Estimating the causal effects of work-related and non-work-related stressors on perceived stress level: A fixed effects approach using population-based panel data.

OBJECTIVES: Prolonged or excessive stress can have a negative impact on health and well-being, and stress therefore constitutes a major public health issue. A central question is what are the main sources of stress in contemporary societies? This study examines the effects of work-related and non-work-related stressors and perceived social support on perceived stress within a causal framework. METHODS: Panel data were drawn from two waves (2013 and 2017) of the population-based health survey "How are you?" conducted in the Central Denmark Region. The analytical sample comprised 9,194 subjects who had responded to both surveys. Work-related and non-work-related stressors included major life events, chronic stressors, daily hassles and lack of social support. Perceived stress was measured with the 10-item Perceived Stress Scale (PSS). Data were analysed using fixed effects regression in a fully balanced design. RESULTS: The largest effects on PSS were seen in own disease, work situation and lack of social support. Other stressors affecting the perceived stress level were financial circumstances, relationship with partner, relationship with family and friends, and disease among close relatives. Most variables had a symmetrical effect on PSS. CONCLUSIONS: The results point to the need for comprehensive policies to promote mental health that span life domains and include both the individual and the group as well as organizational and societal levels. The study indicates that there are multiple potential entry points for stress prevention and stress management. However, it also shows that disease, work situation and social support weigh heavily in the overall picture. This points to the healthcare system and workplace as key institutional venues for action.

The relative importance of work-related and non-work-related stressors and perceived social support on global perceived stress in a cross-sectional population-based sample.

BACKGROUND: High levels of perceived stress have a negative bearing on health and well-being, and stress is a major public health issue. According to the Stress Process Model, stressors are socially patterned and combine to produce strain. Despite this, most studies on stress have focused on work-related stressors leaving non-work determinants under-investigated. The aim of the present study was to determine the relative importance of work-related and non-work-related stressors and perceived social support for the overall perceived stress level. METHODS: Self-reported data were drawn from the 2017 population-based health survey "How are you?" conducted in the Central Denmark Region (N = 32,417). Data were linked with data drawn from national administrative registers. Work- and non-work-related stressors assessed included major life events, chronic stressors and daily hassles. Perceived social support was assessed using a single question. Overall perceived stress was assessed by the 10-item Perceived Stress Scale. We conducted dominance analyses based on a multiple linear regression model to determine the most important explanatory variables of overall perceived stress. Analyses were weighted and adjusted. RESULTS: Work- and non-work-related stressors along with perceived social support explained 42.5% of the total variance (R2) in overall perceived stress. The most important explanatory variables were disease, perceived social support and work situation. The stratified analyses produced slightly varying results ("dominance profiles") of perceived stress between subgroups. Work situation was the most important explanatory variable in the employed group. However, adding non-work-related explanatory variables to the analysis tripled the explained variance. CONCLUSIONS: The overall level of perceived stress can be statistically explained by a combination of work- and non-work-related stressors and perceived social support both at population level and in subgroups. The most important explanatory variables of overall perceived stress are disease, perceived social support and work situation. Results indicate that public health strategies aiming to reduce stress should take a comprehensive approach and address a variety of stressor domains rather than focus on a single domain. TRIAL REGISTRATION: The study was approved by the Danish Data Protection Agency (r. no. 2012-58-0006) and registered in the Central Denmark Region (r. no. 1-16-02-593-16).

Population differences in health-related quality of life between cancer survivors and controls: Does low educational attainment widen the gap?

Aims: This study aimed to compare health-related quality of life (HRQOL) among cancer survivors and controls in the Danish population, with special attention given to the impact of low educational attainment. Comparisons were made at population level and for subgroups stratified by education. Furthermore, comparisons were made for all cancer diagnoses combined and for the 14 most prevalent cancer sites and 'other cancer sites'. Finally, the importance of time since initial diagnosis was examined. Methods: HRQOL was measured using the physical component score (PCS) and mental component score (MCS) of the 12-item Short-Form Health Survey version 2 in a population-based survey. By linking data with the Danish Cancer Registry, 11,166 cancer survivors and 151,117 individuals with no history of cancer were identified. Results: HRQOL was reduced in cancer survivors for all cancers combined and most cancer sites. Differences were found at population level and stratified by educational attainment. PCS was reduced to a similar extent in the three educational groups, whereas MCS was reduced slightly more in the low than in the high educational attainment group. HRQOL increased with time since initial diagnosis during the first years. Conclusions: Cancer survivors had lower HRQOL than controls, and HRQOL was lower in the low than in the high educational attainment group. However, low educational attainment did not widen the gap in HRQOL following a cancer diagnosis. Despite this, the combined effect of low educational attainment and a cancer diagnosis markedly reduced HRQOL in some cancer survivors. The study identified groups of cancer survivors with low HRQOL who may have unmet rehabilitation needs.

Exercise on prescription: changes in physical activity and health-related quality of life in five Danish programmes.

