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FACULTY OF HEALTH AND MEDICAL SCIENCES U N I V E R S I T Y O F C O P E N H A G E N Psychosocial Work Environment and Personal Lifestyle - A prospective study of psychosocial work environment factors as
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FACULTY OF HEALTH AND MEDICAL SCIENCES U N I V E R S I T Y O F C O P E N H A G E N Psychosocial Work Environment and Personal Lifestyle - A prospective study of psychosocial work environment factors as predictors of lifestyle among Danish eldercare workers PhD Thesis, 2014 Helle Susanne Gram Quist This thesis has been submitted to the Graduate School of The Faculty of Health and Medical Sciences, University of Copenhagen PhD Thesis by Helle Susanne Gram Quist Institutes: National Research Centre for the Working Environment, Denmark Faculty of Health and Medical Sciences, University of Copenhagen Name of department: Public Health Author: Helle Susanne Gram Quist Title / Subtitle: Psychosocial Work Environment and Personal Lifestyle A prospective study of psychosocial work environment factors as predictors of lifestyle among Danish eldercare workers. Subject description: Lifestyle, smoking, smoking cessation, body mass index, weight change, leisure-time physical activity, sedentary lifestyle, long-term sickness absence, epidemiology, register data, cohort study, eldercare workers. Submitted: August 7 th, 2014 Defended: November 13 th, 2014 ISBN nr Academic advisors Professor Jakob Bue Bjørner, MD, PhD National Research Centre for the Working Environment, Copenhagen, Denmark Section of Social Medicine, Department of Public Health, University of Copenhagen Associate Professor Ulla Christensen, PhD Section of Social Medicine, Department of Public Health, University of Copenhagen Associate Professor Karl Bang Christensen, PhD Section of Biostatistics, Department of Public Health, University of Copenhagen Assessment committee Chairperson: Professor Åse Marie Hansen, PhD Department of Public Health, Section of Social Medicine, University of Copenhagen, Denmark Assessor representing Danish research: Hans Jørgen Limborg, Work Life Researcher, PhD TeamArbejdsliv Aps., Denmark. Assessor representing international research: Anne Kouvonen, Lecturer in Sociology/ Social Policy, PhD Department of Social Research, University of Helsinki, Finland Preface and acknowledgements My wish to investigate the role of the psychosocial work environment in relation to personal health behavior was rooted in a societal debate of the responsibility of health promotion and prevention of lifestyle-related diseases (in 2008). Part of the debate concerned personal vs. governmental responsibility of public health and health promotion, but it also addressed whether employers have the right to interfere with their employee s weight, exercise-, alcohol- and smoking behavior. Were these entirely private matters? Had the government taken their public health concerns too far? Did I believe in regulation or education? Though no simple answer or solution came to mind, the many headlines had ignited an interest in public health and health promotion. I did, however, believe that part of the solution would be to examine just how important the workplace and the work environment were in relation to personal lifestyle. I wanted to examine and understand which work related factors that could influence personal lifestyle and encourage (or discourage) changes in lifestyle. To me, this knowledge seemed essential in order to implement better health promoting strategies. The PhD project was carried out at the National Research Centre for the Working Environment (NRCWE) in Copenhagen, Denmark between August 2010 and August 2014 (including a maternity leave). The project was conducted within the Epidemiology Research Group and funded by a 3-year grant from The Danish Working Environment Research Fund (grant ). The Danish Elderly Care Cohort Study from which this PhD thesis uses data was completed at NRCWE and funded through grants from the Danish Parliament. The Danish Elderly Care Cohort Study aimed at investigating the work environment and health of workers in the Danish eldercare sector, while also investigating work factors that influence the recruitment and retention of these workers. The Danish Elderly Care Cohort Study was conducted at NRCWE between 2004 and 2009 and provides observational survey data of working conditions in 2005, 2006 and 2008 (baseline and two followup panels). This thesis is a summary of four publications submitted to international peer-reviewed journals (two has been published). Based on data from The Danish Elderly Care Cohort Study, I examined the associations between sickness absence, lifestyle (smoking, leisure-time physical activity and body mass index) and psychosocial work environment factors. To address the relationship between lifestyle and sickness absence, I used a national register on sickness absence called the Danish Register for Evaluation of Marginalization (DREAM), which covers all social transfer payments