Sustainable employability of workers in a vulnerable position The role of occupational health professionals and supervisors Rosanne Schaap
Colofon The studies presented in this thesis were conducted at: Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health research institute, The Netherlands. Financial support for the research included in this thesis was provided by: The Netherlands Organisation for Health Research and Development (ZonMW). Grant numbers: 531001404 and 535001007 Sustainable employability of workers in a vulnerable position. The role of occupational health professionals and supervisors DOI: http://doi.org/10.5463/thesis.439 ISBN: 978-94-6483-487-1 Cover design and layout: Marjolein Roffel Provided by thesis specialist Ridderprint, ridderprint.nl Printing: Ridderprint Layout and design: Michèle Duquesnoy, persoonlijkproefschrift.nl © Copyright 2023 by Rosanne Schaap. All rights reserved. No part of this thesis may be reproduced, stored in a retrieval system, or transmitted in any form or by any means without the written permission from the author or publishers of the included papers.
Table of content Chapter 1 General introduction 7 Part I The effects of exit from work among workers in a high and low socioeconomic position 21 Chapter 2 The effects of exit from work on health across different socioeconomic groups: A systematic literature review 23 Part II The role of occupational health professionals in supporting lower socioeconomic position workers with problems on multiple life domains 55 Chapter 3 Improving the health of workers with a low socioeconomic position: Intervention Mapping as a useful method for adaptation of the Participatory Approach 57 Chapter 4 The Grip on Health intervention to prevent health problems among workers with a lower socioeconomic position: a pilot implementation study 87 Chapter 5 A context analysis with stakeholders’ views for future implementation of interventions to prevent health problems among employees with a lower socioeconomic position 129 Part III The role of supervisors in supporting workers with a work disability 165 Chapter 6 “I noticed that when I have a good supervisor, it can make a lot of difference.” A qualitative study on guidance of employees with a work disability to improve sustainable employability 167 Chapter 7 Training for supervisors to improve sustainable employment of employees with a work disability: a longitudinal effect and process evaluation from an intervention study with matched controls 199 Chapter 8 General discussion 241 Appendix Summary 270 Samenvatting 276 About the author 284 List of publications 285 Portfolio 288 Dankwoord 292
Chapter 1 General introduction
8 Chapter 1 General Introduction The health and sustainable employability of workers in a vulnerable position I would like to start this thesis with the well-known phrase ‘work is healthy.’ People with a job are healthier than people without a job. Work provides income, social contacts, and is often a source of personal identity, which results in good health (1). In contrast, work can also negatively affect health or vice versa; unemployment has negative health consequences (2, 3) and poor health is associated with job loss and disability benefits (4-6). However, some workers face more difficulties to remain sustainably employed. This group consists for a large part of workers with a lower socioeconomic position (SEP) (6, 7). Workers with a lower SEP can include people with a lower education or income level and/or with a lower educated or blue-collar occupation. Workers with a lower SEP are in a more vulnerable position as they not only face more difficulties to (re-)enter the labor market (8) and remain sustainably employed, but also are more likely to exit paid employment (4). Previous research identified why workers with a lower SEP face more difficulties to remain sustainably employed. They more often have unhealthy working conditions, such as physically active jobs, irregular working hours, low job control, high job insecurity and low paid work (9-11). Unhealthy living conditions are also more prevalent among this group of workers, such as smoking, physical inactivity and unhealthy housing conditions (12). Unhealthy working and living conditions may increase the chance of physical and/or mental health problems, and therefore make a significant contribution to socioeconomic health inequalities (10, 12). Furthermore, workers with a lower SEP often have problems on multiple life domains (9, 13). This means that they face a combination of health problems and other problems in- and outside the workplace, such as unhealthy working and living conditions, financial problems or other private or social issues. Problems on multiple life domains are often strongly intertwined (10, 12, 14, 15), making it even more complex for the individual worker to solve these problems and remain sustainably employed. To improve their health and sustainable employability, we should simultaneously focus on factors in multiple life domains. This asks for a more holistic approach, which is in line with the definition of the Positive Health approach ‘the ability to adapt and manage oneself in the light of the physical, emotional and social challenges of life’ (16). Workers who face more difficulties to remain sustainably employed, also consist for a large part of workers with a work disability (7). Next to workers with a lower SEP, workers with a work disability also face more difficulties to enter the labor market and remain sustainably employed due to an illness, disorder, or disability (17). Workers with a work disability can include people with a (mild) intellectual disability, psychological disability, physical disability, and/or learning delay.
