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OBJECTIVE: This study aimed to compare the utility of risk estimation derived from questionnaires and administrative records in predicting long-term sickness absence among shift workers.METHODS: This prospective cohort study comprised 3197 shift-working hospital employees (mean age 44.5 years, 88.0% women) who responded to a brief 8-item questionnaire on work disability risk factors and were linked to 28 variables on their working hour and workplace characteristics obtained from administrative registries at study baseline. The primary outcome was the first sickness absence lasting ≥90 days during a 4-year follow-up.RESULTS: The C-index of 0.73 [95% confidence interval (CI) 0.70–0.77] for a questionnaire-only based prediction model, 0.71 (95% CI 0.67–0.75) for an administrative records-only model, and 0.79 (95% CI 0.76–0.82) for a model combining variables from both data sources indicated good discriminatory ability. For a 5%-estimated risk as a threshold for positive test results, the detection rates were 76%, 74%, and 75% and the false positive rates were 40%, 45% and 34% for the three models. For a 20%-risk threshold, the corresponding detection rates were 14%, 8%, and 27% and the false positive rates were 2%, 2%, and 4%. To detect one true positive case with these models, the number of false positive cases accompanied varied between 7 and 10 using the 5%-estimated risk, and between 2 and 3 using the 20%-estimated risk cut-off. The pattern of results was similar using 30-day sickness absence as the outcome.CONCLUSIONS: The best predictive performance was reached with a model including both questionnaire responses and administrative records. Prediction was almost as accurate with models using only variables from one of these data sources. Further research is needed to examine the generalizability of these findings.

OBJECTIVE: In terms of prevention, it is important to determine effects on cardiovascular disease (CVD) when some workplace psychosocial resources are high while others are low. The aim of the study was to assess the prospective relationship between clustering of workplace psychosocial resources and risk of CVD among employees. METHODS: We pooled data from three cohort studies of 135 669 employees (65% women, age 18–65 years and free of CVD) from Denmark, Finland and Sweden. Baseline horizontal resources (culture of collaboration and support from colleagues) and vertical resources (leadership quality and procedural justice) were measured using standard questionnaire items. Incident CVD, including coronary heart and cerebrovascular disease, was ascertained using linked electronic health records. We used latent class analysis to assess clustering (latent classes) of workplace psychosocial resources. Cox proportional hazard models were used to examine the association between these clusters and risk of CVD, adjusting for demographic and employment-related factors and pre-existing physical and mental disorders. RESULTS: We identified five clusters of workplace psychosocial resources from low on both vertical and horizontal resources (13%) to generally high resources (28%). High horizontal resources were combined with either intermediate [hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.74–0.95] or high (HR 0.88, 95% CI 0.78–1.00) vertical resources were associated with lower risks of CVD compared to those with generally low resources. The association was most prominent for cerebrovascular disease (eg, general high resources: HR 0.80, 95% CI 0.67–0.96). CONCLUSIONS: Individuals with high levels of workplace psychosocial resources across horizontal and vertical dimensions have a lower risk of CVD, particularly cerebrovascular disease.

OBJECTIVE: Whether perceived job insecurity increases the risk of suicidal behaviors is unclear. Improved understanding in this area could inform efforts to reduce suicide risk among those experiencing elevated job insecurity during the COVID-19 pandemic as well as post-pandemic. We aimed to investigate if perceived job insecurity predicted increased risk of suicide mortality and suicide attempts. METHOD: Employees (N=65 571), representative of the Swedish working population who participated in the Swedish Work Environment Survey in 1991–2003, were followed up through 2016 in the National Inpatient and Death Registers. Suicide deaths and suicide attempts were defined according to International Classification of Diseases (ICD) 10 and ICD-8/9 codes of underlying cause of death and in-/outpatient care. Job insecurity and subsequent risk of suicide and suicide attempt were investigated with marginal structural Cox regression analyses and inverse probability of treatment weighting to control for confounding. RESULTS: Perceived job insecurity was associated with an elevated risk of suicide [hazard ratio (HR) 1.51, 95% confidence interval (CI) 1.03–2.20], but not with incident suicide attempts (HR 1.03, CI 0.86–1.24). Estimates remained similar after considering prevalent/previous poor mental health, other work factors, and when restricting the follow up time to ten years. CONCLUSION: The study suggests that job insecurity is associated with an increased risk of suicide mortality. Concerns about elevated job insecurity and suicide levels in the wake of the current pandemic could thus be considered in strategies to reduce the population health impact job insecurity both during and following the COVID-19 pandemic.

