The paper by Chang et al[1] defined a Protective Effectiveness Index (PEI) as a measure of the protection afforded by gloves, whereas in reality it indicates the overall difference in exposure between two groups of workers where other important exposure factors may not be, indeed were not, the same. This raises the possibility that your readers may mistake this index as a reliable guide to glove prot...
The paper by Chang et al[1] defined a Protective Effectiveness Index (PEI) as a measure of the protection afforded by gloves, whereas in reality it indicates the overall difference in exposure between two groups of workers where other important exposure factors may not be, indeed were not, the same. This raises the possibility that your readers may mistake this index as a reliable guide to glove protection and make inappropriate choices when managing risks from dermal exposure.
Chang et al present results from biological monitoring amongst workers exposed to 2-methoxyethanol (2-ME). The authors use the urinary (and plasma) metabolite levels from workers who wore gloves (cotton and butyl rubber) compared with the levels from other workers who did not wear gloves to assess the protective effectiveness of the protective equipment. They defined the PEI as:
where UMAA is the urinary 2-methoxyacetic acid concentrations, the main metabolite of 2-ME, measured in end of shift samples.
The PEI is zero when the average metabolite levels in both groups are identical and 100% when the UMAAwithglove is zero. If the UMAAwithglove is greater than the levels from the group not wearing gloves then the calculated PEI will be negative.
This approach is quite different from the conventional paradigm for the effectiveness of personal protective equipment. For example, for respiratory protection a Protection Factor (PF) is normally expressed as the ratio of the concentration outside the mask to that inside.[2] Cherrie et al[3] have recently published a proposal for evaluating the effectiveness of gloves against chemicals. They define the PF for gloves analogously to that for respiratory protective equipment:
where Usk is the mass uptake through the stratum corneum, either with or without gloves being worn.
Using mathematical simulations they showed that the PFgloves is not constant for a particular glove type but varies depending on the work situation and it decreases as the duration of wearing the gloves increases, even if they are not removed.
One proposal made by Cherrie et al. for measuring the PFgloves was to use a carefully controlled biological monitoring study. In the Chang et al. study the conditions are not controlled and there is no information about the pattern of wearing the gloves. If the gloves were only worn for a proportion of the working shift then the protection may be seriously compromised by periods when the person works with bare hands. Also, for this type of study to be informative there must be negligible uptake from inhalation exposure.
The authors report that the geometric mean personal inhalation exposure level was 3.3ppm (8h time-weighted average) and the workers refused to wear respiratory protective equipment. From the work of Kezic et al[4] this average exposure might be expected to result in about 5mg of UMMA being excreted in the 48h following exposure, suggesting inhalation exposure may contribute an important part of the UMAA measured in this study and consequently reducing the apparent effectiveness of the gloves.
In the Chang et al study we are not told whether there are differences between the average inhalation exposure levels between those who wore gloves and those that did not. From the tabulated data below (abstracted from Table 1 in Chang et al) it would appear that those wearing gloves may have been exposed to higher inhalation levels. Such differences would further confound the interpretation of the protection offered by gloves by reducing the apparent protection.
Table 1
Inhalation exposure levels and wearing of rubber gloves
"Regular" Workers
"Special" workers
Geometric mean
airborne 2-ME (ppm)
2.14
8.13
Percentage workers
wearing rubber gloves
0
12
If we assume that the UMAA level in urine at the end of the shift is proportional to the dermal uptake then the PFgloves for the rubber gloves used in the Chang et al study would be about 4 (the PEI was 74%) and for the cotton gloves it would be 1.1 (PEI=11%) for "Special" workers and 0.85 (PEI= -17%) for "Regular" workers. The figure for butyl rubber gloves appear to be particularly low in comparison to what might be expected. For example, Zellers et al[5] have shown that this type of glove material (in fact the same glove manufacturer as the gloves in Chang et al's study) can provide up to 4h protection against 2-ME without any breakthrough. This further suggests that this study does not reliably assess the protection offered by gloves.
Experimental intervention studies using biological monitoring data are probably the best way of estimating PFgloves. However, it is important to consider and minimise all possible biases and to collect information about usage pattern, particularly the duration of wear and the duration of the tasks.
References
1. Chang, H-Y, Lin, C-C, Shih, T-S, Chan, H, Chou, J-S, and Huang, Y-S, Evaluation of the protective effectiveness of gloves from occupational exposure to 2-methoxyethanol using the biomarkers of 2-methoxyacetic acid levels in the urine and plasma. Occup Environ Med 2004; 61: 697-702.
2. Howie, R, Personal protective equipment, in Occupational Hygiene, J. Harrington and K. Gardiner, Editors. Oxford: Blackwell Science Ltd 1980: 404-416.
3. Cherrie, JW, Semple, S, and Brouwer, D, Gloves and Dermal Exposure to Chemicals: Proposals for Evaluating Workplace Effectiveness. Ann Occup Hyg 2004; 48 (7): 607-615.
4. Kezic, S, Mahieu, K, Monster, AC, and de Wolff, FA, Dermal absorption of vaporous and liquid 2-methoxyethanol and 2-ethoxyethanol in volunteers. Occup Environ Med 1997; 54 (1): 38-43.
5. Zellers, E, Ke, H, D, S, R, S, Patrash, S, Han, M, and Zhang, G, Glove permeation by semiconductor processing mixtures containing glycol-ether derivatives. Am Ind Hyg Assoc J 1992; 53 (2): 105-118.
In response to our study,[1] Kivimäki et al suggested that reported
sickness absence frequencies were underestimates of the total sickness
absence burden in European Union (EU) member countries.[2] This concern
about the veracity of these estimates led Kivimäki et al to caution policy
makers to not use this data to inform policy. While we agree that more
research is needed to establish...
In response to our study,[1] Kivimäki et al suggested that reported
sickness absence frequencies were underestimates of the total sickness
absence burden in European Union (EU) member countries.[2] This concern
about the veracity of these estimates led Kivimäki et al to caution policy
makers to not use this data to inform policy. While we agree that more
research is needed to establish potential biases associated with different
approaches to ascertain accurate asking sickness absence data, we consider
the European Survey on Working Conditions (ESWC) to be useful to inform
the cross-national policy debate. Country-specific studies contribute
knowledge to the evidence base but cross-national studies such as ours
help to provide a stronger basis upon which to make cross-national
inferences. Furthermore, cross-national studies become more relevant as
data accumulate and the data collection quality improves. We hope that
Kivimäki and colleagues are not suggesting the ESWC be discontinued.
