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Objectives To examine the association between cognitive stimulating activities (CSA) in later life (internet/email use, employment, volunteering, evening classes, social club membership and newspaper reading) and risk of cognitive impairment or dementia using marginal structural models to account for time-varying confounding affected by prior exposure. Methods Data were used from the English Longitudinal Study of Ageing waves 1 (2002) to 7 (2014), a nationally representative sample of adults in England aged ≥50. Self-reported participation in CSAs were measured as binary exposures from waves 2 (2004) to 6 (2012), with final sample sizes between n = 3937 and n = 2530 for different CSAs. Baseline exposure and covariates were used to create inverse probability of treatment and censoring weights (IPTCW). IPTCW repeated measures Poisson and linear regression were used to estimate each CSAs effect on risk of probable cognitive impairment or dementia at wave 7 (defined as a score of ≤11/27 on a modified telephone interview for cognitive status (TICS-27)). Results were compared to standard regression adjustment. Results Internet use at any wave (Risk ratios between 0.62 and 0.69) and volunteering in waves 3 to 6 (RRs between 0.516 and 0.633) were associated with reduced risk of cognitive impairment in IPTCW models. Standard estimates were similar for both internet use and volunteering. Newspaper reading (RR 95% Confidence interval 0.74–0.99) and social club membership (RR 95% CI 0.54–0.86) at wave 6 were significantly associated with risk of cognitive impairment in standard models, but not in the IPTCW models (RR 95% CI 0.82–1.11 and 0.60–1.08 respectively). Employment and evening classes were not associated with cognitive impairment in either model. Conclusions We found that volunteering and internet use were associated with reduced risk of cognitive impairment. Associations between newspaper reading or social club membership and cognitive impairment may be due to time-varying confounding affected by prior exposure., Highlights • Confounding affected by past exposure is a problem in studies of cognitive function. • We addressed this using inverse probability weighted marginal structural models. • Volunteering and internet use were protective against cognitive impairment. • Other cognitively stimulating activities were protective with standard regression. • But these associations were non-significant in the marginal structural models.

Highlights • We examined the association between adolescent non-cognitive skills and adult health, using both subjective and objective measures of health. • Conscientiousness is positively associated with your ability to cope with stress and negatively associated with cardiovascular risk. • Agreeableness is positively associated with health-related quality of life and negatively associated with physiological ‘wear and tear’, however is negatively associated with your ability to cope with stress. • Neuroticism is negatively associated with health-related quality of life, and positively associated with physiological ‘wear and tear’ and cardiovascular risk. • All of these associations are stronger at the end of the health distribution that indicates poorer health, except for the cardiovascular risk biomarkers., Several studies have established associations between early-life non-cognitive skills and later-life health and health behaviours. However, no study addresses the more important policy concern about how this relationship varies along the health distribution. We use unconditional quantile regression to analyse the effects of adolescent non-cognitive skills across the distributions of the health-related quality of life at age 50 and biomarkers at age 45 years. We examine the effects of measures of conscientiousness, agreeableness and neuroticism recorded at age 16 for 3585 individuals from the National Child Development Study. Adolescent conscientiousness is positively associated with ability to cope with stress and negatively associated with risk of cardiovascular disease in middle-age. Adolescent agreeableness is associated with higher health-related quality of life and lower physiological ‘wear and tear’, but negatively associated with ability to cope with stress in middle-age. Adolescent neuroticism is associated with lower health-related quality of life, higher physiological ‘wear and tear’, and a higher risk of cardiovascular disease in middle-age. All of these associations are stronger at the lower end of the health distribution except for the cardiovascular risk biomarkers. These associations are robust to correcting for attrition using inverse probability weighting and consistent with causal bounds assuming proportional selection on observables and unobservables. They suggest policies that improve non-cognitive skills in adolescence could offer most long-term health benefit to those with the poorest health.

Background: Little is known of how pension reforms affect the retirement decisions of people with different health statuses, although this is crucial for the understanding of the broader societal impact of pension policies and for future policy development. We assessed how the Finnish statutory pension age reform introduced in 2005 influenced the role of health as a predictor of retirement. Methods: We used register-based data and cox regression analysis to examine the association of health (measured by purchases of psychotropic medication, hospitalizations due to circulatory and musculoskeletal diseases, and the number of any prescription medications) with the risk of retirement at age 63-64 among those subject to the old pension system with fixed age limit at 65 (pre-reform group born in 1937-1941) and the new flexible system with 63 as the lower age limit (post-reform group born in 1941-1945) while controlling for socio-demographic factors. Results: Retirement at age 63-64 was more likely among the post- than the pre-reform group (HR = 1.50; 95% CI 1.43-1.57). This reform-related increase in retirement was more pronounced among those without a history of psychotropic medication or hospitalizations due to circulatory and musculoskeletal diseases, as well as among those with below median level medication use. As a result, poor health became a weaker predictor of retirement after the reform. Conclusion: Contrary to the expectations of the Finnish pension reform aimed at extending working lives, offering choice with respect to the timing of retirement may actually encourage healthy workers to choose earlier retirement regardless of the provided economic incentives for continuing in work. (C) 2016 The Authors. Published by Elsevier Ltd.

Drawing on in-depth interviews with caregivers of left-behind children (LBC) in rural China, this article seeks to explore their understanding of migration motives and the social process of taking on care-giving roles for LBC. The authors argue that there are underlying socio-cultural explanations pertaining to economic motives for migration; such as, making contributions to social events (weddings and funerals) in village life, and fulfilling social obligations for left-behind sons’ futures. Parents migrate to save for sons’, but not daughters’, adult lives. Grandparents, particularly on the paternal side, are expected to fulfil social obligations to care for left-behind grandchildren, even without immediate financial returns. These suggest that left-behind boys, and in particular boys cared for by paternal grandparents, may be at greater risk than other LBC, as they may receive even fewer resources in the form of remittances from migrant parents in their early childhood.

Objectives Little is known about which component, such as social contact of social networks is associated with mental health or whether such an association can be observed across countries. This study examined whether the association between frequent social contact and mental health differs by composition (relatives or friends) and whether the associations are similar across three occupational cohorts from Great Britain, Japan, and Finland. Study design Cross-sectional analysis of data from three prospective cohort studies. Methods Participants were civil servants of a prospective cohort study based in London (Men: n = 4519; Women: n = 1756), in the West Coast of Japan (Men: n = 2571; Women: n = 1102), and in Helsinki, Finland (Men: n = 1181; Women: n = 5633); we included the information on study variables which is complete. Mental health function was the study outcome, indicated by the total score from the Mental Health Component on the Short Form Health Survey36. Participants reported frequencies of contacts with their relatives or friends via a questionnaire. Age, marital status, and occupational position were treated as confounders in this study. Results Findings from multiple regression showed that the associations between social contact and mental health function were different depending on country of origin and gender. Among British or Japanese men, frequent contact with both friends and relatives was positively associated with their mental health function, while only social contact with friends was significantly associated with mental health of Finnish men. In women, the patterns of the associations between social contact and mental health were more distinctive: friends for Great Britain, relatives for Japan, and friends and relatives for Finland. These significant associations were independent of the confounders. Conclusions Social contact was related to mental health of working people; however, culture and gender are likely to be tapped into.

ObjectiveChina’s internal migration has left 61 million children living apart from their parent(s) in rural areas. The present study aimed to examine whether the relative contributions of macronutrients (protein, fat and carbohydrate) to total energy intake differ between children left behind by the father or mother, compared with children from intact families.DesignDrawing on a longitudinal study, the China Health and Nutrition Survey (1997–2009), multilevel modelling analyses (level 1: occasions; level 2: children; level 3: villages) were performed.SettingData from rural communities in nine provinces in China.SubjectsRural children (n975; 555 boys and 420 girls) from 140 villages.ResultsAmong boys of school age, being left behind by the father tended to reduce the relative protein intake by 0·70 % (PPPConclusionsPublic health policies should recognise the influences of parental migration on boys, especially maternal migration, and encourage a more balanced diet for children in rural China.

