Objective The aim of this review was to synthesize the evidence on the potential relationship between nightshift work and breast cancer. Methods We searched multiple databases for studies comparing ...women in shift work to those with no-shift work reporting incidence of breast cancer. We calculated incremental risk ratios (RR) per five years of nightshift work and per 300 night shift increases in exposure and combined these in a random effects dose—response meta-analysis. We assessed study quality in ten domains of bias. Results We identified 16 studies: 12 case—control and 4 cohort studies. There was a 9% risk increase per five years of night-shift work exposure in case—control studies RR 1.09, 95% confidence interval (95% CI) 1.02—1.20; I 2 =37%, 9 studies, but not in cohort studies (RR 1.01, 95% CI 0.97—1.05; I 2 =53%, 3 studies). Heterogeneity was significant overall (I 2 =55%, 12 studies). Results for 300 night shifts were similar (RR 1.04, 95% CI 1.00—1.10; I 2 =58%, 8 studies). Sensitivity analysis using exposure transformations such as cubic splines, a fixed-effect model, or including only better quality studies did not change the results. None of the 16 studies had a low risk of bias, and 6 studies had a moderate risk. Conclusions Based on the low quality of exposure data and the difference in effect by study design, our findings indicate insufficient evidence for a link between night-shift work and breast cancer. Objective prospective exposure measurement is needed in future studies.
Objectives We analyzed the work ability index (WAI) and its first item (work ability score, WAS) – and subsequent four-year changes thereof – as predictors of disability pension (DP). Methods We ...linked survey responses of 5251 Finnish municipal employees, aged 44–58 years, to pension and death register data until 2009. Job content (physical, mental, or mixed) was based on observation. Baseline (1981) WAI was divided into poor (<27), moderate (28–36), and good/excellent (>37) and WAS into poor (0–5), moderate (6–7), and good/excellent (8–10). Four-year changes in these scores were classified as strong decline (<lowest 15th percentile), slight decline, and no change/improved. Cox regression and receiver operating characteristic (ROC) analysis were used. Results During follow-up, 2057 subjects were granted DP. Compared to those with good/excellent WAI, the hazard ratio (HR) for DP related to moderate and poor WAI, respectively, was 2.0 (95% CI 1.8–2.2) and 5.0 (95% CI 4.4–5.6), adjusted for sociodemographic variables and job content. For WAS, the HR were 1.8 (95% CI 1.6–2.0) and 3.4 (95% 3.0–3.8). Four-year decline in WAI/WAS further increased the risk. During the first four years of follow-up, the area under the curve (AUC) for WAI at cut-off point 27 was 0.66 (sensitivity 49.2% and specificity 82.9%) and 0.64 for cut-off point 36 (sensitivity 84.2% and specificity 44.3%). For WAS at cut-off point 5, the figures were AUC 0.63 (sensitivity 41.9% and specificity 85.0%) and AUC 0.65 for cut-off point 7 (sensitivity 78.2% and specificity 52.7%). Conclusion The single-item WAS can be considered a reasonable alternative to the seven-item WAI in describing the risk of DP and as a prognostic tool.
ObjectivesTo examine the association of shift work with and without night work with breast cancer among women in the public sector.MethodsUsing the Finnish Public Sector cohort study (N=33 359, mean ...age of 40.6 years at baseline), we investigated the associations of shift work and potential confounders with incident breast cancer. Exposure to permanent day work or shift work was defined from first two consecutive surveys from 2000, 2004, 2008 or 2012 and past information on exposure in a subcohort (n=20 786). Incident cases of breast cancer (n=1129) were retrieved from the National Cancer Register and the cohort members were followed to the end of 2016. HR and 95% CI from Cox proportional hazard regression models were calculated.ResultsShift work with and without night shifts was not overall associated with breast cancer. When stratified according to age, both shift work without nights (HR 2.01, 95% CI 1.12 to 3.60) and shift work with nights (OR 2.05, 95% CI 1.04 to 4.01) were associated with an increased risk after a period of 10 years or more follow-up among women aged 50 years or older, when adjusted for age, socioeconomic status, children, smoking, alcohol and body mass index. In a subgroup with past information on exposure to shift work, the increased risk by longer exposure to shift work was not significant.ConclusionsThis study provides support for an increased risk of breast cancer among elderly shift workers. However, insufficient information on exposure and intensity of night work may attenuate the risk estimates.
