Prolungamento della vita lavorativa: salute e problemi correlati

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Prolungamento della vita lavorativa salute e
problemi correlati

• Giuseppe Costa e Angelo dErrico
• Servizio di Epidemiologia
• Università di Torino
• ASL 5 del Piemonte

Labor, 22 novembre 2006
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retirability
workability
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retirability
Social inequalities
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Occupational inequalities in mortality in eleven
European countries. Men, 45-59 years
Rate Ratio ratio of mortality rate in lower
occupational groups as compared to that in higher
occupational groups. Asterisk () indicates that
difference in mortality between socio-economic
groups is statistically significant.
Kunst A, et al. Mortality by occupational class
among men 3064 years in 11 European countries.
Soc Sci Med 1998.
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Mortality Rate Ratios in lower occupational
groups as compared to higher occupational groups
men
Mackenbach JP, et al. Widening socio-economic
inequalities in mortality in six Western European
countries. Int J Epidemiol 2003.
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Mortality Rate Ratios in lower occupational
groups as compared to higher occupational groups
men
large relative occupational inequalities widened
during the last two decades
Mackenbach JP, et al. Widening socio-economic
inequalities in mortality in six Western European
countries. Int J Epidemiol 2003.
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• As was the case with mortality, rates of
  morbidity are usually higher among those with a
  lower educational level, occupational class or
  income level
• (Cavelaars A, et al. Morbidity differences by
  occupational class among men in seven European
  countries an application of the
  Erikson-Goldthorpe social class scheme. Int J
  Epidemiol 1998 27 222230).
• Substantial inequalities are also found in the
  prevalence of most specific diseases (including
  mental illness) and most specific forms of
  disability
• (Dalstra JAA, et al. Socio-economic differences
  in the prevalence of common chronic diseases an
  overview of eight European countries. Int J
  Epidemiol 2005 34 316326 Avendano M, et al.
  Socioeconomic disparities in physical health in
  10 European countries. In Boersch-Supan A, et
  al. Health, ageing and retirement in Europe.
  Mannheim Mannheim Research Institute for the
  Economics of Ageing, 2005 89-94).
• Over the past decades, inequalities in morbidity
  by socio-economic position have been rather
  stable
• (Kunst AE, et al. Trends in socio-economic
  inequalities in self-assessed health in 10
  European countries. Int J Epidemiol 2005 34
  295305).
• Together with inequalities in mortality,
  inequalities in morbidity contribute to large
  inequalities in healthy life expectancy (number
  of years lived in good health)
• (Sihvonen A, et al. Socio-economic inequalities
  in health expectancy in Finland and Norway in the
  late 1980s. Soc Sci Med 1998 47(3) 303315).

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retirability
Social inequalities
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societal/neighbourhood context
material
behaviours
selection
phys/chem/ erg hazards
income

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

morbidity
health care
outcomes
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societal/neighbourhood context
material
behaviours
selection
phys/chem/ erg hazards
income

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

morbidity
health care
health related downward mobility is a mechanism
which is in place, its contribution to health
inequalities is likely to be small
outcomes
Cardano M et al. Social Science Medicine, 2004,
58
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Impact of poor health on social mobility within
the labour market
Statistical model Analysis of variance Dependent
variable Social Mobility Metrical Index (SMMI)
R2 .14
Cardano M et al.Social Science Medicine 58
(2004) 15631574
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societal/neighbourhood context
material
behaviours
selection
phys/chem/ erg hazards
income

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

morbidity
health care
outcomes
more controversial the question of the size of
the contribution of intergenerational and
life-course selection to the adult pattern of
health inequalities
Singh-Manoux A et al. Social Science and
Medicine, 2005, 60
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societal/neighbourhood context
material
behaviours
selection
income
phys/chem/ erg hazards

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

within a stable workforce, physical, chemical,
ergonomic, psychosocial risk factors in the
workplaces are determinants that may explain a
larger part of social inequalities in some
specific health risks such as occupational
diseases, cardiovascular disease, muscoloskeletal
disorders, mental health
morbidity
health care
outcomes
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exposed to Job Strain
Sample of 1479 employees in Torino (797 workers
and 682 clerks)
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societal/neighbourhood context
material
behaviours
selection
income
phys/chem/ erg hazards

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

while behavioural and other material
circumstances like income should be involved to
explain the rest, but the relative amount and the
independency of each contribution remain
controversial
morbidity
health care
outcomes
McLeod J et al. J Epidemiol Community Health
2003, 57. Siegrist J et al. Social Science and
Medicine, 2004, 58. Lynch J et al. J Epidemiol
Community Health 2006, 60
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Smoking by social class Italian males 2000
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societal/neighbourhood context
material
behaviours
selection
phys/chem/ erg hazards
income

