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SJP0010.1177/1403494819831821L. L. Andersen et al.Short Title
Scandinavian Journal of Public Health,
1–8
ORIGINAL ARTICLE
Influence of physical and psychosocial working conditions for the
risk of disability pension among healthy female eldercare workers:
Prospective cohort
ANDERSEN LL, VILLADSEN E & CLAUSEN T
National Research Centre for the Working Environment, Copenhagen, Denmark
Abstract
Aim:
To investigate the influence of physical and psychosocial working conditions on the risk of disability pension among
eldercare workers.
Methods:
After responding to a questionnaire in 2005, 4699 healthy female eldercare workers – free from
chronic musculoskeletal pain, depressive symptoms and long-term sickness absence – were followed for 11 years in the
Danish Register for Evaluation of Marginalization. Time-to-event analyses estimated the hazard ratio (HR) for disability
pension from physical exertion during work, emotional demands, influence at work, role conflicts, and quality of leadership.
Analyses were mutually adjusted for these work environmental factors as well as for age, education, smoking, leisure physical
activity and body mass index.
Results:
During follow-up, 7.6% received disability pension. Physical exertion and emotional
demands were associated with risk of disability pension, and both interacted with age. In age-stratified analyses, older
eldercare workers (mean age 53 years at baseline) with moderate and high physical exertion (reference: low) were at increased
risk with HRs of 1.51, 95% CI [1.06–2.15] and 2.54, 95% CI [1.34–4.83], respectively. Younger eldercare workers (mean
age 36 years at baseline) with moderate emotional demands (reference: low) were at decreased risk with an HR of 0.57, 95%
CI [0.37–0.85].
Conclusions:
While a higher level of physical exertion is a risk factor for disability pension among
older female eldercare workers, a moderate level of emotional demands is associated with lower risk among
the younger workers. The age of the worker may be an important factor when providing recommendations for
promoting a long and healthy working life.
Keywords:
Care worker, nurses, physical workload, psychosocial work environment, disability, age
Introduction
The demographic changes in Europe with a grow-
ing proportion of elderly in the population have led
to changes in national pension schemes towards
increased retirement age. Although this may be a
necessity for national economies, some individuals
may not be able to work to a high age due to health
problems and high work demands. Involuntary
early retirement from the labour market in terms of
disability pension is associated with costs and nega-
tive consequences for individuals, workplaces and
societies.
Poor health is the strongest early predictor of dis-
ability pension later in life [1]. However, the work
environment plays an important role in health-related
early retirement from the labour market [2, 3]. High
physical work demands and poor psychosocial work-
ing conditions are risk factors for poor health [4] that
may lead to long-term sickness absence and early
retirement. Studies from the Scandinavian countries
with access to high-quality registers on work- and
retirement-status at the individual level have shown
in the general working population as well as in spe-
cific occupations that high physical workload is a risk
Correspondence: Professor Lars L. Andersen, National Research Centre for the Working Environment, Lersø Parkalle 105, DK-2100 Copenhagen,
Denmark. E-mail: [email protected]
Date received 12 November 2018; reviewed 9 January 2019; accepted 21 January 2019
© Author(s) 2019
Article reuse guidelines: sagepub.com/journals-permissions
https://doi.org/10.1177/1403494819831821
DOI: 10.1177/1403494819831821
journals.sagepub.com/home/sjp
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2
L. L. Andersen et al.
and colleagues, showing that physical work demands
interacted with age in relation to development of self-
rated poor health in the general working population,
where the consequences of high physical work
demands were higher for older workers [18]. Thus,
taking age into account in the interplay between
physical work demands and health-related conse-
quences seems vital. In the same population, Burr
and colleagues found no significant interactions
between psychosocial work factors and age for devel-
opment of poor self-rated health [19]. Thus, a possi-
ble interaction with age may differ depending on the
type of exposure in the working environment.
The aim of this study is to investigate the influence
of the physical and psychosocial work environment
for the risk of disability pension among healthy
female eldercare workers. We hypothesized that
adverse physical and psychosocial working condi-
tions would be prospectively associated with
increased risk of disability pension. We also tested for
possible interactions with age, and based on the study
by Burr and colleagues we hypothesized that physical
working conditions would interact with age [18]. The
analyses concerning the interaction between psycho-
social working conditions and age were exploratory.