Background
People with severe mental illness show high rates of unemployment and work disability, however, they often have a desire to participate in employment. People with severe mental illness ...used to be placed in sheltered employment or were enrolled in prevocational training to facilitate transition to a competitive job. Now, there are also interventions focusing on rapid search for a competitive job, with ongoing support to keep the job, known as supported employment. Recently, there has been a growing interest in combining supported employment with other prevocational or psychiatric interventions.
Objectives
To assess the comparative effectiveness of various types of vocational rehabilitation interventions and to rank these interventions according to their effectiveness to facilitate competitive employment in adults with severe mental illness.
Search methods
In November 2016 we searched CENTRAL, MEDLINE, Embase, PsychINFO, and CINAHL, and reference lists of articles for randomised controlled trials and systematic reviews. We identified systematic reviews from which to extract randomised controlled trials.
Selection criteria
We included randomised controlled trials and cluster‐randomised controlled trials evaluating the effect of interventions on obtaining competitive employment for adults with severe mental illness. We included trials with competitive employment outcomes. The main intervention groups were prevocational training programmes, transitional employment interventions, supported employment, supported employment augmented with other specific interventions, and psychiatric care only.
Data collection and analysis
Two authors independently identified trials, performed data extraction, including adverse events, and assessed trial quality. We performed direct meta‐analyses and a network meta‐analysis including measurements of the surface under the cumulative ranking curve (SUCRA). We assessed the quality of the evidence for outcomes within the network meta‐analysis according to GRADE.
Main results
We included 48 randomised controlled trials involving 8743 participants. Of these, 30 studied supported employment, 13 augmented supported employment, 17 prevocational training, and 6 transitional employment. Psychiatric care only was the control condition in 13 studies.
Direct comparison meta‐analysis of obtaining competitive employment
We could include 18 trials with short‐term follow‐up in a direct meta‐analysis (N = 2291) of the following comparisons. Supported employment was more effective than prevocational training (RR 2.52, 95% CI 1.21 to 5.24) and transitional employment (RR 3.49, 95% CI 1.77 to 6.89) and prevocational training was more effective than psychiatric care only (RR 8.96, 95% CI 1.77 to 45.51) in obtaining competitive employment.
For the long‐term follow‐up direct meta‐analysis, we could include 22 trials (N = 5233). Augmented supported employment (RR 4.32, 95% CI 1.49 to 12.48), supported employment (RR 1.51, 95% CI 1.36 to 1.68) and prevocational training (RR 2.19, 95% CI 1.07 to 4.46) were more effective than psychiatric care only. Augmented supported employment was more effective than supported employment (RR 1.94, 95% CI 1.03 to 3.65), transitional employment (RR 2.45, 95% CI 1.69 to 3.55) and prevocational training (RR 5.42, 95% CI 1.08 to 27.11). Supported employment was more effective than transitional employment (RR 3.28, 95% CI 2.13 to 5.04) and prevocational training (RR 2.31, 95% CI 1.85 to 2.89).
Network meta‐analysis of obtaining competitive employment
We could include 22 trials with long‐term follow‐up in a network meta‐analysis.
Augmented supported employment was the most effective intervention versus psychiatric care only in obtaining competitive employment (RR 3.81, 95% CI 1.99 to 7.31, SUCRA 98.5, moderate‐quality evidence), followed by supported employment (RR 2.72 95% CI 1.55 to 4.76; SUCRA 76.5, low‐quality evidence).