OBJECTIVES: Data mining can complement traditional hypothesis-based approaches in characterizing unhealthy work exposures. We used it to derive a hypothesis-free characterization of working hour patterns in shift work and their associations with sickness absence (SA). METHODS: In this prospective cohort study, complete payroll-based work hours and SA dates were extracted from a shift-scheduling register from 2008 to 2019 on 6029 employees from a hospital district in Southwestern Finland. We applied permutation distribution clustering to time series of successive shift lengths, between-shift rest periods, and shift starting times to identify clusters of similar working hour patterns over time. We examined associations of clusters spanning on average 23 months with SA during the following 23 months. RESULTS: We identified eight distinct working hour patterns in shift work: (i) regular morning (M)/evening (E) work, weekends off; (ii) irregular M work; (iii) irregular M/E/night (N) work; (iv) regular M work, weekends off; (v) irregular, interrupted M/E/N work; (vi) variable M work, weekends off; (vii) quickly rotating M/E work, non-standard weeks; and (viii) slowly rotating M/E work, non-standard weeks. The associations of these eight working-hour clusters with risk of future SA varied. The cluster of irregular, interrupted M/E/N work was the strongest predictor of increased SA (days per year) with an incidence rate ratio of 1.77 (95% confidence interval 1.74–1.80) compared to regular M/E work, weekends off. CONCLUSIONS: This data-mining suggests that hypothesis-free approaches can contribute to scientific understanding of healthy working hour characteristics and complement traditional hypothesis-driven approaches.

OBJECTIVES: This study aimed to examine the contribution of shift work, work time control (WTC) and informal caregiving, separately and in combination, to sleep disturbances in ageing employees. METHODS: Survey data were obtained from two prospective cohort studies with repeated measurements of working conditions, informal caregiving, and sleep disturbances. We used fixed-effect conditional logistic regression analysis to examine whether within-individual changes in shift work, WTC and informal caregiving were associated with changes in sleep. Secondary analyses included between-individuals comparison using standard logistic regression models. Results from the two cohorts were pooled using meta-analysis. RESULTS: Low WTC and informal caregiving were associated with sleep disturbances in within-individual analyses [odds ratios (OR) ranging between 1.13 (95% confidence interval 1.01–1.27) and 1.48 (95% CI 1.29–1.68)] and in between-individuals analyses [OR 1.14 (95% CI 1.03–1.26) to 1.33 (1.19–1.49)]. Shift work alone was not associated with sleep disturbances, but accumulated exposure to shift work, low WTC and informal caregiving was associated with higher risk of sleep disturbances (OR range 1.21–1.76). For some of the sleep outcomes, informal caregiving was related to a higher risk of sleep disturbances when WTC was low and a lower risk when WTC was high. CONCLUSIONS: Informal caregiving and low WTC are associated with risk of sleep disturbances among ageing employees. The findings also suggest that low WTC in combination with informal caregiving may increase the risk of sleep disturbances whereas high WTC may alleviate the adverse impact of informal caregiving on sleep.

OBJECTIVES: Attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders (ASD) and learning disabilities (LD) have an early onset and often persist into adulthood, although their relative contribution to incapacity for work is unclear. We examined this issue among young adults with ADHD, ASD or LD taking into account socioeconomic factors and comorbid mental disorders. METHODS: Recorded diagnoses between the ages of 10–35 years between 2001 and 2010 were derived from nationwide inpatient and specialized outpatient hospital registers in Sweden. We identified 15 632 individuals with a main diagnosis of ADHD, 8238 with ASD, and 1038 with LD, and the matched control group without recorded mental disorders (N=124 536). The outcome was the number of register-based sickness absence and work disability pension (SA-DP) days during a maximum of three years follow-up. RESULTS: Among men, the rate ratio (RR) of SA-DP was 11.17 [95% confidence interval (CI) 9.89–12.60] for ADHD, 35.59 (95% CI 30.30–41.81) for ASD, and 9.20 (95% CI 5.76–14.70) for LD, in comparison to those in the reference group. The corresponding risks among women were RR 12.05 (95% CI 10.30–14.09) for ADHD, RR 28.36 (95% CI 22.96–35.02) for ASD, and RR 9.60 (95% CI 5.83–15.81) for LD. The findings were, to a large extent, similar when individuals on DP at baseline were excluded. Comorbid mental disorders further increased the risk of SA-DP. Educational differences were smaller among the patients than in the reference group. CONCLUSIONS: Early-onset neurodevelopmental disorders, particularly with comorbidity, have a far-reaching impact on adult life in terms of SA and DP.

OBJECTIVES: We examined the extent to which an increase in physical activity would reduce the excess risk of work disability among overweight and obese people (body mass index ≥ 25kg/m^2). METHODS: We used counterfactual modelling approaches to analyze longitudinal data from two Finnish prospective cohort studies (total N=38 744). Weight, height and physical activity were obtained from surveys and assessed twice and linked to electronic records of two indicators of long-term work disability (≥90-day sickness absence and disability pension) for a 7-year follow-up after the latter survey. The models were adjusted for age, sex, socioeconomic status, smoking, and alcohol consumption. RESULTS: The confounder-adjusted hazard ratio (HR) of long-term sickness absence for overweight compared to normal-weight participants was 1.43 [95% confidence interval (CI) 1.35–1.53]. An increase in physical activity among overweight compared to normal-weight individuals was estimated to reduce this HR to 1.40 (95% CI 1.31–1.48). In pseudo-trial analysis including only the persistently overweight, initially physically inactive participants, the HR for long-term sickness absence was 0.82 (95% CI 0.70–0.94) for individuals with increased physical activity compared to those who remained physically inactive. The results for disability pension as an outcome were similar. CONCLUSIONS: These findings suggest that the excess risk of work disability among overweight individuals would drop by 3–4% if they increased their average physical activity to the average level of normal-weight people. However, overweight individuals who are physically inactive would reduce their risk of work disability by about 20% by becoming physically active.

