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Abstract Background Recent findings indicate that wide international variation in the prevalence of disabling regional musculoskeletal pain among working populations is driven by unidentified factors predisposing to pain at multiple anatomical sites. As a step towards identification of those factors, it would be helpful to know whether the prevalence of multisite pain changes when people migrate between countries with differing rates of symptoms; and if so, whether the change is apparent in first generation migrants, and by what age it becomes manifest. Methods To address these questions, we analysed data from an earlier interview-based cross-sectional survey, which assessed the prevalence of musculoskeletal pain and risk factors in six groups of workers distinguished by the nature of their work (non-manual or manual) and their country of residence and ethnicity (UK white, UK of Indian subcontinental origin and Indian in India). Prevalence odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression. Results Among 814 participants (response rate 95.4%), 20.6% reported pain at ≥3 anatomical sites. This outcome was much less frequent in Indian manual workers than among white non-manual workers in the UK (adjusted OR 0.06, 95%CI 0.01–0.36), while rates in Indian non-manual workers were intermediate (OR 0.29, 95%CI 0.12–0.72). However, within the UK, there were only small differences between white non-manual workers and the other occupational groups, including those of Indian sub-continental origin. This applied even when analysis was restricted to participants aged 17 to 34 years, and when second and later generation migrants were excluded. Conclusions The observed differences in the prevalence of multisite pain seem too large to be explained by healthy worker selection or errors in recall, and there was no indication of bias from differences in understanding of the term, pain. Our findings suggest that whatever drives the higher prevalence of musculoskeletal pain in the UK than India is environmental rather than genetic, affects multiple anatomical sites, begins to act by fairly early in adult life, and has impact soon after people move from India to the UK.

Introduction With demographic changes, there is increasing demand for individuals and governments to lengthen working lives. Jobs that are very physically demanding are likely to be more difficult to sustain at older ages. If workers at risk of mismatch of demand and capability could be identified early, there would be opportunities for intervention for health or lifestyle and/or re-training or redeployment.Objective To investigate whether self-reported walking speed (a good measure of function in elderly people) predicted health-related job loss (HRJL) longitudinally over 5 years of follow-up among middle-aged workers.Design Data came from the Health and Employment After Fifty (HEAF) prospective cohort study of middle-aged people (aged 50–64 years) in UK.Setting General population survey (sampling frame was 24 General Practice registers).Participants The cohort included 8134 people recruited in 2013–2014. For the current analyses, 5217 people who ever worked and completed at least one follow-up questionnaire were eligible.Primary outcome Exit from employment mainly or partly for health reasons (HRJL).Results At baseline, very slow walking speed was associated with: obesity, physical inactivity, smoking (men), financial hardship, lower educational attainment and not being in professional occupations. In total, 527 people (10%) reported at least one HRJL during follow-up. After adjustment, the HR for HRJL among men with very slow walking-speed was 4.32, 95% CI 2.72 to 6.87 and among women was 4.47, 95% CI 3.04 to 6.57. After further adjustment for ‘difficulty coping with physical demands at work’, hazards remained doubled in men and women.Conclusions Self-reported walking speed could help identify older workers who are at increased risk of HRJL. This could provide opportunities for intervention through optimising health and lifestyle, restricting physical workload, retraining or redeployment. Early appropriate intervention could enable longer working lives and promote healthier, more equal ageing.

Background: Fatigue is commonly reported in population surveys and has been identified in patients with health conditions as a key co-morbidity which makes remaining in work challenging. Such patients, however, rarely have access to programmes to help them manage their fatigue., Aims: To quantify the relationship between fatigue, work impairment and health-related job loss., Methods: We use data from the Health and Employment After Fifty study, a longitudinal study of people aged 50-64 years when recruited through general practices in England in 2013-14. During follow-up, fatigue was measured using the Fatigue Assessment Scale, work impairment was assessed using the Work Productivity and Activity Impairment scale, and changes in employment status were recorded., Results: A total of 2743 participants were eligible for the current analysis; 23% satisfied criteria for being fatigued. People who were fatigued were less likely to have a partner, university degree, be physically active and were more likely to be obese. Their job was more likely to involve shifts, be perceived as insecure, have reported difficulties coping with job demands, and be unsatisfying. After adjustment for socio-economic, lifestyle and work-related factors, they were almost twice as likely to report both work impairment (relative risk 1.8; 95% confidence interval [CI] 1.6, 2.1) and future health-related job loss, although the latter effect was only in those with other morbidities (incidence rate ratio 1.96; 95% CI 1.03-3.72)., Conclusions: Providing evidence-based support for workers with health conditions who experience fatigue may have an important impact at a population level in terms of extending working lives., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society of Occupational Medicine.)

Background and Purpose: Younger recipients of total hip arthroplasty (THA) highly prioritize returning to preoperative levels of physical activity (PA). Surgeons have tended to give cautious advice concerning high-impact sports participation, but there have been few long-term studies. The purpose of our study was to investigate the risk of revision arthroplasty in relation to postoperative PA levels., Methods: Patients registered in the Geneva Arthroplasty Register (GAR) who had elective THA when they were aged < 65 years were studied. Postoperative PA was collected prospectively 5-yearly using the UCLA activity scale. Cox proportional hazards models were used to estimate associations between PA and risk of revision THA., Results: Amongst 1,370 eligible subjects, median age at THA 58 years (interquartile range 51-61), UCLA scores were available for 973 (71%). During follow-up over 15 years, there were 79 revisions, giving a cumulative risk of 7.4% (95% confidence interval [CI] 5.8-9.4). After adjusting for covariates, we found an increased risk of revision for each unit increase in postoperative PA (HR 1.2, CI 1.1-1.4), and among people performing the most intensive PA (HR 2.7, CI 1.3-5.6) compared with those who were inactive., Conclusion: The overall risk of revision was small but intensive and moderate PA may be associated with an increased risk of revision.

Background: Women increasingly work beyond age 50+ but their occupational health is under-researched., Aims: To investigate what jobs older contemporary women do, when they exit their jobs and what factors predict job exit., Methods: Data came from the Health and Employment After Fifty cohort, which recruited women aged 50-64 at baseline in 2013-14 and has followed them up annually collecting: demographic, lifestyle and work information. Exits from employment were mapped longitudinally over five follow-ups. Time-to-first event Cox regression analyses were used to identify risk factors for job exit., Results: At baseline, 4436 women participated, 64% of whom were working. The proportions of women working at 50-54, 55-60 and over 60 years were 86%, 79% and 38%, respectively. Amongst all women, after adjustment for age, managing comfortably financially and not coping with the mental demands of the job were associated with exit. Risk factors for job exit differed in the age bands: 50-54; 55-59 and >60 years, reflecting socio-economic status, markers of health (musculoskeletal pain and poor self-rated health) and work factors (under-appreciation, job dissatisfaction, temporary/permanent contracts, coping with work's physical demands)., Conclusions: Factors contributing to exit from work among older women differ by age group, after controlling for perceived financial position, age and mental demands of the job. A number of work characteristics predict job exit and suggest that employers can play an important role in supporting women to continue working until older ages. Identification and treatment of musculoskeletal pain could also enable work amongst older women., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society of Occupational Medicine.)

