Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5–89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Reply to comment on 'Bi nanolines on Si(001): Registry with the substrate'

The registry of bismuth dimers, integral components of the bismuth nanoline on Si(001), is examined. In contrast to the currently accepted view, the bismuth dimers are found to be in registry with the two-dimensional lattice created by the silicon dimers. The consequences of this finding are briefly explored.

Non-melanoma skin cancer: Ten years of cancer-registry-based surveillance

The Tasmanian Cancer Registry carried out population-based surveillance of non-melanoma skin cancer (NMSC) from 1978 to 1987. A total of 8,651 NMSC were recorded in 7,160 individuals, representing an age-standardized rate of 161/100,000 per year. Ninety-four percent of cases were based on histological diagnosis. Incidence of basal-cell carcinoma (BCC) was higher than the incidence of squamous-cell carcinoma (SCC). The incidence of NMSC was twice as high in men as in women. Incidence increased substantially with age, more markedly for SCC than BCC. For most body sites, BCC was more frequent, but on highly exposed sites such as the backs of hands, lower limbs in women and ears in men, the incidence of SCC was higher. There was an overall increase of 7% per year in the age-standardized incidence rate of NMSC. The increase was more marked for BCC than for SCC, and was consistent across age groups and both sexes. A first NMSC during the study period was associated with a 12-fold increase among men and a 15-fold increase among women in the risk of development of a new NMSC within 5 years, when compared with the NMSC incidence recorded for the population as a whole.

Occupational burnout and health

Occupational burnout and heath Occupational burnout is assumed to be a negative consequence of chronic work stress. In this study, it was explored in the framework of occupational health psychology, which focusses on psychologically mediated processes between work and health. The objectives were to examine the overlap between burnout and ill health in relation to mental disorders, musculoskeletal disorders, and cardiovascular diseases, which are the three commonest disease groups causing work disability in Finland; to study whether burnout can be distinguished from ill health by its relation to work characteristics and work disability; and to determine the socio-demographic correlates of burnout at the population level. A nationally representative sample of the Finnish working population aged 30 to 64 years (n = 3151-3424) from the multidisciplinary epidemiological Health 2000 Study was used. Burnout was measured with the Maslach Burnout Inventory - General Survey. The diagnoses of common mental disorders were based on the standardized mental health interview (the Composite International Diagnostic Interview), and physical illnesses were determined in a comprehensive clinical health examination by a research physician. Medically certified sickness absences exceeding 9 work days during a 2-year period were extracted from a register of The Social Insurance Institution of Finland. Work stress was operationalized according to the job strain model. Gender, age, education, occupational status, and marital status were recorded as socio-demographic factors. Occupational burnout was related to an increased prevalence of depressive and anxiety disorders and alcohol dependence among the men and women. Burnout was also related to musculoskeletal disorders among the women and cardiovascular diseases among the men independently of socio-demographic factors, physical strenuousness of work, health behaviour, and depressive symptoms. The odds of having at least one long, medically-certified sickness absence were higher for employees with burnout than for their colleagues without burnout. For severe burnout, this association was independent of co-occurring common mental disorders and physical illnesses for both genders, as was also the case for mild burnout among the women. In a subgroup of the men with absences, severe burnout was related to a greater number of absence days than among the women with absences. High job strain was associated with a higher occurrence of burnout and depressive disorders than low job strain was. Of these, the association between job strain and burnout was stronger, and it persisted after control for socio-demographic factors, health behaviour, physical illnesses, and various indicators of mental health. In contrast, job strain was not related to depressive disorders after burnout was accounted for. Among the working population over 30 years of age, burnout was positively associated with age. There was also a tendency towards higher levels of burnout among the women with low educational attainment and occupational status and among the unmarried men. In conclusion, a considerable overlap was found between burnout, mental disorders, and physical illnesses. Still, burnout did not seem to be totally redundant with respect to ill health. Burnout may be more strongly related to stressful work characteristics than depressive disorders are. In addition, burnout seems to be an independent risk factor for work disability, and it could possibly be used as a marker of health-impairing work stress. However, burnout may represent a different kind of risk factor for men and women, and this possibility needs to be taken into account in the promotion of occupational health.