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

The amount of inequalities in health outcomes
attributable to limitation in access to
appropriate and effective health care is related
to the model of health care organization which is
in place
morbidity
health care
outcomes
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Inequalities in different health care indicators
by educational level in Turin
Mortality in colon cancer Coronarografy in AMI Revascularization in AMI Inappropriate hospital admissions
HIGH 1 1 1 1
MEDIUM 1.21 (1.05 - 1.40) 0.93 (0.86 1.02) 0.93 (0.85 1.02) 1.12 (1.03-1.22)
LOW 1.33 (1.16 - 1.51) 0.83 (0.76 0.90) 0.83 (0.76 0.91) 1.19 (1.10-1.29)
less educated individuals may be more vulnerable
to inappropriate hospitalization
Piedmont Region. Health Report 2006
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Inequalities in different health care indicators
by educational level in Turin
Mortality in colon cancer Coronarografy in AMI Re-vascularization in AMI Inappropriate hospital admissions
HIGH 1 1 1 1
MEDIUM 1.21 (1.05 - 1.40) 0.93 (0.86 1.02) 0.93 (0.85 1.02) 1.12 (1.03-1.22)
LOW 1.33 (1.16 - 1.51) 0.83 (0.76 0.90) 0.83 (0.76 0.91) 1.19 (1.10-1.29)
less educated patients with myocardial infarction
may confront more limitations in accessing
effective and appropriate care such as
coronarography and re-vascularization
Piedmont Region. Health Report 2006
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Inequalities in different health care indicators
by educational level in Turin
Mortality in colon cancer Coronarografy in AMI Re-vascularization in AMI Inappropriate hospital admissions
HIGH 1 1 1 1
MEDIUM 1.21 (1.05 - 1.40) 0.93 (0.86 1.02) 0.93 (0.85 1.02) 1.12 (1.03-1.22)
LOW 1.33 (1.16 - 1.51) 0.83 (0.76 0.90) 0.83 (0.76 0.91) 1.19 (1.10-1.29)
less educated patients with colon cancer may
experience more unfavourable outcomes
Piedmont Region. Health Report 2006
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societal/neighbourhood context
material
behaviours
selection
phys/chem/ erg hazards
income

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

morbidity
health care
contextual determinants may make the difference
in buffering the effect of each of the
determinants of health inequalities by providing
supporting environments
outcomes
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Effect of neighbourhood unemployment on mortality
Males aged 15-75
2,00
II vs. I quartile III vs. I quartile Most
unempl. vs. I quartile
1,50
1,00
USA Netherlands London Helsinki
Turin Madrid
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Context/regulation Preferences Constraints Oppor
tunities
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variation in 1991-2005 mortality among adults
(30-59 yrs) that have improved their education
btw 1981 and 1991
Education at 1981 Education at 1981 Education at 1981 Education at 1981
none primary secondary High sc.
males -24.5 -8.6 -15.6 -10.6
females -33.4 -0.6 -3.4 19.0
SLT, unpublished data, 2006
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Aging and health

• Diseases and aging
• Vulnerability to severity
• Functional vulnerability of the target
  organ/tissue
• Vulnerability in mechanisms repairing damages
• Age correlated (latency)
• Long term diseases
• Injuries
• Incidence?
• Vulnerability to severity

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Aging and functional abilities

• Physical
• Coordination, mobility, flexibility, strenght,
  sensorial
• Cardiorespiratory
• Muscoloskeletal
• Obesity
• Mental and social
• Psicomotricity, cognitive, metacognitive,
  motivational
• Relational and role

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MALATTIE MUSCOLO-SCHELETRICHE (MSDs) (I)
ampio spettro di patologie infiammatorie e
degenerative a carico di muscoli, tendini,
legamenti, articolazioni, nervi periferici, e
strutture vascolari che includono

• infiammazioni osteo-tendinee e articolari
  (tenosinovite, epicondilite, borsite)
• disturbi da compressione nervosa (sindrome del
  tunnel carpale, lombosciatalgia)
• osteoartrosi
• mialgia, dolore lombare e sindromi dolorose
  regionali non attribuibili a patologie conosciute

• regioni più comunemente colpite
• tratto lombo-sacrale del rachide
• collo
• spalla
• avambraccio
• mano

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MALATTIE MUSCOLO-SCHELETRICHE (MSDs) (II)