Background: Governments of Western countries need people to work to older ages, however the COVID-19 pandemic impacted the workforce by pushing older adults to retire. Socio-demographic factors that influence the decision to retire in the pre-pandemic period were, poor or good health, finances, marital status, and gender. The aim of this study was to explore aspects that contributed to the decision to retire among middle-aged and older people in England who retired during the COVID-19 pandemic., Methods: In September 2022 semi-structured interviews were conducted with a sample of participants from the Health and Employment After Fifty (HEAF) study who retired since March 2020. Consenting participants were purposively selected to achieve a wide spread of characteristics deemed important in the retirement process. Telephone interviews were conducted, audio-recorded, transcribed and then thematically analysed., Results: 24 interviews were conducted (10 men and 14 women, mean age 65 years). Six themes were identified: four of them were non-COVID-19 aspects while two can be interpreted as impact of COVID-19 on the workforce. Work-related factors were of major importance. A sense of appreciation and attachment in relation to their employer, and conversely high work demands and stress, as well as changes in work responsibilities and work practices since lockdown and/or perception of personal safety in the workplace during the pandemic influenced their retirement decision, as did physical and mental health issues. Another theme suggested that some participants felt they had reached the 'right' age and needed to spend more time with family. Having the financial capacity to retire was widely mentioned but was never the main factor., Conclusions: The decision to retire during the pandemic was multi-factorial although changes to work during lockdown were of great importance. Post-pandemic, our findings suggest that there are modifiable aspects of work, including appreciation and fair pay and work conditions, that employers and policy makers could encourage to retain their older workers., (© 2024. The Author(s).)

Background: To assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of a new case-management intervention to facilitate the return to work of health care workers, on sick leave, having a common mental disorder (CMD)., Methods: A mixed methods feasibility study., Results: Systematic review examined 40 articles and 2 guidelines. Forty-nine National Health Service Occupational Health (OH) providers completed a usual care survey. We trained six OH nurses as case managers and established six recruitment sites. Forty-two out of 1938 staff on sick leave with a CMD were screened for eligibility, and 24 participants were recruited. Out of them, 94% were female. Eleven participants received the intervention and 13 received usual care. Engagement with most intervention components was excellent. Return-to-work self-efficacy improved more in the intervention group than in the usual care group. Qualitative feedback showed the intervention was acceptable., Conclusions: The intervention was acceptable, feasible and low cost to deliver, but it was not considered feasible to recommend a large-scale effectiveness trial unless an effective method could be devised to improve the early OH referral of staff sick with CMD. Alternatively, the intervention could be trialled as a new stand-alone OH intervention initiated at the time of usual OH referral., (© The Author(s) 2022. Published by Oxford University Press on behalf of Faculty of Public Health.)

Background: Little is known about ability to work after unicompartmental knee replacement (UKR) and total knee replacement (TKR), especially in physically-demanding occupations. This study described rates of return-to-work (RTW) and ability to sustain work by job after arthroplasty., Method: Participants from The Clinical Outcomes in Arthroplasty Study (COASt) aged 18-65 were eligible if they underwent UKR or TKR and had at least 5 years' follow-up post-operation. We posted a survey asking about pre-operative occupation, post-operative occupations and associated physical demands, and whether they had quit a job post-surgery due to difficulties with the operated knee (knee-related job loss (KRJL)). We fitted Cox Proportional Hazard Models to investigate the role of demanding physical activities on KRJL., Results: 251 people (143 UKR, 108 TKR) returned a questionnaire, of whom 101 UKR and 57 TKR worked post-operatively. Rates of RTW were highest amongst those in managerial and professional or technical roles, whichever operation they received. RTW was poorest amongst those in elementary occupations. In associate professional/technical occupations, RTW rates were better amongst UKR recipients. Amongst participants who returned to work, 17 reported KRJL (8.5% UKR and 16.7% TKR). Respondents were more likely to have KRJL if their job involved carrying/lifting ≥10 kg (HR:4.81, 95%CI 1.55-14.93) or climbing >30 flights of stairs (HR:4.03, 95%CI 1.36-11.98)., Conclusions: Knee arthroplasty recipients working pre-operatively mostly RTW. RTW may be more difficult after TKR than UKR. Jobs which involve lifting and climbing stairs may be particularly challenging. Surgeons offering knee arthroplasty should counsel patients about workability as well as risk of revision., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Governments need people to work to older ages, but the prevalence of chronic disease and comorbidity increases with age and impacts work ability., Aims: To investigate the effects of objective health diagnoses on exit from paid work amongst older workers., Methods: Health and Employment After Fifty (HEAF) is a population cohort of adults aged 50-64 years recruited from English GP practices which contribute to the Clinical Practice Research Datalink (CPRD). Participants have completed questionnaires about health and work at baseline and annually for 2 years: their responses were linked with their objective health diagnoses from the CPRD and data analysed using Cox regression., Results: Of 4888 HEAF participants ever in paid work, 580 (25%) men and 642 (25%) women exited employment, 277 of them mainly or partly for a health reason (health-related job loss (HRJL)). Amongst HEAF participants who remained in work (n = 3666) or who exited work but not for health reasons (n = 945), there was a similar prevalence of background health conditions. In men and women, HRJL was associated with inflammatory arthritis, sleep disorders, common mental health conditions and musculoskeletal pain. There were however gender differences: widespread pain and lower limb osteoarthritis were associated with HRJL in women but hypertension and cardiovascular disease in men., Conclusions: Improved diagnosis and management of common conditions might be expected to increase working lives. Workplace well-being interventions targeting obesity and increasing mobility might contribute to extended working lives. Employers of predominantly female, as compared with male workforces may need different strategies to retain older workers., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

The COVID-19 pandemic resulted in a dramatic reduction of routine healthcare availability in many European countries. Among a cohort of English middle-aged adults, we explored pre-pandemic and pandemic factors associated with not seeking healthcare during lockdown, and their effect on subsequent self-reported health measures. Longitudinal data from the Health and Employment After Fifty (HEAF) cohort were used. Pre-pandemic data came from the 5th annual follow-up (2019), when participants were aged 56-71 years, and pandemic data were collected by e-survey in February 2021 and November 2021. Response rates of the two e-surveys were 53% and 79%, respectively. Pre-pandemic predictors of not seeking healthcare were: female gender, higher BMI, higher comorbidity, poorer self-rated health and depression; non-care seekers were also more likely to report that family or friends were affected by COVID-19 and to have been advised to shield. Not seeking healthcare during lockdown was associated with a higher risk of reporting worsening of physical, but not mental, health during the later phase of the pandemic. In this cohort, those with generally poorer health were disproportionately more likely to not seek healthcare during lockdown, which may potentially exacerbate pre-existing inequalities and lead to longer-term health consequences.

Background: The COVID-19 pandemic markedly disrupted people's lives. It caused higher mortality and morbidity amongst individuals from poorer socio-economic position (SEP). It is well-recognised that job loss has a negative impact on health. We hypothesised that health effects of the pandemic on middle-aged people might be different depending on SEP and changes in employment., Methods: Data are from the Health and Employment After Fifty (HEAF), a cohort recruited 2013-2014 when aged 50-64 through 24 English general practices. At baseline and annually since, participants completed a questionnaire reporting about demographics, employment, health, lifestyle, and finances. In 2021 we sent an e-survey to all contactable HEAF participants, asking about effects of the first lockdown (March-July 2020). Outcomes were participants' perception of worsening of mental, physical health, and self-rated health (SRH) since lockdown. Associations between SEP, COVID-19 related employment changes and health were explored with Poisson regression with robust standard error, with adjustment for age, sex, and pre-pandemic SRH., Results: In total, 2,469 (53%) returned a usable questionnaire, amongst whom 2,344 provided complete information for these analyses (44% men, mean age 65.7 years). Worsening of mental, physical or SRH since lockdown was reported by 21%, 27% and 17% respectively. Mutually adjusted models showed that reporting struggling financially pre-pandemic (versus living comfortably) was associated with an increased risk of deterioration in: mental (RR = 2.0, 95%CI 1.7-2.5), physical health (RR = 2.0, 95%CI 1.6-2.3), and SRH (RR = 1.6, 95%CI 1.2-2.1). Participants working from home during lockdown and those who lost their job (as opposed to those with unchanged employment) were at increased risk of reporting deterioration in mental health and SRH., Conclusion: In a cohort of older workers, working from home, job loss and poorer pre-pandemic SEP were all associated with worsening of mental health and SRH since lockdown., (© 2022. The Author(s).)