9 General introduction Research shows that labor force participation is the lowest among this group of workers (18). Moreover, problems on multiple life domains are also more prevalent among workers with a work disability (13, 19), which is in accordance with lower SEP workers, also a major barrier for work participation (15, 19). Given the above, parallels exist between workers with a lower SEP and workers with a work disability; i.e. vulnerable position in the labor market, having problems to (re-)enter the labor market, to be sustainably employed and often facing health problems in combination with problems on other life domains. There is also substantial overlap between workers with a lower SEP and workers with a work disability. A large part of workers with a work disability also has a lower socioeconomic position, as people with a disability more often have a lower educational level or little to no work experience (20). Besides, it is also plausible that lower SEP workers more often have a work disability, as they have lower health status and thereby higher chance to develop disabilities and less educational opportunities (21). Hence, both of these groups have in common that they are in a vulnerable position in the labor market, which increases the risk to drop early out of the labor market. Thus, facilitating sustainable employment and the prevention of job loss is what we aim to achieve in this thesis for workers in a vulnerable position, namely workers with a lower SEP and workers with a work disability. Facilitating sustainable employability of workers in a vulnerable position Sustainable employability can be defined as ‘The extent to which workers can achieve and maintain opportunities for valuable work functioning (capabilities) and enjoy the necessary conditions that allow them to make a valuable contribution through their work, now and in the future, while safeguarding their health and welfare’ (22). Central in this definition are the capabilities, which refers to skills and environmental conditions of an individual to achieve valuable work functioning. This definition emphasizes that individual skills, but also factors in the work and personal environment are important to remain sustainably employed. Individual skills for sustainable employment In the Netherlands, the government partially carries the responsibility for the health and wellbeing of all citizens. In the past 20 years changes have taken place in laws and regulations, reflecting a change from a welfare state to a participation society. Everyone who is considered able, must take responsibility for their own health and well-being. According to opponents of this participation society, too much emphasis is placed on the individual responsibility of citizens (23). However, it is increasingly pointed out that the ability of people to make ‘healthy’ choices is overestimated (23). Not all people are equipped to do that due to a lower health literacy. Health literacy enables people to obtain, understand, appraise, and use information to make decisions and take actions in ways that will have a positive 1
10 Chapter 1 impact on health (24). A lower health literacy may be more prevalent among certain groups in the population, such as workers with a lower SEP and workers with an intellectual disability (25, 26). Poor social and economic conditions which are more prevalent among workers in a vulnerable position are associated with a lower health literacy and may result in poor health outcomes (27). Therefore, strengthening health literacy of people in vulnerable positions could reduce health disparities. For this, workers need an enabling environment. In the next paragraph, we describe which factors in the personal and work environment play a role in the sustainable employability of workers in a vulnerable position. Factors in the work and personal environment for sustainable employment Accumulated evidence found that factors in the work environment play a key role in the sustainable employability of workers. The job demand-job resources model (JD-R model) provides an overarching framework to explain how the work environment can affect sustainable employability (28). According to this model psychosocial factors, which can be divided into job demands and job resources, are linked to a range of outcomes such as workers’ well-being, health, and productivity (29-32). For instance, autonomy and social support have a positive impact on well-being and performance (31), and psychological job demands, and low decision latitude have a negative impact on health (30, 32). Furthermore, psychosocial factors in the work environment are often less favorable among workers in a vulnerable position and may partially explain socioeconomic health inequalities (33, 34). Considering this information, it is important for organizations to safeguard work environments that facilitate sustainable employment. Beyond the work environment, factors in the personal environment, such as the circumstances in which people live, social networks or access to (financial) resources also tend to play a role in the health and thereby sustainable employability of workers. For instance, social networks can provide relevant health related information to perform healthy behaviors and provide mental support (35). However, access to and the number of resources is more limited among workers in a vulnerable position, which may lead to poorer health outcomes (36). According to the World Health Organization, factors in the personal environment, besides health care and a healthy lifestyle, can be summarized into social determinants of health (SDH). The WHO states that “SDH are the non-medical factors that influence health and consist of the conditions in which people are born, grow, live and age, and the wider set of forces and systems shaping the conditions of daily life” (37). In summary, the environment of workers strongly influences the ability of people (i.e., individual skills) to deal with (health) problems, which is in line with the definition of sustainable employability and SDH. Therefore, to improve the health and sustainable employability of workers, and especially of those in a vulnerable
