A capital-based approach to better understand health inequalities: Theoretical and empirical explorations.

Background: The persistence of health inequalities may be driven by differences in education and income, but also by other economic and non-economic factors. Our aim was to explore how the association between single-dimensional health and socioeconomic status (SES) changes when including health-related person capital, economic capital, social capital, cultural capital and attractiveness and personality capital. Methods: We used a capital-based approach to understand health inequalities. It presumes intertwined relationships between broadly measured health ('health-related person capital') and embodied resources ('attractiveness and personality capital') on the one hand, and ESC capital, i.e., economic, social, and cultural resources on the other. We used cross-sectional data on 152,592 participants from the Dutch Lifelines cohort study and estimated correlations using partial least squares structural equation modelling. Results: The correlation between SES and health-related person capital (r = 0.15) was stronger than the correlations between SES and single-dimensional health (physical and mental health; r = 0.12 and r = 0.04, respectively). ESC capital, combining economic, social and cultural capital, showed a correlation of 0.34 with health-related person capital. This was stronger than the correlation between health-related person capital and economic capital alone (r = 0.19). Lastly, the correlation between health-related person capital and ESC capital increased when health related, attractiveness and personality resources were combined into a single person capital construct (from r = 0.34 to r = 0.49). Conclusions: This exploratory study shows the empirical interconnectedness of various types of resources, and their potential role in the persistence of health inequalities. Our findings corroborate the idea of considering health as a multidimensional concept, and to extend conventional SES indicators to a broader measurement of economic and non-economic resources.

Do influence at work and possibilities for development mitigate the impact of job demands for workers with and without depression.

OBJECTIVE: Jobs characterized by low job demands and high job resources are associated with better work outcomes, yet it remains unclear whether this is the case for workers with depression. This study examined whether depression moderates the relationship between job demands, job resources, and maintaining employment. METHODS: Data from the longitudinal population-based Lifelines cohort study were matched with register data on employment from Statistics Netherlands (N=55 950). Job demands included quantitative demands and work pace; job resources included influence at work and possibilities for development. The two-way interaction between job demands and depression and the three-way interaction between job demands, job resources and depression were examined in a zero-inflated Poisson regression model with path 1, including a binary employment outcome, and path 2, a count variable including months out of employment. RESULTS: The interaction effect of job demands and depression on being employed was significant [b=-0.22, 95% confidence interval (CI) -0.44‒0.01]. Workers without depression were more likely to be employed whereas workers with depression were less likely to be employed if they had high job demands. The three-way interaction between job demands, job resources, and depression was significant for months out of employment (b=0.15, 95% CI 0.01‒0.29), indicating that workers with depression had more months out of employment when reporting high job demands and high job resources compared to workers without depression. Discussion Although increasing influence at work and possibilities for development to prevent negative work outcomes may be beneficial for workers without depression, this approach might be limited for workers with depression.

Increases in symptoms of depression and anxiety in adults during the initial phases of the COVID-19 pandemic are limited to those with less resources: Results from the Lifelines Cohort Study.

BACKGROUND: The COVID-19 pandemic may have a differential impact on mental health based on an individual's capital, i.e. resources available to maintain and enhance health. We assessed trajectories of depression and anxiety symptoms, and their association with different elements of capital. METHODS: Data on 65,854 individuals (mean baseline age = 50·4 (SD = 12·0) years) from the Lifelines COVID-19 cohort were used. Baseline mental health symptoms were on average measured 4.7 (SD = 1·1) years before the first COVID-19 measurement wave, and subsequent waves were (bi)weekly (March 30─August 05, 2020). Mental health symptom trajectories were estimated using a two-part Latent Class Growth Analysis. Class membership was predicted by economic (education, income, and occupation) and person capital (neuroticism, poor health condition, and obesity) FINDINGS: Most individuals were unlikely to report symptoms of depression (80·6%) or anxiety (75·9%), but stable-high classes were identified for both conditions (1·6% and 6·7%, respectively). The stable-high depression class saw the greatest increase in symptoms after COVID, and the stable-high anxiety class reported an increase in the probability of reporting symptoms after COVID. At the first COVID-measurement, the mean number of symptoms increased compared to baseline (depression:4·7 vs 4·1; anxiety:4·3 vs 4·2); the probability of reporting symptoms also increased (depression:0·96 vs 0·65; anxiety:0·92 vs 0·70). Membership in these classes was generally predicted by less capital, especially person capital; odds ratios for person capital ranged from 1·10-2·22 for depression and 1·08-1·51 for anxiety. INTERPRETATION: A minority of individuals, possessing less capital, reported an increase in symptoms of depression or anxiety after COVID. FUNDING: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Do chronic diseases moderate the association between psychosocial working conditions and work exit? Longitudinal results from 55 950 Dutch workers.