Background Although associations between work stressors and stress-related biomarkers have been reported in cross-sectional studies, the use of single time measurements of work stressors could be one of the reasons for previously inconsistently reported associations. This study examines whether repeated reports of work stress towards the end of the working career predicts allostatic load, a measure of chronic stress related physiological processes. Methods Data from waves 2 to 6 of the English Longitudinal Study of Ageing (ELSA) were analysed, with a main analytical sample of 2663 older adults (aged 50+) who had at least one measurement of effort-reward imbalance between waves 2–6 and a measurement of allostatic load at wave 6. From this main analytical sample, a subsample of 1020 respondents had their allostatic load measured at wave 2. Cumulative work stress over waves 2–6 were measured by the effort-reward imbalance model. Negative binomial regression models were used to estimate the association between effort-reward imbalance and allostatic load after controlling for covariates (categorized age, gender, ethnicity, smoking status, general health, number of medications used, depressive symptoms using the Centre for Epidemiologic Studies Depression Scale, physical activity, and alcohol use in the last 12 months). Results Employees with effort-reward imbalance at the more recent waves 5 (0.09, –0.002–0.17) and 6 (0.13, 0.03–0.22) had higher levels of wave 6 allostatic load compared to those who did not report any imbalance at those waves. The predicted levels of allostatic load by cumulative reports of effort-reward imbalance from the model controlling for wave 2 allostatic load showed that workers who reported two or more occasions of effort-reward imbalance had a higher estimate of the allostatic load index (0.11, 95% CI 0.01 to 0.22) compared to workers who never reported effort-reward imbalance. Conclusion The study finds some evidence that older adults aged 50+ living in England who repeatedly reported work related stressors had higher levels of the allostatic load index than those who did not report any effort-reward imbalance. This association was robust to controlling for a range of potential health and socio-demographic confounders, as well as baseline levels of allostatic load. The findings of a dose-response association between effort-reward imbalance and allostatic load, as well as the timing of the stressor and stress response, suggest that exposure to work-related stressors may have adverse consequences for physiological health through increasing adverse levels of stress related biomarkers.

Background Living in social disadvantage has been conceptualised as a chronic stressor, although this contradicts evidence from recent studies using hair cortisol as a measure of hypothalamus-pituitary-adrenal (HPA) axis activity. The methodological limitations of previous studies investigating the association between socioeconomic position (SEP) and hair cortisol and cortisone are taken into account in this study which examines if lower SEP is associated with higher levels of HPA axis activity as measured by hair cortisol and cortisone among older adults. Methods Cortisol and cortisone levels in hair samples from 2468 participants in the 6th wave of the English Longitudinal Study of Ageing (ELSA) are examined, in relation to educational attainment, wealth, social class, and employment status. Multivariable linear regression models were used to examine the association between socioeconomic position and cortisol and cortisone levels. Inverse probability weighting and multiple imputation were used to compensate for missing data. Interactions between social class and employment status were tested. All models were adjusted for gender, age, interaction between gender and age, ethnicity, marital status, hair treatment, hair colour, nurse visiting month, smoking status, body mass index, self-assessed health, number of medications, and depressive symptoms. Results We found significant differences between the most and least advantaged social classes in their levels of hair cortisol and cortisone. Participants in the lower supervisory social class and retired had increased levels of cortisol (0.71 log(pg/mg), 95% CI 0.14 to 1.28) and cortisone (0.73 log(pg/mg), 95% CI 0.29 to 1.16) compared to participants in the most advantaged social class and those still in work. Among the economically inactive, the most disadvantaged social classes clearly had increased levels of hair cortisol and cortisone. Further analyses that take missing data into account showed that the complete case estimates of hair cortisone in the most disadvantaged groups were underestimated compared to estimates accounting for missing data, such as inverse probability weighting and multiple imputation. Conclusion This study demonstrates that social disadvantage as measured by low SEP is correlated with increased HPA axis activity. The conceptualisation of social disadvantage as a chronic stressor may be valid and previous studies reporting no associations between SEP and hair cortisol may have some methodological limitations. Future analyses using biosocial data may need to take into account and adjust for missing data in biosocial analyses.

Objectives Although urbanisation is generally associated with poverty reduction in low-income and middle-income countries, it also results in increased socioeconomic segregation of the poor. Cities with higher levels of socioeconomic segregation tend to have higher mortality rates, although the evidence is based on ecological associations. The paper examines whether socioeconomic segregation of the poor is associated with higher under-60 years (‘premature’) mortality risk in Indian cities and whether this association is confounded by contextual and compositional sociodemographic and socioeconomic factors. Setting and participants A population representative sample of over one million from 39 427 households living in 1876 urban wards within 59 Indian districts (cities) from the third (2008) District Level Household Survey (DLHS-3). Primary outcome and other measures The outcome was any death under the age of 60 reported by households in the preceding 4years of the DLHS-3. Socioeconomic segregation, estimated at the district (city) level, was measured using an isolation index of the poor and the index of dissimilarity. Results Poor households living in cities where the poor were more isolated had higher probabilities of premature mortality than poor households living in cities where the poor were less isolated. In contrast, it did not matter whether rich households lived in more or less socioeconomically segregated cities. A 1 SD increase in the isolation index was associated with an absolute increase of 1.1% in the probability of premature mortality for the poorest households. Conclusion Increasing segregation of the poor may result in higher premature mortality. As low-income and middle-income countries become increasingly urbanised, there is a risk that this may lead to increased segregation of the poor as well as increased premature mortality.

Socio-economic circumstances influence later-life employment participation, which may take different forms as retirement processes are complex. We aimed to explore the diverse effects of various socio-economic sub-domains on pre- and post-retirement employment. We used Finnish register data to examine socio-economic predictors of time to retirement (i.e. receiving the statutory pension) using Cox regression analysis and on time spent in post-retirement employment using repeated negative binomial regression analysis over a follow-up between the ages of 63 and 68, i.e. the flexible pension age range. An average wage earner still employed at age 62 spent 13.5 months in pre-retirement employment (this corresponds to time to retirement) and 4.8 months in post-retirement employment. Those with tertiary education retired later, but the educational differences in the total time spent in employment were small when post-retirement employment was also considered. There was little variation in the timing of retirement by household income, but those in the highest quintile spent the longest time in post-retirement employment. Upper non-manual employees, home renters and those with high household debt retired later, and those with high household debt also spent a longer time in post-retirement employment. In a national flexible pension age system, high occupational class and household income thus appear to encourage either later retirement or participation in post-retirement employment. However, economic constraints also appear to necessitate continued employment.

Although associations between work stressors and stress-related biomarkers have been reported in cross-sectional studies, the use of single time measurements of work stressors could be one of the reasons for inconsistent associations. This study examines whether repeated reports of work stress towards the end of the working career predicts allostatic load, a measure of chronic stress related physiological processes. Data from waves 2 to 6 of the English Longitudinal Study of Ageing (ELSA) were analysed, with a main analytical sample of 2663 older adults (aged 50+) who had at least one measurement of effort-reward imbalance between waves 2–6 and a measurement of allostatic load at wave 6. Cumulative work stress over waves 2–6 were measured by the effort-reward imbalance model. ELSA respondents who had reported two or more occasions of imbalance had a higher (0.3) estimate of the allostatic load index than those who did not report any imbalance, controlling for a range of health and socio-demographic factors, as well as allostatic load at baseline. More recent reports of imbalance were significantly associated with a higher allostatic load index, whereas reports of imbalance from earlier waves of ELSA were not. The accumulation of work related stressors could have adverse effects on chronic stress biological processes.