We consider the studies by Kivimäki et al to be some of the most
relevant epidemiological studies of sickness absence predictors.[3][4][5]
Although informative, these studies raise several issues in the context of
cross-national comparisons. First, epidemiological cohorts in Finland and
the United Kingdom represent very homogenous and specific working
populations (ie municipal employees, hospital workers and civil
servants) with unknown generalizability to the national representative
surveys studied in our paper or the ones referenced by Kivimäki et
al.[6][7] Second, a fundamental advantage of national workforce surveys is
the ability to capture all workers, whereas registries may lead to an
under representation of marginal work groups typically not included in
national registries. Indeed, Kivimäki et al are not arguing that the
Finnish and British cohorts are representative of the countries’
workforces. Even so, labor market inequalities may cause temporary and
less protected workers to be underrepresented in the type of well-designed
cohort studies they have referenced.[8] Temporary and less protected
workers are important in the EU economy and lack of knowledge about their
labor market experiences as related to sickness absence could lead to
their further marginalization in the policy debate. Third, Kivimäki et al
criticised the data collection method employed in the ESWC. We are not
aware of any cross-national study comparing the reliability, validity and
performance of different sickness absence data collection methods.
Concerns have been raised about who is placed on a sickness absence
registry. Registered data are very conditioned by the country’s social
security system criteria for sickness absence, which complicates between-countries comparisons.[9] Therefore, whether registries are the gold
standard in sickness absence studies remains a point of debate yet to be
closed.
In addition, Kivimäki et al compared our results to two survey based
studies from Finland and Britain, but differences in sample selection and
questionnaire design between these studies may limit comparisons. Our
study included people aged 15 years and older who had any paid job during
the reference week, or who had a job but were temporarily absent. The
recall period for sickness absence was 12 months. The Finnish study was
based on employees aged 25 to 64 using a 6 month recall period for
sickness absence.[10] The British survey investigated the psychiatric
morbidity prevalence among the British adult population. This study
sampled workers aged 16-64 years and excluded workers with a psychosis
diagnosis. Workers who were currently working or had been working in the
last year were asked to report absence days due to their health or
feelings.[11] For these reasons, caution is needed if a direct comparison
between these three studies is intended.
Finally, we agree with Kivimäki et al that potential bias in the ESWC
could be present (see page 868-9 in our article). However, we would argue
that the best sources of data to inform policy are derived from systematic
efforts to collect sickness absence data in a clear and consistent fashion
from a representative sample of the labor force within each country. We
consider the evidence presented by Kivimäki et al to support our argument
of the difficulty in establishing between-country comparisons due to the
fragmented and insufficient sickness absence data available at the
European Union level. We consider our results useful. Although the results
are preliminary and may be subjected to scientific scrutiny, the
comparative findings may provoke researchers to develop standards for
sickness absence studies to facilitate between-country comparisons. In
addition, we hope the observed differences will promote further
investigation into root causes of between-country differences, especially
between northern and southern EU members, as well as within-country gender
differences. We certainly welcome cross-national collaborative efforts
among the EU sickness absence researches to address all these issues.
References
1. Gimeno D, Benavides FG, Benach J, Amick BC III. Distribution of
sickness absence in the European Union countries. Occup Environ Med
2004;61:867-9.
2. Kivimäki M, Vahtera J, Head J, Ferrie JE. Are sickness absence
frequencies in the study of EU countries underestimates? [electronic response to Gimeno D et al. Distribution of sickness absnce in the European Union countries] occenvmed.com 2004 URL direct link to eLetter.
3. Vahtera J, Pentti J, Kivimäki M. Sickness absence as a predictor
of mortality among male and female employees. J Epidemiol Community Health
2004;58:321-6.
4. Kivimäki M, Virtanen M, Vartia M, Elovainio M, Vahtera J,
Keltikangas-Järvinen L. Workplace bullying and the risk of cardiovascular
disease and depression. Occup Environ Med 2003;60:779-83.
5. Kivimäki M, Head J, Ferrie JE, Shipley MJ, Vahtera J, Marmot MG.
Sickness absence as a global measure of health: evidence from mortality in
the Whitehall II prospective cohort study. BMJ 2003;327:364-8.
6. Kauppinen T, Hanhela R, Heikkilä P et al. Work and Health in
Finland 2003. Finnish Institute of Occupational Health, Helsinki, 2004.
7. Stansfeld SA, Head J, Rasul F, Singleton N, Lee A. Occupation and
mental health: Secondary analyses of the ONS Psychiatric Morbidity Survey
of Great Britain. Research Report 168, Health and Safety Executive Books,
2003.
8. Moss NE. [Review of the book Why Are Some People Healthy and
Others Not? The Determinants of Health of Populations, by Robert G. Evans,
Morris L. Barer, and Theodore R. Marmot] Health Affairs 1995;(14) 2:318-
21.
9. Gründemann RWM, van Vuuren CV. Preventing absenteeism at the
workplace. Dublin: European Foundation for the Improvement of Living and
Working Conditions, 1997
10. Kauppinen T, Hanhela R, Heikkilä P et al. Work and Health in
Finland 2003. Finnish Institute of Occupational Health, Helsinki, 2004.
11. Stansfeld SA, Head J, Rasul F, Singleton N, Lee A. Occupation and
mental health: Secondary analyses of the ONS Psychiatric Morbidity Survey
of Great Britain. Research Report 168, Health and Safety Executive Books,
2003.
The paper by Gimeno et al provides a comparison of sickness absence between
15 European Union (EU) countries.[1] According to this study, 14.5% of
employees were absent at least one day in the past 12 months by an
accident at work, by health problems caused by the work, or by other
health problems. For Finnish employees, for instance, this percentage was
24%, the highest among the 15 EU countr...
The paper by Gimeno et al provides a comparison of sickness absence between
15 European Union (EU) countries.[1] According to this study, 14.5% of
employees were absent at least one day in the past 12 months by an
accident at work, by health problems caused by the work, or by other
health problems. For Finnish employees, for instance, this percentage was
24%, the highest among the 15 EU countries, and in the UK 11.7%.
These figures are much lower than those reported previously. A
population-based survey of Finnish employed workforce aged 25 to 64
carried out in 2000 found that 45% of employees took sickness absence
during the past 6 months.[2] Correspondingly, a population based survey of
5400 British adults aged 15-64 reported that 30% of working adults took
time off work in the past year because of their health or feelings.[3]
Three large cohort studies from Finland and the UK have used absence
records instead of self-reports. In 2000, 58% of 77 850 municipal
employees participating in the 10-town study[4] took at least one sickness
absence day and the same percentage was obtained in the Hospital Personnel
Study[5] for 30 864 hospital workers aged 15 to 65. In the Whitehall II
study[6] of over 10 000 British civil servants aged 35 to 55, 57% in men
and 76% in women recorded sick leave 12 months prior to the study entry in
1985-1988.
Based on these national studies, we suspect that the figures
presented by Gimeno et al are underestimates of actual absence
frequency in the EU countries. Data on sickness absence were derived from
face-to-face interviews that were carried out at participant's home, a
rarely applied assessment strategy for sickness absence. It is possible
that the wording of the question led people to report sickness absence
only when they believed it to be work related. The authors note that low
response rates in some countries and healthy worker effect are potential
sources of bias.