BACKGROUND: This study aims to examine whether the presence of chronic diseases or multimorbidity moderates the associations between psychosocial working conditions and work exit through unemployment, work disability or early retirement. METHODS: Data from Lifelines (n=55 950), a prospective population-based cohort study, were enriched with monthly information on employment status from Statistics Netherlands. Working conditions were measured with the Copenhagen Psychosocial Questionnaire. Work exit was defined as unemployment, work disability and early retirement. Participants were classified as having no chronic disease, one chronic disease or multimorbidity. Cause-specific Cox proportional hazard regression models, adjusted for age, gender, education and partnership status, were used to analyse associations between working conditions and work exit. Interaction terms were used to examine moderation by chronic disease status. RESULTS: Higher social support decreased the risk for unemployment, work disability and early retirement. Higher meaning of work decreased the risk of unemployment, and more possibilities for development decreased the risk for work disability. Chronic disease status did generally not moderate associations between working conditions and work exit. Only among workers without a chronic disease, more possibilities for development was associated with a lower risk for unemployment (HR: 0.89; 95% CI: 0.85 to 0.94). CONCLUSION: While efforts to retain workers with chronic diseases in the labour market should continue, favourable psychosocial working conditions are important for all workers.

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

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

Associations of within-individual changes in working conditions, health behaviour and BMI with work ability and self-rated health: a fixed effects analysis among Dutch workers.

OBJECTIVES: This study assessed the associations of (1) within-individual improvements and (2) within-individual deteriorations in working conditions, health behaviour and body mass index (BMI) with changes in work ability and self-rated health among workers. DESIGN: Prospective cohort study. SETTING: The Netherlands. PARTICIPANTS: Persons in paid employment, aged 45-64 years, who participated in the Dutch Study on Transitions in Employment, Ability and Motivation (STREAM) between 2010 and 2017, and improved or deteriorated at least once with respect to working conditions (psychological and emotional job demands, autonomy, social support, physical workload), health behaviour (moderate and vigorous physical activity, smoking status), or BMI between any of two consecutive measurements during the 7-year follow-up. PRIMARY AND SECONDARY OUTCOME MEASURES: Changes in self-reported work ability on a scale from 0 to 10 (1st item of the work ability index) and self-rated health on a scale from 1 to 5 (SF-12). RESULTS: Of the 21 856 STREAM participants, ultimately 14 159 workers were included in the fixed effects analyses on improvements (N=14 045) and deteriorations (N=14 066). Workers with deteriorated working conditions decreased in work ability (ß's: -0.21 (95% CI: -0.25 to -0.18) to -0.28 (95% CI: -0.33 to -0.24)) and health (ß's: -0.07 (95% CI: -0.09 to -0.06) to -0.10 (95% CI: -0.12 to -0.08)), whereas improvements were to a lesser extent associated with increased work ability (ß's: 0.06 (95% CI: 0.02 to 0.09) to 0.11 (95% CI: 0.06 to 0.16)) and health (ß's: 0.02 (95% CI: 0.00 to 0.03) to 0.04 (95% CI: 0.02 to 0.06)). Workers with increased BMI or decreased physical activity reduced in work ability and health. Likewise, decreased BMI or increased vigorous physical activity was associated with improved health. An increase in moderate or vigorous physical activity was modestly associated with a reduced work ability. Quitting smoking was associated with reduced work ability and health. CONCLUSIONS: Compared with improvements, preventing deteriorations in working conditions, health behaviour and BMI, might be more beneficial for work ability and workers' health.

Multimorbidity and exit from paid employment: the effect of specific combinations of chronic health conditions.