OBJECTIVES: Bi-directional associations between perceived effort‒reward imbalance (ERI) at work and neck-shoulder pain have been reported. There is also evidence of associations between ERI and depressive symptoms, and between depressive symptoms and pain while the links between ERI, depressive symptoms and pain have not been tested. We aimed to assess whether depressive symptoms mediate the association between ERI and neck-shoulder pain, as well as the association between neck-shoulder pain and ERI. METHODS: We used prospective data from three consecutive surveys of the Swedish Longitudinal Occupational Survey of Health (SLOSH) study. ERI was assessed with a short version of the ERI questionnaire, and pain was defined as having had neck-shoulder pain that affected daily life during the past three months. Depressive symptoms were assessed with a continuous scale based on six-items of the (Hopkins) Symptom Checklist. Counterfactual mediation analyses were applied using exposure measures from 2010/2012 (T1), depressive symptoms from 2012/2014 (T2), and outcomes from 2014/2016 (T3), and including only those free of outcome at T1 and T2 (N=2876‒3239). RESULTS: ERI was associated with a higher risk of neck-shoulder pain [risk ratio (RR) for total effect 1.22, 95% confidence interval (CI) 1.00–1.48] and 41% of this total effect was mediated through depressive symptoms. Corresponding RR for association between neck-shoulder pain and ERI was 1.34 (95% CI 1.09–1.64), but the mediating role of depressive symptoms was less consistent. CONCLUSIONS: Depressive symptoms appear to be an intermediate factor in the relationship between ERI and neck-shoulder pain.

OBJECTIVES: The aim of this study was to examine the association between co-occurring work stressors and risk of disability pension. METHODS: The work stressors job strain, effort−reward imbalance (ERI), and organizational injustice were measured by a survey in 2008 of 41 862 employees linked to national records of all-cause and cause-specific disability pensions until 2011. Co-occurring work stressors were examined as risk factors of work disability using Cox regression marginal models. RESULTS: Work stressors were clustered: 50.8% had no work stressors [observed-to-expected ratio (O/E)=1.2], 27.4% were exposed to one stressor (O/E=0.61–0.81), 17.7% to two stressors (O/E=0.91–1.73) and 6.4% to all three stressors (O/E=2.59). During a mean follow-up of 3.1 years, 976 disability pensions were granted. Compared to employees with no work stressors, those with (i) co-occurring strain and ERI or (ii) strain, ERI and injustice had a 1.9–2.1-fold [95% confidence interval (CI) 1.7–2.6] increased risk of disability retirement. The corresponding hazard ratios were 1.2 and 1.5 (95% CI 1.0–1.8) for strain and ERI alone. Risk of disability pension from depressive disorders was 4.4–4.7-fold (95% CI 2.4–8.0) for combinations of strain+ERI and strain+ERI+injustice, and 1.9–2.5-fold (95% CI 1.1–4.0) for strain and ERI alone. For musculoskeletal disorders, disability risk was 1.6–1.9-fold (95% CI 1.3–2.3) for strain+ERI and ERI+injustice combinations, and 1.3-fold (95% CI 1.0–1.7) for strain alone. Supplementary analyses with work stressors determined using work-unit aggregates supported these findings. CONCLUSIONS: Work stressors tend to cluster in the same individuals. The highest risk of disability pension was observed among those with work stressor combinations strain+ERI or strain+ERI+injustice, rather than for those with single stressors.

OBJECTIVES: This systematic review and meta-analysis combined published study-level data and unpublished individual-participant data with the aim of quantifying the relation between long working hours and the onset of depressive symptoms. METHODS: We searched PubMed and Embase for published prospective cohort studies and included available cohorts with unpublished individual-participant data. We used a random-effects meta-analysis to calculate summary estimates across studies. RESULTS: We identified ten published cohort studies and included unpublished individual-participant data from 18 studies. In the majority of cohorts, long working hours was defined as working ≥55 hours per week. In multivariable-adjusted meta-analyses of 189 729 participants from 35 countries [96 275 men, 93 454 women, follow-up ranging from 1–5 years, 21 747 new-onset cases), there was an overall association of 1.14 (95% confidence interval (CI) 1.03–1.25] between long working hours and the onset of depressive symptoms, with significant evidence of heterogeneity (I^2=45.1%, P=0.004). A moderate association between working hours and depressive symptoms was found in Asian countries (1.50, 95% CI 1.13–2.01), a weaker association in Europe (1.11, 95% CI 1.00–1.22), and no association in North America (0.97, 95% CI 0.70–1.34) or Australia (0.95, 95% CI 0.70–1.29). Differences by other characteristics were small. CONCLUSIONS: This observational evidence suggests a moderate association between long working hours and onset of depressive symptoms in Asia and a small association in Europe.