11 General introduction position, it is not just a matter of improving individual skills. We should also support workers with enabling factors in the work and personal environment to effectively deal with problems that affect their sustainable employability. Therefore, it is important to investigate how we can support workers in a vulnerable position on how to effectively deal with these (health) problems. The role of occupational health professionals in supporting workers in a vulnerable position To improve the health and sustainable employability of workers in a vulnerable position occupational health professionals (OHPs) can provide adequate support. OHPs are professionals who provide advice and/or guidance to ensure a safe and healthy work environment, such as occupational physicians (OPs) or occupational nurses. In the Netherlands, the Working Conditions Act forms the basis for general rights and duties for employers and workers to ensure safe and healthy working environment. Employers are required to have a contract with an occupational health service and/or OHP, in which the acquired services are specified. Employers are also required to seek support from an OP in case of long-term sickness absence (i.e., more than 6 weeks in the Netherlands), and to perform risk assessments and evaluations on health and safety (RI&E in Dutch). Based on these risk assessments and evaluations OHPs can adapt work tasks and/or working conditions to reduce health risks or implement various tools, such as a preventive medical examination for the early detection of work-related health risks. Workers are also by law enabled to visit, at any time, an OP to receive preventive advice on work-related health problems. However, OHPs still spend most of their time providing advice to workers already on sick leave (38). This is unfortunate, as OHPs can play a key role in the early detection of work-related health risks and problems and initialize actions to prevent early drop-out from the labor market, especially among workers in a vulnerable position. Considering the extensive role of OHPs in the workplace, they could also be very well suited to play a role in the early detection of and solving non-work-related health risks and problems. However, existing interventions mainly focus on the identification of and solving work-related health risks and problems. For example, in the Participatory Approach workers mainly identify and solve workrelated problems under the guidance of an OHP and with involvement of relevant stakeholders at the workplace (39). Even though, the use of the Participatory Approach could also involve identifying and solving non-work-related problems that hinder return to work. Another example is job crafting, wherein workers make proactive changes in their job demands and job resources to optimize the fit between their job and personal needs at work (40). Work-related health risks and problems are important to address, but there is a need for interventions that solve work- and non-work-related health risks and problems. Problems both in- 1
12 Chapter 1 and outside the workplace could play a role in the sustainable employability. For this, more knowledge is needed on how OHPs can fulfill the role of supporting workers in solving problems on multiple life domains, both in- and outside the workplace. Interventions that focus on problems on multiple life domains are especially important for workers in a vulnerable position. However, literature on how to address and support workers with problems on multiple life domains is scarce. Taken this into account, we aim to develop and evaluate a preventive intervention for OHPs to support workers with a lower SEP solving problems on multiple life domains. The role of supervisors in supporting workers in a vulnerable position To improve the health and sustainable employability of workers in a vulnerable position, supervisors could also play a vital role (41). Ample research shows that social support from supervisors can have a positive impact on workers’ motivation, well-being, and health (22, 28). For example, workers receiving positive feedback that they are performing well, could subsequently improve their performance and motivation to work (42). Furthermore, a good relationship with their supervisor and receiving social support is essential for workers to remain working (43, 44). Support from supervisors could also play a role in addressing unfavorable factors, such as physical or psychological job demands. For instance, a study among workers with intellectual disabilities, indicated that supervisor support reduced job demands (45). Supervisors could help workers to adjust their work to their needs by making appropriate adjustments in the workplace or in their work tasks. Also, more support can be generated if supervisors are involved, which may result in a higher chance that adjustments will take place and maintained (46). Hence, (social) support from supervisors plays a key role in achieving sustainable employability (47), especially for workers in a vulnerable position that more often face unfavorable factors in the workplace. Over the past years, many factors have been identified on which supervisors can act to improve the sustainable employability of workers with a work disability (48, 49). For example, for workers with an intellectual disability, social support and having autonomy is positively associated with job satisfaction (50, 51). Subsequently, leadership interventions specifically for the guidance of workers with a work disability have been developed, but information on the effectiveness of these interventions is lacking. Furthermore, many studies have been conducted regarding the guidance of supervisors at the workplace. However, to our knowledge these studies mainly focused on the perspectives of supervisors and colleagues, and not on the needs of workers from the perspective of the worker with a disability themselves. The perspectives of workers with a disability may differ from the perspectives of their supervisors or colleagues without a work disability. Taken this into account, we aim to explore the needs of workers with