in Denmark. The completion of this PhD would have been impossible had it not been for the help and encouragement from several people. First and foremost, I am indebted to my primary supervisor, Professor Jakob Bue Bjørner from the National Research Centre for the Working Environment. I am grateful for your support and reassurance. Thanks for your dedication and commitment; your ability to keep me focused and for helping me improve my skills. I also wish to recognize and thank my other advisors Ulla Christensen and Karl Bang Christensen from the University of Copenhagen for their guidance, support and patience. I appreciate it so much! Each of the co-authors, in particular Birthe L. Thomsen, also deserve acknowledgement for their critical feedback and help along the way. I wish to thank my colleagues, in particular Pernille Tufte, Malene Friis Andersen and Mette Andersen Nexø, for a pleasant collegial environment and for making life as a PhD student funny and meaningful. I wish you the very best in your future careers. A sincere thank you goes to Elsa Bach, the Director of Research Coordination at the NRCWE for her support over the years. Finally, I wish to thank my other half, my closest friend and beloved husband for his endless love and support. Thanks for always understanding and encouraging me and for always being you! Willum, Elliott and Colin my baby boys I look forward to the day when you understand what I have completed. You are a constant reminder of what is truly important in this world. Helle Gram Quist List of figures Figure 1 Illustration of the overall hypothesized causal relationships in this thesis 2 Figure 2 The Health lifestyles paradigm by Cockerham 4 Figure 3 Causal pathways between lifestyle, work environment and sickness absence 13 Figure 4 Overview of study design and data sources 22 Figure 5 Overview of study population in Study Figure 6 Overview of design, population and analyses used in study Figure 7 Illustration of job types in Karasek's Job Strain Model 43 List of tables Table 1 Contents of the Copenhagen Psychosocial Questionnaire (COPSOQ) 26 Table 2 Hazard Ratios for onset of long-term sickness absence during 12 months of follow-up 36 Table 3 Logistic regression with change in BMI as dependent variable 37 Table 4 Association between psychosocial work factors and low leisure-time physical activity 38 Table 5 Association between psychosocial work factors and change in leisure-time physical activity 39 Table 6 Total variance explained by workgroups 40 Table 7 General linear model results 40 Contents 1. Introduction Background Lifestyle Health lifestyle theory Psychosocial work environment, health outcomes and lifestyle Psychosocial work environment factors Long-term sickness absence Lifestyle, work environment and sickness absence in the eldercare sector A framework linking lifestyle, psychosocial work factors and sickness absence The role of colleagues Research aims and hypotheses Methods Study design and data sources The Danish Elderly Care Cohort Study The Danish Register for Evaluation of Marginalization Population Measurements and operationalization Measurement of the psychosocial work environment Measurement of the lifestyle variables Measurement of long-term sickness absence Statistical Analyses Statistical analyses in study Statistical analyses in study Statistical analyses in study Statistical analyses in study Results Study 1: Influence of lifestyle-factors on long-term sickness Study 2: Psychosocial work environment factors and weight change Study 3: Psychosocial work environment and leisure-time physical activity Study 4: Do colleagues influence our lifestyle? Discussion Principal findings Relations to previous research Pathway 1: Psychosocial work environment and lifestyle (Study 2 and 3) Pathway 2: Lifestyle and sickness absence (Study 1)... 48 How colleagues influence lifestyle (Study 4) Methodological considerations The focus on a single occupational group The social context in workplaces Measurement of psychosocial work environment Measurement of lifestyle variables Measurement of long-term sickness absence Secondary data analysis Bias and confounding Summary of strength and weaknesses Generalizability Conclusion and perspectives English summary Danish summary References... 71 1. Introduction In modern western societies, chronic diseases caused by an unhealthy lifestyle are important causes of death and absenteeism from work. Smoking, unhealthy diet, physical inactivity, and harmful use of alcohol are generally acknowledged as important risk factors for (or causes of) chronic diseases [1]. In 2013, a Danish national population survey found that 22% of all adults are smokers (17% smoke on a daily basis); 47% are overweight (13% of them are considered obese); 16% are physically inactive during leisure-time and 14% eat unhealthy (not enough fruit, vegetables and fish and too much saturated fat) [2]. Finally, 9% drink more alcohol in a typical week than recommended by the national guidelines [2]. These modifiable lifestyle risk factors explain a large