Inconsistency of surrogate measures of alcohol-related accidents in South Australia

Three major changes in drink driving enforcement have occurred in South Australia since 1981. The effect of these changes on a number of surrogate measures of alcohol involvement in accidents were investigated. The surrogates included alcohol involvement of driver fatalities, and combinations of casualty, serious casualty, single vehicle and nighttime accidents. Data from previous studies were also cited. It was found that relationships between surrogate measures were inconsistent, and incompatible with assumptions about drink driving levels and related accidents. It was concluded that until these effects are understood the use of surrogate measures should be treated with caution.

Socioeconomic Status, Occupational Factors and Lifestyle as Predictors of Hospitalisation for Back Disorders

The aim of this dissertation was to examine the determinants of severe back disorders leading to hospital admission in Finland. First, back-related hospitalisations were considered from the perspective of socioeconomic status, occupation, and industry. Secondly, the significance of psychosocial factors at work, sleep disturbances, and such lifestyle factors as smoking and overweight was studied as predictors of hospitalisation due to back disorders. Two sets of data were used: 1) the population-based data comprised all occupationally active Finns aged 25-64, and included hospitalisations due to back disorders in 1996 and 2) a cohort of employees followed up from 1973 to 2000 having been hospitalised due to back disorders. The results of the population-based study showed that people in physically strenuous industries and occupations, such as agriculture and manufacturing, were at an increased risk of being hospitalised for back disorders. The lowest hospitalisation rates were found in sedentary occupations. Occupational class and the level of formal education were independently associated with hospitalisation for back disorders. This stratification was fairly consistent across age-groups and genders. Men had a slightly higher risk of becoming hospitalised compared with women, and the risk increased with age among both genders. The results of the prospective cohort study showed that psychosocial factors at work such as low job control and low supervisor support predicted subsequent hospitalisation for back disorders even when adjustments were made for occupational class and physical workload history. However, psychosocial factors did not predict hospital admissions due to intervertebral disc disorders; only admissions due to other back disorders. Smoking and overweight predicted, instead, only hospitalisation for intervertebral disc disorders. These results suggest that the etiological factors of disc disorders and other back disorders differ from each other. The study concerning the association of sleep disturbances and other distress symptoms with hospitalisation for back disorders revealed that sleep disturbances predicted subsequent hospitalisation for all back disorders after adjustment for chronic back disorders and recurrent back symptoms at baseline, as well as for work-related load and lifestyle factors. Other distress symptoms were not predictive of hospitalisation.

Occupational determinants of pancreatic cancer

Objective and background. Tobacco smoking, pancreatitis and diabetes mellitus are the only known causes of pancreatic cancer, leaving ample room for yet unidentified determinants. This is an empirical study on a Finnish data on occupational exposures and pancreatic cancer risk, and a non-Bayesian and a hierarchical Bayesian meta-analysis of data on occupational factors and pancreatic cancer. Methods. The case-control study analyzed 595 incident cases of pancreatic cancer and 1,622 controls of stomach, colon, and rectum cancer, diagnosed 1984-1987 and known to be dead by 1990 in Finland. The next-of-kin responded to a mail questionnaire on job and medical histories and lifestyles. Meta-analysis of occupational risk factors of pancreatic cancer started off with 1,903 identified studies. The analyses were based on different subsets of that database. Five epidemiologists examined the reports and extracted the pertinent data using a standardized extraction form that covered 20 study descriptors and the relevant relative risk estimates. Random effects meta-analyses were applied for 23 chemical agents. In addition, hierarchical Bayesian models for meta-analysis were applied to the occupational data of 27 job titles using job exposure matrix as a link matrix and estimating the relative risks of pancreatic cancer associated with nine occupational agents. Results. In the case-control study, logistic regressions revealed excess risks of pancreatic cancer associated with occupational exposures to ionizing radiation, nonchlorinated solvents, and pesticides. Chlorinated hydrocarbon solvents and related compounds, used mainly in metal degreasing and dry cleaning, are emerging as likely risk factors of pancreatic cancer in the non-Bayesian and the hierarchical Bayesian meta-analysis. Consistent excess risk was found for insecticides, and a high excess for nickel and nickel compounds in the random effects meta-analysis but not in the hierarchical Bayesian meta-analysis. Conclusions. In this study occupational exposure to chlorinated hydrocarbon solvents and related compounds and insecticides increase risk of pancreatic cancer. Hierarchical Bayesian meta-analysis is applicable when studies addressing the agent(s) under study are lacking or very few, but several studies address job titles with potential exposure to these agents. A job-exposure matrix or a formal expert assessment system is necessary in this situation.