Methods
Study design and population
The design is a prospective cohort study with long-
term register follow-up. Collection of the baseline
data started ultimo 2004, but the main data collec-
tion took place in the spring of 2005. Questionnaires
were sent to 12,744 eldercare workers of which 9949
(78%) responded. For the present analyses, we
excluded male respondents (N
=
234) and workers
who were not directly engaged in care services
(N
=
1021, of which some were also included in the
male population of 234). Of the remaining popula-
tion (N
=
8952), we excluded those who were not
completely healthy (N
=
4253). The definition of
being healthy was based on three criteria, 1) not hav-
ing chronic musculoskeletal pain (>30 days during
the last year) in the low back, neck/shoulders or
knees (not in any of the regions)[20]; 2) having a
normal score on the major depressive inventory (i.e.
less than 20) [21]; and 3) being free from long-term
sickness absence (Danish Register for Evaluation of
Marginalization (DREAM) register) during the year
prior to responding to the questionnaire [22]. All
three conditions needed to be fulfilled. Thus, a total
of 4699 healthy female eldercare workers were
included. This comprised social and healthcare
assistants, social and healthcare helpers, other care
factor for disability pension [5, 6]. Considering the
psychosocial working conditions, previous studies
have shown that low influence at work [3] and low
social support [7] predicts increased risk of disability
pension. Moreover, these findings are replicated in a
systematic review by Knardahl and colleagues, who
concluded that adverse psychosocial working con-
ditions contribute to an increased risk of disability
pension [8].
The European countries are facing a shortage of
nurses and the increased proportion of elderly adds
to the pressure on healthcare systems [9]. This is fur-
ther challenged by the fact that healthcare work, e.g.
at hospitals or in eldercare, can be both physically
and mentally demanding. In the Danish eldercare
sector, we have previously found that high physical
exertion during healthcare work is associated with
increased risk of developing [10] and sustaining [11]
musculoskeletal disorders as well as long-term sick-
ness absence [12]. Likewise, psychosocial working
conditions – such as low influence at work – are asso-
ciated with development of musculoskeletal disor-
ders [13]. Other studies indicate that adverse
psychosocial working conditions, such as low influ-
ence at work, poor quality of leadership, high emo-
tional demands and high role conflicts are associated
with increased risk of long-term sickness absence in
employees with client-centred work tasks [14]. Such
findings are important because poor health, expressed
as sickness absence from work, can be an early pre-
dictor for later disability pension [15]. Contrary to
these findings, a 15-year prospective cohort study
among nurses in Denmark reported that work envi-
ronment influenced the risk of disability pension only
to a minor degree, and that the main prognostic fac-
tor was poor musculoskeletal health at baseline [1].
However, because the work environment can also
contribute to poor musculoskeletal health such con-
clusions should be considered with care. Another
way could be to investigate the influence of the work
environment among currently healthy workers on the
risk of future disability pension.
The inherent age-related changes in the physical
capacity of the worker should also be considered in
relation to healthcare work. Ageing is associated with
a decrease of physical capacity, and from the age of
30 muscle strength starts to decline by 1–2% per year
[16]. Thus, at the age of 60 the average healthcare
worker will have lost more than a third of the initial
muscle strength capacity. This may lead to an imbal-
ance between physical work demands and the physi-
cal capacity of the individual worker. This imbalance
increases the risk of a range of health-related conse-
quences, especially in jobs characterized by high
physical demands [17]. This was supported by Burr
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Working environment and risk of disability pension
3
Table I. Baseline characteristics of the 4699 healthy female eldercare workers. Characteristics of the age-stratified groups
�½
and
>
45 years
are also shown.
