm vibration syndrome (including vibration-induced white finger), Dupuytren's contracture, or hypothenar hammer syndrome. We used a 16-item checklist for assessing the risk of bias. We present results narratively, and we conducted random effects meta-analyses if possible. We included 10 studies with more than 24,381 participants. Our results showed statistically significant associations between the exposure to hand-arm vibrations and the occurrence of the selected disorders, with pooled odds ratios ranging between 1.35 (95% CI: 1.28 to 2.80) and 3.43 (95% CI: 2.10 to 5.59). Considerable between-study heterogeneity was observed. Our analyses show that exposure to vibrating tools at work is associated with an increased risk for the occurrence of selected disorders of the hands. Due to the majority of studies being cross-sectional, no firm conclusion is possible regarding causal relationships between vibration exposure and disorder occurrence. Future research should specifically address whether reducing exposure to hand-held vibrating tools at work reduces the incidence of the disorders of the hands investigated in this systematic review.

Socio-economic determinants of healthcare costs in early life: a register-based study in the Netherlands.

BACKGROUND: Children with low socioeconomic status (SES) have an increased risk of a suboptimal start in life with ensuing higher healthcare costs. This study aims to investigate the effects of individual- (monthly household income) and contextual-level SES (household income and neighborhood deprivation), and perinatal morbidity (preterm birth and small for gestational age ((<10th percentile), SGA)) on healthcare costs in early life (0-3 years of age). METHODS: Individual-linked data from three national registries (Perinatal Registry Netherlands, Statistics Netherlands, and Healthcare Vektis) were obtained of all children born between 2011 and 2014 (N = 480,471) in the Netherlands. Binomial logistic regression was used to model annual healthcare costs as a function of their household income (per €1000), neighborhood deprivation index (range - 13.26 - 10.70), their perinatal morbidity and demographic characteristics. Annual healthcare cost were dichotomized into low healthcare costs (Q1-Q3 below €1000) and high healthcare costs (Q4 €1000 or higher). RESULTS: Children had a median of €295 annual healthcare costs, ranging from €72 to €4299 (5-95%). Binomial logistic regression revealed that for every €1000 decrease in monthly household income, the OR for having high healthcare costs is 0.99 (0.99-0.99). Furthermore, for every one-unit increase in neighborhood deprivation the OR for having high healthcare costs increase 1.02 (1.01-1.02). Finally, the model revealed an OR of 2.55 (2.48-2.61) for preterm born children, and an OR of 1.44 (1.41-1.48) for children SGA, to have high healthcare costs compared to their healthy peers. CONCLUSION: More neighborhood deprivation was directly related to higher healthcare costs in young children. On top of this, lower household income was consistently and independently related to higher healthcare costs. By optimizing conditions for low SES populations, the impact of low SES circumstances on their healthcare costs can be positively influenced. Additionally, policies that influence more timely and appropriate healthcare use in low SES populations can reduce healthcare costs further.

The association of specific industry-related air pollution with occurrence of chronic diseases: A register-based study.

Air pollution may contribute to onset and progression of chronic diseases such as cardiovascular and respiratory diseases. Most studies have focused on the contribution of traffic-related exposure to PM10 or PM2.5. Our aim was to investigate the association of different components of industry-related air pollution on the occurrence of chronic diseases. A register-based repeated cross-sectional study was conducted among 89,714 subjects (2012) with 536,599 annual observations (2012-2017) living in the vicinity of a large industrial area in the Netherlands. Information from the dispensed medication registration was linked with a dispersion model to characterize annual individual-level exposure of all subjects at place of residence. Associations between annual exposure (concentration and duration) to particulate matter (PM10), nitrogen oxides (NOX), sulphur dioxide (SO2), and volatile organic compounds (VOC) with annual dispensed medication for cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions were investigated by multivariate logistic regression analysis with generalized estimating equations (GEE) while controlling for confounders. Exposure to PM10 and to NOX (per µg/m3) were significantly associated with medication for cardiovascular diseases (OR 1.06, 95CI% 1.06-1.06 and OR 1.01, 95%CI 1.01-1.01 respectively). Exposures to PM10 and SO2 (per µg/m3) were significantly associated with medication for inflammatory conditions (OR 1.05, 95%CI 1.00-1.09 and OR 1.07, 95%CI 1.01-1.14 respectively). Exposure to SO2 was inversely associated with respiratory diseases (OR 0.91, 95%CI 0.86-0.97). Except for inflammatory conditions, exposure duration (years) was significantly associated with the other three chronic diseases (OR varying from 1.01 to 1.03). This study indicates that specific air pollution components caused by industry may contribute to the occurrence of cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions.