The gap in occupational earnings between children from parents of higher versus lower socioeconomic background widens over the life course. This gap can be at least partly explained by family background characteristics in childhood but the extent to which parental social mobility in childhood can provide additional explanatory power is less well researched. This study compares socially mobile and socially stable families in childhood with static measures of parental socioeconomic status with respect to the children’s life course occupational earnings using data from the 1958 National Child Development Study. In doing so, this study investigates the extent to which the children’s life course occupational earnings are constrained by their parents’ (lack of) social mobility during childhood. Furthermore, the strength of intergenerational socioeconomic transmission may depend on specific socioeconomic characteristics of the parents. Therefore, this study explores the influence of changes in childhood socioeconomic characteristics, namely father’s social class and housing ownership status, both separately and combined for assessing independent effects, on adult life course occupational earnings whilst also controlling for maternal education, sex and region of residence. Using life course step function multilevel models, the results indicate that parental social mobility predicts life course occupational earnings over and above socioeconomic variables measured when the child was 16. Moreover, the father’s social class mobility measure showcases greater intergenerational accumulation of social (dis)advantage. We also demonstrate social mobility during childhood appears to have long lasting and independent effects on life course occupational earnings.

Background Self-Rated Health (SRH) is predictive of morbidity and mortality, correlates well with objective measurements of physical function and is simple to use in multidisciplinary surveys. It could be a useful way of comparing health policies in different countries. However, it may not be comparable between countries which may wish to contrast health policies, for example Britain and Japan, because of linguistic, cultural or health differences. We aimed to test for differences in the association between SRH and physical function (grip strength), mental health (depression) and cardiovascular risk (smoking and BMI) between older adults in Japan and England. Methods Data were used from the English Longitudinal Study of Ageing (ELSA; 2004, 2008 and 2012) and the Japanese Study of Ageing and Retirement (JSTAR; 2007, 2009 and 2011), giving n=10, 174 ELSA participants and n=4279 JSTAR participants, all aged 50 and above. Multilevel binary logistic regression was used to test whether participants’ country of residence was associated with odds of fair or poor SRH and whether the country of residence would moderate associations between SRH and grip strength, depression, smoking or BMI. Results Japanese women (15.6%) and men (14.1%) were less likely to report fair/poor SRH than English women (23.6%) and men (24.1%). After adjusting for covariates these differences remained for men (Odds Ratio [OR] for Japanese men 0.64, 95% CI 0.74–0.85) but not for women (OR for Japanese women 1.02, 95% CI 0.47–1.34). Grip strength (OR’s women 0.86–0.89; men 0.91–0.94), depression (OR’s women 4.40–6.82; men 5.25–9.26), BMI (OR’s women 1.11–1.16; men 1.10–1.15) and smoking status (OR’s≥20 cigarettes per day women 3.07–7.22; men 2.13–4.54) were associated with fair/poor SRH. No interactions were found between country and grip strength (OR’s women 0.95–1.03; men 0.99–1.05) or depression (OR’s women 0.63–1.39; men 0.50–1.22) but were found for BMI (OR’s women 0.89–0.98; men 0.87–0.97) and smoking (OR’s≥20 cigarettes per day women 0.12–0.34; men 0.20–0.55). The interaction between country and BMI reduced when the analysis was restricted to those with a BMI less than 30 (OR’s women 0.93–1.07; men 0.90–1.05). Conclusion Our findings agree with previous research that SRH captures general physical and mental health similarly across countries. We may need more caution comparing SRH across countries when considering other aspects of health. We find that cardiovascular risk has different associations with SRH in England and Japan, possibly reflecting differences in cultural norms and different stages in their obesity and tobacco epidemics.

Background Greater cumulative life-course exposure to socioeconomic disadvantage is associated with higher levels of inflammatory biomarkers, C-Reactive protein and fibrinogen which are associated with increased cardiovascular disease risk. However, in most existing studies, researchers often use complete case data for analyses and ignore the impact of missing data on inference for blood based biomarker data. The English Longitudinal Study of Ageing (ELSA) has considerable missing data but the impact of missingness on inference is seldom examined. This paper aims primarily to examine whether the levels of adulthood inflammatory biomarkers of C-Reactive protein and fibrinogen can be explained by life course socioeconomic position. We evaluate the typologies of missing data under Missing Completely at Random and Missing at Random mechanisms and methods for compensating for missing data under these mechanisms. Methods This paper uses cross-sectional data from Wave 2 of ELSA (2004) which includes 9432 men and women aged over 52 living in England. However, only 6000 people had data for C-Reactive protein and fibrinogen. Logistic Regression modelling is implemented to identify predictors of missingness in ELSA health examination and blood collection. We use multiple linear regression modelling for analysing the association between socioeconomic position and C-Reactive protein and fibrinogen after accounting for different mechanisms of non-response using the following methods: complete case analysis (listwise deletion), inverse probability weighting and multiple imputations. Results Participants who refused to respond to the health examination were more likely to be renters, White, single, living in London or with poor assessed health. Those who refused to give a blood sample were more likely to be older female, living East of England or London, had cancer/cardiovascular disease/stroke and poorer self-assessed health. Complete case analysis showed that people with lower education level [0.14(CI0.04–0.25) and working in lower supervisory position [0.17(CI0.04–0.30)] were more likely to have higher C-Reactive protein levels. While people in the highest wealth quintile were less likely to have higher C-Reactive protein [−0.26(CI-0.36,–0.14)] and fibrinogen levels [−0.02(CI-0.04,–0.004)]. These associations remained similar in inverse probability weighting and multiple imputations although there was some variation in the estimates from the different methods for compensating for missing data. Conclusion While associations between socioeconomic position and inflammatory markers were similar across different approaches for compensating for missing data, there were differences in the estimated coefficients suggesting that it is important to account for missing biomarker data for statistical inference.

Background Chronic malnutrition is a major global health challenge, particularly in low- and middle-income countries (LMICs). Malnutrition, in particularly stunting in early childhood, is associated with developmental delay, including cognitive deficits and poor academic performance, often leading to reduced work capacity in adulthood. Few studies have examined the long-term influence of chronic malnutrition in early life on subsequent cognitive outcome and how recovering from early stunting can benefit cognitive development in a cross-national context. Methods Analysing data on 8062 children in Ethiopia (n=1,999), India (2,011), Peru (n=2,052) and Vietnam (n=2,000) from the Young Lives Study, a cross-national cohort study on child poverty and wellbeing in the developing world, we studied younger cohort, enrolled in 2002 at ages 6–17.9 months (round 1), followed in 2006 at 5 years old (round 2) and in 2009 at 8 years old (round 3) to explore whether duration of chronic malnutrition in early life matters for cognitive outcome and whether recovery from early stunting benefits for cognitive development. The duration of stunting was defined as having a HAZ Height-for-Age Z scores (HAZ) -2 in subsequent rounds after baseline. Cognitive outcome was assessed at age 8 using the Peabody Picture Vocabulary Test (PPVT) to evaluate vocabulary skills and listening comprehension. Results Longer term of being stunted was associated with lower cognitive scores at age 8 for both girls (p Conclusion Policy makers and program planners should consider redoubling efforts to prevent stunting and promote catch-up growth over the first few years of life, especially for girls, as a way of improving children’s physical and intellectual development. Given the important role girls and women play in contributing to national and global economies, improving nutrition in early childhood of girls in developing countries is a long-term economic investment and driver of economic growth.