Background: Multisite musculoskeletal pain is common and disabling. This study aimed to prospectively investigate the distribution of musculoskeletal pain anatomically, and explore risk factors for increases/reductions in the number of painful sites., Methods: Using data from participants working in 45 occupational groups in 18 countries, we explored changes in reporting pain at 10 anatomical sites on two occasions 14 months apart. We used descriptive statistics to explore consistency over time in the number of painful sites, and their anatomical distribution. Baseline risk factors for increases/reductions by ≥3 painful sites were explored by random intercept logistic regression that adjusted for baseline number of painful sites., Results: Among 8927 workers, only 20% reported no pain at either time point, and 16% reported ≥3 painful sites both times. After 14 months, the anatomical distribution of pain often changed but there was only an average increase of 0.17 painful sites. Some 14% workers reported a change in painful sites by ≥3. Risk factors for an increase of ≥3 painful sites included female sex, lower educational attainment, having a physically demanding job and adverse beliefs about the work-relatedness of musculoskeletal pain. Also predictives were as follows: older age, somatizing tendency and poorer mental health (each of which was also associated with lower odds of reductions of ≥3 painful sites)., Conclusions: Longitudinally, the number of reported painful sites was relatively stable but the anatomical distribution varied considerably. These findings suggest an important role for central pain sensitization mechanisms, rather than localized risk factors, among working adults., Significance: Our findings indicate that within individuals, the number of painful sites is fairly constant over time, but the anatomical distribution varies, supporting the theory that among people at work, musculoskeletal pain is driven more by factors that predispose to experiencing or reporting pain rather than by localized stressors specific to only one or two anatomical sites., (© 2022 European Pain Federation - EFIC®.)

Background: We investigated the feasibility of recruiting patients unemployed for more than 3 months with chronic pain using a range of methods in primary care in order to conduct a pilot trial of Individual Placement and Support (IPS) to improve quality of life outcomes for people with chronic pain., Methods: This research was informed by people with chronic pain. We assessed the feasibility of identification and recruitment of unemployed patients; the training and support needs of employment support workers to integrate with pain services; acceptability of randomisation, retention through follow-up and appropriate outcome measures for a definitive trial. Participants randomised to IPS received integrated support from an employment support worker and a pain occupational therapist to prepare for, and take up, a work placement. Those randomised to Treatment as Usual (TAU) received a bespoke workbook, delivered at an appointment with a research nurse not trained in vocational rehabilitation., Results: Using a range of approaches, recruitment through primary care was difficult and resource-intensive (1028 approached to recruit 37 eligible participants). Supplementing recruitment through pain services, another 13 people were recruited (total n = 50). Randomisation to both arms was acceptable: 22 were allocated to IPS and 28 to TAU. Recruited participants were generally not 'work ready', particularly if recruited through pain services., Conclusion: A definitive randomised controlled trial is not currently feasible for recruiting through primary care in the UK. Although a trial recruiting through pain services might be possible, participants could be unrepresentative in levels of disability and associated health complexities. Retention of participants over 12 months proved challenging, and methods for reducing attrition are required. The intervention has been manualised.

Objectives: To investigate the rates of return to work and workability among working-age people following total hip arthroplasty (THA)., Methods: Participants from the Geneva Arthroplasty Registry and the Clinical Outcomes for Arthroplasty Study aged 18-64 years when they had primary THA and with at least 5 years' follow-up were mailed a questionnaire 2017-2019. Information was collected about preoperative and post-THA employment along with exposure to physically demanding activities at work or in leisure. Patterns of change of job were explored. Survival analyses using Cox proportional hazard models were created to explore risk factors for having to stop work because of difficulties with the replaced hip., Results: In total, 825 returned a questionnaire (response 58%), 392 (48%) men, mean age 58 years, median follow-up 7.5 years post-THA. The majority (93%) of those who worked preoperatively returned to work, mostly in the same sector but higher rates of non-return (36%-41%) were seen among process, plant and machine operatives and workers in elementary occupations. 7% reported subsequently leaving work because of their replaced hip and the risk of this was strongly associated with: standing >4 hours/day (HR 3.81, 95% CI 1.62 to 8.96); kneeling/squatting (HR 3.32, 95% CI 1.46 to 7.55) and/or carrying/lifting ≥10 kg (HR 5.43, 95% CI 2.29 to 12.88)., Conclusions: It may be more difficult to return to some (particularly physically demanding) jobs post-THA than others. Rehabilitation may need to be targeted to these types of workers or it may be that redeployment or job change counselling are required., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Stammering (stuttering) is a speech condition with high heterogeneity, affecting approximately 1% of adults. Research shows it can limit career progression, impact job performance and quality of life., Aims: To assess the psychosocial impact of stammering among healthcare workers and to develop a new workplace support intervention., Methods: A cross-sectional questionnaire of healthcare workers who stammer with qualitative work and a survey of occupational health (OH) usual care to assess the need for a workplace intervention., Results: Data from 470 staff questionnaires and 32 OH clinicians were analysed. Eighty-four per cent rated their stammering severity as mild-to-moderate, with the majority reporting adverse impact on job performance and career progression. Most experienced a high degree of anxiety and embarrassment at work, with avoidance behaviours commonplace. Four per cent of respondents sought OH advice for work difficulties. Qualitative data highlighted practical challenges staff experience in the workplace. Sixty-five per cent supported the proposal for a new workplace intervention. We found workplace stress and anxiety were the most common reasons for OH referrals, and we found wide variation in the scope of OH assessments and work adjustments recommended. Most OH respondents reported insufficient clinical knowledge of speech disorders and their impact on work., Conclusions: Stammering can have a negative impact of workers' job performance and job satisfaction. This can precipitate feelings of stress and anxiety, and can affect self-identity at work. We found wide variation in the provision of OH usual care. The results informed the development of a new workplace intervention., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Night/shift work may be increasing but there are few data about the prevalence amongst older workers. With governments encouraging people to work to older ages, it is important to know how feasible night/shift work is for them and whether there are any adverse health consequences., Aims: Amongst current older workers (aged 50-64 years), to explore the prevalence of night/shift working and evaluate its health impacts and sustainability over 4 years of follow-up., Methods: Data from the Health and Employment After Fifty cohort were used to describe the demographic, job and health characteristics of men and women undertaking night/shift work. Longitudinal data were used to examine the number and nature of exits annually thereafter., Results: Amongst the 5409 working at baseline, 32% reported night/shift work in sectors which differed by sex. Night/shift workers were more likely to be: current smokers; doing physically demanding work; struggling to cope at work; dissatisfied with their hours; depressed; sleeping poorly; rating their health poorly. Women whose job involves night work were more likely to exit the workforce over 4 years., Conclusions: Almost one in three contemporary UK older workers report night/shift work. We found some evidence of adverse impacts on health, sleep and well-being and higher rates of job exit amongst women. More research is needed but night/shift work may be challenging to sustain for older workers and could have health consequences., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Introduction: Numerous environmental factors within supermarkets can influence the healthfulness of food purchases. This research aims to identify the changes in store healthfulness scores and assess the variations by store type and neighborhood deprivation using an adapted Consumer Nutrition Environment tool., Methods: Between January and May 2019, a total of 104 supermarkets in London were surveyed on 1-3 occasions. The adapted Consumer Nutrition Environment tool included data on 9 variables (variety, price, quality, promotions, shelf placement, store placement, nutrition information, healthier alternatives, and single fruit sale) for 11 healthy and 5 less healthy food items. An algorithm was used to create a composite score of in-store healthfulness and to assess inter-rater reliability. Longitudinal changes in overall store healthfulness and individual variables were investigated using multivariable hierarchical mixed models. Descriptive statistics were used to describe the differences by store type and neighborhood deprivation in each month. All analyses were conducted between January and July 2020., Results: The adapted Consumer Nutrition Environment tool showed acceptable inter-rater reliability. Large stores exhibited healthier environments than small stores (p<0.001), with a similar pattern for each of the 9 individual variables. Within large stores, the overall healthfulness score did not change over the study period. Promotions on more healthful items increased in February (p=0.04), and the availability of healthier alternatives for less healthy foods decreased in March (p=0.01). Within small stores, there was a trend toward increasing healthfulness (p<0.001), primarily owing to more promotions on healthy items (p<0.001). There was no difference in overall healthfulness by neighborhood deprivation., Conclusions: The adapted Consumer Nutrition Environment tool is sensitive to longitudinal changes in environmental variables that contribute to store healthfulness. A wider application of this tool could be used to map in-store environments to identify targets for interventions to encourage healthier food purchasing., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Clustering of observations is a common phenomenon in epidemiological and clinical research. Previous studies have highlighted the importance of using multilevel analysis to account for such clustering, but in practice, methods ignoring clustering are often employed. We used simulated data to explore the circumstances in which failure to account for clustering in linear regression could lead to importantly erroneous conclusions., Methods: We simulated data following the random-intercept model specification under different scenarios of clustering of a continuous outcome and a single continuous or binary explanatory variable. We fitted random-intercept (RI) and ordinary least squares (OLS) models and compared effect estimates with the "true" value that had been used in simulation. We also assessed the relative precision of effect estimates, and explored the extent to which coverage by 95% confidence intervals and Type I error rates were appropriate., Results: We found that effect estimates from both types of regression model were on average unbiased. However, deviations from the "true" value were greater when the outcome variable was more clustered. For a continuous explanatory variable, they tended also to be greater for the OLS than the RI model, and when the explanatory variable was less clustered. The precision of effect estimates from the OLS model was overestimated when the explanatory variable varied more between than within clusters, and was somewhat underestimated when the explanatory variable was less clustered. The cluster-unadjusted model gave poor coverage rates by 95% confidence intervals and high Type I error rates when the explanatory variable was continuous. With a binary explanatory variable, coverage rates by 95% confidence intervals and Type I error rates deviated from nominal values when the outcome variable was more clustered, but the direction of the deviation varied according to the overall prevalence of the explanatory variable, and the extent to which it was clustered., Conclusions: In this study we identified circumstances in which application of an OLS regression model to clustered data is more likely to mislead statistical inference. The potential for error is greatest when the explanatory variable is continuous, and the outcome variable more clustered (intraclass correlation coefficient is ≥ 0.01).