OBJECTIVES: This study aimed to develop and validate a risk prediction model for long-term sickness absence. METHODS: Survey responses on work- and lifestyle-related questions from 65 775 public-sector employees were linked to sickness absence records to develop a prediction score for medically-certified sickness absence lasting >9 days and ≥90 days. The score was externally validated using data from an independent population-based cohort of 13 527 employees. For both sickness absence outcomes, a full model including 46 candidate predictors was reduced to a parsimonious model using least-absolute-shrinkage-and-selection-operator (LASSO) regression. Predictive performance of the model was evaluated using C-index and calibration plots. RESULTS: Variance explained in ≥90-day sickness absence by the full model was 12.5%. In the parsimonious model, the predictors included self-rated health (linear and quadratic term), depression, sex, age (linear and quadratic), socioeconomic position, previous sickness absences, number of chronic diseases, smoking, shift work, working night shift, and quadratic terms for body mass index and Jenkins sleep scale. The discriminative ability of the score was good (C-index 0.74 in internal and 0.73 in external validation). Calibration plots confirmed high correspondence between the predicted and observed risk. In >9-day sickness absence, the full model explained 15.2% of the variance explained, but the C-index of the parsimonious model was poor (

Past decades have been characterized by technological changes and globalization of the economy, which has led to a change in employment conditions worldwide. Flexible labor markets and decreased impact of trade unions have contributed to the increase and emergence of insecure ‘non-standard’ forms of employment, such as temporary agency jobs and zero-hour job contracts. During the past ten years, there has been an increase, albeit slight, in precariousness of work in developed countries (1). Although precarious employment is a societal issue with potential adverse effects on health, the majority of research activity has focused on proximal psychosocial working conditions within the workplace, which however, represents a small aspect of a complex system involving labor markets, employment and working conditions, psychosocial working conditions, and the relationship with health. While an internationally accepted scientific definition is lacking, precarious employment can be conceptualized as accumulated unfavorable aspects of employment (contract) quality. These unfavorable aspects may include temporary job contracts, job insecurity, vulnerability, lack of control and employee rights, nonstandard or substandard working time arrangements, limited training and employability opportunities, and low salary (2). The point is that while any single dimension does not necessarily indicate precariousness, accumulating adversities result in precarious employment (3). Young people in particular seem to be at risk of health problems when exposed to precarious employment (4). A recent systematic review also concluded that some dimensions of precarious employment were associated with occupational injuries and accidents (5). In this issue of the Scandinavian Journal of Work, Environment & Health, Rönnblad et al (6) present the first systematic review and meta-analysis on the relationship between precarious employment and mental health. They found 16 studies that met their inclusion criteria: prospective studies with data on working age active labor market participants from European Economic Area, Switzerland, Australia, New Zealand, Canada, and the US during 2000‒2017. In the included studies, the assessed exposure was single or multiple dimensions of precarious employment, and workers exposed were compared to those not exposed. Outcomes that were related to mental health were included. Of the included studies, only five studies used multidimensional exposure (ie, measured more than one dimension of precariousness). The review was carefully conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocol (PRISMA-P) guidelines. The authors conclude that moderate quality evidence was found for adverse effect of job insecurity on mental health. Evidence of very low quality was found for single dimensions of temporary job contracts and unpredictable working hours on mental health. The quality problems in these studies included inconsistent evidence and limited total number of studies. No quality rating was conducted for the five studies using multidimensional measure of precariousness. However, a meta-analysis was performed, which gave a summary odds ratio of 2.01 (95% CI 1.60-2.53) for the association between precarious employment and poor mental health. This was interpreted as representing “an indication of where the effect sizes would probably disperse when studying more than one dimension of precarity simultaneously” (6). The authors give a clear recommendation that observational studies with single exposures, particularly overly broad category of temporary employment and general job insecurity, should not be prioritised in future studies. Rather, high-quality studies using multidimensional exposure to precarious employment were found to be scarce, and the authors had to exclude many studies due to poor or inadequate study designs. It thus seems clear that we need to develop a common measure for precarious employment which is of high quality and widely used in the scientific community. This means development, testing, and validation studies for measuring precariousness, and theoretical discussions on the concept. The Employment Precariousness Scale is a step towards this goal (7, 8). However, as the response rates to questionnaire data are decreasing internationally, and there are widely known biases in self-reported data such as ‘common method bias’ (9, 10), we may need additional data sources. Moreover, as Rönnblad et al note, precarious employees are almost by definition, difficult to follow longitudinally. Here, register data and secondary use of digital data sources (‘big data’) may provide additional information. For example, objective information on employment contracts, salaries, unionisation, and working hours are available through employers’ registers, at least in the Nordic countries. The level of worker organization (union representation) and training are available through national registers (in Finland: Statistics Finland). In fact, Van Aerden and her colleagues (11) have used latent class cluster analysis of survey data and found that it is empirically possible to identify separate clusters of employment quality based on information on employment contract, income level, uncompensated work, long working hours, schedule unpredictability, involuntary part-time employment, training opportunities, information on occupational