13 General introduction a work disability regarding the guidance from their supervisors and evaluate an intervention for supervisors to improve the guidance of workers with a work disability at the workplace. Aims and outline of this thesis Considering the current research gaps, the overall aim of thesis is to address the importance of improving the health and sustainable employability of workers in a vulnerable position, more specifically workers with a lower SEP and workers with a work disability, and to investigate how workers with a lower SEP and with problems on multiple life domains can be adequately supported by OHPs, and how workers with a work disability can be adequately supported by supervisors at the workplace. The specific aims are: 1. To investigate the differences of exit from work on health among workers with a low SEP, as opposed to workers with a high SEP. 2. To develop and evaluate a preventive intervention for OHPs to improve the health and sustainable employability of workers with a lower SEP and with problems on multiple life domains, and to explore facilitators and barriers for implementation of these types of preventive interventions in occupational health practice. 3. To explore the needs of workers with a work disability with respect to the guidance of supervisors in relation to their sustainable employability and to evaluate an intervention for supervisors to improve the sustainable employability of workers with a work disability. The first aim is addressed in chapter 2 and describes the results of a systematic review, wherein the effects of exit from work on health were investigated among both workers with a low or high SEP. The remaining chapters focus on evaluations of interventions that were implemented in practice. Chapter 3, 4 and 5 addresses the second aim and focuses on workers with a lower SEP and the role of OHPs in addressing problems on multiple life domains. Chapter 3 outlines the development of a participatory intervention for OHPs to identify and solve health problems on multiple life domains among workers with a lower SEP. Chapter 4 describes the process evaluation of this intervention in a pilot implementation study. Chapter 5 builds on that and investigates contextual factors for implementation of these types of interventions in occupational health practice. Chapter 6 and 7 addresses the third aim and focuses on workers with a work disability and the role of supervisors. Chapter 6 describes the experiences of workers with a work disability regarding the guidance of their supervisors. 1
14 Chapter 1 Chapter 7 describes the evaluation of an intervention for supervisors to improve the guidance of workers with a work disability, including an effect and process evaluation. The last chapter, chapter 8 summarizes and discusses the main findings and discusses methodological considerations. This chapter will be completed with recommendations for research, policy and practice and the main conclusions of this thesis.
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17 General introduction 35. André S, Kraaykamp G, Meuleman R. Een (on) gezonde leefstijl: opleiding als scheidslijn. Sociaal en Cultureel Planbureau (SCP); 2018. 36. Uphoff EP, Pickett KE, Cabieses B, Small N, Wright J. A systematic review of the relationships between social capital and socioeconomic inequalities in health: a contribution to understanding the psychosocial pathway of health inequalities. International Journal for Equity in Health. 2013;12:54. 37. World Health Organization. Social Determinants of Health [Available from: https:// www.who.int/health-topics/social-determinants-of-health#tab=tab_1]. 38. Sakowski P, Marcinkiewicz A. Health promotion and prevention in occupational health systems in Europe. International Journal of Occupational Medicine and Environmental Health. 2019;32(3):353-61. 39. Huysmans MA, Schaafsma FG, Viester L, Anema JR. Multidisciplinaire Leidraad Participatieve Aanpak op de Werkplek – Hoofddocument en achtergronddocument. VU Medisch Centrum: EMGO Instituut voor onderzoek naar Gezondheid en Zorg; 2016. 40. Tims M, Bakker AB, Derks D. Development and validation of the job crafting scale. Journal of Vocational Behavior. 2012;80(2):173-86. 41. Schreuder JA, Groothoff JW, Jongsma D, van Zweeden NF, van der Klink JJL, Roelen CAM. Leadership Effectiveness: A Supervisor’s Approach to Manage Return to Work. Journal of Occupational Rehabilitation. 2013;23(3):428-37. 42. Akkermans J, Brenninkmeijer V, Van Den Bossche SN, Blonk RW, Schaufeli WB. Young and going strong? A longitudinal study on occupational health among young employees of different educational levels. Career Development International. 2013;18(4):416-35. 43. Oude Hengel KM, Blatter BM, Geuskens GA, Koppes LL, Bongers PM. Factors associated with the ability and willingness to continue working until the age of 65 in construction workers. International Archives of Occupational and Environmental Health. 2012;85(7):783-90. 44. Den Boer H, van Vuuren T, de Jong J. Job Design to Extend Working Time: Work Characteristics to Enable Sustainable Employment of Older Employees in Different Job Types. Sustainability. 2021;13(9):4719. 45. Flores N, Jenaro C, Orgaz BM, Martín-Cilleros MV. Understanding Quality of Working Life of Workers with Intellectual Disabilities. Journal of Applied Research in Intellectual Disabilities. 2011;24(2):133-41. 46. Daniels K, Gedikli C, Watson D, Semkina A, Vaughn O. Job design, employment practices and well-being: a systematic review of intervention studies. Ergonomics. 2017;60(9):1177-96. 47. Jabeen Q, Nadeem MS, Raziq MM, Sajjad A. Linking individuals’ resources with (perceived) sustainable employability: Perspectives from conservation of resources and social information processing theory. International Journal of Management Reviews. 2021;24(2):233-54. 48. Van Ooijen R, Koning PW, Boot CR, Brouwer S. The contribution of employer characteristics to continued employment of employees with residual work capacity: evidence from register data in The Netherlands. Scandinavian Journal of Work, Environment & Health. 2021;47(6):435-45. 49. Vooijs M, Putnik K, Hermans L, Fermin B, Hazelzet AM, van Genabeek JA. Duurzame plaatsing in werk van werknemers met een arbeidsbeperking. Leiden: TNO; 2019. 50. Kocman A, Weber G. Job Satisfaction, Quality of Work Life and Work Motivation in Employees with Intellectual Disability: A Systematic Review. Journal of Applied Research in Intellectual Disabilities. 2018;31(1):1-22. 1
18 Chapter 1 51. Akkerman A, Janssen CG, Kef S, Meininger HP. Perspectives of Employees with Intellectual Disabilities on Themes Relevant to Their Job Satisfaction. An Explorative Study using Photovoice. Journal of Applied Research in Intellectual Disabilities. 2014;27(6):542-54.