Needs and preferences of women with prior severe preeclampsia regarding app-based cardiovascular health promotion.

BACKGROUND: Women with prior severe preeclampsia are at an increased risk for cardiovascular diseases later in life compared to women who had a normotensive pregnancy. The objective of this study was to assess their needs and preferences regarding app-based cardiovascular health promotion. METHODS: Patients (n = 35) of the Follow-Up PreEClampsia Outpatient Clinic (FUPEC), Erasmus MC, the Netherlands, participated in an anonymous online survey. The main outcomes under study were women's needs for health behavior promotion, and their preferences with respect to intervention delivery. Descriptive statistics were used to evaluate needs, and thematic analysis was used to analyze preferences. RESULTS: Women's primary need for health behavior promotion pertained to their fat and sugar intake and physical activity; for some, to their mental health (practices), fruit and vegetable intake, salt intake, and water intake; and for a few, to their alcohol and tobacco use. Most women preferred an app-based intervention to include, in descending order: the tracking of health-related metrics, an interactive platform, the use of behavior change strategies, the provision of information, and personalization. CONCLUSION: Cardiovascular health promotion targeting women with prior severe preeclampsia should feel relevant to its audience. App-based interventions are likely to be well received if they target fat and sugar intake and physical activity. These interventions should preferably track health-related metrics, be interactive, contain behavior change strategies, provide information, and be personalized. Adopting these findings during intervention design could potentially increase uptake, behavior change, and behavior change maintenance in this population.

The Effect of Written and Video Discharge Instructions After Mild Traumatic Brain Injury on Healthcare Costs and Productivity Costs.

OBJECTIVE: To compare healthcare and productivity costs between patients with mild traumatic brain injury (mTBI) who received verbal discharge instructions only and patients who received an additional flyer with or without video instructions. SETTING: Emergency departments (EDs) of 6 hospitals in the Netherlands. PARTICIPANTS: In total, 1155 adult patients with mTBI (384 with verbal instructions; 771 with additional flyer with or without video instructions) were included. DESIGN: Cost study with comparison between usual care and intervention. METHODS: Medical and productivity costs up to 3 months after presentation at the ED were compared between mTBI patients with usual care and mTBI patients who received the intervention. RESULTS: Mean medical costs per mTBI patient were slightly higher for the verbal instructions-only cohort (€337 vs €315), whereas mean productivity costs were significantly higher for the flyer/video cohort (€1625 vs €899). Higher productivity costs were associated with higher working age, injury severity, and postconcussion symptoms. CONCLUSION: This study showed that the implementation of flyer (and video) discharge instructions for patients with mTBI who present at the ED increased reports of postconcussion symptoms and reduced medical costs, whereas productivity costs were found to be higher for the working population in the first 3 months after the sustained head injury.

Study design of PerfectFit@Night, a workplace health promotion program to improve sleep, fatigue, and recovery of night shift workers in the healthcare sector.