Background: Loneliness is an important public health issue associated with mortality and morbidity. Often researched amongst older people, less is known about risk factors for loneliness among adults aged 50-64 years who are in work. We investigated (a) if exit from the workforce increases the odds of loneliness; (b) whether adverse psychosocial work factors are associated with increased odds of loneliness over 2 years of follow-up; and (c) whether the association is stronger among subjects still working compared with those who have exited the workforce., Methods: Data came from the Health and Employment After Fifty (HEAF) study, a large population cohort who provided questionnaire information about work and health at baseline and 2 annual follow-ups. Logistic regression was used to explore the association between psychosocial risk factors and loneliness at follow-up 2, with adjustment for loneliness at baseline, sex, age, self-rated health, living alone, and mental health diagnosis., Results: Of the initial 8134 participants, 4521 were working at baseline and provided data for this analysis. Of those, 507 (11.2%) were defined as lonely at 2 years' follow-up. Exiting the workforce was not significantly associated with loneliness (OR = 1.1, 95%CI: 0.7-1.7). However, negative psychosocial work factors predicted loneliness at follow-up. After mutual adjustment, lack of choice at work (OR: 1.5, 95%CI: 1.1-1.9), often lying awake worrying about work (OR: 1.4, 95%CI: 1.0-1.9) and perceived not coping with physical demands of the job (OR: 1.3, 95%CI: 1.0-1.7) were independent predictors, with associations robust to adjustment for demographic factors and health. Associations were only slightly altered when we restricted the sample to those who remained in work until the end of follow-up., Conclusions: Loneliness amongst middle-aged working adults is not predicted by permanent work exit but is predicted by individuals' perceptions about their work. Provision of good-quality work, matched to the capacity of the older worker, could prevent loneliness.

Objectives: To describe when patients return to different types of work after elective carpal tunnel release (CTR) surgery and identify the factors associated with the duration of sickness absence., Design: Multicentre prospective observational cohort study., Setting and Participants: Participants were recruited preoperatively from 16 UK centres and clinical, occupational and demographic information were collected. Participants completed a weekly diary and questionnaires at four and 12 weeks postoperatively., Outcomes: The main outcome was duration of work absence from date of surgery to date of first return to work., Results: 254 participants were enrolled in the study and 201 provided the follow-up data. Median duration of sickness absence was 20 days (range 1-99). Earlier return to work was associated with having surgery in primary care and a self-reported work role involving more than 4 hours of daily computer use. Being female and entitlement to more than a month of paid sick leave were both associated with longer work absences. The duration of work absence was strongly associated with the expected duration of leave, as reported by participants before surgery. Earlier return to work was not associated with poorer clinical outcomes reported 12 weeks after CTR., Conclusions: There was wide variation in the duration of work absence after CTR across all occupational categories. A combination of occupational, demographic and clinical factors was associated with the duration of work absence, illustrating the complexity of return to work decision making. However, preoperative expectations were strongly associated with the actual duration of leave. We found no evidence that earlier return to work was harmful. Clear, consistent advice from clinicians preoperatively setting expectations of a prompt return to work could reduce unnecessary sickness absence after CTR. To enable this, clinicians need evidence-informed guidance about appropriate timescales for the safe return to different types of work., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: The NHS is the biggest employer in the UK. Depression and anxiety are common reasons for sickness absence among staff. Evidence suggests that an intervention based on a case management model using a biopsychosocial approach could be cost-effective and lead to earlier return to work for staff with common mental health disorders., Objective: The objective was to assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of an early occupational health referral and case management intervention to facilitate the return to work of NHS staff on sick leave with any common mental health disorder (e.g. depression or anxiety)., Design: A multicentre mixed-methods feasibility study with embedded process evaluation and economic analyses. The study comprised an updated systematic review, survey of care as usual, and development of an intervention in consultation with key stakeholders. Although this was not a randomised controlled trial, the study design comprised two arms where participants received either the intervention or care as usual., Participants: Participants were NHS staff on sick leave for 7 or more consecutive days but less than 90 consecutive days, with a common mental health disorder., Intervention: The intervention involved early referral to occupational health combined with standardised work-focused case management., Control/comparator: Participants in the control arm received care as usual., Primary Outcome: The primary outcome was the feasibility and acceptability of the intervention, study processes (including methods of recruiting participants) and data collection tools to measure return to work, episodes of sickness absence, workability (a worker's functional ability to perform their job), occupational functioning, symptomatology and cost-effectiveness proposed for use in a main trial., Results: Forty articles and two guidelines were included in an updated systematic review. A total of 49 of the 126 (39%) occupational health providers who were approached participated in a national survey of care as usual. Selected multidisciplinary stakeholders contributed to the development of the work-focused case management intervention (including a training workshop). Six NHS trusts (occupational health departments) agreed to take part in the study, although one trust withdrew prior to participant recruitment, citing staff shortages. At mixed intervention sites, participants were sequentially allocated to each arm, where possible. Approximately 1938 (3.9%) NHS staff from the participating sites were on sick leave with a common mental health disorder during the study period. Forty-two sick-listed NHS staff were screened for eligibility on receipt of occupational health management referrals. Twenty-four (57%) participants were consented: 11 (46%) received the case management intervention and 13 (54%) received care as usual. Follow-up data were collected from 11 out of 24 (46%) participants at 3 months and 10 out of 24 (42%) participants at 6 months. The case management intervention and case manager training were found to be acceptable and inexpensive to deliver. Possible contamination issues are likely in a future trial if participants are individually randomised at mixed intervention sites., Harms: No adverse events were reported., Limitations: The method of identification and recruitment of eligible sick-listed staff was ineffective in practice because uptake of referral to occupational health was low, but a new targeted method has been devised., Conclusion: All study questions were addressed. Difficulties raising organisational awareness of the study coupled with a lack of change in occupational health referral practices by line managers affected the identification and recruitment of participants. Strategies to overcome these barriers in a main trial were identified. The case management intervention was fit for purpose and acceptable to deliver in the NHS., Trial Registration: Current Controlled Trials ISRCTN14621901., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 25, No. 12. See the NIHR Journals Library website for further project information.