We feel that the data presented by Gimeno et al are far too
preliminary to be the basis of any policy at this stage or of conclusions
regarding differences in absence frequency between nations. We fully agree
with their recommendation for further research on sickness absence in EU
countries.
References
1. Gimeno D, Benavides FG, Benach J, Amick BCIII. Distribution of
sickness absence in the European Union countries. Occup Environ Med
2004;61:867-9.
2. Kauppinen T, Hanhela R, Heikkilä P et al. Work and Health in
Finland 2003. Finnish Institute of Occupational Health, Helsinki, 2004.
3. Stansfeld SA, Head J, Rasul F, Singleton N, Lee A. Occupation and
mental health: Secondary analyses of the ONS Psychiatric Morbidity Survey
of Great Britain. Research Report 168, Health and Safety Executive Books,
2003.
4. Vahtera J, Pentti J, Kivimäki M. Sickness absence as a predictor
of mortality among male and female employees. J Epidemiol Community Health
2004;58:321-6.
5. Kivimäki M, Virtanen M, Vartia M, Elovainio M, Vahtera J,
Keltikangas-Järvinen L. Workplace bullying and the risk of cardiovascular
disease and depression. Occup Environ Med 2003;60:779-83.
6. Kivimäki M, Head J, Ferrie JE, Shipley MJ, Vahtera J, Marmot MG.
Sickness absence as a global measure of health: evidence from mortality in
the Whitehall II prospective cohort study. BMJ 2003;327:364-8.
Pattani and colleagues present some interesting and useful findings
in an area of great importance to the delivery of health care within the
United Kingdom.[1] They note that “doctors were nearly four times more likely
to return to work as health care assistants and support staff” and that
“this may reflect more flexible working opportunities for highly skilled
staff”. I would suggest that it might al...
Pattani and colleagues present some interesting and useful findings
in an area of great importance to the delivery of health care within the
United Kingdom.[1] They note that “doctors were nearly four times more likely
to return to work as health care assistants and support staff” and that
“this may reflect more flexible working opportunities for highly skilled
staff”. I would suggest that it might also reflect the nature of the
reason for retirement and how the workplace can be adjusted to deal with
this. Having been involved in the assessment of NHS ill-health pension
applications during the study period my impression (with observer bias)
was that the major reason for doctors applying was either stress related
or where a cardiovascular problem was the primary problem the rationale
was often that it was exacerbated by workplace stress. Finding work where
the stressors are diminished by say reduced working hours or workloads for
doctors would seem to be easier than finding work with reduced
muscoloskeletal demands for those jobs which essentially involve
significant amounts of manual handling (eg health care assistants) who
have musculoskeletal disease.
They also note “there are no formal arrangements to redeploy staff
whose ill health prevents them from continuing in such posts”. It would be
useful if the NHS Pensions Scheme, and indeed any occupational health
pension scheme, considered whether provisions of the Disability
Discrimination Act in terms of reasonable adjustments had been
appropriately applied before concluding that the individual was
permanently incapable of doing their job. A Treasury report on ill health
retirement in the public sector, published in 2000, stated, “the evidence
suggests that redeployment and rehabilitation are not always investigated
actively” and that “if there is no requirement to consider alternative
duties, redeployment may not be actively considered. The employee’s skills
and experience can thus be unnecessarily lost to the service.”[2]
Pattani’s paper gives us a useful insight into the potential of those
who have retired from the NHS due to ill health. The next step is to go
back to the workplace and examine the factors that lead to an application
for ill-health retirement.
References
1. Pattani S, Constantinovici N, and Williams S. Predictors of re-employment and quality of life in NHS staff one year
after early retirement because of ill health; a national prospective study. Occup Environ Med 2004; 61: 572-576.
2. HM Treasury. Review of ill health retirement in the public sector.
London: HM Treasury, July 2000
Atkinson et al,[1] reported “particularly among those monitored for
plutonium exposure there was a significant excess mortality from cancer of
the pleura”.
However, they also note the lack of a trend for radiation
dose. The authors’ suggest that these cancers are mostly mesothelioma and
that asbestos is the likely causative agent. There is no mention of other
agents that can cause mesothe...
Atkinson et al,[1] reported “particularly among those monitored for
plutonium exposure there was a significant excess mortality from cancer of
the pleura”.
However, they also note the lack of a trend for radiation
dose. The authors’ suggest that these cancers are mostly mesothelioma and
that asbestos is the likely causative agent. There is no mention of other
agents that can cause mesothelioma; although they elude to other causes
(“…are strongly related to exposure to asbestos.”). I would like to point
out that others [2-4] reported ionizing radiation as a possible aetiological
agent for mesothelioma. This appears to include a case4 involving short-
term ionizing radiation exposure. In addition, mesothelioma appears to be
caused by a number of other agents (e.g. sugar cane, viruses)[5,6] besides
asbestos and radiation. It has been suggested that non-asbestos causes of
mesothelioma may be as high as 87%,[7] although a lower percent has been
reported (around 13%).[8] Readers need to be aware that there appears to be
many agents, including spontaneous events5, which may be responsible for
cases of pleural cancer (mesothelioma).
References
1. Atkinson WD., Law DV., Bromley KJ., Inskip HM. Mortality of
employees of the United Kingdom atomic energy authority, 1946-87. Occup
Environ Med. 2004; 61:577-85.
2. Lerman Y, Learman Y, Schachter P, Herceg B, Lieberman Y, Yellin A.
Radiation associated malignant pleural mesothelioma. Thorax. 1991;46:463-
4.
3. Hoffman J, Mintzer D, Warhol MJ. Malignant mesothelioma following
radiation therapy. Am J Med. 1994;94:379-92.
4. Mizuki M, Yukishige K, Abe Y, Tsuda T. A case of malignant pleural
mesothelioma following exposure to atomic radiation in Nagasaki.
Respirology. 1997;2:201-5.
5. Hubbard R. The aethiology of mesothelioma: are risk factors other
than asbestos exposure important? Thorax 1997;52:406-7.
6. Lange JH. Other non asbestos causes of mesothelioma besides the
SV40 virus. (eletter) Thorax. 2004;
http://thorax.bmjjournals.com/cgi/eletters/57/4/353#161
7. Peterson JT, Greenberg SD, Buffler PA. (1984) Non-asbestos-related
malignant mesothelioma: a review. Cancer 54:951-60.
8. Yates DH, Corrin B, Stidolph PN, Browne K. Malignant mesothelioma
in south east England: clincopathological experience of 272 cases. Thorax
1997:52:507-12.
Gimeno, Amick, Benavides and Benach [1] raise a number of issues with
a paper recently published in Occupational and Environmental Medicine.[2]
It is important that researchers cross-examine others’ findings and
conclusions, as well as explain and defend their own findings and
conclusions, so that debate can proceed that is both informed and useful
for policy and practice.