Prevocational training (RR 1.26, 95% CI 0.73 to 2.19; SUCRA 40.3, very low‐quality evidence) and transitional employment were not considerably different from psychiatric care only (RR 1.00,95% CI 0.51 to 1.96; SUCRA 17.2, low‐quality evidence) in achieving competitive employment, but prevocational training stood out in the SUCRA value and rank.
Augmented supported employment was slightly better than supported employment, but not significantly (RR 1.40, 95% CI 0.92 to 2.14). The SUCRA value and mean rank were higher for augmented supported employment.
The results of the network meta‐analysis of the intervention subgroups favoured augmented supported employment interventions, but also cognitive training. However, supported employment augmented with symptom‐related skills training showed the best results (RR compared to psychiatric care only 3.61 with 95% CI 1.03 to 12.63, SUCRA 80.3).
We graded the quality of the evidence of the network ranking as very low because of potential risk of bias in the included studies, inconsistency and publication bias.
Direct meta‐analysis of maintaining competitive employment
Based on the direct meta‐analysis of the short‐term follow‐up of maintaining employment, supported employment was more effective than: psychiatric care only, transitional employment, prevocational training, and augmented supported employment.
In the long‐term follow‐up direct meta‐analysis, augmented supported employment was more effective than prevocational training (MD 22.79 weeks, 95% CI 15.96 to 29.62) and supported employment (MD 10.09, 95% CI 0.32 to 19.85) in maintaining competitive employment. Participants receiving supported employment worked more weeks than those receiving transitional employment (MD 17.36, 95% CI 11.53 to 23.18) or prevocational training (MD 11.56, 95% CI 5.99 to 17.13).
We did not find differences between interventions in the risk of dropouts or hospital admissions.
Authors' conclusions
Supported employment and augmented supported employment were the most effective interventions for people with severe mental illness in terms of obtaining and maintaining employment, based on both the direct comparison analysis and the network meta‐analysis, without increasing the risk of adverse events. These results are based on moderate‐ to low‐quality evidence, meaning that future studies with lower risk of bias could change these results. Augmented supported employment may be slightly more effective compared to supported employment alone. However, this difference was small, based on the direct comparison analysis, and further decreased with the network meta‐analysis meaning that this difference should be interpreted cautiously. More studies on maintaining competitive employment are needed to get a better understanding of whether the costs and efforts are worthwhile in the long term for both the individual and society.
Objectives: The aim of this study was to examine whether changes in work shifts and shift intensity are related to changes in difficulties to fall asleep, fatigue, and sleep length. Methods: ...Questionnaire responses of hospital employees (N=7727, 93% women) in 2008, 2012, 2014 and 2015 were linked to daily-based records of working hours during three months preceding each survey. We used conditional logistic regression and longitudinal fixed-effects analyses to investigate odds ratios (OR) and 95% confidence intervals (CI) for each 25% within-individual change in the proportion of working hour characteristics in relation to changes in fatigue, difficulties to fall asleep, and 24-hour sleep length. Results: Change in night but not in morning or evening shifts was associated with parallel changes in odds for longer sleep length (OR 1.45, 95% CI 1.28-1.64) and fatigue during free days (OR 1.38, 95% CI 1.16-1.64). Similarly, short shift intervals and having ＞2 but not ＞4 consecutive night shifts were associated with increased odds of fatigue during work and difficulties to fall asleep (OR 1.42, 95% CI 1.19-1.72 and OR 1.10, 95% CI 1.05-1.19, respectively). Among workers aged ≥50 years, the associations were the strongest between night shifts and longer sleep (OR 2.24, 95% CI 1.52-3.81) and between higher proportion of short shift intervals and fatigue during free days (OR 1.68, 95% CI 1.10-2.54). Conclusions: Among shift workers with fatigue or sleep problems, decreasing the proportion of night shifts and quick returns and giving preference to quickly forward-rotating shift systems may reduce fatigue.