Cancer survivors at work : Work-related problems and factors associated with their employment, work ability and social support from the work community

Due to the improved prognosis of many forms of cancer, an increasing number of cancer survivors are willing to return to work after their treatment. It is generally believed, however, that people with cancer are either unemployed, stay at home, or retire more often than people without cancer. This study investigated the problems that cancer survivors experience on the labour market, as well as the disease-related, sociodemographic and psychosocial factors at work that are associated with the employment and work ability of cancer survivors. The impact of cancer on employment was studied combining the data of Finnish Cancer Registry and census data of the years 1985, 1990, 1995 or 1997 of Statistics Finland. There were two data sets containing 46 312 and 12 542 people with cancer. The results showed that cancer survivors were slightly less often employed than their referents. Two to three years after the diagnosis the employment rate of the cancer survivors was 9% lower than that of their referents (64% vs. 73%), whereas the employment rate was the same before the diagnosis (78%). The employment rate varied greatly according to the cancer type and education. The probability of being employed was greater in the lower than in the higher educational groups. People with cancer were less often employed than people without cancer mainly because of their higher retirement rate (34% vs. 27%). As well as employment, retirement varied by cancer type. The risk of retirement was twofold for people having cancer of the nervous system or people with leukaemia compared to their referents, whereas people with skin cancer, for example, did not have an increased risk of retirement. The aim of the questionnaire study was to investigate whether the work ability of cancer survivors differs from that of people without cancer and whether cancer had impaired their work ability. There were 591 cancer survivors and 757 referents in the data. Even though current work ability of cancer survivors did not differ between the survivors and their referents, 26% of cancer survivors reported that their physical work ability, and 19% that their mental work ability had deteriorated due to cancer. The survivors who had other diseases or had had chemotherapy, most often reported impaired work ability, whereas survivors with a strong commitment to their work organization, or a good social climate at work, reported impairment less frequently. The aim of the other questionnaire study containing 640 people with the history of cancer was to examine extent of social support that cancer survivors needed, and had received from their work community. The cancer survivors had received most support from their co-workers, and they hoped for more support especially from the occupational health care personnel (39% of women and 29% of men). More support was especially needed by men who had lymphoma, had received chemotherapy or had a low education level. The results of this study show that the majority of the survivors are able to return to work. There is, however, a group of cancer survivors who leave work life early, have impaired work ability due to their illness, and suffer from lack of support from their work place and the occupational health services. Treatment-related, as well as sociodemographic factors play an important role in survivors' work-related problems, and presumably their possibilities to continue working.