Gimeno, Amick, Benavides and Benach [1] raise a number of issues with
a paper recently published in Occupational and Environmental Medicine.[2]
It is important that researchers cross-examine others’ findings and
conclusions, as well as explain and defend their own findings and
conclusions, so that debate can proceed that is both informed and useful
for policy and practice.
In the original paper, I present findings that suggest the perceived
risk from occupational stress varied across countries in the EU. I
interpreted the findings as suggesting an element of social construction
is present in such perceived risk, and that this element of social
construction could have implications for policy, in respect of risk
communication, for example.
There are two important things to note about these conclusions.
First, I analysed perceived risk from occupational stress, and not
objective risk. These are recognised as two separate entities.[3] Whilst
they are arguably intertwined closely in occupational stress and emotional
health,[4] these data do not speak to this issue, and I drew no
conclusions concerning objective risk. However, perceived risk is an
important issue that can have practical implications, as noted.[2]
Second, it is uncontroversial in many areas concerned with risks to
health (e.g. nuclear power, food) that risk is partially socially
constructed, at this social construction has important practical
implications.[5] There is no reason I know of why there should be
controversy concerning the practical implications of a socially
constructed element to risk from occupational stress.
Gimeno et al. raise four concerns.
1. The first issue is related to sample selection. The data were drawn from
the Third European Survey on Working Conditions (ESWC), and then a more
homogenous sample selected of people working in the same country as their
nationality. Albeit imperfect (as noted by Gimeno et al), this procedure
excludes workers who are more likely to have recent extensive experience
of different working cultures. As noted in the paper, then, ‘variation
within individuals due to multiple influences of work cultures was
minimized’. Note I use the term minimized, rather than excluded.
Notwithstanding, this procedure provides a more accurate means of
assessing socio-cultural influences on perceived risk of occupational
stress than was possible just by comparing responses across country of
data collection or by comparing people of different nationalities.
Gimeno et al. explain that there is an influx of foreign workers into
the EU, and that these workers may be exposed to more hazardous working
conditions. Gimeno et al. make the argument that ‘removing workers who may
be experiencing the greatest stress and hazardous working conditions from
the sample may represent a severe selection bias’. I would agree with
Gimeno et al.had the purpose of the paper been to determine objective risk
in all areas of the labour market in the countries surveyed. Further, I
agree that such workers are an important section of EU labour markets
deserving of research in their own right with a view to informed
intervention to enhance their working conditions – and such research
should include assessment of perceived and objective risk in due course.
However, the purpose of the paper was to determine whether there is a
socially constructed element in the perceptions of stress that can be
attributed to socio-cultural variables at the national level. Including
such workers may well have skewed the data by introducing a level of bias
related to the nationality of immigrant workers in a country.
Gimeno note ambiguity with the statement "individuals who were
working in a different country as their nationality". As well as re-
reading the paper, I have conducted an electronic search of the paper, and
cannot find this quote. Therefore I am unsure of the context of the quote,
and so cannot be sure of the source of the perceived ambiguity. However,
Gimeno et al. do raise issues not covered in the ESWC data concerning
assimilation of social constructs and life-course data, all of which are
relevant to propagation of cultural values at an individual level [6] and
possibly also risk perception. However, by including only those people who
list their nationality as being the same as the country they work in, it
is a reasonable assumption that they will be familiar with the dominant
cultural values of that country (even if they do not subscribe to those
values themselves). Other data would be desirable of course, but
unfortunately, they are not available.
2. The second concern raised by Gimeno et al concerns the use index of
perceived risk of occupational stress. They raise an issue concerned with
principal components analysis (PCA) conducted on the whole sample, rather
than the sub-set used to compare the EU countries. It seems that the
implication of this argument is that a different cluster of symptoms would
be uncovered by PCA conducted on the sub-sample. I re-analysed the data,
using only those people that worked in the same country as their
nationality. PCA indicated the same pattern of relationships between
perceived risk of symptoms.
What does this analysis mean though? It seems that a cluster of
symptoms – which may be labelled stress – are commonly perceived as co-
occurring. This might be because when such symptoms occur, they commonly
occur together. This could reflect a physiological process, or heightened
cognitive processing of physical sensations during emotional episodes.[7]
However, as other analyses in [2] show, the extent to which the risk of
experiencing these symptoms is attributed to work has a socially
constructed component.
Gimeno et al. do raise the point that important differences might
exist between individual health-related outcomes, and that these health-
related outcomes might vary between factors such as type of employment,
gender etc. First, in [2], I did control for industry, demographic
factors, job dissatisfaction and perceived working conditions. In this
way, factors that might represent cross-national variations in working
practices (such as working hours) and individual level factors (such as
job dissatisfaction) could not be said to account for the pattern of
findings. Second, the ESWC contains many individual level questions
assessed by single item indicators. By looking at health outcomes
assessed by single indicators, there is danger that any findings reflect
the error of measurement embedded in single item indicators of
indeterminate reliability - rather than the true variable of interest.
This threat is magnified in analyses involving large samples, where even
small differences due to error can be labelled statistically reliable. By
producing a scale – with an acceptable reliability coefficient (a=0.73),
this possibility is lessened.[2]
Gimeno et al. also bring attention to the nature of the questions in
the ESWC that I used to examine cross-national differences. It is
important to note that the question I used asked participants to attribute
various symptoms to work, not whether those symptoms were currently being
experienced. Therefore, the question reflects a perception of the impact
of work on symptoms – and not symptoms themselves or any underlying
pathology. Therefore, any conclusions drawn from the data cannot reflect
anything other than factors influencing the perceived influence of work on
various symptoms.
3. The third concern raised by Gimeno et al regards the empirical status of
my conclusion that workers in lower ranked countries might be less likely
to attribute minor or non-specific psychosomatic symptoms to work when
consulting with health practitioners. Whilst Gimeno et al are aware of no
data that support such a conclusion, this conclusion – however conditional
the language within which it is phrased - cannot be dismissed without
further work. There is evidence that indicates emotional displays and
discussion of life stress during consultation might cause misdiagnosis.[8] This potential for misdiagnosis arguably warrants further
investigation.
4. The fourth concern raised by Gimeno et al. concerns the discussion section,
especially in relation to conclusions with respect to the UK. I conclude
that the media and socio-cultural factors – specifically cultural
attitudes – might influence perceptions of risk from occupational stress.
There is an extensive literature relating to these issues in relation to
other risks – and some of the more prominent examples were referenced in
[2]. There is also discussion elsewhere of socio-cultural factors and the
media in influencing perceptions of risk from occupational stress [9] and
in politicising stress as a social issue that subsequently influences
reporting of stress.[10]
Gimeno et al. suggest that classifying countries according to common
characteristics could provide an a priori basis for explaining the pattern
of findings. The cultural approach to risk perception [11] provides one
such approach. In this framework, countries with an individualist
orientation (Ireland and Great Britain in this sample) would be expected
to be ranked lower than other countries. This was indeed the case in [2].