All
Mean
N
Age
Sex
Women
Men
BMI
Smoking
Yes
No
Leisure time physical activity
Low
Moderate
High
Physical exertion during work (1–7)
Psychosocial work environment (0–100)
Emotional demands
Influence at work
Role conflicts
Quality of leadership
4699
44.7
SD
10.3
100
0
24.6
4.2
35.8
64.2
24.8
45.3
29.9
3.6
43.6
47.3
39.9
59.3
1.1
18.1
20.2
15.3
21.3
3.7
42.9
46.9
41.3
59.2
1.1
17.9
19.6
14.9
21.4
24.7
4.5
34.0
66.0
24.9
45.7
29.4
3.6
44.3
47.7
38.4
59.4
1.1
18.4
20.8
15.6
21.3
%
age
�½
45 years
Mean
2336
36.2
SD
6.6
100
0
24.6
4.0
37.7
62.3
24.7
44.9
30.4
%
age
>
45 years
Mean
2363
53.1
SD
4.9
100
0
%
1-7: Seven point physical exertion scale from ‘very, very light’ to ‘very, very strenuous’. 0-100: Normalized COPSOQ score, where 0 is
lowest and 100 is highest. BMI
=
body mass index.
staff with no or short-term education and registered
nurses/therapists. Table I shows the baseline charac-
teristics on the included population of healthy female
eldercare workers.
Ethical approval and data protection
The Danish Data Protection Agency was notified of
and registered the study. According to Danish law,
questionnaire- and register-based studies need nei-
ther approval from ethical and scientific committees
nor informed consent. All data was de-identified and
analysed anonymously.
Risk factors
Physical work environment.
To obtain a global impres-
sion of the physical work demands, we asked about
the perceived physical exertion during work based on
Borg’s Rate of Perceived Exertion (RPE) scale, which
in relation to the physical demands of healthcare
work has shown predictive validity for development
of musculoskeletal disorders [10] and long-term
sickness absence [12]. The Borg RPE scale is the
most validated tool to measure physical exertion in
different contexts, e.g. during manual handling tasks
[23]. Using a 7-point scale, participants replied to
the question: ‘How would you rate your physical
exertion while working with the patients?’ Partici-
pants replied on a scale of 1) very, very light; 2) very
light; 3) light; 4) somewhat strenuous; 5) strenuous;
6) very strenuous; and 7) very, very strenuous [24].
For the subsequent statistical analyses we trichoto-
mized responses, where 1–3 were defined as ‘low
physical exertion’, 4–5 as ‘moderate physical exer-
tion’ and 6–7 as ‘high physical exertion’.
Psychosocial work environment.
Using the Copenha-
gen Psychosocial Questionnaire (COPSOQ), we
assessed four distinct dimensions of the psychosocial
work environment relevant for eldercare workers: 1)
emotional demands (four items; Cronbach’s
α:
0.81);
2) influence at work (four items; Cronbach’s
α:
0.75);
3) role conflicts (four items; Cronbach’s
α:
0.66);
and 4) quality of leadership (four items; Cronbach’s
α:
0.89) [13, 25]. Sample items for each of the four
respective dimensions are as follows: 1) ‘Is your work
emotionally demanding?’2) ‘Do you have a large
degree of influence concerning your work?’ 3) ‘Are
contradictory demands placed on you at work?’ 4)
‘To what extent would you say that your immediate
superior is good at work planning?’ Participants
replied on a 5-point Likert scale. The sum of the
scales were normalized on a scale of 0–100 according
to the COPSOQ test score manual [13, 25]. For the
subsequent statistical analyses we trichotomized
responses based on the response quartiles, where the
lower quartile was defined as ‘low’, the two middle
quartiles as ‘moderate’ and the upper quartile as
‘high’.
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4
L. L. Andersen et al.
9.4 (SAS Institute, Cary, NC, USA) was used. We
used the LIFETEST procedure to produce Kaplan–
Meier curves for a visual representation of the
hazards.
The analyses were mutually adjusted for physical
exertion and the four psychosocial work environment
variables. In addition to the mutual adjustments for
the work environment variables, Model 1 was
adjusted for age and Model 2 for age, education,
smoking, BMI, and leisure time physical activity.
Based on the work by Burr and colleagues [18], we
also tested each of the work environment variables
for interaction with age. In case of significant interac-
tion, we performed age-stratified analyses.
Results
Table I shows the baseline characteristics of the 4699
healthy female eldercare workers as well as for the
age-stratified groups
�½
and
>
45 years. The mean
age of the study population was 45 years and the
mean BMI in the normal range, i.e. below 25. About
one third was smokers and the majority had a moder-
ate level of leisure time physical activity. The younger
and older workers were on average 36 and 53 years,
and were quite comparable in terms of lifestyle and
work.