The Europeanisation of occupational health services: A study of the impact of EU policies

This study concerns Framework Directive 89/391/EEC on health and safety at work, which encouraged improvements in occupational health services (OHS) for workers in EU member states. Framework Directive 89/391/EEC originally aimed at bringing the same level of occupational health and safety to employees in both the public and private sectors in EU member states. However, the implementation of the framework directive and OHS varies widely among EU member states. Occupational health services have generally been considered an important work-related welfare benefit in EU member states. The purpose of this study was to analyse OHS within the EU context and then analyse the impact of EU policies on OHS implementation as part of the welfare state benefit. The focus is on social, health, and industrial policies within welfare state regimes as well as EU policy-making processes affecting these policies in EU member states. The research tasks were divided into four groups related to the policy, functions, targets,and actors of OHS. The questions related to policy tried to discover the role of OHS in other policies, such as health, social, and labour market policies within the EU. The questions about functions sought to describe the changes, as well as the path dependence, of OHS in EU member states after the framework directive. The questions about targets were based on the general aims of WHO and the ILO in relation to equity, solidarity, universality, and access to OHS. The questions on actors were designed to understand the variety of stakeholders interested in OHS. The actors were supranational (EU, ILO, and WHO), national (ministries, institutes, and professional organisations), and social partners (trade unions and employers organisations). The study data were collected by interviewing 92 people in 15 EU member states, including representatives of ministries, institutions, research,trade unions, employers organisations, and occupational health organisations. Other documents were collected from the Internet,databases, libraries, and conference materials for a systematic review of the policies, strategies, organisation, financing, and monitoring of OHS in EU member states. Different analytical methods were used in the data analysis. The main findings of the study can be summarised as follows. First, occupational health services is a context-dependent phenomenon, which therefore varies according to the development of the welfare state in general, and depends on each country s culture, history, economy, and politics. The views of different stakeholders in EU member states concerning the impact and possibilities of OHS to improve health vary from evidence-based opinions to the sporadic impact of OHS on occupational health. OHS as a concept is vaguely defined by the EU, whereas the ILO defines OHS content. The tasks of OHS began as preventive and protective services for workers. However, they have moved towards multidisciplinary and organisational development as well as the workplace health promotion sphere.Since 1989 OHS has developed differently in different EU member states depending on the starting position of those states, but planning and implementation are crucial phases in the process toward better OHS coverage, equity, and access. Nevertheless, the data used for the planning and legitimisation of OHS activities are mainly based on occupational health data rather than on OHS data. This makes decisions on political or policy grounds inaccurate. OHS is still an evolving concept and benefit for workers, but the Europeanisation of OHS reflects contextual changes, such as the impact of the internal market, competition, and commercialisation on OHS. Stronger cooperation and integration with health, social, and employment services would be an asset for workers, because of new epidemics, an epidemiological shift towards new risks, an ageing labour market, and changes in the labour market. Different methods and approaches are needed in order to study the results of integrated services. In the future, more detailed information will be needed about the actual impact of EU policies on OHS and decision-making processes in order to get OHS into different policies in the EU and its member states. Further results and effects of OHS processes on occupational health need to be analysed more carefully. The adoption of a variety of research strategies and a multidisciplinary approach to understand the influence of different policies on OHS in the EU and its member states would highlight the options and opportunities to improve workers occupational health. Key subject headings: Occupational health services, EU policy, policymaking,framework directive 89/391/EEC

Older job seekers' job search intensity: The interplay of proactive personality, age and occupational future time perspective

Long-term unemployment of older people can have severe consequences for individuals, communities and ultimately economies, and is therefore a serious concern in countries with an ageing population. However, the interplay of chronological age and other individual difference characteristics in predicting older job seekers' job search is so far not well understood. This study investigated relationships among age, proactive personality, occupational future time perspective (FTP) and job search intensity of 182 job seekers between 43 and 77 years in Australia. Results were mostly consistent with expectations based on a combination of socio-emotional selectivity theory and the notion of compensatory psychological resources. Proactive personality was positively related to job search intensity and age was negatively related to job search intensity. Age moderated the relationship between proactive personality and job search intensity, such that the relationship was stronger at higher compared to lower ages. One dimension of occupational FTP (perceived remaining time left in the occupational context) mediated this moderating effect, but not the overall relationship between age and job search intensity. Implications for future research, including the interplay of occupational FTP and proactive personality, and some tentative practical implications are discussed.