health and safety issues, and employee involvement. The majority of these measures could be identified through register databases. Rönnblad and his colleagues (6) further suggest that job insecurity should be studied as an outcome or mediator between other labor market exposures and health outcomes. This suggestion could be expanded to other indicators of precarious employment as well. For example, the model of sustainable employability by van der Klink et al (12) considers opportunities to develop new knowledge and skills (capabilities) as core element of sustainable employability. The model postulates a process where a worker can convert his/her resources into opportunities to achieve valuable goals. The major point of the model is that people are more likely to be sustainably employable if their work does not merely represent a means to earn a living. Precarious employees have a poor labor market status and, by definition (dimension of precarious employment), poor opportunities to develop their capabilities. Future research could thus investigate whether precarious employment, or dimensions of precariousness, mediate or moderate the relationship between work and labor market exposures and health-related outcomes. The independent effect of precarious employment from adversity related to low income should be addressed. Furthermore, to date, research on precarious employment has been based on data with assessment of precarious employment at one time point only (1). However, the dynamic nature of the labor market sets requirements to future research so that we need to consider changes of employment relationships over time, across the individual’s working life course. New methods, such as trajectory analyses and multi-state models would give valuable information on employment trajectories and dynamic intersections between precarious employment and other work and employment related characteristics across the working life course. References 1. Benach J, Vives A, Tarafa G, Delclos C, Muntaner C. What should we know about precarious employment and health in 2025? Framing the agenda for the next decade of research. Int J Epidemiol. 2016 Feb;45(1):232-8. https://doi.org/10.1093/ije/dyv342 2. Julia M, Vanroelen C, Bosmans K, Van Aerden K, Benach J. Precarious employment and quality of employment in relation to health and well-being in Europe. Int J Health Serv. 2017 Jul;47(3):389-409. https://doi.org/10.1177/0020731417707491 3. Koranyi I, Jonsson J, Ronnblad T, Stockfelt L, Bodin T. Authors’ response to “Multiple-job holding is not a type of precarious employment”. Scand J Work Environ Health. 2019 Jan 1;45(1):100. https://doi.org/10.5271/sjweh.3789 4. Vancea M, Utzet M. How unemployment and precarious employment affect the health of young people: A scoping study on social determinants. Scand J Public Health. 2017 Feb;45(1):73-84. https://doi.org/10.1177/1403494816679555 5. Koranyi I, Jonsson J, Ronnblad T, Stockfelt L, Bodin T. Precarious employment and occupational accidents and injuries - a systematic review. Scand J Work Environ Health. 2018 Jul 1;44(4):341-50. https://doi.org/10.5271/sjweh.3720 6. Rönnblad T, Grönholm E, Jonsson J, Koranyi I, Orellana C, Kreshpaj B, et al. Precarious employment and mental health: a systematic review and meta-analysis of longitudinal studies. Scand J Work, Environ Health - online first. https://doi.org/10.5271/sjweh.3797 7. Vives A, Amable M, Ferrer M, Moncada S, Llorens C, Muntaner C, et al. The Employment Precariousness Scale (EPRES): psychometric properties of a new tool for epidemiological studies among waged and salaried workers. Occup Environ Med. 2010 Aug;67(8):548-55. https://doi.org/10.1136/oem.2009.048967 8. Vives A, Gonzalez F, Moncada S, Llorens C, Benach J. Measuring precarious employment in times of crisis: the revised Employment Precariousness Scale (EPRES) in Spain. Gac Sanit. 2015 Sep-Oct;29(5):379-82. https://doi.org/10.1016/j.gaceta.2015.06.008 9. Thorsen SV, Flyvholm MA, Bultmann U. Self-reported or register-based? A comparison of sickness absence data among 8110 public and private employees in Denmark. Scand J Work Environ Health. 2018 Nov 1;44(6):631-8. https://doi.org/10.5271/sjweh.3747 10. Gupta N, Heiden M, Mathiassen SE, Holtermann A. Is self-reported time spent sedentary and in physical activity differentially biased by age, gender, body mass index, and low-back pain? Scand J Work Environ Health. 2018 Mar 1;44(2):163-70. https://doi.org/10.5271/sjweh.3693 11. Van Aerden K, Moors G, Levecque K, Vanroelen C. Measuring employment arrangements in the European labor force: A typological approach. Social Indicators Research. 2014 May 01;116(3):771-91. https://doi.org/10.1007/s11205-013-0312-0 12. van der Klink JJ, Bultmann U, Burdorf A, Schaufeli WB, Zijlstra FR, Abma FI, et al. Sustainable employability--definition, conceptualization, and implications: A perspective based on the capability approach. Scand J Work Environ Health. 2016 Jan;42(1):71-9. https://doi.org/10.5271/sjweh.3531

OBJECTIVES: The aim of this study was to examine occupational class differences in working more than six months beyond the mandatory retirement age and factors that may contribute to these differences. METHODS: The study comprised a prospective cohort study of a total of 5331 Finnish municipal employees (73% women) who were not on work disability pension and reached the age eligible for old-age pension in 2005–2011. Occupational class included four categories: managers and professionals, lower grade non-manual, skilled manual, and elementary occupations. Survey responses while at work were linked to national health and pension registers. RESULTS: A total of 921 participants (17.3%) worked beyond the pensionable age. Compared with elementary workers, skilled manual workers had a similar probability [gender-adjusted risk ratio (RR) 0.95, 95% confidence interval (95% CI) 0.72–1.23] while lower grade non-manual workers had a 2.03-fold (95% CI 1.59–2.58), and managers and professionals had a 1.79-fold (95% CI 1.41–2.27) probability of working beyond the pensionable age. Adjustment for physical workload (32.0% in lower non-manual, 36.7% in managers and professionals), work time control (20.4% and 11.4%) and perceived work ability (16.5% and 29.1%) contributed to the largest attenuation for these associations. Analyses using a counterfactual approach suggested greater mediated effects for physical workload and work time control than those observed in traditional mediation analyses. CONCLUSIONS: Employees with higher occupational classes are two times more likely to continue working beyond the retirement age compared to those with lower occupational classes. A large proportion of these differences were explained by having physically light job, better work time control, and better self-rated work ability among employees with high occupational class.