BACKGROUND: Healthcare workers need to be at work 24 h a day to ensure continuity of care in hospitals. However, shift work - particularly night shifts - can have negative acute and long-term effects on health and productivity due to disturbances in the circadian rhythm. Shift work is also associated with unhealthy lifestyle behaviors such as poor sleep hygiene and diet. The PerfectFit@Night intervention aims to improve sleep and recovery, and reduce fatigue, and therewith contribute to sustainable employability of healthcare workers. The current study describes the intervention and the evaluation and implementation. METHODS: The study population will consist of healthcare workers, nurses and physicians, with night shifts in a large Dutch academic hospital. The intervention consists of individual and environmental intervention elements: i) an e-learning for healthcare workers to increase knowledge and awareness on a healthy lifestyle during night shifts, ii) a powernap bed to take powernaps during night shifts, iii) the availability of healthy food at the department during night shifts, iv) a workshop on healthy rostering at the level of the department, and v) individual sleep coaching among the high risk group. In a longitudinal prospective study, data will be collected 1 month before the start of the intervention, in the week before the start of the intervention, and three and 6 months after the start of the intervention. The primary outcomes are sleep, fatigue, and need for recovery. The implementation process will be evaluated using the framework of Steckler and Linnan. Cost-benefit analyses from the employers perspective will be conducted to understand the possible financial consequences or benefits of the implementation of PerfectFit@Night. DISCUSSION: The feasibility and effectiveness of this workplace health promotion program will be investigated by means of an effect, process and economic evaluation. If proven effective, PerfectFit@Night can be implemented on a larger scale within the healthcare sector. TRIAL REGISTRATION: Netherlands Trial Register trial number NL9224 . Registered 17 January 2021.

Development and validation of a prediction model for unemployment and work disability among 55 950 Dutch workers.

BACKGROUND: This study developed prediction models for involuntary exit from paid employment through unemployment and disability benefits and examined if predictors and discriminative ability of these models differ between five common chronic diseases. METHODS: Data from workers in the Lifelines Cohort Study (n = 55 950) were enriched with monthly information on employment status from Statistics Netherlands. Potential predictors included sociodemographic factors, chronic diseases, unhealthy behaviours and working conditions. Data were analyzed using cause-specific Cox regression analyses. Models were evaluated with the C-index and the positive and negative predictive values (PPV and NPV, respectively). The developed models were externally validated using data from the Study on Transitions in Employment, Ability and Motivation. RESULTS: Being female, low education, depression, smoking, obesity, low development possibilities and low social support were predictors of unemployment and disability. Low meaning of work and low physical activity increased the risk for unemployment, while all chronic diseases increased the risk of disability benefits. The discriminative ability of the models of the development and validation cohort were low for unemployment (c = 0.62; c = 0.60) and disability benefits (c = 0.68; c = 0.75). After stratification for specific chronic diseases, the discriminative ability of models predicting disability benefits improved for cardiovascular disease (c = 0.81), chronic obstructive pulmonary disease (c = 0.74) and diabetes mellitus type 2 (c = 0.74). The PPV was low while the NPV was high for all models. CONCLUSION: Taking workers' particular disease into account may contribute to an improved prediction of disability benefits, yet risk factors are better examined at the population level rather than at the individual level.

Organophosphate and carbamate insecticide exposure is related to lung function change among smallholder farmers: a prospective study.

INTRODUCTION AND AIM: Exposure to some insecticides may cause airway obstruction, but existing evidence is limited by cross-sectional designs and inadequate confounder control. We investigated the relation between organophosphate and carbamate insecticides and pulmonary function in a prospective study accounting for important confounders. METHODS: In a cohort of 364 smallholder farmers in Uganda (69% women), participants underwent pre-bronchodilator spirometry at baseline (September/October 2018) and at two follow-up visits (November/December 2018 and January/February 2019). Exposure to carbamate and organophosphate insecticides was assessed using haemoglobin-adjusted erythrocyte acetylcholinesterase (AChE/Hb). Less than 3% of participants were lost to follow-up. We calculated Z-scores for FEV1, FVC and FEV1/FVC using the Global Lung Function Initiative equations. Data were analysed in linear mixed and fixed effect models accounting for family relationships and repeated measures of exposure and outcome. RESULTS: Low AChE/Hb was significantly associated with low FEV1 Z-score in both unadjusted and adjusted analyses. Compared with individuals with AChE/Hb 25.90 U/g (50th percentile, reference), those with lower AChE/Hb 24.50 U/g (35th percentile) had mean FEV1 Z-score 0.045 (0.003 to 0.087) lower, and persons with higher AChE/Hb 27.30 U/g (65th percentile) had a mean FEV1 Z-score 0.043 (-0.002 to 0.087) higher compared with the reference. Similar, but numerically smaller and statistically non-significant effects were seen for Z-scores of FVC and FEV1/FVC. CONCLUSION: Exposure to organophosphate and carbamate insecticides may lead to lung function decline. Our results add to the growing evidence of health effects in relation to exposure to organophosphate and carbamate insecticides, underlining the importance of minimising exposure.