Background: Chronic pain is a common cause of health-related incapacity for work among people in the UK. Individualised placement and support is a systematic approach to rehabilitation, with emphasis on early supported work placement. It is effective in helping people with severe mental illness to gain employment, but has not been tested for chronic pain., Objective: To inform the design of a definitive randomised controlled trial to assess the clinical effectiveness of individualised placement and support for people unemployed because of chronic pain., Methods: A mixed-methods feasibility study comprising qualitative interviews and focus groups with key stakeholders, alongside a pilot trial., Study Participants: Primary care-based health-care professionals, employment support workers, employers, clients who participated in an individualised placement and support programme, and individuals aged 18-64 years with chronic pain who were unemployed for at least 3 months., Intervention: An individualised placement and support programme integrated with a personalised, responsive pain management plan, backed up by communication with a general practitioner and rapid access to community-based pain services., Outcomes: Outcomes included stakeholder views about a trial and methods of recruitment; the feasibility and acceptability of the individualised placement and support intervention; study processes (including methods to recruit participants from primary care, training and support needs of the employment support workers to integrate with pain services, acceptability of randomisation and the treatment-as-usual comparator); and scoping of outcome measures for a definitive trial., Results: All stakeholders viewed a trial as feasible and important, and saw the relevance of employment interventions in this group. Using all suggested methods, recruitment was feasible through primary care, but it was slow and resource intensive. Recruitment through pain services was more efficient. Fifty people with chronic pain were recruited (37 from primary care and 13 from pain services). Randomisation was acceptable, and 22 participants were allocated to individualised placement and support, and 28 participants were allocated to treatment as usual. Treatment as usual was found acceptable. Retention of treatment-as-usual participants was acceptable throughout the 12 months. However, follow-up of individualised placement and support recipients using postal questionnaires proved challenging, especially when the participant started paid work, and new approaches would be needed for a trial. Clients, employment support workers, primary care-based health-care professionals and employers contributed to manualisation of the intervention. No adverse events were reported., Conclusion: Unless accurate and up-to-date employment status information can be collected in primary care health records, or linkage can be established with employment records, research such as this relating to employment will be impracticable in primary care. The trial may be possible through pain services; however, clients may differ. Retention of participants proved challenging and methods for achieving this would need to be developed. The intervention has been manualised., Trial Registration: Current Controlled Trials ISRCTN30094062., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 25, No. 5. See the NIHR Journals Library website for further project information.

Objectives: Health and job satisfaction are key independent determinants of ability to work to older ages. We investigated the interaction of these two important factors on health-related job loss (HRJL) over 2 years of follow-up comparing male and female older workers., Methods: A population sample of adults aged 50-64 years, recruited from 24 English general practices in the Health and Employment After Fifty (HEAF) study, completed questionnaires at baseline with follow-ups at 12 and 24 months. Multiple-record Cox proportional hazards models were performed to explore the main effects of, and potential interactions between, job satisfaction and self-rated health (SRH) as predictors of time to first HRJL., Results: Of the initial 8134 participants, 5143 were ever in work in the study period. Among men, 5.7% and 14.3% reported job dissatisfaction (those in good and poor SRH, respectively), while among women these percentages were 4.6 and 12.9. HRJL was reported by 106 men and 176 women. Men in good health dissatisfied with their job had a sixfold (HR=6.4; 95% CI 3.3 to 12.4) increased risk of HRJL compared with men satisfied with their job (significant multiplicative interaction). Women dissatisfied with their job were more likely to have an HRJL within 2 years of follow-up irrespective of their SRH., Conclusions: SRH and job dissatisfaction have important individual effects on the risk of stopping work for health among older workers. These findings point to the importance of job satisfaction in reducing health-related exit from paid work among older workers., Competing Interests: Competing interests: CC has received consultancy and honoraria from Alliance for Better Bone Health, Amgen, Eli Lilly, GSK, Medtronic, Merck, Novartis, Pfizer, Roche, Servier, Takeda and UCB., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Hand dermatitis is highly prevalent among nurses due to their frequent exposure to wet work. Providing cost-effective dermatological health surveillance for this occupational group presents a challenge to health service providers., Aims: To ascertain the predictive value of nurses' self-assessment of whether they had current hand dermatitis using a screening questionnaire when compared with the assessment made by a dermatologist of the nurses' hand photographs., Methods: We conducted a cross-sectional study comparing the self-report decision made by student and intensive care nurses using a single hand dermatitis screening question with the clinical assessment of their hand photographs made by dermatologists using a standardized photographic guide., Results: We analysed data collected at study baseline (n = 1599). The results showed that the screening question had a high negative predictive value (91%; 95% CI 89-93), but a low positive predictive value (39%; 95% CI 34-45). It demonstrated acceptable accuracy in distinguishing those with and without the disease (area under the receiver operator curve = 0.7) and had a high specificity (86%; 95% CI 84-88) but a sensitivity of only 52% (95% CI 46-59) in identifying hand dermatitis., Conclusions: We found that nurses were able to accurately self-assess themselves as not having any signs of hand dermatitis. By contrast, they were less able to accurately self-assess positive cases suggesting under-recognition of early disease. We propose that a questionnaire containing a single hand dermatitis screening question should be considered as a tool for screening out clear cases as part of a workplace health surveillance programme for detecting hand dermatitis., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Context: Product placement strategies have been used to influence customers' food purchases in food stores for some time; however, assessment of the evidence that these techniques can limit unhealthy, and promote healthy, food choices has not been completed., Objective: This systematic review aimed to determine how product placement strategies, availability, and positioning, in physical retail food stores located in high-income countries, influence dietary-related behaviors., Data Sources: From a search of 9 databases, 38 articles, 17 observational studies, and 22 intervention studies met the study inclusion criteria., Data Extraction: Two reviewers independently extracted data relating to study design, study population, exposures, outcomes, and key results. Each study was also assessed for risk of bias in relation to the research question., Data Analysis: Meta-analysis was not possible owing to heterogeneous study designs and outcomes. As recommended by Cochrane, results were synthesized in effect direction plots using a vote-counting technique which recorded the direction of effect and significance level according to the expected relationship for health improvement., Conclusions: The majority of studies showed that greater availability and more prominent positioning of healthy foods, or reduced availability and less prominent positioning of unhealthy foods, related to better dietary-related behaviors. A large number of results, however, were nonsignificant, which likely reflects the methodological difficulties inherent in this research field. Adequately powered intervention studies that test both the independent and additive effects of availability and positioning strategies are needed., Systematic Review Registration: PROSPERO registration no. 42016048826., (© The Author(s) 2020. Published by Oxford University Press on behalf of the International Life Sciences Institute.)