OBJECTIVES: The aim of this study was to investigate the association between the length of sickness absence and sustained return to work (SRTW) and the predictors of SRTW in depression, anxiety disorders, intervertebral disc disorders, and back pain in a population-based cohort of employees in the Finnish public sector. METHODS: We linked data from employers’ registers and four national population registers. Cox proportional hazards regression analysis with a cluster option was applied. SRTW was defined as the end of the sickness benefit period not followed by a recurrent sickness benefit period in 30 days. RESULTS: For depression, the median time to SRTW was 46 and 38 days among men and women, respectively. For anxiety disorders, the figures were 24 and 22 days, for intervertebral disc disorders, 42 and 41 days, and, for back pain, 21 and 22 days among men and women respectively. Higher age and the persistence of the health problem predicted longer time to SRTW throughout the diagnostic categories. Comorbid conditions predicted longer time to SRTW in depression and back pain among women. CONCLUSIONS: This large cohort study adds scientific evidence on the length of sickness absence and SRTW in four important diagnostic categories among public sector employees in Finland. Further research taking into account, eg, features of the work environment is suggested. Recommendations on the length of sickness absence at this point should be based on expert opinion and supplemented with research findings.

OBJECTIVES: Work-related stress has been linked to increased risk of disability pensioning, but the association between perceived justice of managerial behavior and decision-making processes at the workplace (ie, organizational justice) and risk of disability pensioning remains unknown. We examined the associations of organizational justice and its relational and procedural components with all-cause and diagnosis-specific disability pensions with repeated measures of justice. METHODS: Data from 24 895 employees responding to repeated surveys on organizational justice in 2000–2002 and 2004 were linked to the records of a national register for disability pensions from 2005–2011. Associations of long-term organizational justice (average score from two surveys) with disability pensions were studied with Cox proportional hazard regression adjusted for demographics, socioeconomic status, baseline health and health risk behavior, stratified by sex. RESULTS: During a mean follow-up of 6.4 years, 1658 (7%) employees were granted disability pension (282 due to depression; 816 due to musculoskeletal diseases). Higher organizational justice was associated with a lower risk of disability pensioning [hazard ratio (HR) per one-unit increase in 5-point justice scale 0.87 (95% CI 0.81–0.94)]. For disability pension due to depression and musculoskeletal diseases, the corresponding HR were 0.77 (95% CI 0.65–0.91) and 0.87 (95% CI 0.79–0.97), respectively. Adjustment for job strain and effort–reward imbalance attenuated the HR by 20–80%. CONCLUSIONS: Supervisors` fair treatment of employees and fair decision-making in the organizations are associated with a decreased risk of disability pensioning from all-causes, depression and musculoskeletal diseases. These associations may be attributable to a wider range of favorable work characteristics.

OBJECTIVES: Using Swedish population-based register data, we examined the extent to which comorbid conditions contribute to the risk of disability pension among people with diabetes. METHODS: We carried out Cox proportional hazard analyses with comorbid conditions as time-dependent covariates among 14 198 people with newly diagnosed diabetes in 2006, and 39 204 people free from diabetes during the follow-up from 2007–2010. The average follow-up times were 46 and 48 months for those with and without diabetes, respectively. RESULTS: For those with diabetes only, the incidence of all-cause disability pension was 9.5 per 1000 person-years. The highest incidence of disability pension were for those with: diabetes and depression (23.6); diabetes and musculoskeletal disorder (30.6), and those with diabetes and more than one comorbid condition (36.5). The incidence rate was 5.8 for those without diabetes. Diabetes was associated with a 2.30 times [95% confidence interval (95% CI) 2.09–2.54] higher risk of disability pension (adjusted for sociodemographic factors). This association attenuated by 41% after further adjustment for comorbid chronic conditions. While diabetes was a risk factor for disability pension due to musculoskeletal disorders and diseases of the circulatory system, even after accounting for the above-mentioned conditions, the association between disability pension due to mental disorders and diabetes was diluted after adjustment for mental disorders. CONCLUSIONS: Although diabetes is an independent risk factor for disability pension, comorbid conditions contribute to this risk to a large degree.