Background There is little evidence on whether becoming re-employed in poor quality work is better for health and well-being than remaining unemployed. We examined associations of job transition with health and chronic stress-related biomarkers among a population-representative cohort of unemployed British adults. Methods A prospective cohort of 1116 eligible participants aged 35 to 75 years, who were unemployed at wave 1 (2009/10) of the UK Household Longitudinal Study, were followed up at waves 2 (2010/11) and 3 (2011/12) for allostatic load biomarkers and self-reported health. Negative binomial and multiple regression models estimated the association between job adversity and these outcomes. Results Compared with adults who remained unemployed, formerly unemployed adults who transitioned into poor quality jobs had higher levels of overall allostatic load (0.51, 0.32–0.71), log HbA1c (0.06

Background Since 2002, Afghanistan has made much effort to achieve universal health coverage. According to the UN Sustainable Development Goal 3, target eight, the provision of quality care to all must include usually underserved groups, including people with disabilities. We investigated whether a decade of international investment in the Afghan health system has brought quality health care to this group. Methods We used data from two representative household surveys, one done in 2005 and one in 2013, in 13 provinces of Afghanistan, that included questions about activity limitations and functioning difficulties, socioeconomic factors, perceived availability of health care, and experience with coverage of health-care needs. We used multilevel modelling and tests for interaction to investigate factors associated with differences in perception between timepoints and whether village remoteness affected changes in perception. Findings The 2005 survey included 334 people, and the 2013 survey included 961 people. Mean age, employment, and asset levels of participants with disabilities increased slightly between 2005 and 2013, but the level of education decreased. Formal education and higher asset level were associated with improved availability of health care and positive experience with coverage of health-care needs, whereas being employed was only associated with the latter. Perceived availability of health care and positive experience with coverage of health-care needs significantly worsened in 2013 compared with in 2005 (227 [69%] perceived that services were available in 2005 vs 405 [44%] in 2013, p

Objectives This study aimed to evaluate (i) whether work, family, behavioral and sleep quality characteristics differ among individuals with different time in bed (TIB), and (ii) whether and how much the U-shaped associations between TIB and health can be explained by these characteristics. Methods Participants were 3510 employees (2371 males and 1139 females) aged 20–65 years working in local government in Japan. They completed a questionnaire regarding work, family, and behavioral characteristics. Sleep quality and physical and mental functioning were evaluated using the Pittsburgh Sleep Quality Index and the Short Form 36. Results High job demands, long work hours, and high work–family conflict were more prevalent among those with short TIB. Those with long TIB had daily drinking habits. Whereas those with short TIB had poor sleep, mainly due to poor subjective sleep quality and daytime dysfunction, those with long TIB had poor sleep, mainly due to long sleep latency, poor sleep efficiency and sleep disturbances. The U-shaped associations between TIB and poor physical and mental health, with the best health observed in those spending ~8 h in bed, weakened considerably after adjustment for sleep quality, followed by work and family characteristics. After adjusting for behavioral characteristics and long-standing illnesses, the associations hardly changed. Conclusions The U-shaped associations between TIB and health may be explained by U-shaped associations between TIB and poor sleep and psychosocial stress in work and family life.

BACKGROUND: China's unprecedented internal migration has left 61 million rural children living apart from parents. This study investigates how being left behind is associated with children's growth, by examining children's height and weight trajectories by age, testing the accumulation and critical period life course hypotheses. METHODS: Data were drawn from five waves of the China Health and Nutrition Survey (CHNS). Multiple cohorts of children under 6 years old from 1997-2009 were examined (N = 2,555). Growth curve models investigated whether height and weight trajectories differ for children who were left behind at different stages of the life course: in early childhood (from ages 0-5 but not afterwards), in later childhood (from ages 6 to 17 only), and in both early and later childhood (from ages 0-5 and from ages 6-17), compared to their peers from intact households. RESULTS: Boys who were left behind at different life stages of childhood differed in height and weight growth compared with boys from intact families. No significant associations were found for girls. As young boys turned into adolescents, those left behind in early childhood tended to have slower height growth and weight gain than their peers from intact households. There was a 2.8 cm difference in the predicted heights of boys who were left behind in early childhood compared to boys from intact households, by the age of 14. Similarly, the difference in weight between the two groups of boys was 5.3 kg by the age of 14. CONCLUSIONS: Being left behind during early childhood, as compared to not being left behind, could lead to slower growth rates of height and weight for boys. The life course approach adopted in this study suggests that early childhood is a critical period of children's growth in later life, especially for boys who are left behind. The gender paradox in China, where sons are preferred, but being left behind appears to affect boys more than girls, needs further exploration.

OBJECTIVE: This study assessed associations between social relationships and oral health outcomes and whether these associations were explained by demographic, socioeconomic, and behavioral factors, and physical health. METHODS: We used the National Health and Nutrition Examination Survey (1999-2004) data on 4014 adults aged 60 years or older. Oral health outcomes were edentulism, number of decayed teeth, root decay, number of sound or filled teeth, and self-rated oral health. Social relationships referred to social networks (marital status, number of close friends) and social support (emotional support need, provision of financial support). Analyses consisted of regression models sequentially adjusting for demographic, socioeconomic, behavioral, and physical health confounders. RESULTS: In fully adjusted models, widowed or divorced/separated individuals had fewer sound or filled teeth than those married or living with a partner: rate ratio (95% confidence interval)=0.89 (0.82 to 0.97) and 0.90 (0.83 to 0.97), respectively. People with four to six close friends had fewer decayed teeth and lower probability for root decay than those with fewer friends. Emotional support need was associated with 1.41 (1.05 to 1.90) higher odds for root decay and 1.18 (1.04 to 1.35) higher odds for poorer self-rated oral health. Lack of financial support was associated with more decayed teeth. Edentulism was not related to any social network and social support markers. CONCLUSIONS: Social relationships are associated with clinical measures of current disease, markers of good oral function, and subjective oral health, but not with clinical measures of a lifetime history of oral disease among older Americans.

PurposeParents face an increased risk of psychological distress compared with adults without children, and families with children also have lower average household incomes. Past research suggests that absolute income (material position) and income status (psychosocial position) influence psychological distress, but their combined effects on changes in psychological distress have not been examined. Whether absolute income interacts with income status to influence psychological distress are also key questions.MethodsWe used fixed-effects panel models to examine longitudinal associations between psychological distress (measured on the Kessler scale) and absolute income, distance from the regional mean income, and regional income rank (a proxy for status) using data from 29,107 parents included in the UK Millennium Cohort Study (2003–2012).ResultsPsychological distress was determined by an interaction between absolute income and income rank: higher absolute income was associated with lower psychological distress across the income spectrum, while the benefits of higher income rank were evident only in the highest income parents. Parents’ psychological distress was, therefore, determined by a combination of income-related material and psychosocial factors.ConclusionsBoth material and psychosocial factors contribute to well-being. Higher absolute incomes were associated with lower psychological distress across the income spectrum, demonstrating the importance of material factors. Conversely, income status was associated with psychological distress only at higher absolute incomes, suggesting that psychosocial factors are more relevant to distress in more advantaged, higher income parents. Clinical interventions could, therefore, consider both the material and psychosocial impacts of income on psychological distress.