• rappresentano il 67 di tutte le malattie da
  lavoro negli U.S.A. (BLS, 2001), il 71 in Svezia
  e il 39 in Danimarca (Westgaard Winkel, 1997)
• negli U.S.A., Canada, Finlandia, Svezia e U.K.
  causano più assenteismo e più invalidità di
  qualsiasi altro gruppo di malattie da lavoro
  (Badley et al., 1994 Feeney et al., 1998 Leijon
  et al., 1998)
• dal 1990 al 2000 incremento di posture scomode o
  dolorose, movimentazione carichi e lavoro ad alta
  rapidita di esecuzione riferiti dai lavoratori
  europei (Paoli Merlliè, 2001)
• Nel 2000 costituivano più del 50 delle malattie
  preofessionali riconosciute dallINAIL (Colombini
  et al., 2003)
• Circa il 50 dei soggetti con disturbi
  muscolo-scheletrici allarto superiore non ha
  segni obiettivi (Punnett, 1998, 2000)
• Nella maggior parte dei casi, i disturbi
  muscolo-scheletrici a carico dellarto superiore
  non possono essere classificati in specifiche
  categorie diagnostiche (Sluiter, 2000)

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MALATTIE MUSCOLO-SCHELETRICHE (MSDs) Fattori
di rischio (da studi epidemiologici e
sperimentali)

• elevato ritmo di lavoro e movimenti ripetuti
• tempo di recupero insufficiente
• sollevamento di pesi e intensi sforzi manuali
• posture del corpo non-neutrali (statiche o
  dinamiche)
• elevata pressione meccanica concentrata su una
  piccola superficie
• vibrazioni segmentali o diffuse
• esposizione locale o diffusa al freddo
• fattori psicosociali, come alte richieste
  psicologiche (high demand) e basso grado di
  controllo sul proprio lavoro (low control)

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MALATTIE MUSCOLO-SCHELETRICHE (MSDs) Frazione
attribuibile allesposizione a rischi fisici sul
lavoro Patologie del rachide
National Research Council and Institute of
Medicine, 2001
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MALATTIE MUSCOLO-SCHELETRICHE (MSDs) Frazione
attribuibile allesposizione a rischi fisici sul
lavoro Patologie dellarto superiore
National Research Council and Institute of
Medicine, 2001
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MALATTIE MUSCOLO-SCHELETRICHE (MSDs)
Diffusione dellesposizione Sollevare pesi
eccessivi (CGIL, 1999)
Settore produttivo
Sanità 71.4
Prodotti a base di amianto, cemento amianto e altri minerali non metalliferi 70.0
Poste 69.2
Industrie alimentari, bevande, tabacco 64.9
Pubblica amministrazione, organizzazioni internazionali 63.6
Legno, paglia, vimini 62.5
Produzione e distribuzione di gas 61.7
Concia 60.9
Carta 60.4
Laterizi, cemento, ceramica, vetro 59.4
Produzione di elettrodomestici e di materiale elettrico e elettronico 59.1
Tessile 58.1
Energia elettrica 55.8
Igiene pubblica e cimiteri, raccolta, depurazione e distribuzione acqua 54.9
Stampa, editoria, laboratori fotografici, registrazione dischi e video 54.5
Pneumatici e articoli in gomma 54.1
Prodotti in plastica 50.0
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MALATTIE MUSCOLO-SCHELETRICHE (MSDs) Stima del
numero di casi attribuibili allesposizione a
fattori ergonomici in Piemonte - Patologie del
rachide

• Assumendo una prevalenza del 15 alla popolazione
  occupata e i valori della AF al limite inferiore
  del range
• 27.000 casi prevalenti dovuti alla movimentazione
  di materiale
• 47.000 a frequente flessione e torsione del busto
• 77.000 a sforzi molto intensi
• 35.000 a posture incongrue
• 45.000 a vibrazioni trasmesse al rachide
• Assumendo unincidenza del 4.5 alla popolazione
  occupata e i valori della AF al limite inferiore
  del range
• 8.000 nuovi casi allanno dovuti alla
  movimentazione di materiale
• 14.000 a frequente flessione e torsione del busto
• 23.000 a sforzi molto intensi
• 10.000 a posture incongrue
• 13.000 a vibrazioni trasmesse al rachide

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MALATTIE MUSCOLO-SCHELETRICHE (MSDs) Stima del
numero di casi attribuibili allesposizione a
fattori ergonomici in Piemonte - Patologie
dellarto superiore

• Assumendo una prevalenza del 15 alla popolazione
  occupata e i valori della AF al limite inferiore
  del range
• 132.000 casi prevalenti dovuti a movimenti
  ripetuti
• 195.000 a sforzi molto intensi
• 110.000 a vibrazioni trasmesse allarto superiore
  
• Assumendo unincidenza del 6 alla popolazione
  occupata e i valori della AF al limite inferiore
  del range
• 53.000 nuovi casi allanno a movimenti ripetuti
• 78.000 a sforzi molto intensi
• 44.000 a vibrazioni trasmesse allarto superiore

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MALATTIE MUSCOLO-SCHELETRICHE (MSDs)
Prevenibilità