Summary
We examined shift work with or without night work as a risk factor for fatigue and short or long sleep. In a prospective cohort study with 4‐ and 6‐year follow‐ups (the Finnish Public Sector ...study), we linked survey responses of 3,679 full‐time hospital employees on sleep duration and fatigue to records on daily working hours in 2008 (baseline), 2012 and 2014. We used logistic regression to estimate risk ratios and their confidence intervals to examine whether continuous exposure to shift work or changes between shift work and day work were associated with short (≤6.5 hr) or long (≥9.0 hr) sleep over 24 hr and fatigue at work and during free days. Compared with continuous day work and adjusting for age, gender, education and fatigue/sleep duration at baseline, continuous shift work with night shifts was associated with increased fatigue during free days (risk ratio = 1.38, 95% confidence interval 1.17–1.63) and long sleep (risk ratio = 8.04, 95% confidence interval 2.88–22.5, without adjustment for education) after 6‐year follow‐up. Exposure to shift work without night shifts increased only long sleep after 6 years (risk ratio = 5.87, 95% confidence interval 1.94–17.8). A change from day work to shift work with or without night shifts was associated with an increased risk for long sleep, and a change from shift work to day work with a decreased risk for long sleep and fatigue. This study suggests that irregular shift work is a modifiable risk factor for long sleep and increased fatigue, probably reflecting a higher need for recovery.
Osteoarthritis of the knee is considered to be related to knee straining activities at work. The objective of this review is to assess the exposure dose-response relation between kneeling or ...squatting, lifting, and climbing stairs at work, and knee osteoarthritis.
We included cohort and case–control studies. For each study that reported enough data, we calculated the odds ratio (OR) per 5,000 hours of cumulative kneeling and per 100,000 kg of cumulative lifting. We pooled these incremental ORs in a random effects meta-analysis.
We included 15 studies (2 cohort and 13 case–control studies) of which nine assessed risks in more than two exposure categories. We considered all but one study at high risk of bias. The incremental OR per 5,000 hours of kneeling was 1.26 (95% confidence interval 1.17–1.35, 5 studies, moderate quality evidence) for a log-linear exposure dose-response model. For lifting, there was no exposure dose-response per 100,000 kg of lifetime lifting (OR 1.00, 95% confidence interval 1.00–1.01). For climbing, an exposure dose-response could not be calculated.
There is moderate quality evidence that longer cumulative exposure to kneeling or squatting at work leads to a higher risk of osteoarthritis of the knee. For other exposure, there was no exposure dose-response or there were insufficient data to establish this. More reliable exposure measurements would increase the quality of the evidence.
Objective This study examined the associations between shift work and use of antihypertensive, lipid-lowering, and antidiabetic medications. Methods Survey data from two cohorts of Finnish men (N=11 ...998) and women (N=49 944) working in multiple occupations where shift work was used were linked to national Drug Prescription Register data, with up to 11 years of follow-up. In each cohort, age-stratified Cox proportional hazard regression models were computed to examine any incident use of prescription medication for each of the three medical conditions, separately comparing each of two groups of rotating shift workers (those whose schedules included night shifts, and those whose schedules did not include night shifts) with day workers who worked in a similar range of occupations. Results In the larger cohort, among participants aged 40-49 at baseline, shift work without night shifts was associated with increased use of type-2 diabetes medication after adjustments for sex, occupational status, marital status, alcohol consumption, smoking, and physical activity hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.01-1.62, while shift work with night shifts was associated with increased use of dyslipidemia medication after adjustments (HR 1.33, 95% CI 1.12-1.57). There were no such associations among younger and older shift workers. Also in the larger cohort, among those aged <50 years at baseline, both types of shift work were associated with increased use of hypertension medication after adjustments up to HR 1.20 (95% CI 1.05-1.37). There were no positive associations in the smaller cohort. Conclusions There was mixed evidence regarding the use of medications for cardiovascular risk factors by shift workers. Selection effects may have affected the associations.