BACKGROUND: Despite the growing popularity of mixed-methods studies and considerable emphasis on the potential value of qualitative research to the trial endeavour, there remains a dearth of published studies reporting on actual contribution. This paper presents a critically reflective account of our experience of the actual value of undertaking qualitative research alongside a pilot cluster randomised controlled trial of a guided e-learning intervention for managers in an NHS Mental Health Trust to improve employee wellbeing and reduce sickness absence. For the qualitative study we undertook 36 in-depth interviews with key informants, managers and employees. We observed and took in-depth field notes of 10 meetings involving managers and employees at the Trust, and the two qualitative researchers acted as participant observers at steering committee and monthly research team meetings. We adopted a narrative methodological orientation alongside a thematic approach to data analysis, eliciting a rich account of the complexities of managing stress at work.RESULTS: We identified two key overarching roles played by the qualitative research: 'problematising' and 'contextualising'. Specifically, the qualitative data revealed and challenged assumptions embedded in the trial about the nature of the learning process, and exposed the slippery and contested nature of abstracted variables, on which a trial depends. The qualitative data challenged the trial's logic model, and provided a rich understanding of the context within which the trial and intervention took place.CONCLUSIONS: While acknowledging the ever-present tension in mixed-methods research between the requirements of quantitative research to represent the social world as abstracted variables, and the goal of qualitative research to explore and document the complexity of social phenomena, we adopted a pragmatic position that enabled us to engage with this tension in a productive and partially integrative way. Our critically reflective account of the praxis of integration illuminated opportunities and challenges for maximising the value of qualitative research to a trial. This paper sets out tangible illustrative lessons for other mixed-methods researchers endeavouring to get the most from qualitative research.TRIAL REGISTRATION: This study is registered as ISRCTN58661009 . Registration was submitted on 22 April 2013 and completed on 17 June 2013.

There has been considerable debate over the importance of the health selection hypothesis for explaining social gradients in health. Although studies have argued that it may not be an important explanation of social gradients in health, previous analyses have not estimated, simultaneously, the relative effect of health on changes in social position and of social position on changes in health (social causation). Cross-lagged longitudinal analyses using structural equation models enable the estimation of the relative size of these pathways which would be useful in determining the relative importance of the health selection hypothesis over the social causation hypothesis. Data from four phases of the Whitehall II study (initially consisting of 10,308 men and women aged 35-55 in the British civil service) were collected over a 10 year period. There was no evidence for an effect of mental (GHQ-30 and SF36) or physical health (SF-36) on changes in employment grade. When financial deprivation was used as a measure of social position, there was a significant effect of mental health on changes in social position among men although this health selection effect was over two and a half times smaller than the effect of social position on changes in health. The results suggest that the development of social gradients in health in the Whitehall II study may not be primarily explained in terms of a health selection effect.

Objectives: All health care providers in England are required to conduct surveys of their patients' experience of health care. Data from such surveys contribute to the 'star rating' performance indicators. However, there are concerns that these subjective measures may be influenced more by characteristics of patients than by true variations in the quality of care. The purpose of this paper is threefold: to determine the relationship between demographic characteristics and an index measure of patients' reported experience; to explore the extent to which patients' experiences may be accounted for by the particular National Health Service (NHS) trust they attended; and to assess how meaningful a summary index is in terms of its ability to discriminate between providers. Methods: Data from patients in the National Survey of National Health Service Patients treated for coronary heart disease in 194 NHS trusts. Patients were sent questionnaires after discharge, with a covering letter and a prepaid stamped addressed envelope. Up to two reminders were sent to non-responders. Multi-level linear regression models were used to estimate the extent to which patients' experiences differed between trusts and the association of demographic variables with the summary index. Results: In total, 116 872 patients were sent questionnaires, but 3399 proved to be ineligible for the survey. Responses were gained from 84 310 (74.3% of eligible respondents). Age and sex were most strongly associated with reported patients' experiences. However, the actual impact of age and sex on patients' experience is small, accounting for less than 3% of the variance. The proportion of the variance that was accounted for by the hospital trust in which patients were treated was only 5%. Conclusions: Demographic characteristics do not appear to account for differences between hospital trusts in patients' experience of health care. However, there is considerable variation in patients' experience within each provider. This would suggest that summary indices of patients' experience should not be used to rank providers, although detailed information from patient surveys have a useful role in determining priorities for quality improvement within individual hospitals and for assessing changes over time.

Children living in low-income households face elevated risks of behavioral problems, but the impact of absolute and relative income to this risk remains unexplored. Using the U.K. Millennium Cohort Study data, longitudinal associations between Strengths and Difficulties Questionnaire scores and absolute household income, distance from the regional median and mean income, and regional income rank were examined in 3- to 12-year-olds (n = 16,532). Higher absolute household incomes were associated with lower behavioral problems, while higher income rank was associated with lower behavioral problems only at the highest absolute incomes. Higher absolute household incomes were associated with lower behavioral problems among children in working households, indicating compounding effects of income and socioeconomic advantages. Both absolute and relative incomes therefore appear to influence behavioral problems.

Research in epidemiology highlights the necessity to adopt a life course perspective that considers different stages of the life course to explain health or diseases later on. For example, recent studies now show links between stress during working life and health in older ages. This is an important development and points to the recent advancements of analysing longitudinal data to link past exposures with outcomes at later stages of an individual’s life. But this is only one aspect of the life course perspective. In fact, life course research has much more to offer for the study of work stress and health than studying long-term effects of an earlier life exposure on later life health. The life course perspective also draws the attention to a set of important principles that shape individual life courses, and thereby could help to elucidate the development of health and diseases in an extended framework. These principles, in particular, draw attention to the importance of accumulation and duration of disadvantages throughout the life course, further, to consider the timing of exposures within individual life courses, and also, its ordering and embeddedness within larger employment trajectories. Along these lines, the present chapter first briefly summarizes the core concepts of the life course perspective, and illustrates what they offer for the study of long-term associations between work stress and health. We then describe studies on work stress and health addressing the life course perspective.

Recent discourses in the area of neighbourhood effects on health have advocated for a relational perspective of space and place, focussing on the mutually reinforcing and reciprocal relationship between the environment and the individual. An example of such relationship is that of the interaction between area deprivation and individual ethnicity on reports of self-rated health, which we explored using cross-sectional data from the 2007 Citizenship Survey linked to the 2001 UK census. We aimed to examine whether the association between area deprivation and poor self-rated health differs for ethnic minority groups, as compared to white British people. Following from this, we also examined whether possible differential associations were mediated by ethnic density effects and perceptions of and satisfaction with neighbourhood characteristics. Results of random effects multilevel logistic regression models showed the detrimental association between area deprivation and self-rated health to be of greater magnitude and stronger for white British people than for ethnic minority people. This differential association was not mediated by ethnic density effects or perceptions of and satisfaction with neighbourhood characteristics.

Prevalence of obesity is rising in Latin America and increasingly affecting socially disadvantaged groups, particularly women. Conditional cash transfers are recently established welfare interventions in the region. One, Familias en Accion, transfers ∼20% of average monthly income to women in Colombia's poorest families. Previous work has found that families buy more food as a result. We tested the hypothesis that participation in Familias would be associated with increasing body mass index (BMI) in participating women.Women from participating areas and control areas (matched on environmental and socioeconomic criteria) were surveyed in 2002 and 2006. Pregnant, breast-feeding or women aged18 or with BMI18.5 kg m(-2) were excluded. The sample comprises 835 women from control and 1238 from treatment areas. Because some treatment areas started Familias shortly before baseline data collection, a dummy variable was created that identified exposure independent of time point or area. Follow-up was 61.5%. BMI was measured by trained personnel using standardized techniques. Overweight was defined as BMI ≥ 25 kg m(-2) and obesity as ≥ 30 kg m(-2). The effect of Familias was estimated using linear regression (or logistic regression for dichotomous outcomes) in a double-difference technique, controlling for several individual, household and area characteristics, including parity and baseline BMI, using robust standard-errors clustered at area-level in an intention-to-treat analysis.At baseline, women's mean age was 33.3 years and mean BMI 25.3 kg m(-2); 12.3% women were obese. After adjustment, exposure to Familias was significantly associated with increased BMI (β=0.25; 95% confidence interval (CI) 0.03, 0.47; P=0.03). Age (β=0.09; 95% CI 0.06, 0.13; P0.001) and household wealth (β=0.78; 95% CI 0.41, 1.15; P0.001) were also positively associated with BMI. Familias was also associated with increased odds of obesity (odds ratio (OR)=1.27; 95% CI 1.03, 1.57; P=0.03), as was age (OR=1.04; 95% CI 1.02, 1.06; P=0.001).Conditional cash transfers to poor women in Colombia are independently associated with increasing BMI and obesity risk. Although conditional cash transfers are generally regarded as popular and successful schemes, parallel interventions at individual, household and community level are needed to avoid unanticipated adverse outcomes.