part of the deaths caused by chronic diseases. In Denmark, estimation of etiological fractions (the proportion of avoidable deaths if the risk factor was removed) has suggested that smoking and alcohol is the cause of approximately and deaths each year, respectively. This corresponds to approximately 24% of all deaths being caused by smoking and 5% being caused by alcohol [2]. Furthermore, estimations from the Danish Health and Medicines Authority indicate that 7-8% of all deaths in Denmark are caused by physical inactivity and that inactive people generally die five to six years earlier than active people [3]. Unhealthy lifestyle also contributes to the development of chronic diseases, which can lead to sickness absence from work. Research studies have pointed toward an association between psychosocial work and unhealthy lifestyles [4-10], although the results are varying (see section for a detailed discussion). There is solid evidence of unhealthy behaviors, including smoking, heavy drinking, overweight and physical inactivity, increasing the risk of sickness absence [11-13]. Thus, a causal relationship between psychosocial work environment, lifestyle and sickness absence can be presented. As chronic diseases are becoming more and more prevalent [2], more and more focus has been placed on lifestyle risk factors. As a results, health is today seen as an achievement and something we are supposed to work at [14] (page 49). The goal is to stay (or become) healthy and to minimize the risk of illness and improve our well-being. However, lifestyle is also affected by living conditions, structural and environmental factors. Besides, chronic disease is not an isolated endpoint; in fact, chronic diseases can lead to other negative outcomes such as death, limited work 1 ability and increased sickness absence. Thus, the relationship between lifestyle, chronic diseases and sickness absence is multifaceted. Below I present a model that illustrates the core assumptions of this thesis: sociodemographic-, structural- and environmental factors affects lifestyle which in turn affects work force affiliation (directly and indirectly though chronic diseases). Thus, personal lifestyle can be considered an intermediate factor in the relationship between work environment and long-term sickness absence. It is important to note, that the model indicates some (but not all) of the pathways and that lifestyle factors also mutually affect each other, which is not illustrated. Figure 1 Illustration of the overall hypothesized causal relationships in this thesis Figure 1 illustrates the assumptions that work force affiliation is affected by lifestyle factors (partly through their influence on chronic disease), which are affected by biological, structural and social conditions. This PhD focuses on three key components; the psychosocial work environment, lifestyle and longterm sickness absence. Specifically, this PhD examines the association between psychosocial work factors and personal lifestyle (measured by smoking, physical activity, and body mass index), the potential influence of colleagues on personal lifestyle, as well as the association between lifestyle and long-term sickness absence. 2 2. Background In this chapter, I first introduce and discuss the main concepts of the thesis; lifestyle and health behavior, psychosocial work environment and sickness absence, while also introducing the theoretical foundation of the thesis. Subsequently, I address the main concepts in the context of the eldercare sector and finally, I present a framework on how lifestyle, the psychosocial work environment and sickness absence may influence each other Lifestyle The words lifestyle and health behavior are often used interchangeably and no single definition of the two aspects exists. Generally, lifestyle is used to describe activities and patterns of behavior in groups, while health behavior describes the actions and behavior of the individuals [15]. In medical sociology, both terms cover personal behavior (whether premeditated or driven by habits) that can influence our health [16] and both reflect the individuals social and cultural identity [15]. The American medical sociologist William C. Cockerham defined lifestyle as a collective activity that goes beyond the psychology of the single person and is embedded in the norms, values, and practices of groups, social classes, and societies that shape and establish parameters for individual behavior [17] (page 1315). Health behavior can be something you do once (e.g. a medical check-up), or something done periodically (e.g. use sunblock), or over a long period of time (e.g. daily physical activity). The latter type is also referred to as lifestyle. Other examples of lifestyle include dietary habits, physical activity, smoking, alcohol intake, sexual behaviors, and substance abuse. Lifestyle can contribute to the development of diseases, but it can also help prevent it. One can differentiate between sicknesspromoting and health-promoting factors; smoking is a sickness-promoting factor, while