Socioeconomic inequalities in the food environment and body composition among school-aged children: a fixed-effects analysis.

BACKGROUND: There is limited evidence regarding socioeconomic inequalities of exposure to the food environment and its contribution to childhood obesity. METHODS: We used data from 4235 children from the Generation R Study, a large birth-cohort conducted in the city of Rotterdam, The Netherlands. We included 11,277 person-observations of body mass index (BMI) and 6240 person-observations of DXA-derived fat mass index (FMI) and fat-free mass index (FFMI) when children were between 4 and 14 years. We applied linear regression models to evaluate changes in the relative and absolute exposure of fast-food outlets, and the healthiness of the food environment within 400 m from home by maternal education. Furthermore, we used individual-level fixed-effects models to study changes in the food environment to changes in BMI, FMI and FFMI. RESULTS: Children from lower educated mothers were exposed to more fast-food outlets at any time-point between the age of 4 and 14 years. Over a median period of 7.1 years, the absolute (0.6 fast-food outlet (95% CI: 0.4-0.8)) and relative (2.0%-point (95% CI: 0.7-3.4)) amount of fast-food outlets increased more for children from lower as compared to higher educated mothers. The food environment became more unhealthy over time, but no differences in trends were seen by maternal education level. Changes in the food environment were not associated with subsequent changes in BMI, FMI and FFMI. For children from lower educated mothers not exposed to fast-food at first, we found some evidence that the introduction of fast-food was associated with small increases in BMI. CONCLUSIONS: Our findings provide evidence of widening inequalities in exposure to fast-food in an already poor food environment. Access to more fast-food outlets does not seem to have an additional impact on BMI in contemporary contexts with ubiquitous fast-food outlets.

A framework for exploring non-response patterns over time in health surveys.

BACKGROUND: Most health surveys have experienced a decline in response rates. A structured approach to evaluate whether a decreasing - and potentially more selective - response over time biased estimated trends in health behaviours is lacking. We developed a framework to explore the role of differential non-response over time. This framework was applied to a repeated cross-sectional survey in which the response rate gradually declined. METHODS: We used data from a survey conducted biannually between 1995 and 2017 in the city of Rotterdam, The Netherlands. Information on the sociodemographic determinants of age, sex, and ethnicity was available for respondents and non-respondents. The main outcome measures of prevalence of sport participation and watching TV were only available for respondents. The framework consisted of four steps: 1) investigating the sociodemographic determinants of responding to the survey and the difference in response over time between sociodemographic groups; 2) estimating variation in health behaviour over time; 3) comparing weighted and unweighted prevalence estimates of health behaviour over time; and 4) comparing associations between sociodemographic determinants and health behaviour over time. RESULTS: The overall response rate per survey declined from 47% in 1995 to 15% in 2017. The probability of responding was higher among older people, females, and those with a Western background. The response rate declined in all subgroups, and a faster decline was observed among younger persons and those with a non-Western ethnicity as compared to older persons and those with a Western ethnicity. Variation in health behaviours remained constant. Prevalence estimates and associations did not follow the changes in response over time. On the contrary, the difference in probability of participating in sport gradually decreased between males and females, while no differential change in the response rate was observed. CONCLUSIONS: Providing insights on non-response patterns over time is essential to understand whether declines in response rates may have influenced estimated trends in health behaviours. The framework outlined in this study can be used for this purpose. In our example, in spite of a major decline in response rate, there was no evidence that the risk of non-response bias increased over time.

Effect of Video Discharge Instructions for Patients With Mild Traumatic Brain Injury in the Emergency Department: A Randomized Controlled Trial.