During 11 year follow-up, 7.6% received disability
pension. Table II shows the overall results for the risk
of disability pension
before
testing for possible inter-
actions. In these analyses only physical exertion and
emotional demands were significantly associated
with disability pension. In subsequent interaction
analyses, significant interactions between age and
physical exertion (p
<
0.05) as well as age and emo-
tional demands (p
<
0.05) were found. Thus, age-
stratified analyses were performed. None of the other
psychosocial variables interacted with age.
Table III shows the age-stratified analyses for the
variables that significantly interacted with age.
Among the older eldercare workers, moderate and
high physical exertion (reference: low) were risk fac-
tors for disability pension during follow-up, HRs
1.51, 95% CI [1.06–2.15] and 2.54, 95% CI [1.34–
4.83], respectively. Among the younger eldercare
workers, moderate emotional demands (reference:
low) were in the fully adjusted model associated with
decreased risk of disability pension during follow-up,
HR 0.57, 95% CI [0.37–0.85].
Discussion
The main finding of this study is that age interacted
with physical exertion and emotional demands in the
risk of disability pension during 11 year follow-up.
Outcome
Registered disability benefit payments were obtained
from the DREAM register, which was initiated in
1991 [26]. The DREAM register contains weekly
information on granted disability benefits, sickness
absence, employment, education, etc. for Danish res-
idents. It is only possible for residents with perma-
nent full or partial loss of workability to obtain
disability benefits. The municipality decides whether
a person is entitled to disability benefits. Normally
the person goes through a process with involvement
of different departments in the municipality (work-,
health-, education-, and social-department) before
disability benefits can be granted. A full disability
pension entails a complete dropout from the labour
market. However, there are also disability benefits
with partial work or work on certain conditions.
Because all of these conditions require loss of work-
ability, we defined ‘disability pension’ in the present
study as receiving any type of registered disability
benefit, requiring permanent full or partial loss of
workability. This included flex jobs and variants
hereof, sheltered jobs, and full disability pension
comprising a total of 13 categories of disability ben-
efits payment in the DREAM register.
Confounders
Potential confounders from the baseline question-
naire included age (continuous variable), education
(categories of specific healthcare education, e.g.
social and health care assistant, social and health care
helper, nurse, nurse aide, therapist, none), body mass
index (BMI) (kg/m
2
, continuous variable), smoking
status (dichotomous variable depicting smoker/non-
smoker), and leisure time physical activity (low, mod-
erate, and high level) [27]. These confounders were
chosen as both education and lifestyle are associated
with the risk of disability pension.
Statistical analysis
The Cox proportional hazards model was used to
estimate hazard ratios (HR) and 95% confidence
intervals (95% CI) of the physical and psychosocial
work environment variables for receiving disability
pension during follow-up. The follow-up time was 11
years (until week 26 of 2016) or until censoring,
which occurred in the case of death, voluntary early
retirement pension, state pension, or emigration. If
an individual had a registered disability benefit pay-
ment in any given week within the follow-up period,
the survival times were non-censored and referred to
as event times. The estimation method was maxi-
mum likelihood and the PHREG procedure of SAS
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Working environment and risk of disability pension
Table II. Hazard ratios for disability pension during 11 year follow-up among the 4699 healthy female eldercare workers.
N
Physical exertion
Low
Moderate
High
Emotional demands
Low
Moderate
High
Influence at work
High
Moderate
Low
Role conflicts
Low
Moderate
High
Quality of leadership
High
Moderate
Low
1891
2392
236
978
2521
1144
1285
2139
1221
987
2126
1538
1360
2057
1126
Model 1
1
1.22 (0.96–1.54)
1.83 (1.18–2.85)
1
0.72 (0.55–0.94)
0.69 (0.49–0.96)
1
1.02 (0.78–1.32)
0.88 (0.64–1.21)
1
0.81 (0.61–1.08)
0.99 (0.72–1.35)
1
0.81 (0.62–1.05)
0.87 (0.64–1.18)
Model 2
5
1
1.15 (0.89–1.48)
1.67 (1.05–2.66)
1
0.87 (0.65–1.16)
0.88 (0.62–1.26)
1
1.04 (0.79–1.37)
0.82 (0.59–1.15)
1
0.89 (0.65–1.20)
1.12 (0.80–1.57)
1
0.82 (0.62–1.07)
0.91 (0.66–1.26)
Model 1: Controlled for age
+
mutually adjusted for all five working environment variables.