Aim: The objectives of this study were to examine the relationship between social network, social support and periodontal disease among older American adults and to test whether social network and support mediates socioeconomic inequality in periodontal disease. Materials and Methods: Data pertaining to participants aged 60 years and over from the National Health and Nutrition Examination Survey 2001-2004 were used. Periodontal disease variables were extent loss of periodontal attachment 3 mm and moderate periodontitis. Social support and networks were indicated by the need for emotional support, number of close friends and marital status. Results: Widowed and those with lowest number of friends had higher rates of the extent of loss of periodontal attachment (1.27, 95% CI: 1.03, 1.58) and (1.22, 95% CI: 1.03, 1.45), respectively. Marital status and number of friends were not significantly associated with moderate periodontitis after adjusting for behavioural factors. The need for more emotional support was not related to periodontal disease in this analysis. Social networks and support had no impact on socioeconomic inequality in periodontal disease. Conclusion: Certain aspects of social network, namely being widowed and having fewer friends, were linked to the extent of loss of periodontal attachment but not to the definition of moderate periodontitis, in older adults. © 2011 John Wiley & Sons A/S.

Objective The aim of this study was to investigate the contribution of physical inactivity to the excess mortality from coronary heart disease (CHD) observed in the UK South Asian population. Design An observational longitudinal study with follow-up mortality data from NHS registries. Setting Data from the Health Survey for England, 1999 and 2004. Participants 13 293 White and 2120 South Asian participants aged ≥35 years consented to the mortality follow-up. Main outcome measures Deaths from CHD. Results South Asian participants were more likely to be physically inactive than white participants (47.0% vs 28.1%). Deaths from CHD were more common in UK South Asian participants, particularly among Pakistani and Bangladeshi groups (HR 2.87, 95% CI 1.74 to 4.73), than in UK white participants, and South Asian people experienced an event at an age on average 10 years younger than white people. Physical inactivity explained >20% of the excess CHD mortality in the South Asian sample, even after adjustment for potential confounding variables (including socioeconomic position, smoking, diabetes and existing cardiovascular disease). Conclusions Physical inactivity makes a significant contribution to the excess CHD mortality observed in the South Asian population in the UK. This highlights the importance of prioritising the promotion of physical activity in this high-risk population.

Poor physical and mental functioning are more common among women than men and those with disadvantaged work and family characteristics. This study aims to clarify whether sex differences in health functioning can be explained by sex differences in work and family characteristics. The subjects were 3787 civil servants (2525 men and 1262 women), aged 20-65, working in a local government on the west coast of Japan. A questionnaire survey was conducted in January 2003. Low employment grade, high demands, long work hours, shift work, being unmarried, having no young children, high family-to-work conflict and high work-to-family conflict were more common among women than men and were independently associated with poor physical and mental functioning. The age-adjusted odds ratios (ORs) of women for poor health functioning were 1.80 for poor physical functioning and 1.77 for poor mental functioning. When adjusted for employment grade and work characteristics (control, demand, support, work hours, and shift work), the sex differences in health functioning attenuated. When adjusted for family characteristics (family structure and work-family conflicts), the sex differences in health functioning further attenuated and were no longer statistically significant. Sex differences in family characteristics contributed more to sex difference in mental functioning than sex differences in work characteristics. Japan belongs to conservative welfare regimes. In such countries, men are able to concentrate on their work with relative freedom from their family tasks and responsibilities, whereas women feel difficulties in maintaining their work-life balances. Such sex differences in work- and family-related stresses may contribute to sex difference in health. Longitudinal research is necessary to clarify the causal nature of these associations.

Context: Evidence for an association of measures of generalized and central obesity with salivary cortisol secretion is equivocal. Objective: The objective of this study was to assess the relationship between body mass index (BMI), waist circumference, and salivary cortisol. Design: The design was a cross-sectional study of BMI, waist circumference, and salivary cortisol from phase 7 (2002–2004) of the Whitehall II study. Setting: The occupational cohort was originally recruited in 1985–1988. Participants: Participants included 2915 men and 1041 women aged 50–74 yr with complete information on height, weight and waist circumference, and cortisol secretion. Outcome Measures: Saliva samples were taken on waking, waking plus 0.5, 2.5, 8, and 12 h, and bedtime for the assessment of cortisol. The cortisol awakening response and slope in diurnal secretion were calculated. Results: After adjustment for age, sex, social position, waking time, and time since waking of sample collection, increasing central and generalized obesity was associated with lower waking cortisol (P = 0.001). U-shaped associations were apparent between diurnal slope in salivary cortisol and both BMI and waist circumference (P < 0.0001 for quadratic term). For example, the shallowest (most adverse) slopes in salivary cortisol were associated with highest (>31 kg/m2) and lowest ( 0.05). Conclusion: The associations of measures of generalized and central obesity with diurnal slope in salivary cortisol are not linear in older adults. These nonlinear associations may explain previously described mixed findings.

STUDY OBJECTIVES: Short sleep duration is associated with increased CHD (coronary heart disease) mortality and morbidity, although some evidence suggests that sleep disturbance is just as important. We investigated whether a combination of short sleep duration and sleep disturbance is associated with a higher risk of CHD than their additive effects. SETTING: The Whitehall II study. PATIENTS OR PARTICIPANTS: The Whitehall II study recruited 10,308 participants from 20 civil service departments in London, England. Participants were between the ages of 35 and 55 years at baseline (1985-1988) and were followed up for an average of 15 years. INTERVENTIONS: N/A. MEASUREMENTS: Sleep hours and sleep disturbance (from the General Heath Questionnaire-30) were obtained from the baseline survey. CHD events included fatal CHD deaths or incident nonfatal myocardial infarction or angina (ICD-9 codes 410-414 or ICD-10 120-25). RESULTS: Short sleep duration and sleep disturbance were both associated with increased hazards for CHD in women as well as in men, although, after we adjusted for confounders, only those reporting sleep disturbance had a raised risk. There was some evidence for an interaction between sleep duration and sleep disturbance. Participants with short sleep duration and restless disturbed nights had the highest hazard ratios (HR) of CHD (relative risk:1.55, 95% confidence interval:1.33-1.81). Among participants who did not report any sleep disturbance, there was little evidence that short sleep hours increased CHD risk. CONCLUSION: The effect of short sleep (< or = 6 hours) on increasing CHD risk is greatest among those who reported some sleep disturbance. However, among participants who did not report any sleep disturbance, there was little evidence that short sleep hours increased CHD risk.

BACKGROUND: Previous studies report contradictory findings regarding health effects of retirement. This study examines longitudinally the associations of retirement with mental health and physical functioning. METHODS: The participants were 7584 civil servants from the Whitehall II cohort study aged 39-64 years at baseline and 54-76 years at the last follow-up. Self-reported mental health and physical functioning were assessed using the Short Form Medical Outcomes Survey questionnaire, and the scales were scored as T-scores (mean [SD] = 50 [10]). Retirement status and health were assessed with 6 repeated measurements over a 15-year period. RESULTS: The associations between retirement and health were dependent on age at retirement, reason for retirement, and length of time spent in retirement. Compared with continued employment, statutory retirement at age 60 and early voluntary retirement, respectively, were associated with 2.2 (95% confidence interval = 1.7 to 2.8) and 2.2 (1.7 to 2.7) points higher mental health and with 1.0 (0.6 to 1.5) and 1.1 (0.8 to 1.4) points higher physical functioning. Retirement due to ill health was associated with poorer mental health (-0.7 points [-1.62 to 0.2]) and physical functioning (-4.5 points [-5.1 to -3.9]). Within-subject analyses suggested a causal interpretation for statutory and voluntary retirement, but health selection for retirement due to ill health. CONCLUSIONS: Longitudinal analyses of repeat data suggest that health status improves after statutory and voluntarily retirement, although the improvement seems to attenuate over time. By contrast, the association between retirement due to ill health and subsequent poor health seems to reflect selection rather than causation.