19 General introduction 1
Part I The effects of exit from work among workers in a high and low socioeconomic position
Chapter 2 The effects of exit from work on health across different socioeconomic groups: A systematic literature review Rosanne Schaap Astrid de Wind Pieter Coenen Karin Proper Cécile Boot Published in: Social Science & Medicine. 2018, 198:36-45.
24 Chapter 2 Abstract Exit from work leads to different effects on health, partially depending on the socioeconomic status (SES) of people in the work exit. Several studies on the effects of exit from work on health across socioeconomic groups have been performed, but results are conflicting. The aim of this review is to systematically review the available evidence regarding the effects of exit from work on health in high and low socioeconomic groups. A systematic literature search was conducted using PubMed, Embase, Web of Science, CINAHL and PsycINFO. Search terms related to exit from work, health, SES, and design (prospective or retrospective). Articles were included if they focused on: exit from work (early/statutory retirement, unemployment, or disability pension); health (general, physical, or mental health and/or health behaviour); SES (educational, occupational and/or income level); and inclusion of stratified or interaction analyses to determine differences across socioeconomic groups. This search strategy resulted in 22 studies. For general, physical, or mental health and health behaviour, 13 studies found more positive effects of exit from work on health among employees with a higher SES compared to employees with a lower SES. These effects were mainly found after early/statutory retirement. In conclusion, the effects of exit from work, or more specific the effects of early/statutory retirement on health are different across socioeconomic groups. However, the findings of this review should be interpreted with caution as the studies used heterogeneous health outcomes and on each health outcome a limited number of studies was included. Yet, the positive effects of exit from work on health are mainly present in higher socioeconomic groups. Therefore, public health policies should focus on improving health of employees with a lower SES, in particular after exit from work to decrease health inequalities. Keywords: Exit from work; General health; Health behaviour; Mental health; Physical health; Socioeconomic groups; Socioeconomic status; Systematic review.
25 The effects of exit from work on health across different socioeconomic groups Introduction A rising life expectancy and decreasing birth rates causes a demographic transition in which Western society is confronted with an ageing population (1, 2). This means, relatively fewer workers to compensate for the elderly not being active in the workforce. The percentage of retired elderly compared to the active working population is expected to increase further in Europe, i.e. from 28% in 2014 to 50% in 2060 (3). This poses great challenges for the welfare state, such as providing pensions and long-term healthcare. To keep the welfare state affordable, many Western countries raised their statutory retirement age (4). Exit from work can be viewed as a major life transition, as it is accompanied by social, psychological, and environmental changes in one’s life (5). Social changes may involve the increase of social contact, because more time can be spent with family and friends; psychological changes could be role loss, as people’s identity might be determined by their job; and environmental changes could be loss of adverse or favorable work characteristics, such as high mental demands or receiving appreciation at work. Two recent systematic literature reviews on the effects of exit from work on health concluded that exit from work has both positive and negative effects on health (6, 7). For example, people with work related low back pain, will likely benefit from the work exit, because it can take away the source of their pain (i.e. physical health) or physical activity may increase, because exit from work provides more time for leisure-time physical activity (i.e. health behaviour). Otherwise, exit from work can also have adverse health effects, such as the increase of stress caused by the loss of income and work responsibilities (i.e. general health and mental health). Hence, exit from work holds different effects on health, depending on the circumstances in which a transition takes place (6-10). Moreover, effects may be different for various health outcomes, such as general, physical, or mental health and health behaviour (6, 7). The effects of exit from work on health may also be different across people from low or high socioeconomic groups (10-12), which is determined by occupation, education, and income (13, 14). Until now, studies have shown contradictory results regarding the effects of exit from work on health for different socioeconomic groups. Previous research demonstrated that people with a higher SES experience a larger decline in general health compared to people with a lower SES (15). Conversely, other studies demonstrated that people with a higher SES experience an increase in mental and physical health compared to people with a lower SES (16, 17). Thus, evidence with regard to the relationship between health and exit from work among different socioeconomic groups remains inconclusive. Therefore, the aim of this review is to systematically review the available evidence regarding the effects of exit from work on health in high and low socioeconomic groups. 2