diet and exercise can be both sickness-promoting and health-promoting factors [18]. Throughout this thesis, I use the term lifestyle. Lifestyle is influenced and affected by other factors, such as life conditions and biological factors (e.g. age, gender, and genetic predisposition). Life conditions cover the aspects under which we live, such as income, education, employment, family situation, the neighborhood and pollution. Life conditions and lifestyle mutually affect each other. However, personal lifestyle is also a matter of 3 structural factors like the work environment and the economy. In this thesis, I focus on two lifestyle risk factors: smoking and leisure-time physical activity. A third variable, body mass index (BMI) is also utilized in the studies. While BMI is not a lifestyle variable in itself, I use BMI as a proxy indicator for dietary habits and physical activity Health lifestyle theory In order to explain how lifestyle, psychosocial work environment and sickness absence are related, I first turn to William C. Cockerham s Health lifestyles paradigm [14] and present it as the theoretical foundation for this thesis (Figure 2). The Health lifestyle paradigm is based on the notion that lifestyle and health outcomes are the result of the interaction between social structures and individual choices. Cockerham posits that health lifestyles are collective patterns of healthrelated behavior based on choices from options available to people according to their life chances [14] (page 56). In other words, personal lifestyle is not just a matter of personal choice (i.e. food selection in regard to overweight), but also the result of structural conditions, such a social class (i.e. food availability due to income or geographical location). Figure 2 The Health lifestyles paradigm by Cockerham 4 According to Cockerham, the interplay between life chances (structure) and life choices (agency) influences our dispositions to act, also referred to as habitus. Habitus can be seen as perceptions in the mind that guides our behavior so that it is considered appropriate in any given situation or setting [14] (page 70). It is these perceptions that influence our lifestyle practices, such as dietary and alcohol intake, physical activity and smoking. Central to Cockerham s model is also the notion of collectivities, which refers to shared norms and values in groups of individuals, through shared social relationships, such as work relations, religion or friendships [14] (page 65). Thus, this thesis is centered on a belief that lifestyle should be seen as an individual reaction (choice), which is manifested within interpersonal relationships that are further situated in a large social structure (e.g. the environment). This has also been emphasized by Martikainen et al. who suggest that psychosocial explanations of health are essentially viewed here as processes that cannot be fully captured by single measures at one level, but require due attention to macro and micro (individual) level factors as well [19] (page 1092) Psychosocial work environment, health outcomes and lifestyle Empirical evidence points to the associations between psychosocial work factors, lifestyle and health related outcomes. The psychosocial work environment is associated with health outcomes such as lower mental health, depression, cardiovascular disease, coronary heart disease, cancer and musculoskeletal disorders [20-24]. Other negative outcomes of an unfortunate psychosocial work environment include sickness absence, burnout and a generally poor health [12;25-28]. Regarding the association between psychosocial work factors and lifestyle, the associations vary for each risk factor and results are generally a bit more inconclusive. There is strong evidence that smoking and smoking cessation is associated with psychosocial work factors [4;29-32]. For example, low rewards and high demands can increase the risk of smoking, while high control and low strain can increase the likelihood of smoking cessation. Results are more inconclusive when examining weight change and leisure-time physical activity. Some studies found that work stress was associated with increased BMI and obesity [5-7], while others found no relationship or an inconsistent relationship [33;34]. Similarly, some studies have found that high job strain (high demands and low control) was associated with physical inactivity [10;33;35;36], while others have found no or inconsistent associations [8;33;37]. Detailed discussions of these results are provided in section Over the years, researchers have developed a number of theories (and models) to assess and understand just how the psychosocial work environment affects our health negatively. One of the most influential models is the Job Strain model, which was developed by Robert Karasek in 1979 [38;39]. The Job Strain model focuses on two job characteristics; psychological demands and control. Job control covers the aspect of controlling one s own work situation (decision autho
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