BACKGROUND: This study aimed to assess the association between multimorbidity and exit from paid employment, and which combinations of chronic health conditions (CHCs) have the strongest association with exit from paid employment. METHODS: Data from 111 208 workers aged 18-64 years from Lifelines were enriched with monthly employment data from Statistics Netherlands. Exit from paid employment during follow-up was defined as a change from paid employment to unemployment, disability benefits, economic inactivity or early retirement. CHCs included cardiovascular diseases (CVD), chronic obstructive pulmonary disease (COPD), rheumatoid arthritis (RA), type 2 diabetes (T2DM) and depression. Cox-proportional hazards models were used to examine the impact of multimorbidity and combinations of CHCs on exit from paid employment. RESULTS: Multimorbidity increased the risk of exiting paid employment compared with workers without CHCs (hazard ratio (HR): 1.52; 95% confidence interval (CI): 1.35-1.71) or one CHC (HR: 1.14; 95% CI: 1.01-1.28). The risk for exit from paid employment increased among workers with COPD if they additionally had CVD (HR: 1.39; 95% CI: 1.03-1.88), depression (HR: 1.46; 95% CI: 1.10-1.93) or RA (HR: 1.44; 95% CI: 1.08-1.91), for workers with T2DM if they additionally had CVD (HR: 1.43; 95% CI: 1.07-1.91) or depression (HR: 2.09; 95% CI: 1.51-2.91) and for workers with depression who also had T2DM (HR: 1.68; 95% CI: 1.21-2.32). CONCLUSION: This study showed that workers with multimorbidity, especially having a combination of COPD and depression or T2DM and depression, have a higher risk for early exit from paid employment and, therefore, may need tailored support at the workplace.

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

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

Influence of changing working conditions on exit from paid employment among workers with a chronic disease.

OBJECTIVES: To investigate the relation between changes in working conditions and exit from paid employment among workers with a chronic disease. METHODS: Six waves from the longitudinal Study on Transitions in Employment, Ability and Motivation (2010-2016), enriched with tax-based employment information from Statistics Netherlands (2011-2017), were available for 4820 chronically ill workers aged 45-63 years (mean 55.3 years, SD 5.1). A change in working conditions (physical workload, psychological job demands, job autonomy, emotional job demands and social support) was defined as an increase or decrease between two consecutive waves of at least one SD. Discrete-time survival models with repeated measurements were used to estimate the relative risk (RR) of a change in working conditions on exiting paid employment in the following year compared with no change and consecutive favourable working conditions. RESULTS: A favourable change in physical workload lowered the risk to exit paid employment (RR 0.46, 95% CI 0.22 to 0.94). An adverse change in psychosocial working conditions, especially a decrease in social support (RR 2.07, 95% CI 1.52 to 2.81), increased the likelihood to exit paid employment. In contrast, a favourable change in psychological job demands increased the risk to exit paid employment (RR 1.57, 95% CI 1.09 to 2.24). Multiple adverse changes increased the risk to exit paid employment up to six times (RR 6.06, 95% CI 2.83 to 12.98). CONCLUSIONS: Changes in working conditions among workers with chronic diseases influence exit from paid employment. Ensuring that working conditions can be adapted to the needs of workers with a chronic disease may help to extend working life.

Reading or Listening to a Gain- or Loss-Framed Health Message: Effects of Message Framing and Communication Mode in the Context of Fruit and Vegetable Intake.

Gain-framed health messages are found to be more effective when targeting prevention behaviors. However, framing research has only minimally investigated the role of communication mode, another important factor in health communication. This study explored the role of communication mode in interaction with message framing, and the influence of two individual differences related to involvement as conditions under which gain framing can lead to health behavior change. Participants (N = 258) were exposed to either an auditory or written health message concerning fruit and vegetable intake, with either gain- or loss-framed arguments. In addition, the online experiment consisted of baseline and posttest measures, among which intention to consume sufficient fruit and vegetables. Moderating effects of perceived baseline fruit and vegetable consumption and baseline intention were assessed. A significant interaction between message framing and communication mode was observed: In case of a gain-framed message, an auditory message resulted in a higher intention than a written message. This pattern was most explicitly found among those with a lower perceived fruit and vegetable intake at baseline. Although further research is warranted in health persuasion research, the findings can possibly be used to target health interventions better at specific groups of people who behave less healthy.