However, countries with a more egalitarian orientation, such as the Nordic
countries and Germanic countries, would be predicted to be ranked near the
top, and countries with more hierarchical work cultures – such as France –
would be expected to be ranked lower than the Nordic and Germanic
countries. The results clearly do not bear such predictions out (see 12
for a cultural typology of European countries).
Therefore, the ranking of countries may reflect more complex
processes than simple categorisation of countries on cultural or other
factors. This conclusion is supported by some of the literature cited in
[2] that has been used to discuss the British case [9,13-15]. In
this literature, a number of suggestions have been made, in which, factors
such as the media, socio-cultural factors and cognitive processes in the
perception of risk have been advocated as explanations or partial
explanations for perceived risk from occupational stress. I do not know
the extent to which the scientific and policy literature in other
countries covers such issues, but the fact there is open debate in the
scientific community concerning such issues in Britain makes Britain a
useful focus for analysis. Moreover, the British case with respect to
monitoring stress and intervention is now more interesting, given the
introduction of Stress Management Standards by the UK Health and Safety
Executive. In due course, the British case will provide a useful focus for
analysis of how advisory rather than coercive processes influence
reporting and perception of occupational stress. It was for these reasons
that the discussion section had some focus on the British case.
So rather than further cross-national comparisons on perceptions of
stress – now we know they exist but not why - researchers might find it
useful to examine individual countries on a case-by-case basis, so as to
build rich pictures of the factors that influence perceived risk from
stress in any one societal context and explain in more detail the pattern
of findings in [2]. Once such exploratory work has been completed,
research can move to hypothesis testing.
Finally, Gimeno et al. note that different rankings are apparent if
different dependent variables are used. This should not be surprising – I
can think of no reason why sickness absence has to necessarily mirror
findings with attributions of stress-related symptoms to work – although
there might be several reasons why they could be loosely coupled. Stress
is not the only reason for absence from work.
Whether the ranking in [2] is more or less accurate and the reasons
for the rankings, only further research can tell. However, the socially
constructed elements of stress have real policy implications. They are
worthy of further debate and research. To ignore them or deny them
ultimately will be to the detriment of policy, intervention and
occupational health.
2. Daniels, K. Perceived risk from occupational stress: a survey of
15 European countries. Occup Environ Med, 2004; 61: 467-70.
3. Royal Society. Risk: Analysis, Perception and Management. London:
Royal Society, 1992.
4. Daniels K, Harris C, Briner R. Understanding the Risks of Stress:
A Cognitive Approach. Sudbury: HSE Books, 2002.
5. Kasperson RE, Kasperson JX, Renn O. The social amplification of
risk: progress in developing an integrative framework. In S Krimsky, D
Golding (eds) Social theories of risk. London: Praeger, 1992.
6. Berry JW. Immigration, acculturation, and adaptation. Applied
Psychology: An International Review, 1997; 46: 5-34.
7. Kirmayer LJ, Robbins JM, Paris J. Somatoform disorders:
personality and the social matrix of somatic distress. Journal of Abnormal
Psychology, 1994; 103: 125-136.
8. Ellington L, Wiebe D. Neuroticism, symptom presentation, and
medical decision making. Health Psychology, 1999; 18: 634-643.
9. Daniels, K. Why aren’t managers concerned about occupational
stress? Work & Stress, 1996; 10: 352-366.
10. Barley SR, Knight DB. Toward a cultural theory of stress
complaints. In B.M.Staw & L.L. Cummings (Eds.), Research in
organizational behavior, 1992; 14: 1-48.
11. Thompson M, Ellis R, Wildavsky A. Cultural Theory. Boulder:
Westview, 1990.
12. Ronen S, Shenkar, D. Clustering countries on attitudinal
dimensions: a review and synthesis. Academy of Management Review, 1985;
10: 435-454.
13. Wesseley S, Hotopf M. Are some public health issues better
neglected? Lancet 2001; 357: 976-7.
14. Newton T. ‘Managing stress’ emotion and power at work. London:
Sage, 1995.
15. Rick J, Hillage J, Honey S, Perryman S. Stress: big issue, but
what are the problems? Brighton: The Institute for Employment Studies,
1997.
16. Gimeno D, Benavides FG, Benach J, Amick III BC. Distribution of
sickness absence in the European Union Countries. Occup Environ Med (in
press).
In a recent short report, a summary of the results of a
workplace based colorectal tumour-screening programme in UK was given.[1]
During 2001-02 we organised a similar programme within BASF's – the
world's largest chemical company – Ludwigshafen/Germany site. Our findings
were published in a German language paper.[2] Our target group included all
13 265 actively working employees aged 45 years or above. Those exp...
In a recent short report, a summary of the results of a
workplace based colorectal tumour-screening programme in UK was given.[1]
During 2001-02 we organised a similar programme within BASF's – the
world's largest chemical company – Ludwigshafen/Germany site. Our findings
were published in a German language paper.[2] Our target group included all
13 265 actively working employees aged 45 years or above. Those expressing
interest were given a standardised questionnaire concerning risk factors
for colorectal cancer and a test for occult faecal blood (FOBT). If the
test was positive and/or a positive answer was given to the question on
blood in the stool or on a positive family history, colonoscopy – to be
arranged via the general practitioner – was advised, in line with the
recommendations of the German Society of Digestive and Metabolic Diseases.
Finally, 3732 employees (337 women, 3395 men; mean age 52 years) had
completed the questionnaire and the FOBT results were available (28 % of
the target group). Colonoscopy was recommended to 688 employees, 323 of
whom (47 %) underwent the investigation. Nine of the subjects already had
manifest cancer, six of them in the early stage T1 or T2. Adenomatous
polyps were found in an additional 61 and subsequently excised.
Cost-benefit calculations were done in a twofold manner: at company
level and at public-health system level. The financial cost of screening
at company level was € 108 000 (testing kits plus office materials € 6000,
staff costs € 102 000). Based on the employer's obligation in Germany to
compensate disease-related lost work time during the first six weeks a
benefit due to avoided lost work time was calculated to be 1 110 000 (cost
-benefit ratio 1:10). The financial cost of the programme at public-health
system level was € 50 000 (specialist visit, colonoscopy plus removal of
adenoma). The benefit was calculated to be € 700 000 by avoided hospital
stay and surgery (cost-benefit ratio 1:14). In the future our workplace
based programme will be offered routinely.
References
(1) ECHO: Workplace based faecal occult blood screening. Occup Environ
Med 2004; 61,413
(2) Webendörfer S, Messerer P, Eberle F et al. Darmkrebs-Vorsorge im
Betrieb. Dtsch Med Wochenschr 2004; 129: 239-243
A recent article by Daniels [1] in this journal presented
occupational stress data from the 15 European Union (EU) countries.
Cross-
national comparisons contribute to our scientific understanding of how and
why health-related indicators (i.e. stress) are unequally distributed
across countries and provide clues and guidelines for researchers, policy
makers and trade unions at the EU level. Howeve...