Introduction: Rapidly increasing population old age dependency ratios create a growing economic imperative for people to work to older ages. However, rates of older worker employment are only increasing slowly. Amongst a cohort of contemporary older workers, we investigated risk factors for health-related job loss (HRJL) over 2 years of follow-up., Methods: HEAF is a population based cohort study of adults in England (aged 50-64 years at baseline) who provided information about socio-demographic characteristics, lifestyle, and work at baseline and annual follow-ups. Exits from paid work were mapped and risk factors for HRJL explored in a multiple-record survival dataset by Cox proportional hazards models., Results: 2475 (75%) men and 2668 (66%) women were employed; 115 (4.6%) men and 182 (6.8%) women reported HRJL. Employment as road transport drivers/in vehicle trades (men), or as teaching/education/nursing/midwifery professionals or in caring personal services (women), was more frequent among people exiting work for health-related versus non-health-related reasons. Principal socio-demographic and lifestyle risk factors for HRJL were: struggling financially (men and women); low physical activity (men); being overweight or obese, and current smoking (women). Mutually adjusted work-related risk factors for HRJL were job dissatisfaction, and not coping with the physical (hazard ratio [95% confidence interval]: men 5.34[3.40,8.39]; women 3.73[2.48,5.60]) or mental demands (women only, 2.02[1.38,2.96]) of work., Conclusions: Employment characteristics of contemporary older workers differ by sex. Job satisfaction and perceived ability to cope with the physical and mental demands of work are key determinants of HRJL which employers could potentially influence to enable work to older ages., Competing Interests: The authors have declared that no competing interests exist.

Background: Occupational hand dermatitis poses a serious risk for nurses., Objectives: To evaluate the clinical and cost-effectiveness of a complex intervention in reducing the prevalence of hand dermatitis in nurses METHODS: This was a cluster randomized controlled trial conducted at 35 hospital trusts, health boards or universities in the UK. Participants were (i) first-year student nurses with a history of atopic conditions or (ii) intensive care unit (ICU) nurses. Participants at intervention sites received access to a behavioural change programme plus moisturizing creams. Participants at control sites received usual care. The primary outcome was the change of prevalent dermatitis at follow-up (adjusted for baseline dermatitis) in the intervention vs. the control group. Randomization was blinded to everyone bar the trials unit to ensure allocation concealment. The trial was registered on the ISRCTN registry: ISRCTN53303171., Results: Fourteen sites were allocated to the intervention arm and 21 to the control arm. In total 2040 (69·5%) nurses consented to participate and were included in the intention-to-treat analysis. The baseline questionnaire was completed by 1727 (84·7%) participants. Overall, 789 (91·6%) ICU nurses and 938 (84·0%) student nurses returned completed questionnaires. Of these, 994 (57·6%) had photographs taken at baseline and follow-up (12-15 months). When adjusted for baseline prevalence of dermatitis and follow-up interval, the odds ratios (95% confidence intervals) for hand dermatitis at follow-up in the intervention group relative to the controls were 0·72 (0·33-1·55) and 0·62 (0·35-1·10) for student and ICU nurses, respectively. No harms were reported., Conclusions: There was insufficient evidence to conclude whether our intervention was effective in reducing hand dermatitis in our populations. Linked Comment: Brans. Br J Dermatol 2020; 183:411-412., (© 2020 The Authors. British Journal of Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Objectives: To explore the association of sickness absence ascribed to pain at specific anatomical sites with wider propensity to musculoskeletal pain., Methods: As part of the CUPID (Cultural and Psychosocial Influences on Disability) study, potential risk factors for sickness absence from musculoskeletal pain were determined for 11 922 participants from 45 occupational groups in 18 countries. After approximately 14 months, 9119 (78%) provided follow-up information about sickness in the past month because of musculoskeletal pain, including 8610 who were still in the same job. Associations with absence for pain at specific anatomical sites were assessed by logistic regression and summarised by ORs with 95% CIs., Results: 861 participants (10%) reported absence from work because of musculoskeletal pain during the month before follow-up. After allowance for potential confounders, risk of absence ascribed entirely to low back pain (n=235) increased with the number of anatomical sites other than low back that had been reported as painful in the year before baseline (ORs 1.6 to 1.7 for ≥4 vs 0 painful sites). Similarly, associations with wider propensity to pain were observed for absence attributed entirely to pain in the neck (ORs up to 2.0) and shoulders (ORs up to 3.4)., Conclusions: Sickness absence for pain at specific anatomical sites is importantly associated with wider propensity to pain, the determinants of which extend beyond established risk factors such as somatising tendency and low mood. Better understanding of why some individuals are generally more prone to musculoskeletal pain might point to useful opportunities for prevention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Three billion people use biomass fuel for cooking and heating globally. We assessed the association between acute coronary syndromes (ACS) and use of biomass fuel for cooking., Methods: We conducted a case-control study among women living in defined areas that were served by two tertiary care hospitals. A total of 364 women admitted to cardiac care units with ACS were compared with 727 controls, individually matched for age, who were inpatients at the same hospitals with a miscellany of diagnoses. Exposure to biomass fuel and other risk factors was ascertained through a questionnaire and assessed by conditional logistic regression., Results: After adjustment, risk of ACS was elevated in women who had ever used biomass for cooking. In comparison with never users, the odds ratio for those who currently cooked with biomass was 4.8 (95% confidence interval 1.7, 13.8). However, among those who had ever used biomass, there was no decline in risk with time since last exposure., Conclusions: The study found increased risk of ACS from use of biomass for cooking. However, full benefits from interventions may not accrue in short term.

To assist interpretation of a study in rural Pakistan on the use of biomass for cooking and the risk of coronary heart disease, we continuously monitored airborne concentrations of fine particulate matter (PM 2.5 ) and carbon monoxide (CO) for up to 48 h in the kitchens of households randomly selected from the parent study. Satisfactory data on PM 2.5 and CO respectively were obtained for 16 and 17 households using biomass, and 19 and 17 using natural gas. Linear regression analysis indicated that in comparison with kitchens using natural gas, daily average PM 2.5 concentrations were substantially higher in kitchens that used biomass in either a chimney stove (mean difference 611, 95% CI: 359, 863 µg/m 3 ) or traditional three-stone stove (mean difference 389, 95% CI: 231, 548 µg/m 3 ). Daily average concentrations of CO were significantly increased when biomass was used in a traditional stove (mean difference from natural gas 3.7, 95% CI: 0.8, 6.7 ppm), but not when it was used in a chimney stove (mean difference -0.8, 95% CI: -4.8, 3.2 ppm). Any impact of smoking by household members was smaller than that of using biomass, and not clearly discernible. In the population studied, cooking with biomass as compared with natural gas should serve as a good proxy for higher personal exposure to PM 2.5 .

Background: To explore the relationship between radiographic spondylolisthesis and occupational factors in a case-control study nested within the Wakayama Spine Study (WSS)., Methods: The WSS is a cross-sectional observational study amongst Japanese adults. All participants completed a lifetime occupational history and underwent X-rays of the lumbar spine (L1-S1) according to a pre-defined protocol. One trained surgeon graded the presence of a spondylolisthesis based upon ≥5% anterior or posterior slip at one or more levels. Cases, with lumbar spondylolisthesis, were compared with controls without, for their principal occupation and occupational exposures., Results: In total, data were available for 722 adults (245 men and 477 women), mean age 70.1 (range 53-93) years. According to the pre-defined radiographic criteria, 117 were defined with spondylolisthesis (cases), leaving 605 controls. Cases were not significantly different from controls for age, gender, BMI, smoking or alcohol intake. However, cases were more than twice as likely to report occupational driving ≥4 h/day (OR 2.39, 95% CI 1.08-5.27) after adjustment for age, gender and BMI. Additionally, after stratification by age using 75 years as a cut-point, cases were more than 3-fold more likely to report having worked in the agricultural/ fishing industries (OR 3.47, 95% CI 1.29-9.29) among those aged < 75 years. A reduced risk of being a case was associated with climbing slopes/steps and walking., Conclusions: A history of occupational driving and working in the agricultural/fishing industry were associated with radiographic spondylolisthesis in this cross-sectional population study. This finding requires further evaluation in longitudinal studies.