ObjectivesThe aim of this prospective study was to examine the role of physical workload, leisure-time physical activity, obesity and smoking in predicting the occurrence and course of multisite ...musculoskeletal pain (MSP).MethodsData on physical and psychosocial workload, lifestyle factors and MSP were based on questionnaire surveys of 385 Finnish female kitchen workers. MSP (defined as pain at three or more of seven sites) during the past 3 months was measured repeatedly at 3-month intervals over 2 years. Four different patterns (trajectories) in the course of MSP were identified. The authors analysed whether the determinants at baseline predicted the occurrence of MSP (1) at the 2-year follow-up and (2) over the total of nine measurements during the 2 years by exploiting the MSP trajectories. Logistic regression was used.ResultsHigh physical workload at baseline was an independent predictor of MSP at the 2-year follow-up (OR 3.8, 95% CI 1.7 to 8.5) in a model allowing for age, psychosocial factors at work and lifestyle. High physical workload (OR 2.0, 95% CI 1.0 to 4.0) and moderate (OR 2.4, 95% CI 1.2 to 4.9) or low (OR 2.3, 95% CI 1.1 to 4.7) physical activity predicted persistent MSP. Obesity (OR 2.8, 95% CI 1.0 to 7.8) predicted an increased, and not being obese (OR 3.7, 95% CI 1.1 to 12.7) a decreased, prevalence of MSP in models similarly including all covariates. Smoking had no effect.ConclusionThe results emphasise the importance of high physical workload, low to moderate physical activity and obesity as potential modifiable risk factors for the occurrence and course of MSP over time.
CONTEXT Nearly half of adult cancer survivors are younger than 65 years, but the association of cancer survivorship with employment status is unknown. OBJECTIVE To assess the association of cancer ...survivorship with unemployment compared with healthy controls. DATA SOURCES A systematic search of studies published between 1966 and June 2008 was conducted using MEDLINE, CINAHL, EMBASE, PsycINFO, and OSH-ROM databases. STUDY SELECTION Eligible studies included adult cancer survivors and a control group, and employment as an outcome. DATA EXTRACTION Pooled relative risks were calculated over all studies and according to cancer type. A Bayesian meta-regression analysis was performed to assess associations of unemployment with cancer type, country of origin, average age at diagnosis, and background unemployment rate. RESULTS Twenty-six articles describing 36 studies met the inclusion criteria. The analyses included 20 366 cancer survivors and 157 603 healthy control participants. Studies included 16 from the United States, 15 from Europe, and 5 from other countries. Overall, cancer survivors were more likely to be unemployed than healthy control participants (33.8% vs 15.2%; pooled relative risk RR, 1.37; 95% confidence interval CI, 1.21-1.55). Unemployment was higher in breast cancer survivors compared with control participants (35.6% vs 31.7%; pooled RR, 1.28; 95% CI, 1.11-1.49), as well as in survivors of gastrointestinal cancers (48.8% vs 33.4%; pooled RR, 1.44; 95% CI, 1.02-2.05), and cancers of the female reproductive organs (49.1% vs 38.3%; pooled RR, 1.28; 95% CI, 1.17-1.40). Unemployment rates were not higher for survivors of blood cancers compared with controls (30.6% vs 23.7%; pooled RR, 1.41; 95% CI, 0.95-2.09), prostate cancers (39.4% vs 27.1%; pooled RR, 1.11; 95% CI, 1.00-1.25), or testicular cancer (18.5% vs 18.1%; pooled RR, 0.94; 95% CI, 0.74-1.20). For survivors in the United States, the unemployment risk was 1.5 times higher compared with survivors in Europe (meta-RR, 1.48; 95% credibility interval, 1.15-1.95). After adjustment for diagnosis, age, and background unemployment rate, this risk disappeared (meta-RR, 1.24; 95% CI, 0.85-1.83). CONCLUSION Cancer survivorship is associated with unemployment.
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