A recent article by Daniels [1] in this journal presented
occupational stress data from the 15 European Union (EU) countries.
Cross-
national comparisons contribute to our scientific understanding of how and
why health-related indicators (i.e. stress) are unequally distributed
across countries and provide clues and guidelines for researchers, policy
makers and trade unions at the EU level. However, we are concerned the
data’s strengths and limitations are not explained appropriately to inform
the policy debate. Specifically we have four concerns.
Our first concern is related to sample selection. The data were drawn
from the Third European Survey on Working Conditions (ESWC) conducted in
2000.[2] The sampling strategy was designed to obtain nationally
representative samples of the total active population, including non-
Europeans if they could be interviewed in the national language of the
country where they worked. Daniels asserted occupational stress is
socially constructed and thus used nationality to obtain a more
homogeneous sample. However, removing workers who may be experiencing the
greatest stress and hazardous working conditions from the sample may
represent a severe selection bias.[3]
The inflow of foreign workers (especially the so called low-skilled
immigrants) to the EU advanced industrial countries is increasing.[4]
Immigrant workers are becoming a significant part of the active EU
population and are likely to rise sharply with the addition of the ten new
EU countries.[5,6] Compared to native workers, non-EU nationals have
greater problems obtaining jobs.[7] They may obtain employment in
contractual jobs where exposure to work-related stressors is high.[8] It
is plausible foreign workers are more frequently employed in ‘bad’ jobs
exposed to more hazardous work environments.[9]
Furthermore, because of the ambiguity of the statement "individuals
who were working in a different country as their nationality" (i.e.
immigrants) – it is unclear who is being excluded and whether the issue of
the social construction of stress can be redressed through the exclusion.
The ESWC does not identify whether a person was born in the country of
present nationality, lived in the same country since birth with or without
the nationality of that country, or lived, or was born, elsewhere before
coming to the country of present nationality. Neither does the ESWC
provide data on when, in a life course perspective, the arrival of a
person to a country occurred which may be relevant for assimilating social
constructs by an individual. All these factors can influence health
variability and without such detailed data deductions based only on a
person’s nationality seems uncertain.
Second, information bias can affect the results.[3] By means of
principal component analyses, Daniels grouped a number of items (stress,
anxiety, irritability, sleeping problems, stomach ache, headache, or
overall fatigue) to create an "index of perceived risk from occupational
stress". However, two methodological issues have to be considered. First,
if, as Daniels argues, stress is socially constructed and thereby biased
by nationality, how can be the occupational stress index be created using
the total sample instead of only those workers who were working in the
same country as their nationality. We would agree this was the appropriate
approach if Daniels would not have argued for a social construction of
stress. Second, in the ESWC questionnaire, a filter question existed
before the selection of the symptoms that the author did not mention. Only
after replying that their work affected their health, which some 60% of
the workers did, could participants endorse any of 22 symptoms.[2] In
analyses using the same data set,[8,10,11] we found differences in
various health-related outcomes (stress, overall fatigue, job
dissatisfaction and sickness absence) by country, type of employment, and
gender.[12] So, grouping items without exploring individual symptom
variation might hide important differences.
Third, in the discussion section, Daniels stated that according to
his findings, compared to workers in higher ranked countries, British
workers and workers in other lower ranked countries may be less likely to
attribute minor or non-specific psychosomatic symptoms to work (or might
attribute them erroneously to other life domains) when consulting with
health practitioners. We are aware of no data to support such an
assertion. Hence, the findings do not support this conclusion, so we
suggest prudence in the application of these results to policy and
practice decisions.
Fourth, Daniels ranked the EU countries investigated according to the
number of stress related symptoms attributed to work. From these
differences Daniels’s made inferences about how sociocultural factors and
the role of the media can affect health perceptions. Given the concerns
expressed above abut selection and information bias we wonder how the
results led to these inferences. Furthermore, although Daniels recognised
that these processes may not apply to other EU countries, he focused
almost the entire discussion section on the UK, building an idiosyncratic
and ad hoc explanation for the UK that seems unsupported by the research.
A way to facilitate more systematic analyses could be by classifying the
countries according to certain common characteristics. In social and
policy research, different typologies have been proposed. For instance,
Esping-Andersen’s typology has proven to be useful in comparing welfare
states and may be helpful in the present study’s context.[13]
Moreover, the Daniels’ ranking is very different, and in some cases
completely inverse, than the one obtained by us when analyzing sickness
absence data from the same survey.[14] Among other factors that could
explain this divergence, it has to be considered that different outcomes
could present different between-countries distributions. Compared to
Daniels’ occupational stress index, sickness absence is recognised as a
public health surveillance measure indicating countries economic
performance.[15] Rankings are an important tool scientists can use to
communicate with policy makers. The ESWC provides a unique data source for
scientists. Differences between our work and Daniels illustrates the need
to develop mechanisms to enable researchers using the ESWC to share
results prior to publication.
Finally, we do understand that the space available for short papers
limits the author’s possibility to explain in detail all relevant issues.
However, we think that authors should give the reader as much information
as needed to judge the results validity.
References
1.Daniels K. Perceived risk from occupational stress: a survey of 15
European countries. Occup Environ Med 2004; 61: 467-70.
2.Paoli P, Merllié D. Third European Survey on Working Conditions
2000. Dublin: European Foundation for the Improvement of Living and
Working Conditions Luxembourg: Office for Official Publication of the
European Communities, 2001.
3.Szklo M, Nieto FJ. Understanding lack of validity: Bias. In: Szklo
M, Nieto FJ. Epidemiology. Beyond the Basics. Gaithersburg: Aspen
Publishers, Inc., 2000; 125-76.
4.Lowell BL, Kemper Y. Transatlantic Roundtable on Low-skilled
Migration in the Twenty-first Century: Prospects and Policies.
International Migration 2004;42(1):117-40.
5.Hilderink H, van der Gaag N, van Wissen L, Jennissen R, Román A,
Salt J, Clarke J, Pinkerton C. Analysis and forecasting of international
migration by major groups - Part III. Luxembourg: Office for Official
Publication of the European Communities, 2003.
6.Angrist JD, Kugler AD. Protective or counter-productive? Labour
market institutions and the effect of immigration on EU natives. Economic
Journal 2003; 113(488): F302-F331.
7.Thorogood D, Winqvist K. Women and men migrating to and from the
European Union. Statistics in focus 2/2003. European Communities, 2003.
8.Wrench J. Preventing Racism at the Workplace. A summary. European
Foundation for the Improvement of Living and Working Conditions.
Luxembourg: Office for Official Publications of the European Communities,
1996.
9.Benach J, Gimeno D, Benavides FG. Employment status and health.
Dublin: European Foundation for the Improvement of Living and Working
Conditions. Luxembourg: Office for Official Publication of the European
Communities, 2002.