• Conclusioni dello studio del National Academy of
  Science (National Research Council Institute of
  Medicine, 2001)
• la prevenzione di queste malattie mediante la
  riduzione delle esposizioni e possibile
• produce significativi risparmi per i datori di
  lavoro
• riduce lesperienza di disabilita dei lavoratori
• Maggiori possibilità di ridurre il rischio di
  MSDs per mezzo di interventi multipli, che
  comprendano (Silverstein Clark, 2004 Karsh et
  al., 2001 Amell Kumar, 2002 Westgaard
  Winkel, 1997)
• riprogettazione di postazioni di lavoro
• cambiamenti dellorganizzazione
• interventi di promozione della salute
• Documento di consenso ISPESL-EPM su MSDs arto
  superiore (Colombini et al., 2003)
• Lista di lavorazioni a rischio
• Indicatori per lo screening dellesposizione a
  ripetitività, forza, posture incongrue e impatti
  ripetuti
• Indicazioni per la sorveglianza sanitaria

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Scelta di priorità
Assegnazione di punteggi da 0 a 3 ad una serie
di caratteristiche del rischio allinterno di
ogni settore produttivo  frequenza e gravità
delle patologie considerate nella popolazione
generale,  forza dellassociazione tra
esposizione professionale e occorrenza delle
patologie,  diffusione e livello
dellesposizione nei diversi settori,  proporzion
e di addetti impiegati in ogni comparto sul
totale degli occupati sul territorio regionale,
 prevenibilità dellesposizione,  fattibilità
delleffettuazione di interventi preventivi nel
settore.
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Tabella 11 Ranghi di priorità dei più
rappresentati settori produttivi, totali e per
patologia
     
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Commitment to adapt working conditions to aging?
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Low physical exercise by social class - Italian
males 2000
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Tabella 1. Differenze in prevalenza () di
fattori di modificazione della capacità
lavorativa tra lavoratori anziani e lavoratori
giovani (sopra o sotto i 45 anni) in Italia nel
1996 (Kauppinen 1998)
(almeno per metà di orario lavoro)
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Core
Periphery
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Healthy life expectancy by occupation, males
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Healthy life expectancy by occupation, females
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Differences in life expectancy at 35 yrs by
social class, Turin males 2000 - 2005
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Differences in life expectancy at 35 yrs by
social class, Turin males 2000 - 2005
Anticipating retirement age?
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Mortality 1991-99 by social class among healthy
retired 1981-91
High class Clerks Self employed Working class
males 1,14 1,14 1,38 1,13
females 0,95 1,54 1,08 1,34
RRs age adjusted reference still employed
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Differences in life expectancy at 35 yrs by
income deciles, Turin males 2000 - 2005
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Differences in life expectancy at 35 yrs by
income deciles, Turin males 2000 - 2005
Adjusting benefits according to life expectancy?
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societal/neighbourhood context
material
behaviours
selection
income
phys/chem/ erg hazards

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

morbidity
DIRECT RESPONSIBILITY
health care
outcomes
57
societal/neighbourhood context
material
behaviours
selection
phys/chem/ erg hazards
income

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

CONTRIBUTING RESPONSIBILITY
morbidity
health care
outcomes
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societal/neighbourhood context
material
behaviours
selection
phys/chem/ erg hazards
income

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

morbidity
health care
INDIRECT RESPONSIBILITY
outcomes
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societal/neighbourhood context
material
behaviours
selection
phys/chem/ erg hazards
income

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

morbidity
health care
EQUITY AUDIT
outcomes
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societal/neighbourhood context
material
behaviours
selection
phys/chem/ erg hazards
income

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

ADVOCACY
morbidity
health care
outcomes
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societal/neighbourhood context
support
SUPPORT IN SOCIETY
material
behaviours
psychosocial
selection
phys/chem/ erg hazards
income
dem/contr ff/rew

• downward mobility
• Inter-generational
• through life-course
• in adult age
• (healthy w. effect)

morbidity
health care
outcomes
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social-health events/status
Turin Longitudinal Study
Socio-economic status
Causes of death cod. A.S.L. 1981-2003 cod. Istat
1970-1991
Census 1971
Hospital discharges 1995-2005
Census 1981
Census 1991
Drug prescriptions 1997-2005
Census 2001
Cancer Incidence 1985-2001
Demographical events
Ambulatory services and emergency care 2002-2003
Municipality population registry 1971-05
Social assistance 1987-1995 (2005)
Life status migration Reproductive history ...
Drug addiction treatments 1979-1994
Occupational injuries, dyalisis treatments,
diabete diagnoses
63
TLS population cohorts
1991 census
1971 census
2001
1981 census
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TLS census-population registry linkage
Population registry uncomplete update
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TLS longitudinal dimension