This study aims to examine social class differences in smoking, heavy drinking, unhealthy food habits, physical inactivity and obesity, and work-related psychosocial factors as explanations for these differences. This is done by comparing employee cohorts from Britain, Finland and Japan. Social class differences in health behaviours are found in the two western European countries, but not in Japan. The studied psychosocial factors related to work, work-family interface and social relationships did not explain the found class differences in health behaviours.

CONTEXT: The association of short sleep duration with cortisol secretion has not been thoroughly examined in large community dwelling populations and the relative importance of short sleep duration and sleep disturbance is unclear. OBJECTIVE: The objective of the study was to assess the relationships between self-reported sleep duration, sleep disturbance, and salivary cortisol secretion. DESIGN: This was a cross-sectional analysis using data from phase 7 (2002-2004) of the Whitehall II study. Sleep disturbances were assessed using a modified version of the Jenkins Scale. SETTING: The occupational cohort was originally recruited in 1985-1989. PARTICIPANTS: Analyses included 2751 participants with complete cortisol measures and who collected their first sample within 15 min of waking, were not on medication affecting cortisol secretion, and had complete information for all covariates. OUTCOME MEASURE: Six saliva samples were taken on waking, waking + 0.5, 2.5, 8, and 12 h and bedtime for the assessment of the cortisol awakening response and the slope in cortisol secretion across the day. RESULTS: In mutually adjusted analyses, both sleep duration and disturbances were independently associated with a flatter diurnal slope in cortisol secretion, such that evening cortisol secretion was raised in those reporting short sleep duration and high sleep disturbance. Short sleep duration was also associated with the cortisol awakening response. These effects were independent of a number of covariates, including waking time on day of sampling and stress on the day of cortisol assessment. CONCLUSION: Short sleep duration and increased sleep disturbances are independently associated with diurnal slope in cortisol secretion of a large community-based cohort of middle-aged men and women.

Objectives To examine whether the association between psychosocial factors at work and incident coronary heart disease (CHD) is explained by pre-employment factors, such as family history of CHD, education, paternal education and social class, number of siblings and height. Methods A prospective cohort study of 6435 British men aged 35–55 years at phase 1 (1985–1988) and free from prevalent CHD at phase 2 (1989–1990) was conducted. Psychosocial factors at work were assessed at phases 1 and 2 and mean scores across the two phases were used to determine long-term exposure. Selected pre-employment factors were assessed at phase 1. Follow-up for coronary death, first non-fatal myocardial infarction or definite angina between phase 2 and 1999 was based on clinical records (250 events, follow-up 8.7 years). Results The selected pre-employment factors were associated with risk for CHD: HRs (95% CI) were 1.33 (1.03 to 1.73) for family history of CHD, 1.18 (1.05 to 1.32) for each quartile decrease in height and 1.16 (0.99 to 1.35) for each category increase in number of siblings. Psychosocial work factors also predicted CHD: 1.72 (1.08 to 2.74) for low job control and 1.72 (1.10 to 2.67) for low organisational justice. Adjustment for pre-employment factors changed these associations by 4.1% or less. Conclusions In this occupational cohort of British men, the association between psychosocial factors at work and CHD was largely independent of family history of CHD, education, paternal educational attainment and social class, number of siblings and height.

OBJECTIVE To investigate the effect of psychosocial stress at work on risk of type 2 diabetes, adjusting for conventional risk factors, among a sample of British, white-collar, middle-aged men and women. RESEARCH DESIGN AND METHODS This was a prospective analysis (1991–2004) from the Whitehall II cohort study. The current sample consists of 5,895 Caucasian middle-aged civil servants free from diabetes at baseline. Type 2 diabetes was ascertained by an oral glucose tolerance test supplemented by self-reports at baseline and four consecutive waves of data collection including two screening phases. The job strain and iso-strain models were used to assess psychosocial work stress. RESULTS Iso-strain in the workplace was associated with a twofold higher risk of type 2 diabetes in age-adjusted analysis in women but not in men (hazard ratio 1.94 [95% CI 1.17–3.21). This effect remained robust to adjustment for socioeconomic position and outside work stressors and was only attenuated by 20% after adjustment for health behaviors, obesity, and other type 2 diabetes risk factors. CONCLUSIONS Psychosocial work stress was an independent predictor of type 2 diabetes among women after a 15-year follow-up. This association was not explained by potential confounding and mediating factors. More evidence from prospective studies using the same work stress models is needed to support the current findings and provide further information on sex differences.

Work–family conflicts are associated with poor health. However, work–family conflicts and health behaviors have been little studied. This study examined the associations of conflicts between paid work and family life with unhealthy behaviors among British, Finnish, and Japanese employees. Data were derived from postal questionnaire surveys among 40 to 60 years old employees from three cohorts, the British Whitehall II Study (n = 3,397), the Finnish Helsinki Health Study (n = 4,958), and the Japanese Civil Servants Study (n = 2,901). Outcomes were current smoking, heavy drinking, physical inactivity, and unhealthy food habits. Work–family conflicts were measured with eight items. Age, marital status, and occupational class were adjusted for in logistic regression analyses. Work–family conflicts had few and inconsistent associations with unhealthy behaviors in all three cohorts. In the Finnish cohort, strong work–family conflicts were associated with current smoking among men. Women with strong conflicts had more often unhealthy food habits and were more often heavy drinkers than women with weaker conflicts. Likewise, British women with strong work–family conflicts were more often heavy drinkers. Although work–family conflicts were fairly prevalent in the examined cohorts, these conflicts had but few associations with the studied key health behaviors.

OBJECTIVE—Although it is possible that the association between depression and the metabolic syndrome is a “two-way street,” the metabolic syndrome as a predictor of depression has been little investigated. We examined whether the metabolic syndrome is associated with the onset of depressive symptoms in a cohort of middle-aged British civil servants. RESEARCH DESIGN AND METHODS—Analyses included 5,232 participants (41–61 years of age) from the Whitehall II prospective cohort study. Depressive symptoms were assessed in 1991–1993 and again 6 years later using the depression subscale from the 30-item General Health Questionnaire. Metabolic syndrome was assessed in 1991–1993, according to National Cholesterol Education Program criteria. RESULTS—Presence of the metabolic syndrome was associated with an increased risk of future depressive symptoms, odds ratio 1.38 (95% CI 1.02–1.96) after adjustment for potential confounders. Of the five components, only central obesity, high triglyceride levels, and low HDL cholesterol levels predicted depressive symptoms. These components explained most of the association between the metabolic syndrome and the onset of depressive symptoms. CONCLUSIONS—Our results suggest that the metabolic syndrome, in particular the obesity and dyslipidemia components, is predictive of depressive symptoms.

Objectives. Studies have reported an inverse association between fear of crime and subjective mental and physical health. We investigated the direction of causality and the curtailment of physical and social activities as a possible mediating pathway. Methods. We analyzed data from 2002 to 2004 of the Whitehall II study, a longitudinal study of more than 10 000 London-based civil servants aged 35 to 55 years at baseline. Results. Fear of crime was associated with poorer mental health, reduced physical functioning on objective and subjective indicators, and lower quality of life. Participants reporting greater fear were 1.93 (95% confidence interval [CI]=1.55, 2.41) times as likely to have depression as those reporting lower fear of crime and had lower mental health scores (0.9 points on the Medical Outcomes SurveyShort Form 36; 95% CI=0.4, 1.3). They exercised less, saw friends less often, and participated in fewer social activities compared with the less fearful participants. Curtailed physical and social activities helped explain the link between fear of crime and health. Conclusions. Fear of crime may be a barrier to participation in health-promoting physical and social activities. Public health practitioners should support fear-reduction initiatives.