10.Benach J, Gimeno D, Benavides FG, Martínez JM, Torné MM. Types of
employment and health in the European Union: changes from 1995 to 2000.
Eur J Public Health (in press).
11.Gimeno D, Benavides FG, Amick III BC, Benach J, Martínez JM.
Psychosocial factors and work-related sickness absence among permanent and
non-permanent employment. J Epidemiol Community Health (in press).
12.Karjalainen A (Coordinator). Work and health in the EU. A
statistical portrait. Data 1994–2002. Luxembourg: Office for Official
Publication of the European Communities, 2004.
13.Esping-Andersen G. The three worlds of welfare capitalism.
Princeton (NJ): Princeton University Press, 1990.
14.Gimeno D, Benavides FG, Benach J, Amick III BC. Distribution of
sickness absence in the European Union countries Occup Environ Med (in
press).
15.Kivimaki M, Head J, Ferrie JE, Shipley MJ, Vahtera J, Marmot MG.
Sickness absence as a global measure of health: evidence from mortality in
the Whitehall II prospective cohort study. BMJ 2003 16;327:364-9.
In the March 2003 issue of Occupational and Environmental Medicine,
Muirhead et al.[1] described an analysis of mortality and cancer incidence
among UK participants in the UK atmospheric nuclear weapons test
programme.
Comparisons were made between a pre-defined cohort of test
participants and a matched control group. Both groups of men were
identified during the 1980s from contemporary...
In the March 2003 issue of Occupational and Environmental Medicine,
Muirhead et al.[1] described an analysis of mortality and cancer incidence
among UK participants in the UK atmospheric nuclear weapons test
programme.
Comparisons were made between a pre-defined cohort of test
participants and a matched control group. Both groups of men were
identified during the 1980s from contemporary records held by the Ministry
of Defence (MoD). Comparison with data from other sources indicated that
85% of eligible test participants were included in the study cohort.
Mortality and cancer incidence were ascertained in exactly the same way
for test participants and controls, using the National Health Service
Central Registers (NHSCRs), as is standard for many epidemiological
studies in the UK. Only 0.1% of the men were lost to follow-up. Cross-
checks were also conducted at other organisations. In the electronic
section of the December 2003 issue of the journal, Roff [2] has suggested
that the study was flawed because of “under-ascertainment of multiple
myeloma”.
This suggestion is incorrect. The critical scientific condition that
must be met in a cohort study such as ours is that test participants and
controls should be identified in the same way so that the extent of
ascertainment of cancers in the two groups will be the same. In this way,
the design of the study avoids bias arising through ascertainment of
cancers being more complete in the test participant group or in the
control group. To supplement cases in an ad hoc way could introduce bias,
and we were careful to avoid this. Indeed, it has been suggested that
self-response bias occurred in an investigation of US test veterans [3]
that used additional ascertainment strategies along the lines suggested by
Roff.
Roff refers to the inter-comparison of cases ascertained by NRPB and
herself. This inter-comparison is described in more detail in a report [4] published at the same time as the analysis by Muirhead et al.[1] The
key points to emerge from the inter-comparison were as follows:
1. Roff did not identify an unexpectedly large number of men falling
within the definition of test participants but who were not in the NRPB
cohort. Out of 47 confirmed test participants on her list, 9 were not in
the NRPB cohort. This percentage, namely 19%, is compatible with the
value of 15% estimated previously (two-sided p=0.41). It is not “at least
30%” as Roff appears to suggest.
2. The inter-comparison did not reveal additional death certificates
or cancer registrations with multiple myeloma among test participants
known to NRPB, during the period for which mortality and cancer data were
largely complete. Whilst the completeness of myeloma registration is not
known precisely, an exercise conducted for Hodgkin’s disease (5) during
the 1970s and 1980s would suggest that about 90% of cases during this
period are contained on the NHSCRs. The findings of the inter-comparison
and of related checks (e.g. using data held by the Leukaemia Research Fund[4]) are consistent with this estimate.
More generally, Roff has confused the issues of identifying a cohort
and ascertaining cases within that cohort. For example, she states that
cases not identified by linkage to the NHSCRs were treated as independent
responders. This is incorrect: independent responders are men who were
identified as being potential test participants on the basis of
information other than searches of contemporary MoD records, and whose
participation was confirmed subsequently. In particular, many of these
independent responders were identified because of their health and hence
they represent a selected group. We have presented results from an
analysis of mortality among independent responders.[4] However, to add
the independent responders to the main cohort of test participants would
lead to bias.
We do not accept Ms Roff’s conclusion or the approach that she has
taken in her paper. An independent Advisory Group (Chairman: Professor
Nicholas Wald) oversaw our analysis and was satisfied that the
epidemiological methods we used were sound.
Competing interests: Funding for the maintenance of this database and
for its analysis has been provided by the Ministry of Defence.
References
1. Muirhead CR, Bingham D, Haylock RGE, et al. Follow up of
mortality and incidence of cancer 1952-1998 in men from the UK who
participated in the UK's atmospheric nuclear weapons tests and
experimental programmes. Occup Environ Med 2003; 60: 165-72.
2. Roff SR. Under-ascertainment of multiple myeloma among
participants in UK atmospheric atomic and nuclear weapons tests. Occup
Environ Med 2003; 60: e18.
3. Johnson JC, Thaul S, Page WF, Crawford H. Mortality of Veteran
Participants in the CROSSROADS Nuclear Test. Washington, DC: National
Academy Press, 1996.
4. Muirhead CR, Bingham D, Haylock RGE, et al. Mortality and cancer
incidence 1952-1998 in UK participants in the UK atmospheric nuclear
weapons tests and experimental programmes. Chilton, NRPB-W27, 2003.
(http://www.nrpb.org/publications/w_series_reports/2003/nrpb_w27.htm)
5. Swerdlow AJ, Douglas AJ, Vaughan Hudson G and Vaughan Hudson B.
Completeness of cancer registration in England and Wales: an assessment
based on 2,145 patients with Hodgkin’s disease independently registered by
the British National Lymphoma Investigation. Br J Cancer 1993; 67: 326-
329.
In a recent interesting research report published in your journal,
Andersen et al. [1] performed a 4-year prospective COHORT study with
yearly assessments trying to develop variables that could predict the
development of new onset neck/shoulder pain. They determined that
repetitive movements of the shoulder/arm, jobs with high demands and low
control were variables which were all independently a...
In a recent interesting research report published in your journal,
Andersen et al. [1] performed a 4-year prospective COHORT study with
yearly assessments trying to develop variables that could predict the
development of new onset neck/shoulder pain. They determined that
repetitive movements of the shoulder/arm, jobs with high demands and low
control were variables which were all independently associated with
development of neck/shoulder pain.