26 Chapter 2 Methods Search strategy and study selection A systematic literature search was conducted in the databases PubMed, Embase, Web of Science, CINAHL and PsycINFO up to November 1, 2016. Search terms related to: 1) exposure, i.e. exit from work, 2) outcome, i.e. health, 3) strata, i.e. SES and 4) design, i.e. prospective or retrospective. The search terms can be found in the supplementary files. Articles identified in the databases were combined and duplicates were removed. For final inclusion, articles had to fulfil all of the following inclusion criteria. First, an article was eligible when the population had left the workforce at the end of the study period. Exit from work was defined as “withdrawal of older workers (i.e.55 years or older) from paid working life” and was differentiated in three types of exit routes: 1) statutory retirement or early retirement taking place before the statutory retirement age – i.e. via an early retirement scheme, 2) unemployment and 3) disability pension (6, 8, 18). Hereby, older workers were 55 years or older, because on average workers were 55 years old when they left the workforce (19). Second, an article had to report on at least one health component, before and after the work exit. Health was conceptualized as general, physical, or mental health and/or health behaviour. General health refers to how people perceived their health in general (e.g. how do you rate your health in general), physical health refers to physiological body functions (e.g. pain and disabilities), mental health refers to psychological wellbeing (e.g. mental functioning and depression) and health behaviour refers to behaviours that will likely influence one’s health either positive or negative (e.g. diet and physical activity) (6, 7, 20-22). Also, the health outcome BMI was categorized under health behaviours, because overweight and obesity are considered as a risk factor for non-communicable diseases and may result from the unhealthy behaviours having an unhealthy diet and physical inactivity (23). Third, an article had to include at least one indicator of SES (i.e. educational, occupational and/or income level) (13, 14), and included analyses to distinguish health effects across socioeconomic groups, either through stratification or an interaction term. This means that articles were excluded that only included SES as a confounding factor. Fourth, only articles with a longitudinal study design (either retrospective or prospective) were included. Fifth, articles published from 2001 were included to only provide information on the effects of exit from work processes that are taking place right now. Sixth, only articles in English and published in a peer reviewed journal were included. Two reviewers (RS and AdW) independently started with the screening of 600 articles on title and abstract. Thereafter, discrepancies were discussed in order to come to agreement on the interpretation and completeness of the inclusion criteria. When all discrepancies were discussed, the remaining articles (i.e.
27 The effects of exit from work on health across different socioeconomic groups 4165) were screened by one reviewer (RS) on title and abstract. Screening of 4765 articles on title and abstract resulted in 108 articles that were screened on full text. Screening of full-text articles was performed by two reviewers (RS and AdW) independently. Discrepancies were discussed until consensus was reached and a third reviewer (CB) was consulted in case consensus could not be reached. Finally, references of the included articles were checked for other possibly relevant articles. Data extraction and quality assessment One reviewer (RS) performed the data extraction by using a predefined dataabstraction form, extracting the following data per study: author, publication year and country, population (i.e. dataset, cohort or register, n, sex and age), design (i.e. type and follow-up period) statistical analyses (i.e. stratification and/ or interaction term), assessment of exit route (i.e. early/statutory retirement, unemployment or disability pension), health and SES, and the results of the effects of exit from work on health across socioeconomic groups. In case of uncertainty about the extracted data a second reviewer (AdW) was consulted. The quality assessment was performed by two reviewers (RS and AdW) independently and based on a set of nine predefined criteria (Table 1). The criteria were predominantly based on one review that focused solely on the relation between exit from work and health and on already existing criteria lists in the field of public health (6, 24-26). Each quality criterion was rated positive (+), negative (−) or not applicable (n.a.). Criteria 3, 4 and 5, were rated not applicable in studies with register data, because they could not provide information on participation rates. Differences in scores between reviewers (RS and AdW) were discussed and were resolved in consensus meetings. Studies with a minimum of 5 points (> 50%) were regarded as of high methodological quality (6, 24, 25). Studies in which criteria 3, 4 and 5 were rated not applicable and with a minimum of 3 points (> 50%) were regarded as of high methodological quality. The data extraction and quality assessment were performed per study to avoid multiplication. This means that some articles resulting from the same dataset, register or cohort were merged. Nevertheless, many articles resulting from the same dataset, register or cohort were not merged as they differed with regard to the health outcome. Consequently, different (smaller) datasets were retrieved from one large dataset, resulting in different studies. 2