BACKGROUND: Exercise prescribed by the general practitioner may be an important health-improving intervention for inactive individuals with lifestyle diseases. The objective was to analyse changes in physical activity and health-related quality of life among participants in five similar 'Exercise on Prescription' (EoP) programmes. METHODS: The analysis was based on self-reported information in a follow-up design without a control group. The intervention comprised group training twice weekly in the first 2 months and once weekly in the following 2 months (24 sessions in all) combined with four to five sessions of motivational counselling. Self-report questionnaires were administered at the first contact and again after 4, 10 and 16 months. Outcome measures were changes in self-reported activity levels converted to metabolic equivalents and health-related quality of life measured by standard instruments (SF-12v2 and EQ-5D). RESULTS: 449 individuals (59% women, mean age 57 years) agreed to participate in the study. Dropout was considerable [123 (27%); 231 (52%) 297 (66%) after 4, 10 and 16 months]. Participants increased their physical activity level and health-related quality of life from baseline to 4 months and maintained improvement throughout the observation period. One in three to six participants increased their physical activity level and one in 4-10 achieved improvements in health-related quality of life. CONCLUSION: Exercise on prescription can contribute to improvements in physical activity level and health-related quality of life in physically inactive patients with or at increased risk of developing lifestyle diseases. An acceptable number of participants achieved and maintained improvements in physical activity level and health-related quality of life.

Exercise on prescription in general practice: a systematic review.

'Exercise on Prescription' (EoP) is used for initiating physical activity among sedentary patients with signs of lifestyle diseases. EoP is personalized secondary prevention in primary healthcare. This review addresses EoP using a Health Technology Assessment perspective and aims to answer the following questions: (1) Does EoP increase physical activity level or physical fitness, and is more intensive EoP more effective than less intensive? (2) Is EoP acceptable and feasible in general practice? (3) Is EoP acceptable to and feasible for sedentary patients? (4) Is EoP cost-effective? EoP studies were searched using Medline thesaurus topic, Medline WinSPIRS, reference lists of recent reviews, and NLM Gateway Locator plus. A total of 22 studies were included in the review. Most studies reported moderate improvements in physical activity or physical fitness for 6-12 months. Among patients receiving EoP 10% more had improved physical activity level compared with controls and mean aerobic fitness was improved by 5-10% among EoP patients compared with controls. Little evidence existed in support of the hypothesis that more intensive EoP is more effective. EoP was acceptable and feasible to GPs and patients volunteering for EoP. However, little is known about non-completers, patients declining EoP, and GPs not highly motivated for using EoP. Only one study addressed health economic issues. It found EoP cost-effective, but comparisons with other interventions have not been performed. Even though most studies in this review presented favourable results for EoP there is a lack of evidence in several fields. In particular we lack high-quality studies evaluating EoP schemes that are sustainable in everyday use in general practice.

Muscle fiber type distribution and nonlinear .VO(2)-power output relationship in cycling.

PURPOSE: We examined whether reported deviations from linearity of the oxygen uptake (.VO(2))-to-power output (W) relationship during intense cycling exercise correlated with the percentage Type II fibers in the exercising muscle. METHODS: Twelve trained young men with known fiber type distribution in the vastus lateralis muscle performed step-increment exercise (40 W.3 min(-1)) to exhaustion. RESULTS: .VO(2) increased linearly with W up to about 50% .VO(2max) with a regression equation of .VO(2) (mL.min-1) = 661 + 9.73 W and a correlation coefficient (r) of 1.000. Subsequent .VO(2) values were all greater than corresponding linear estimates (P < 0.001 or 0.0001). Peak exercise excess .VO(2) (measured minus estimated .VO(2) assuming linearity) averaged (SD) 434 (192) mL O(2).min-1 or 10.3 (4.7) % .VO(2max). A comprehensive curvilinearity index defined as the sum of measured minus estimated .VO(2) at the four highest completed exercise trials averaged 973 (460) mL O(2).min-1 or 21.5 (9.4) % .VO(2max). Correlations between percentage Type II fibers and either of the two expressions of curvilinearity were nonsignificant. Delta [H+] (arterialized capillary blood) from basal level to peak exercise correlated with the submaximal curvilinearity index (r = 0.59-0.64; P < 0.05) but not with peak excess .VO(2). There was a trend toward a correlation between delta La and curvilinearity index in % .VO(2max)(r = 0.52; P < 0.10) but not with any of the other curvilinearity expressions. The relative ventilatory activity expressed as .V(E)-to-.VO(2) ratio tended to correlate with peak excess .VO(2) (P < 0.10) but not with curvilinearity index. Signals from motion sensors indicate that coactivation of upper-body musculature coincided with deviation from linearity in the .VO(2)-W relationship. CONCLUSION: VO2 during step-increment cycling increases linearly with power output up to about 50% .VO(2max)and then curvilinearly. The degree of curvilinearity is not related to muscle fiber type distribution in the vastus lateralis, and only marginally and insignificantly related (P < 0.10) to the relative degree of hyperventilation or to lactate response. Acidosis, on the other hand, correlated significantly with curvilinearity index. The inclusion of isometrically working, upper-body muscular groups during high-intensity cycling may also contribute to the overshoot in oxygen cost.