It is to be noted that Nahit et al.[2]
have also previously noted an association between high job demands and low
job control and development of musculoskeletal pain. Nahit et al.[2] also noted that those who perceived their work as stressful most of the
time, were more likely to report pain.[2]
From another standpoint, Fishbain et al. [3,5,6] and Rosomoff et al. [4] have examined if pre-injury job satisfaction impacts on “intent” to
return to work after pain facility treatment. In the first reports
Fishbain et al. [3] demonstrated that chronic pain patients not intending
to return to work after pain facility treatment were more likely to
complain of job dissatisfaction. In the second report from this group,
Rosomoff et al. [4] demonstrated that an association between non-intent to
return to work after pain facility treatment and pre-injury job
dissatisfaction was similarly found across Workers’ Compensation and non-
Workers’ Compensation chronic pain patients. In the third reports,
Fishbain et al. [5] looked at actual return to work after pain facility
treatment in relation to these variables. They found that actual return
to work was predicted at one month ”by intent”, perceived job stress and
job like (job dissatisfaction) plus other variables. At 36 months, return
to work was predicted by “intent” and by perceived job stress plus other
variables. In the final study, Fishbain et al. [6] attempted to predict
“intent” to return to work after pain facility treatment in relation to
actual return to work. “Intent” was predicted by perceived pre-injury job
stress plus other variables. In addition, those chronic pain patients who
intended to return and did not were predicted by whether there was a job
to go back to. Also chronic pain patients not intending to go back to work
to the pre-injury job initially, but doing so later, were predicted by
having a job to go back. Overall, this series of studies points to a
strong relationship between pre-injury work variables such as job
dissatisfaction and “intent” to return to that job after treatment. In
addition, these studies indirectly support the findings of Nahit et al.[2]
It seems that in trying to understand the low back pain injury/neck
pain injury and recovery process, it is important to take into account
work related perceptions such as those of perceived job dissatisfaction
and job stress. It is likely that some of the patients identified in
Anderson’s et al. study [1] as developing neck/shoulder pain would have
gone on to develop chronic pain. It is also likely that a significant
percentage of the patients developing chronic pain would have perceived
their pre-injury job as stressful. Thus, rehabilitation efforts with these
patients would have been difficult at best. As such, there is communality
between Anderson’s et al. findings [1] and that of Fishbain [3,5,6] and
colleagues.[4] As pointed out by Anderson et al. [1] workplace
interventions should be geared toward preventing the development of
chronic pain.
References
1. Andersen JH, Kaergaard A, Mikkelsen S, Jensen UF, Frost P, Bonde
JP, Fallentin N, Thomsen JF. Risk factors in the onsets of neck/shoulder
pain in a prospective study of workers in industrial and service
companies. Occup J Env. Med 2003;60(9):649-5.
2. Nahit ES, Pritchard CM, Cherry NM et al. The influence of work related
psychosocial factors and psychological distress on regional
musculoskeletal pain: a study of newly employed workers. J Rheumatology
2001;28:6:1378-1384.
3. Fishbain DA, Rosomoff HL, Cutler R et al. Do chronic pain patients’
perceptions about their preinjury jobs determine their intent to return to
the same type of job post-pain facility treatment? Clin J Pain 1995;11:267
-278.
4. Rosomoff HL, Fishbain DA, Cutler R et al. Do chronic pain patients’
perceptions about their preinjury jobs differ as a function of worker
compensation and non-worker compensation status? Clin J Pain 1997;12:2997-
306.
5. Fishbain DA, Cutler B, Rosomoff HL et al. The prediction of chronic
pain patient “intents,” and “discrepancy with non-intent” for return to
work post pain facility treatment. Clin J Pain 1999;15:141-150.
6. Fishbain DA, Cutler RB, Rosomoff HL, Khalil T, Steele-Rosomoff R.
Impact of chronic pain patient’s job perception variables on actual return
to work. Clin J Pain 1997;13(3):197-205.
Dear Editor
The paper by Chang et al[1] defined a Protective Effectiveness Index (PEI) as a measure of the protection afforded by gloves, whereas in reality it indicates the overall difference in exposure between two groups of workers where other important exposure factors may not be, indeed were not, the same. This raises the possibility that your readers may mistake this index as a reliable guide to glove prot...
Dear Editor
In response to our study,[1] Kivimäki et al suggested that reported sickness absence frequencies were underestimates of the total sickness absence burden in European Union (EU) member countries.[2] This concern about the veracity of these estimates led Kivimäki et al to caution policy makers to not use this data to inform policy. While we agree that more research is needed to establish...
Dear Editor
The paper by Gimeno et al provides a comparison of sickness absence between 15 European Union (EU) countries.[1] According to this study, 14.5% of employees were absent at least one day in the past 12 months by an accident at work, by health problems caused by the work, or by other health problems. For Finnish employees, for instance, this percentage was 24%, the highest among the 15 EU countr...
Dear Editor
Pattani and colleagues present some interesting and useful findings in an area of great importance to the delivery of health care within the United Kingdom.[1] They note that “doctors were nearly four times more likely to return to work as health care assistants and support staff” and that “this may reflect more flexible working opportunities for highly skilled staff”. I would suggest that it might al...
Dear Editor
Atkinson et al,[1] reported “particularly among those monitored for plutonium exposure there was a significant excess mortality from cancer of the pleura”.
However, they also note the lack of a trend for radiation dose. The authors’ suggest that these cancers are mostly mesothelioma and that asbestos is the likely causative agent. There is no mention of other agents that can cause mesothe...
Dear Editor
Gimeno, Amick, Benavides and Benach [1] raise a number of issues with a paper recently published in Occupational and Environmental Medicine.[2] It is important that researchers cross-examine others’ findings and conclusions, as well as explain and defend their own findings and conclusions, so that debate can proceed that is both informed and useful for policy and practice.
In the original...
In a recent short report, a summary of the results of a workplace based colorectal tumour-screening programme in UK was given.[1]
During 2001-02 we organised a similar programme within BASF's – the world's largest chemical company – Ludwigshafen/Germany site. Our findings were published in a German language paper.[2] Our target group included all 13 265 actively working employees aged 45 years or above. Those exp...
Dear Editor
A recent article by Daniels [1] in this journal presented occupational stress data from the 15 European Union (EU) countries.
Cross- national comparisons contribute to our scientific understanding of how and why health-related indicators (i.e. stress) are unequally distributed across countries and provide clues and guidelines for researchers, policy makers and trade unions at the EU level. Howeve...
Dear Editor
In the March 2003 issue of Occupational and Environmental Medicine, Muirhead et al.[1] described an analysis of mortality and cancer incidence among UK participants in the UK atmospheric nuclear weapons test programme.
Comparisons were made between a pre-defined cohort of test participants and a matched control group. Both groups of men were identified during the 1980s from contemporary...
Dear Editor
In a recent interesting research report published in your journal, Andersen et al. [1] performed a 4-year prospective COHORT study with yearly assessments trying to develop variables that could predict the development of new onset neck/shoulder pain. They determined that repetitive movements of the shoulder/arm, jobs with high demands and low control were variables which were all independently a...
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