The buffering effect of selection, optimization, and compensation strategy use on the relationship between problem solving demands and occupational well-being: A daily diary study

This study investigated within-person relationships between daily problem solving demands, selection, optimization, and compensation (SOC) strategy use, job satisfaction, and fatigue at work. Based on conservation of resources theory, it was hypothesized that high SOC strategy use boosts the positive relationship between problem solving demands and job satisfaction, and buffers the positive relationship between problem solving demands and fatigue. Using a daily diary study design, data were collected from 64 administrative employees who completed a general questionnaire and two daily online questionnaires over four work days. Multilevel analyses showed that problem solving demands were positively related to fatigue, but unrelated to job satisfaction. SOC strategy use was positively related to job satisfaction, but unrelated to fatigue. A buffering effect of high SOC strategy use on the demands-fatigue relationship was found, but no booster effect on the demands-satisfaction relationship. The results suggest that high SOC strategy use is a resource that protects employees from the negative effects of high problem solving demands.

Remaining time and opportunities at work: Relationships between age, work characteristics, and occupational future time perspective

The authors adapted the concept of future time perspective (FTP) to the work context and examined its relationships with age and work characteristics (job complexity and control). Structural equation modeling of data from 176 employees of various occupations showed that age is negatively related to 2 distinct dimensions of occupational FTP: remaining time and remaining opportunities. Work characteristics (job complexity and control) were positively related to remaining opportunities and moderated the relationship between age and remaining opportunities, such that the relationship became weaker with increasing levels of job complexity and control.

Was wollen jüngere und ältere Erwerbstätige erreichen? Altersbezogene Unterschiede in den Inhalten und Merkmalen beruflicher Ziele [What do younger and older workers want to accomplish? Age-related differences in content and characteristics of occupational goals ]

Demographic changes necessitate that companies commit younger workers and motivate older workers through work design. Age-related differences in occupational goals should be taken into account when accomplishing these challenges. In this study, we investigated goal contents and goal characteristics of employees from different age groups. We surveyed 150 employees working in the service sector (average age = 44 years, age range 19 to 60 years) on their most important occupational goals. Employees who stated goals from the area of organizational citizenship were significantly older than employees with other goals. Employees who stated goals from the areas of training and pay/career were significantly younger than employees with other goals. After controlling for gender, education, and work characteristics, no age-related differences were found in the goal areas teamwork, job security, working time, well-being, and new challenges. In addition, no relationships were found between age and the goal characteristics specificity, planning intensity, as well as positive and negative goal emotions. We recommend that companies provide older workers with more opportunities for organizational citizenship and commit younger workers by providing development opportunities and adequate pay

Links between emotional job demands and occupational well-being: Age differences depend on type of demand

In the growing health care sector, meeting emotional job demands is crucial to organizational outcomes but may negatively affect employees’ well-being. Drawing on the emotional aging literature, we predicted that two common emotional job demands, display demands (expressing positive, negative, and neutral emotions toward clients) and sensitivity demands (knowing what the client is feeling), affect older health care workers’ occupational well-being differently than young workers, as indicated by their job satisfaction and need for recovery. Survey data from employees of senior care homes (N = 141, aged between 17 and 62 years) confirmed the moderating role of age for links between emotional job demands and occupational well-being indicators. Emotional display demands were generally positively associated with emotional dissonance; however, the association between demands to display neutral emotions and emotional dissonance was stronger among young compared with older employees. In contrast, among older but not young employees, emotional dissonance was negatively associated with job satisfaction, and emotional sensitivity demands were positively associated with need for recovery. These findings suggest that age may confer both advantages (facing neutral display demands) and vulnerabilities (facing emotional dissonance and sensitivity demands) in managing emotional job demands.