28 Chapter 2 Table 1. Criteria list for assessment of methodological quality of longitudinal studies (6, 24, 26) CriteriaA Participation 1. Adequate description of source population (i.e. clear in- and exclusion criteria) 2. Adequate description of sampling frame, recruitment methods, period, and place of recruitment 3. Participation rate at baseline at least 80% or non-response not selective (i.e. selected population does not significantly differ in key characteristics from source population) Attrition 4. Provision of the response rate (n or %) during follow-up measurements 5. Response at follow-up at least 80% of the n at baseline or non-response during follow-up measurements not selective (i.e. follow-up population does not significantly differ in key characteristics from selected population) Data collection 6. Temporal determination of the work exit B Data analyses 7. Statistical model used appropriate and described with point estimates and measures of precision (i.e. CI or SE) 8. Population size suitable for answering the research question 9. Important confounders or effect modifiers (i.e. age, sex) identified and adjusted for (i.e. stratification and/or interaction term) A: rating of criteria: + = positive; - = negative; n.a. = not applicable; B: Temporal determination of the work exit means how regular this transition was assessed. Studies were rated positive if exit from work was determined on an annual basis. If this was not the case studies were rated negative. Abbreviations: n=sample size; CI=confidence interval; SE=standard error Results Study selection The flow chart, presented in Fig. 1, demonstrates the study selection. The search strategy yielded 8961 articles. After removing duplicates, 4765 articles were screened on title and abstract, and subsequently, 108 articles on full text. The search resulted in 19 articles (17, 27-44). The references of these articles were screened, which resulted in five additional articles (15, 45-48). In total, 22 studies were included in this review. Study characteristics The study characteristics are presented in Tables 2–4. The most remarkable differences are described here. Sample sizes ranged from 186 to 245,082 participants (35, 47). For measuring the effects of exit from work on health, studies mostly used the following datasets cohorts and registers; the Health and
29 The effects of exit from work on health across different socioeconomic groups Retirement Study (HRS) (8 studies) (17, 27, 29-31, 34, 38, 39, 41, 45), French national gas and electricity company cohort (GAZEL cohort) (5 studies) (40, 42-44, 48), Whitehall II study (2 studies) (33, 37) and Longitudinal Aging Study Amsterdam (LASA) (2 studies) (15, 35). All studies were prospective, and the follow-up period ranged from 4 to 18 years. Figure 1. Flow chart For the assessment of the type of exit route, two studies used register data (42, 43), the other studies relied on self-reports. Early/statutory retirement was measured in 19 studies (15, 17, 27, 28, 31-45, 47, 48) and unemployment and disability pension were both measured in three studies (29, 30, 33, 39, 42, 46). Various measures were used for the assessment of health, i.e. physical health included physical functioning (29, 30, 33, 41-43), chronic morbidity (28), cardiovascular 2
30 Chapter 2 diseases (44) and sleep disturbances (33); mental health included cognitive development (28), depression (29, 46) and mental functioning (33, 36, 37, 43, 46) and health behaviour included BMI (17, 31, 45), physical activity (27, 34, 35, 48) and alcohol consumption (44). Several indicators for SES were used, i.e. occupational level (12 studies) (17, 27, 28, 31, 33, 37, 40-46, 48), educational level (11 studies) (15, 28, 30, 32, 34-36, 38, 39, 41, 47) and income level (2 studies) (29, 30). Moreover, various operationalization’s of these indicators were used. To illustrate, some studies operationalized occupational level as blue and white-collar occupations (31, 41, 45), while another study operationalized occupational level as manual or non-manual occupations (46). Quality assessment On average, studies scored 85% on the quality assessment (Table 2). All studies were considered of high quality and three studies even obtained a score of 100% (32, 46, 47). The criterion that scored the lowest was the temporal determination of the work exit. In 15 studies, the temporal determination of the work exit was measured over a period of more than a year (17, 27-31, 33-39, 41-43, 45), The criteria that scored the highest were the description of the