Established in 2008 and comprising over 60 researchers, the IPD-Work (individual-participant data meta-analysis in working populations) consortium is a collaborative research project that uses pre-defined meta-analyses of individual-participant data from multiple cohort studies representing a range of countries. The aim of the consortium is to estimate reliably the associations of work-related psychosocial factors with chronic diseases, disability, and mortality. Our findings are highly cited by the occupational health, epidemiology, and clinical medicine research community. However, some of the IPD-Work’s findings have also generated disagreement as they challenge the importance of job strain as a major target for coronary heart disease (CHD) prevention, this is reflected in the critical discussion paper by Choi et al (1). In this invited reply to Choi et al, we aim to (i) describe how IPD-Work seeks to advance research on associations between work-related psychosocial risk factors and health; (ii) demonstrate as unfounded Choi et al’s assertion that IPD-Work has underestimated associations between job strain and health endpoints; these include the dichotomous measurement of job strain, potential underestimation of the population attributable risk (PAR) of job strain for CHD, and policy implications arising from the findings of the IPD-Work consortium; and (iii) outline general principles for designing evidence-based policy and prevention from good-quality evidence, including future directions for research on psychosocial factors at work and health. In addition, we highlight some problems with Choi et al’s approach.

OBJECTIVES: Research on temporary employment as a risk factor for work disability due to depression is mixed, and few studies have measured work disability outcome in detail. We separately examined the associations of temporary employment with (i) the onset of work disability due to depression, (ii) the length of disability episodes, and (iii) the recurrence of work disability, taking into account the possible effect modification of sociodemographic factors. METHODS: We linked the prospective cohort study data of 107 828 Finnish public sector employees to national registers on work disability (>9 days) due to depression from January 2005 to December 2011. RESULTS: Disability episodes were longer among temporary than permanent employees after adjustment for age, sex, level of education, chronic somatic disease, and history of mental/behavioral disorders [cumulative odds ratio (COR) 1.37, 95% confidence interval (95% CI) 1.25–51). The association between temporary employment and the length of depression-related disability episodes was more pronounced among participants with a low educational level (COR 1.95, 95% CI 1.54–2.48) and older employees (>52 years; COR 3.67, 95% CI 2.83–4.76). The association was weaker in a subgroup of employees employed for ≥50% of the follow-up period (95% of the original sample). Temporary employment was not associated with the onset or recurrence of depression-related work disability. CONCLUSIONS: Temporary employment is associated with slower return to work, indicated by longer depression-related disability episodes, especially among older workers and those with a low level of education. Continuous employment might protect temporary employees from prolonged work disability.

OBJECTIVES: Job strain has previously been shown to predict disability pension, but it is unknown whether effort-reward imbalance (ERI), another major stress model, is also associated with disability pension. METHODS: We examined ERI as a risk factor for diagnosis-specific disability pension in a cohort of 51 874 public-sector employees in Finland. To control for reporting bias, work unit-level scores of ERI (based on the survey responses of 35 260 employees in 2000–2002) were constructed and linked to all eligible employees. A sub-cohort of the respondents was analyzed also with individual-level ERI. Disability pension data were derived from national pension registers with no loss to follow-up. The outcomes were all-cause disability pension and disability pension due to depression, musculoskeletal diseases, and ischemic heart diseases (IHD). Multivariate Cox proportional hazard models (adjusted for sociodemographic factors, baseline health, and work-related characteristics) were used for analyses. RESULTS: During a mean 8.9 years of follow-up, 4542 participants were granted disability pension. An increased risk for disability pension due to depression was detected for both high work unit- and individual-level ERI [hazard ratio (HR) 1.63, 95% confidence interval (95% CI) 1.31–2.04 and HR 1.90, 95% CI 1.51–2.40, respectively]. High individual-level ERI increased the risk of disability pension due to musculoskeletal diseases (HR 1.32, 95% CI 1.13–1.53), but no association was observed for work unit-level ERI (HR 1.02, 95% CI 0.88–1.19). ERI was not associated with disability pension due to IHD. CONCLUSION: The present study showed a consistent association between high ERI and an increased risk of disability pension due to depression.

OBJECTIVES: Associations between psychosocial work environment and excess weight have not been systematically addressed. The aim of this systematic review was to summarize the published evidence for the associations of psychosocial factors at work and long work hours with weight-related outcomes . Methods We conducted a search of Medline and Embase for all original articles published up to September 2012 using predefined keywords. After excluding studies with a definite selection bias, we included 39 articles. RESULTS: About 60% of the studies reported at least one positive association between psychosocial factors at work and a weight-related outcome. However, 76% of the tested associations were found to be non-significant. Furthermore, the associations were rather weak. Studies of higher quality tended to observe associations more often than those of lower quality. Positive associations were found more frequently (i) among women versus men, (ii) in cross-sectional versus longitudinal studies, and (iii) for overweight or obesity versus other outcomes. About 70% of the studies reported positive associations between long work hours and weight-related outcomes. All four studies that evaluated the association between working overtime and weight gain (three longitudinal and one cross-sectional), showed a positive association among men and two of them also observed associations among women. CONCLUSIONS: We found evidence for weak associations between psychosocial factors at work and excess weight. Associations were observed between long work hours, working overtime, and weight gain, especially among men. More cohort studies among non-obese baseline participants using appropriate analytical methods based on an elaborated hypothetical model are needed.