Background: Although strategies have been developed to minimise the risk of occupational hand dermatitis in nurses, their clinical effectiveness and cost-effectiveness remain unclear., Objectives: The Skin Care Intervention in Nurses trial tested the hypothesis that a behaviour change package intervention, coupled with provision of hand moisturisers, could reduce the point prevalence of hand dermatitis when compared with standard care among nurses working in the NHS. The secondary aim was to assess the impact of the intervention on participants' beliefs and behaviour regarding hand care, and the cost-effectiveness of the intervention in comparison with normal care., Design: Cluster randomised controlled trial., Setting: Thirty-five NHS hospital trusts/health boards/universities., Participants: First-year student nurses with a history of atopic tendency, and full-time intensive care unit nurses., Intervention: Sites were randomly allocated to be 'intervention plus' or 'intervention light'. Participants at 'intervention plus' sites received access to a bespoke online behaviour change package intervention, coupled with personal supplies of moisturising cream (student nurses) and optimal availability of moisturising cream (intensive care unit nurses). Nurses at 'intervention light' sites received usual care, including a dermatitis prevention leaflet., Main Outcome Measure: The difference between intervention plus and intervention light sites in the change of point prevalence of visible hand dermatitis was measured from images taken at baseline and at follow-up., Randomisation: Fourteen sites were randomised to the intervention plus arm, and 21 sites were randomised to the intervention light arm., Blinding: The participants, trial statistician, methodologist and the dermatologists interpreting the hand photographs were blinded to intervention assignment., Numbers Analysed: An intention-to-treat analysis was conducted on data from 845 student nurses and 1111 intensive care unit nurses., Results: The intention-to-treat analysis showed no evidence that the risk of developing dermatitis was greater in the intervention light group than in the intervention plus group (student nurses: odds ratio 1.25, 95% confidence interval 0.59 to 2.69; intensive care unit nurses: odds ratio 1.41, 95% confidence interval 0.81 to 2.44). Both groups had high levels of baseline beliefs about the benefits of using hand moisturisers before, during and after work. The frequency of use of hand moisturisers before, during and after shifts was significantly higher in the intensive care unit nurses in the intervention plus arm at follow-up than in the comparator group nurses. For student nurses, the intervention plus group mean costs were £2 lower than those for the comparator and 0.00002 more quality-adjusted life-years were gained. For intensive care unit nurses, costs were £4 higher and 0.0016 fewer quality-adjusted life-years were gained., Harms: No adverse events were reported., Limitations: Only 44.5% of participants in the intervention plus arm accessed the behaviour change package., Conclusion: The intervention did not result in a statistically significant decrease in the prevalence of hand dermatitis in the intervention plus group., Future Work: Participants had a high level of baseline beliefs about the importance of using hand moisturisers before, during and after work. Future research should focus on how workplace culture can be changed in order for that knowledge to be actioned., Trial Registration: Current Controlled Trials ISRCTN53303171., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 23, No. 58. See the NIHR Journals Library website for further project information., Competing Interests: Ira Madan reports being the chairperson of the National Institute for Health Research (NIHR)’s Health Technology Assessment (HTA) Mental Health panel from 1 January 2018 to December 2020. Vaughan Parsons reports personal fees from the magazine Occupational Health at Work during the conduct of the trial. Alison Wright reports other grants from the NIHR HTA programme during the conduct of the study. Julia Smedley reports other grants from NIHR via Guy’s and St Thomas’ NHS Foundation Trust (lead centre) during the conduct of the study (HTA reference number 15/107/02). Hywel Williams is Director of the HTA programme and chairperson of the HTA Commissioning Board. From 1 January 2016, he became Programme Director for the HTA programme.

Background: Previous research has indicated that wide international variation in the prevalence of disabling low back pain among working populations is largely driven by factors predisposing to musculoskeletal pain more generally. This paper explores whether the same applies to disabling wrist/hand pain (WHP)., Methods: Using data from the Cultural and Psychosocial Influences on Disability (CUPID) study, we focused on workers from 45 occupational groups (office workers, nurses and other workers) in 18 countries. Among 11,740 participants who completed a baseline questionnaire about musculoskeletal pain and potential risk factors, 9082 (77%) answered a further questionnaire after a mean interval of 14 months, including 1373 (15%) who reported disabling WHP in the month before follow-up. Poisson regression was used to assess associations of this outcome with baseline risk factors, including the number of anatomical sites other than wrist/hand that had been painful in the 12 months before baseline (taken as an index of general propensity to pain)., Results: After allowance for other risk factors, the strongest associations were with general pain propensity (prevalence rate ratio for an index ≥6 vs. 0: 3.6, 95% confidence interval 2.9-4.4), and risk rose progressively as the index increased. The population attributable fraction for a pain propensity index > 0 was 49.4%. The prevalence of disabling WHP by occupational group ranged from 0.3 to 36.2%, and correlated strongly with mean pain propensity index (correlation coefficient 0.86)., Conclusion: Strategies to prevent disability from WHP among working populations should explore ways of reducing general propensity to pain, as well as improving the ergonomics of occupational tasks.

Objectives: To explore the associations of hypertension and coronary heart disease (CHD) with use of biomass fuel for cooking., Design: Comparative cross-sectional study., Setting: Rural villages in Sindh, Pakistan., Participants: Women aged ≥40 years who had used biomass fuel for cooking for at least the last year (n=436), and a comparison group (n=414) who had cooked only with non-biomass fuel during the last year were recruited through door-to-door visits. None of those who were invited to take part declined., Primary and Secondary Outcome Measures: Hypertension was determined from blood pressure measurements and use of medication. CHD was assessed by three measures: history of angina (Rose angina questionnaire), previous history of 'heart attack', and definite or probable changes of CHD on ECG. Potentially confounding risk factors were ascertained by questionnaire and anthropometry. Associations of hypertension and CHD with use of biomass and other risk factors were assessed by logistic regression, and summarised by ORs with 95% CIs., Results: After adjustment for potential confounders, there was no association of hypertension (OR: 1.0, 95% CI 0.8 to 1.4) angina (OR: 1.0, 95% CI 0.8 to 1.4), heart attack (OR: 1.2, 95% 0.7 to 2.2) or ECG changes of CHD (OR: 0.8, 95% CI 0.6 to 1.2) with current use of biomass for cooking. Nor were any associations apparent when analyses were restricted to long-term (≥10 years) users and non-users of biomass fuel., Conclusions: A linked air monitoring study indicated substantially higher airborne concentrations of fine particulate matter in kitchens where biomass was used for cooking. It is possible that associations with CHD and hypertension were missed because most of the comparison group had used biomass for cooking at some time in the past, and risk remains elevated for many years after last exposure., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To explore the association of MRI-diagnosed severe lumbar spinal stenosis with occupation., Methods: Occupational data were collected by questionnaire and all participants underwent spine MRI scans using the same protocol. Central lumbar spinal stenosis (LSS) was graded qualitatively. Those with severe LSS (>two-thirds narrowing) were compared with the controls with lesser degrees of stenosis or no stenosis., Results: Data were available for 722 subjects, mean age 70.1 years. 239 (33%) cases with severe LSS were identified. Factory/construction workers had an almost four-fold increased risk of severe LSS after adjustment for age, sex, smoking, and walking speed amongst those aged <75 years (OR 3.97, 95%CI 1.46-10.85). Severe LSS was also associated with squatting ≥1 h/day (OR 1.76, 95%CI 1.01-3.07) but this association became non-significant after adjustment., Conclusion: Further research is needed but this study adds more evidence that occupational factors are associated with an increased risk and/or severity of degenerative disease of the lumbar spine., (© 2019 The Authors. American Journal of Industrial Medicine Published by Wiley Periodicals, Inc.)