STUDY OBJECTIVE: We measure the effect of video discharge instructions on postconcussion symptoms in patients with mild traumatic brain injury in the emergency department. METHODS: A multicenter randomized controlled trial was conducted in which patients with mild traumatic brain injury were randomly assigned to either intervention (verbal, written, and video discharge information) or control (verbal and written discharge information only). All patients were interviewed 1 week and 3 months from randomization. Primary outcome measure was the Rivermead Post-Concussion Symptoms Questionnaire at 3 months. Secondary outcomes were correct recall, Hospital Anxiety and Depression Scale score, health-related quality of life (12-Item Short Form Health Survey), return visits, and patient satisfaction. RESULTS: A total of 2,883 patients were assessed for eligibility, of whom 381 were included in the control group and 390 in the video intervention group. Difference in mean total Rivermead Post-Concussion Symptoms Questionnaire score between the 2 groups was 0.2 at 1 week and 0.3 at 3 months after traumatic brain injury (estimated effect -0.7; 95% confidence interval -2.1 to 0.7). There was also no difference in Hospital Anxiety and Depression Scale score, recall, 12-Item Short Form Health Survey score, return visits, and patient satisfaction between the control and intervention group. CONCLUSION: Severity of postconcussion symptoms in patients with mild traumatic brain injury did not improve by adding video information to standard care. Also, there was no difference in recall, health-related quality of life, return visits, and patient satisfaction between the control and intervention groups.

Socioeconomic inequalities in effectiveness of and compliance to workplace health promotion programs: an individual participant data (IPD) meta-analysis.

BACKGROUND: This individual patient data (IPD) meta-analysis aimed to investigate socioeconomic inequalities in effectiveness on healthy behavior of, and compliance to, workplace health promotion programs. METHODS: Dutch (randomized) controlled trials were identified and original IPD were retrieved and harmonized. A two-stage meta-analysis was conducted where linear mixed models were performed per study (stage 1), after which individual study effects were pooled (stage 2). All models were adjusted for baseline values of the outcomes, age and gender. Intervention effects were assessed on physical activity, diet, alcohol use, and smoking. Also, we assessed whether effects differed between participants with low and high program compliance and. All analyses were stratified by socioeconomic position. RESULTS: Data from 15 studies (n = 8709) were harmonized. Except for fruit intake (beta: 0·12 [95% CI 0·08 0·15]), no effects were found on health behaviors, nor did these effects differ across socioeconomic groups. Only participants with high compliance showed significant improvements in vigorous and moderate-to-vigorous physical activity, and in more fruit and less snack intake. There were no differences in compliance across socioeconomic groups. CONCLUSIONS: Workplace health promotion programs were in general not effective. Neither effectiveness nor compliance differed across socioeconomic groups (operationalized by educational level). Even though stronger effects on health behavior were found for participations with high compliance, effects remained small. The results of the current study emphasize the need for new directions in health promotion programs to improve healthy behavior among workers, in particular for those in lower socioeconomic position.

The influence of unhealthy behaviours on early exit from paid employment among workers with a chronic disease: A prospective study using the Lifelines cohort.

OBJECTIVES: This study examined the risk of unhealthy behaviours and the additive effects of multiple unhealthy behaviours on exit from paid employment among workers with a chronic disease and investigated effect modification by gender and educational level. METHODS: Data from the Lifelines cohort, collected between 2006 and 2013, were enriched with registry data from Statistics Netherlands with up to 11 years follow-up. Workers with a chronic disease were selected (n = 11,467). The influence of unhealthy behaviours (physical inactivity, smoking, unhealthy diet, high alcohol intake, and obesity) on exit from paid employment (unemployment, disability benefits, early retirement, and economic inactivity) was examined using competing risk models. To examine effect modification by gender and educational level, interaction terms were added. RESULTS: Smoking and low fruit intake increased the risk to exit paid employment through unemployment and disability benefits. Low vegetable intake increased the risk of unemployment, obesity the risk of receiving disability benefits, and high alcohol intake the risk of early retirement. Physical inactivity was not associated with any exit from paid employment. Having multiple unhealthy behaviours increased the risk of both unemployment and of receiving disability. No consistent effect modification for gender or educational level was found. CONCLUSIONS: Unhealthy behaviours increased the risk to exit paid employment through unemployment and disability benefits among workers with a chronic disease, and this risk increased when having multiple unhealthy behaviours. Health promotion to support workers with chronic diseases to make healthier choices may help to extend their working life.