OBJECTIVES: The aim of this study was to examine the co-occurrence of obesity and sleep problems among employees and workplaces. METHODS: We obtained data from 39 873 men and women working in 3040 workplaces in 2000–2002 (the Finnish Public Sector Study). Individual- and workplace-level characteristics were considered as correlates of obesity and sleep problems, which were modelled simultaneously using a multivariate, multilevel approach. RESULTS: Of the participants, 11% were obese and 23% reported sleep problems. We found a correlation between obesity and sleep problems at both the individual [correlation coefficient 0.048, covariance 0.047, standard error (SE) 0.005) and workplace (correlation coefficient 0.619, covariance 0.068, SE 0.011) level. The latter, but not the former, correlation remained after adjustment for individual- and workplace-level confounders, such as age, sex, socioeconomic status, shift work, alcohol consumption, job strain, and proportion of temporary employees and manual workers at the workplace. CONCLUSIONS: Obese employees and those with sleep problems tend to cluster in the same workplaces, suggesting that, in addition to targeting individuals at risk, interventions to reduce obesity and sleep problems might benefit from identifying “risky” workplaces.

OBJECTIVES: We examined whether having a high percentage of pupils with special educational needs (SEN) in basic education schools increases the risk of sickness absence among teachers and whether this risk is dependent on the pupil–teacher ratio (PTR), an indicator of teacher resources at school. METHODS: We obtained register data on 8089 teachers working in 404 schools in 10 municipalities in Finland during the school year 2004–2005. We used multilevel multinomial regression models to examine the risk of teachers’ short- and long-term sickness absence in relation to the percentage of SEN pupils and the PTR at school. We tested the equality of trends in groups with high and low PTR using PTR × SEN interaction term. RESULTS: After adjustment for teacher and school characteristics, the risk for long-term absences was higher among teachers at schools with a high percentage of SEN pupils than among teachers at schools with a low percentage of SEN pupils [odds ratio (OR) 1.5, 95% confidence interval (95% CI) 1.2–1.8). This was also the case for short-term absences (OR 1.4, 95% CI 1.2–1.7). In analyses stratified by the PTR levels, the association between the percentage of SEN pupils and long-term absences was 15% higher among teachers with a high PTR than among those with a low PTR (P for interaction=0.10). CONCLUSIONS: Teachers’ sickness absenteeism seems to increase with a higher percentage of SEN pupils, especially when the PTR is high. Teacher resources at schools that have a high percentage of SEN pupils should be well maintained to ensure the health of teachers.

OBJECTIVE: This study examined whether indicators of poor health and health risk behaviors among hospital staff differ between the ward specialties. METHODS: Across 21 hospitals in Finland, 8003 employees (mean age 42 years, 87% women, 86% nurses) working in internal medicine, surgery, obstetrics and gynecology, pediatrics, intensive care, and psychiatry responded to a baseline survey on health and health risk behaviors (response rate 70%). Responses were linked to records of sickness absence and medication over the following 12 months. RESULTS: Psychiatric staff had higher odds of smoking [odds ratio (OR) 2.58, 95% confidence interval (95% CI) 2.14–3.12], high alcohol use (OR 1.55, 95% CI 1.21–1.99), physical inactivity (OR 1.30, 95% CI 1.11–1.53), chronic physical disease (OR 1.19, 95% CI 1.04–1.36), current or past mental disorders (OR 1.81, 95% CI 1.50–2.17), and co-occurring poor health indicators (OR 2.65, 95% CI 2.08–3.37) as compared to those working in other specialties. They also had higher odds of sickness absence due to mental disorders (OR 1.40, 95% CI 1.02–1.92) and depression (OR 1.61, 95% CI 1.02–2.55) at follow-up after adjustment for baseline health and covariates. Personnel in surgery had the lowest probability of morbidity. No major differences between specialties were found in the use of psychotropic medication. CONCLUSION: The prevalence of hospital employees with an adverse health risk profile is higher in psychiatric wards than other specialties.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of a 4-week primary prevention program (vocationally oriented multidisciplinary early rehabilitation or VOMR) in reducing the risk of long-term work disability among public sector employees at risk of deteriorating work capacity because of work-related strain. METHODS: As a part of the prospective Finnish public sector study, a follow-up study was carried out among 1394 public sector employees who underwent VOMR and their 4146 propensity score-matched controls. Baseline characteristics of 41 488 employees with full data on all 25 matching variables, measured from survey responses and national health registers, were used to calculate a propensity score for each employee to be granted rehabilitation. The cases were compared with the controls using Cox proportional hazard models as regards the risk of long-term work disability (sick leave >90 days or retirement on health grounds) after rehabilitation. RESULTS: During a mean follow-up of 2.8 years [standard deviation (SD) 1.49, range 0.04–5.0], incident all-cause work disability was observed for 6.1% of the rehabilitants and 6.2% of the controls [hazard ratio (HR) 0.98, 95% confidence interval (95% CI) 0.76–1.25]. The corresponding HR for the main causes of work disability stemming from musculoskeletal diseases and mental disorders were 0.86 (95% CI 0.57–1.30) and 1.08 (95% CI 0.67–1.74), respectively. CONCLUSIONS: VOMR was not associated with a lowered risk of long-term work disability compared to the controls. No support was obtained for the effectiveness of primary prevention for work disability in a low-risk cohort of employees.