Objective To extend the model of effort–reward imbalance at work to close and more general social relationships and test the associations with different measures of health. Lack of reciprocity at work is associated with poorer health in a number of studies. However, few studies have analysed the effect of nonreciprocity in other kinds of social relationships on health. Methods The Whitehall II Study is an ongoing prospective study of British civil servants (n=10 308 at baseline in 1985–88). Cross-sectional data from the latest phase (7, n=6944 in 2002–04) were used in the analyses. The main exposure was a questionnaire measuring nonreciprocal social relations in partnership, parent–children, and general trusting relationships. Health measures included the SF-36 mental and physical component scores, General Health Questionnaire-30 depression subscale, Jenkins' Sleep disturbance questionnaire, and the Rose Angina questionnaire. Logistic and linear regression models were analysed, adjusted for potential confounders, and mediators of the association. Results Lack of reciprocity is associated with all measures of poorer health. This association attenuates after adjustment for previous health and additional confounders and mediators but remains significant in a majority of models. Negative social support from a close person is independently associated with reduced health, but adjusting for this effect does not eliminate the association of nonreciprocity with poor health. Conclusion The effort–reward imbalance at work model has been extended to close and more general social relationships. Lack of reciprocity in partnership, parent–children and general trusting relationships is associated with poorer health.

Objective: To examine the effects of unfairness on incident coronary events and health functioning. Design: Prospective cohort study. Unfairness, sociodemographics, established coronary risk factors (high serum cholesterol, hypertension, obesity, exercise, smoking and alcohol consumption) and other psychosocial work characteristics (job strain, effort–reward imbalance and organisational justice) were measured at baseline. Associations between unfairness and incident coronary events and health functioning were determined over an average follow-up of 10.9 years. Participants: 5726 men and 2572 women from 20 civil service departments in London (the Whitehall II Study). Main outcome measures: Incident fatal coronary heart disease, non-fatal myocardial infarction and angina (528 events) and health functioning. Results: Low employment grade is strongly associated with unfairness. Participants reporting higher levels of unfairness are more likely to experience an incident coronary event (HR 1.55, 95% CI 1.11 to 2.17), after adjustment for age, gender, employment grade, established coronary risk factors and other work-related psychosocial characteristics. Unfairness is also associated with poor physical (OR 1.46, 95% CI 1.20 to 1.77) and mental (OR 1.54, 95% CI 1.19 to 1.99) functioning at follow-up, controlling for all other factors and health functioning at baseline. Conclusions: Unfairness is an independent predictor of increased coronary events and impaired health functioning. Further research is needed to disentangle the effects of unfairness from other psychosocial constructs and to investigate the societal, relational and biological mechanisms that may underlie its associations with health and heart disease.

Positive energy balance is the major cause of obesity, and chronic stress may be a contributory factor. The authors examined cumulative work stress, using the Job Strain Questionnaire on four occasions, as a predictor of obesity in a prospective 19-year study of 6,895 men and 3,413 women (aged 35–55 years) in the Whitehall II cohort in London, United Kingdom (baseline: 1985–1988). A dose-response relation was found between work stress and risk of general obesity (body mass index 30 kg/m2) and central obesity (waist circumference >102 cm in men, >88 cm in women) that was largely independent of covariates. The imputed odds ratios of body mass index obesity for one, two, and three or more reports of work stress adjusted for age, sex, and social position were 1.17, 1.24, and 1.73 (trend p < 0.01), respectively. For waist obesity, the corresponding findings were 1.17, 1.41, and 1.61 (trend p < 0.01). Work stress effect was modestly attenuated after exclusion of obese individuals at baseline and further adjustments for smoking; intakes of dietary fiber, fruits and vegetables, and alcohol; and levels of physical activity during follow-up. This study provides prospective, population-based evidence that chronic work stress predicts general and central obesity.

BackgroundPsychosocial work environments influence employee well-being. There is a need for an evaluation of organisational-level interventions to modify psychosocial working conditions and hence employee well-being.ObjectiveTo test the acceptability of the trial and the intervention, the feasibility of recruitment and adherence to and likely effectiveness of the intervention within separate clusters of an organisation.DesignMixed methods: pilot cluster randomised controlled trial and qualitative study (in-depth interviews, focus group and observation).ParticipantsEmployees and managers of a NHS trust. Inclusion criteria were the availability of sickness absence data and work internet access. Employees on long-term sick leave and short-term contracts and those with a notified pregnancy were excluded.InterventionE-learning program for managers based on management standards over 10 weeks, guided by a facilitator and accompanied by face-to-face meetings. Three clusters were randomly allocated to receive the guided e-learning intervention; a fourth cluster acted as a control.Main outcome measuresRecruitment and participation of employees and managers; acceptability of the intervention and trial; employee subjective well-being using the Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS); and feasibility of collecting sickness absence data.ResultsIn total, 424 employees out of 649 approached were recruited and 41 managers out of 49 were recruited from the three intervention clusters. Of those consenting, 350 [83%, 95% confidence interval (CI) 79% to 86%] employees completed the baseline assessment and 291 (69%, 95% CI 64% to 73%) completed the follow-up questionnaires. Sickness absence data were available from human resources for 393 (93%, 95% CI 90% to 95%) consenting employees. In total, 21 managers adhered to the intervention, completing at least three of the six modules. WEMWBS scores fell slightly in all groups, from 50.4 to 49.0 in the control group and from 51.0 to 49.9 in the intervention group. The overall intervention effect was 0.5 (95% CI –3.2 to 4.2). The fall in WEMWBS score was significantly less among employees whose managers adhered to the intervention than among those employees whose managers did not (–0.7 vs. 1.6, with an adjusted difference of 1.6, 95% CI 0.1 to 3.2). The intervention and trial were acceptable to managers, although our study raises questions about the widely used concept of ‘acceptability’. Managers reported insufficient time to engage with the intervention and lack of senior management ‘buy-in’. It was thought that the intervention needed better integration into organisational processes and practice.ConclusionsThe mixed-methods approach proved valuable in illuminating reasons for the trial findings, for unpacking processes of implementation and for understanding the influence of study context. We conclude from the results of our pilot study that further mixed-methods research evaluating the intervention and study design is needed. We found that it is feasible to carry out an economic evaluation of the intervention. We plan a further mixed-methods study to re-evaluate the intervention boosted with additional elements to encourage manager engagement and behaviour change in private and public sector organisations with greater organisational commitment.Study registrationCurrent Controlled Trials ISRCTN58661009.FundingThis project was funded by the NIHR Public Health Research programme and will be published in full inPublic Health Research; Vol. 3, No. 9. See the NIHR Journals Library website for further project information.

The literature on social deprivation, social exclusion, and health forms part of the vast body of evidence on the social inequalities in health. People in the most disadvantaged social groups and communities experience a multitude of different types of social exclusion processes such as homelessness, school exclusions, or long-term unemployment, which in turn results in poor health, disease, and disability. The associations between poor health and different dimensions of deprivation, such as income, area, employment, and educational deprivation are well documented. However, there remains some debate about the causal direction of the association. The links between poor health and social exclusion processes such as discrimination, mental illness, homelessness, and asylum seeking are also well documented. Policy responses have tended to focus on lifting the most deprived and excluded individuals out of poverty. However, others have argued on the need for proportionate universalism, which focuses on reducing the steepness of the social gradient in health, through policy actions that are universal, applicable, and appropriate across different social groups.