75 Inability to work fulltime, prevalence and associated factors DISCUSSION In a large cross-sectional register based study among a year cohort of applicants assessed for a long-term work disability benefit, the prevalence of inability to work fulltime was 39.4%. Regarding the degree of inability to work fulltime, the number of applicants who could work up to 4 h per day was approximately three times higher in comparison with applicants who could work up to 2 or 6 h per day. In the total sample, including all disease groups, associated factors for inability to work fulltime were higher age, female gender, higher education and multimorbidity. Applicants with diseases of the blood, the respiratory system, neoplasms and diseases of the genitourinary and circulatory system had higher odds for being assessed with inability to work fulltime, while applicants with diseases of the musculoskeletal system, pregnancy and diseases of the skin and injury had lower odds. Studying the association of age, gender, education level and multimorbidity within specific disease groups compared to all other diseases, showed a varying picture. Within 10 of the disease groups, female gender showed higher odds for inability to work fulltime and within seven of the disease groups higher education had the same but weaker effect. Age showed only small effects, and associations with multimorbidity varied. The prevalence of inability to work fulltime in our study, 39.4%, is substantial but within the variation found in other Dutch studies, showing prevalences varying between 17 and 48% [17, 22]. The variation between prevalences may be due to differences in included populations. Our sample included applicants, generally 2 years after sick leave, applying for long-term disability benefit (WIA), with all diseases. The two Dutch studies differed on the types of work disability benefit and timeframe. The distribution of the degree of inability to work fulltime is in line with findings of other Dutch studies [17, 22] and in European countries [20, 21]. In Sweden (especially in the period between 1960 and 1990) [40], other Nordic countries [21] and Belgium [20], halftime work is a legally accepted degree of limitation in work disability assessment during sick leave. However, these numbers are difficult to translate into other samples and social security systems and therefore results of these studies should be considered in the contexts of the social security systems in the countries in which the studies are performed. Higher age, female gender, higher education and multimorbidity showed higher risks of inability to work fulltime. Although the odds ratios for age and multimorbidity were not that large (1.01 and 1.06 respectively), the cumulative effect of age and working years is substantial; with increasing age, people suffer more from (and have) more chronic diseases [23, 41]. In line with our findings, previous studies showed that women have a greater risk of negative work outcomes such as sick leave and disability [42]. In our study, higher education has a strong positive association with inability to work 4
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