Objective: Our aim was to assess the safety of cyclooxygenase-2 (COX-2) inhibitors in the management of osteoarthritis (OA) in a systematic review and meta-analysis of randomized, placebo-controlled trials., Methods: A comprehensive literature search was undertaken in the databases MEDLINE, Cochrane Central Register of Controlled Trials (Ovid CENTRAL) and Scopus. Randomized, double-blind, placebo-controlled, parallel-group trials that assessed adverse events (AEs) with COX-2 inhibitors in patients with OA were eligible for inclusion. Two authors appraised titles, abstracts and full-text papers for suitability and then assessed the studies for random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data and selective outcomes reporting. The primary outcomes of interest were gastrointestinal disorders, cardiac disorders, vascular disorders, nervous system disorders, skin and subcutaneous tissue disorders, hepatobiliary disorders, renal and urinary disorders, as well as overall severe and serious AEs, drug-related AEs and mortality. Secondary outcomes were withdrawals due to AEs (i.e. the number of participants who stopped the treatment due to an AE) and total number of AEs (i.e. the number of patients who experienced any AE at least once)., Results: Database searches identified 2149 records from which, after exclusions, 40 trials were included in the meta-analysis. The use of COX-2 inhibitors in OA was associated with a significant increased risk of drug-related AEs compared with placebo (relative risk (RR) 1.26, 95% CI 1.09-1.46; I 2  = 24%). The risk of upper gastrointestinal complications (including dyspepsia, gastritis and heartburn) was significantly increased with COX-2 inhibitors versus placebo (RR 1.19, 95% CI 1.03-1.38; I 2  = 0%), particularly for abdominal pain, which increased by 40% with COX-2 inhibitors (RR 1.40, 95% CI 1.08-1.80; I 2  = 0%). The risk of hypertension increased by 45% overall (RR 1.45, 95% CI 1.01-2.10; I 2  = 25%); however, when rofecoxib was removed from the analysis the risk of hypertension in the COX-2 inhibitor group was no longer significant (RR 1.21, 95% CI 0.80-1.83; I 2  = 20%). The overall risk of heart failure and edema was increased by nearly 70% with COX-2 inhibitors versus placebo (RR 1.68, 95% CI 1.22-2.31; 0%) and this level of risk did not change appreciably when rofecoxib was excluded (RR 1.67, 95% CI 1.21-2.29; 0%)., Conclusions: In our analysis, COX-2 inhibitors were associated with an increased risk of upper gastrointestinal AEs, especially abdominal pain. We also found an increased risk of cardiovascular AEs with COX-2 inhibitors, namely hypertension, heart failure and edema.

Objective: We aimed to assess the safety of opioids in the management of osteoarthritis (OA) in a systematic review and meta-analysis of randomized, placebo-controlled trials., Methods: A comprehensive literature search was undertaken in the MEDLINE, Cochrane Central Register of Controlled Trials (Ovid CENTRAL), and Scopus electronic databases. Randomized, double-blind, placebo-controlled, parallel-group trials that assessed adverse events (AEs) with opioids in patients with OA were eligible for inclusion. Two authors appraised titles, abstracts and full-text papers for suitability and then assessed the studies for random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data and selective outcomes reporting. The primary outcomes of interest were gastrointestinal (GI) disorders, cardiac disorders, vascular disorders, nervous system disorders, skin and subcutaneous tissue disorders, renal and urinary disorders, respiratory, thoracic and mediastinal disorders, as well as overall severe and serious AEs and drug-related AEs. Secondary outcomes were withdrawals due to AEs (i.e. the number of participants who stopped the treatment due to an AE) and total number of AEs (i.e. the number of patients who experienced any AE at least once)., Results: Database searches identified 2189 records, from which, after exclusions, 17 papers were included in the meta-analysis. More disorders of the lower GI tract (constipation, fecaloma) were reported with both immediate-release (IR) and extended-release (ER) formulations of opioids versus placebo: IR opioids (relative risk [RR] 5.20, 95% confidence interval [CI] 3.42-7.89); ER opioids (RR 4.22, 95% CI 3.44-5.17). The risk of upper GI AEs increased fourfold with ER opioids compared with placebo (RR 4.03, 95% CI 0.87-18.62), and the risk of nausea, vomiting or loss of appetite increased four- to fivefold with both formulations: IR opioids (RR 3.39, 95% CI 2.22-5.18); ER opioids (RR 4.03, 95% CI 3.37-4.83). An increased risk of dermatologic AEs (rash and pruritis; IR opioids: RR 3.60, 95% CI 1.74-7.43; ER opioids: RR 7.87, 95% CI 5.20-11.89) and central nervous system disorders (dizziness, headache, fatigue, somnolence, insomnia; IR opioids: RR 2.76, 95% CI 1.90-4.02; ER opioids: RR 2.76, 95% CI 2.19-3.47) was found with all opioid formulations versus placebo., Conclusions: Our results confirm that there are considerable safety and tolerability issues surrounding the use of opioids in OA, and support the recommendation of international and national guidelines to use opioids in OA after other analgesic options, and for short time periods.

Background: To improve population diet environmental strategies have been hailed the panacea because they require little agency or investment of personal resources; this contrasts with conventional strategies that rely on individuals to engage high levels of agency and make deliberate choices. There is an immediate need to improve understanding of the synergy between the psychological and environmental determinants of diet in order to optimise allocation of precious public health resources. This study examined the synergistic and relative association between a number of food environment and psychological factors and the dietary behaviours of a population sample of women with young children., Methods: Women in Hampshire were recruited from children's centres and asked about their demographic characteristics, psychological resources, dietary behaviours (food frequency questionnaire) and perceptions of healthy food access and affordability. Three local food environment factors were objectively assessed: i) spatial access to food outlets using activity spaces; ii) healthfulness of the supermarket where women did their main food shop, (based on nine in-store factors including price, placement and promotion on seven healthy and five less healthy foods); iii) nutrition environment of children's centres visited frequently by the women, assessed via staff-administered questionnaire. A theoretical model linking environmental factors to dietary behaviours, both directly and indirectly through three factors representing individual agency (psychological resources, perceived food affordability, perceived food accessibility), was tested using Structural Equation Modelling., Results: Complete data were available for 753 women. The environment of women's main supermarket was indirectly related to their dietary behaviours through psychological resources and perceived food affordability. Shopping at supermarkets classified as having a healthier in-store environment was associated with having greater psychological resources associated with healthy eating (standardised regression weight β = 0.14SD, p = 0.03) and fewer food affordability concerns (β = - 0.14SD, p = 0.01), which in turn related to healthier dietary behaviours (β = 0.55SD, < 0.001 and β = - 0.15, p = 0.01 respectively). The three food environment factors were not directly associated with dietary behaviour (p > 0.3). The overall model fit was good (CFI = 0.91, RMSEA = 0.05 [0.05, 0.06])., Conclusions: This pathway analysis identified three focal points for intervention and suggests that high-agency interventions targeting individual psychological resources when combined with low-agency supermarket environment interventions may confer greater benefits on dietary behaviours than either intervention alone.