Model 2: Controlled for the same as Model 1
+
education
+
smoking
+
BMI
+
leisure time physical activity.
Table III. Age-stratified analyses with hazard ratios for disability pension during 11 year follow-up among younger (�½ 45 years, mean age
36 years) and older workers (> 45 years, mean age 53 years). Interactions with age were only significant for physical exertion and emotional
demands, respectively.
N
�½
45 years
Physical exertion
Low
Moderate
High
Emotional demands
Low
Moderate
High
>45
years
Physical exertion
Low
Moderate
High
Emotional demands
Low
Moderate
High
Model 1
Model 2
898
1244
130
493
1286
532
1
0.95 (0.68–1.35)
1.46 (0.77–2.77)
1
0.48 (0.33–0.71)
0.52 (0.32–0.84)
1
0.80 (0.55–1.17)
1.03 (0.52–2.02)
1
0.57 (0.37–0.85)
0.71 (0.43–1.19)
993
1148
106
485
1235
612
1
1.49 (1.08–2.06)
2.19 (1.19–4.03)
1
1.02 (0.69–1.51)
0.87 (0.55–1.40)
1
1.51 (1.06–2.15)
2.54 (1.34–4.83)
1
1.30 (0.85–1.97)
1.10 (0.66–1.84)
Model 1: Controlled for age
+
mutually adjusted for all five working environment variables.
Model 2: Controlled for the same as Model 1
+
education
+
smoking
+
BMI
+
leisure time physical activity.
While higher levels of physical exertion were risk fac-
tors for disability pension among older female elder-
care workers, a moderate level of emotional demands
was associated with lower risk among younger elder-
care workers. In the present study, influence at work,
role conflicts and quality of leadership were not sig-
nificant risk factors for disability pension.
Physical work demands interacted with age in
relation to the risk of disability pension during 11
year follow-up. In the age-stratified analyses, only
older workers were at increased risk. In the fully
adjusted statistical model, moderate and high physi-
cal exertion among older workers were associated
with 51% (HR 1.51) and 154% (HR 2.54) increased
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6
L. L. Andersen et al.
at first glance, but it seems plausible that certain lev-
els of emotional demands can be construed as posi-
tive occupational challenges that may provide
employees with the opportunity to develop new skills
and abilities to deal successfully with emotionally
demanding situations [29]. Successful mastery of
occupational challenges may contribute to enhancing
the experience of meaning at work, which again has
been found to be negatively associated with risk of
disability retirement [30].
We were surprised not to find significant associa-
tions between the three other indicators of psycho-
social working conditions and risk of disability
pension: influence at work, role conflicts, and qual-
ity of leadership. In contrast to the present study,
some previous studies have shown an association
between low influence at work and disability pen-
sion [3, 8]. There may be several reasons for the dif-
ferences between findings. First, the present study
used any type of registered disability benefit, requir-
ing permanent full or partial loss of workability as
endpoint, whereas another Danish study used only
full disability pensioning as endpoint [3]. Second,
there were differences in the duration of follow-up
in the two studies (11 years vs. 5.9 years), and a pos-
sible change in psychosocial working conditions
over the years may have increased the risk of null-
findings. Third, we excluded respondents with ill
health (i.e. musculoskeletal disorders, depression,
and long-term sickness absence) from the present
study, which may have led to more conservative risk
estimates than in the other study, where respond-
ents with symptoms of ill health were not excluded.
The advantage of excluding respondents with
symptoms of ill health is that we reduce the risk of
observing spurious associations between working
conditions and risk of disability pension that in
effect may reflect the ill health of respondents. The
disadvantage of excluding respondents with symp-
toms of ill health may be that we provide more con-
servative associations between working conditions
and risk of disability pension, because the healthy
population may be more robust than those who
have already developed ill health from the poor
working conditions. Fourth, the previous Danish
study had a sample size of more than 40,000 indi-
viduals from four different occupational groups,
whereas the present study included only 4000
healthy female healthcare workers. The difference in
sample size will per se influence the likelihood of
statistically significant findings. Finally, different
psychosocial risk factors may simply exist in differ-
ent occupational groups.