source population and statistical model. An extensive version of the quality assessment can be found in the supplementary files. Table 2. Study characteristics Author, publication year and country Population (dataset, cohort or register, n, sex, and age) Design (type and follow-up period) Statistical analyses (stratification and/or interaction term) Quality assessment score Chung et al., 2009 (A) & FormanHoffman et al., 2008 & Gueorguieva et al., 2011 United States (17, 31, 45) HRS n=2,096-10,565 Male 52-57% Mean age 56.760.5 (range 50-71; SD 3.3) Prospective Follow-up 8-10 years Stratification; occupational level 89% Chung et al., 2009 (B) United States (27) HRS n=11,469 Male 47% Mean age 60.3 (SD 4.8) Prospective Follow-up 6 years Stratification; occupational level Interaction term; exit from work with occupational level 78%
31 The effects of exit from work on health across different socioeconomic groups Table 2. Study characteristics Author, publication year and country Population (dataset, cohort or register, n, sex, and age) Design (type and follow-up period) Statistical analyses (stratification and/or interaction term) Quality assessment score De Grip et al., 2015 Netherlands (28) MAAS n=1,360 No data on age and sex Prospective Follow-up 1993-1995, 1999-2001 and 20052007 Interaction term; exit from work with educational level 78% Gallo et al., 2006 United States (29) HRS n=3,555 Male 48% Mean age 55.0 (range 51-61) Prospective Follow-up 6 years Stratification; income level Interaction term; exit from work with income level 89% Gallo et al., 2009 United States (30) HRS n=6,469 Male 52% Mean age 55.0 (SD 2.9) Prospective Follow-up 6 years Interaction term; exit from work with educational level and income level 89% Hessel, 2016 Europe (32) EU-SILC n=139,683 Male 54% No data on mean age (range 50-74) Prospective Follow-up 3 years Stratification; educational level 100% Jokela et al., 2010 England (33) Whitehall II study n=7,584 Male 69% No data on mean age (range 54-76) Prospective Follow-up 15 years Stratification; occupational level 67% Kämpfen et al., 2016 United States (34) HRS n=13,491 Male 43% Mean age 65.3 (range 50-80) Prospective Follow-up 6 years Stratification; educational level 89% Koeneman et al., 2012 Netherlands (35) LASA n=186 Male 67% Mean age 58.7 (SD 2.6) Prospective Follow-up 1992-1993 and 1995-1996 Interaction term; exit from work with educational level 78% 2
32 Chapter 2 Table 2. Study characteristics Author, publication year and country Population (dataset, cohort or register, n, sex, and age) Design (type and follow-up period) Statistical analyses (stratification and/or interaction term) Quality assessment score Laaksonen et al., 2012 Finland (46) National register data of the Finnish Centre for Pensions n=7,005 No data on sex Mean age 53.5 (SD 7.5) Prospective Follow-up 10 years Interaction term; exit from work with occupational level 100% Latif, 2013 Canada (36) NPHS n=12,947 Male 48% Mean age 65.5 (no data on range and SD) Prospective Follow-up 18 years Stratification; educational level 89% Mein et al., 2003 England (37) Whitehall II study n=1,010 Male 64% No data on mean age (range 54-59) Prospective Follow-up 3 years Stratification; occupational level 67% Moon et al., 2012 United States (38) HRS n=5,422 Male 46% Mean age 58.0 (SD 5.7) Prospective Follow-up 10 years Stratification; educational level Interaction term; exit from work with educational level 89% Olesen et al., 2015 Denmark (47) Register-based Labor Force Statistics and the DREAM n=245,082 Male 51% Mean age 61.8 (range 60-68) Prospective Follow-up 6 years Stratification; educational level 100%
33 The effects of exit from work on health across different socioeconomic groups Table 2. Study characteristics Author, publication year and country Population (dataset, cohort or register, n, sex, and age) Design (type and follow-up period) Statistical analyses (stratification and/or interaction term) Quality assessment score Rijs et al., 2012 Netherlands (15) LASA n=506 Male 64% Mean age 58.2 (range 55-64 years) Prospective Follow-up 1992-1993 and 1995-1996 Stratification; educational level Interaction term; exit from work with educational level 89% Salm, 2009 United States (39) HRS n=6,867 Male 40% Mean age 55.5 (SD 5.0) Prospective Follow-up 8 years Interaction term; exit from work with educational level 78% Sjösten et al., 2012 France (48) GAZEL cohort n=2,711 Male 63% Mean age 58.0 (range 50-66; SD 2.4) Prospective Follow-up 8 years Stratification; occupational level Interaction term; exit from work with occupational level 89% Vahtera et al., 2009 France (40) GAZEL cohort n=14,714 Male 79% Mean age 55.0 (range 37-63) Prospective Follow-up 14 years Stratification; occupational level Interaction term; exit from work with occupational level 89% Van Zon et al., 2016 United States (41) HRS n=7,242 Male 49% Mean age 57.0 (SD 3.6) Prospective Follow-up 20 years Interaction term; exit from work with occupational level and educational level 89% Westerlund et al., 2009 France (42) GAZEL cohort n=14,714 Male 79% Mean age 54.6 (SD 2.9) Prospective Follow-up 14 years Stratification; occupational level Interaction term; exit from work with occupational level 78% 2
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