Our study has both strengths and limitations.
The inclusion of a homogenous group of healthy
risk, respectively. The present results elaborate on
previous findings showing increased risk of develop-
ing poor general health and musculoskeletal disor-
ders, as well as long-term sickness absence from high
physical work demands among healthcare workers
[10–12] and in the general working population [4,
18, 28]. Some of the previous studies also included
age-stratified analyses. In the general working popu-
lation of Denmark, high physical work demands were
associated with development of self-rated poor health
among older, but not younger, workers [18]. Together
with the present results, these findings could indicate
several things. First, younger workers may be more
resilient to high physical work demands. Physical
capacity, in terms of muscle strength, peaks around
30 years of age and declines 1–2% per year hereafter
[16]. Thus, older workers may be less fit than younger
workers to deal with high physical work demands.
Second, in Denmark, granted disability benefits
require that there is a permanent full or partial loss of
workability. Poor health and workability from high
physical work demands may take decades to fully
develop, and younger workers exposed to high physi-
cal demands may therefore be less likely to initially
fall into this category. Third, the process of achieving
disability benefit in Denmark is long. Normally the
person goes through a process that often takes several
years with involvement of different departments in
the municipality, including the work-, health-, educa-
tion-, and social department, before disability bene-
fits can be granted. Therefore, younger workers
applying for disability benefits will have to go through
a number of different attempts to improve workabil-
ity. Thus, although younger workers were not at
increased risk of disability pension from high physical
work demands in the present study with 11 year fol-
low-up, this does not exclude that they are at
increased risk of developing poor health from high
physical work demands. A recent study from our
research centre showed that both younger and older
workers in the general working population were at
increased risk of long-term sickness absence from
combined factors related to the physical working
environment, including physical exertion during
work, poor working postures, bodily fatigue after
work, and work-limiting pain [4]. Thus, in compari-
son with long-term sickness absence or a decline in
self-rated health, granted disability pension may sim-
ply reflect an endpoint with a worse and more per-
manent loss of workability.
For psychosocial working conditions, emotional
demands interacted with age, and in the age-stratified
analysis we found a protective effect from medium
levels of emotional demands in predicting risk of
disability pension. This finding may seem surprising
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Working environment and risk of disability pension
female eldercare workers has several methodological
advantages. First, poor health at baseline may lead to
misclassification bias of exposures in the working
environment, and simply adjusting for health status
at baseline as a confounder may not fully control for
this. For this reason, we excluded those with poor
health at baseline. Second, the study population
reduces the bias from socioeconomic confounding
as they were all eldercare workers. Third, the type of
exposure at work leading to the perception of physi-
cal exertion – e.g. patient handling – is quite uniform
between eldercare workers. By contrast, studies in
the general working population asking about per-
ceived physical exertion may include a mixture of
static and dynamic work tasks with manual material
handling and/or handling of humans depending on
the specific occupation. However, there are also lim-
itations to our study. First, because of the inclusion
and exclusion criteria, the results should be inter-
preted only in relation to female healthcare workers
and cannot be generalized to the general working
population or other occupations with high physical
work demands. Second, the inclusion and exclusion
criteria did not allow us to investigate the influence
of poor health at baseline in relation to disability
pension. However, as it is known that poor health
per se is a predictor of later disability pension [1],
this research question was not relevant in relation to
the aim of the present study investigating the influ-
ence of the working environment on the risk of dis-
ability pension. Third, the entire life history of
exposures in the working environment cannot be
captured by a single questionnaire, and previous
unknown exposures may also influence the risk of
disability pension.
Conclusions
While a higher level of physical exertion is a risk fac-
tor for disability pension among older female elder-
care workers, a moderate level of emotional demands
is associated with lower risk among the younger
workers. The age of the worker should be considered
when providing recommendations for promoting a
long and healthy working life.
Acknowledgements
The authors thank the co-workers from the Danish
Health Care Worker Cohort (DHCWC) 2004 study
group for their contribution to the data collection.
Conflict of interest
The authors declared no potential conflicts of inter-
est with respect to the research, authorship and/or
publication of this article.
Funding
7
The study was supported by a grant from the Danish
Parliament (SATS-pulje). The funder had no role in
study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
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