3 Continuation...
Emotional demands at work and risk of long-term sickness Continuation........
We measured income as the annual disposable household income in euros (after-tax), categorized into deciles based on the distribution within the study population. Statistical analysis After confirming by visual inspection of survival plots that proportional hazard assumptions were not violated, we used Cox regression to estimate hazard ratios (HRs) and 95% CIs for the association between high emotional demands at work at baseline in 2000 and first episode of long-term sickness absence during follow-up from Jan 1, 2001, to Dec 31, 2010. We censored due to retirement (early, disability, or statutory), emigration, death, or end of study (Dec 31, 2010), whichever came first. We fitted three models. Estimates were adjusted for sex and age (model one) and further adjusted for cohabitation, migration background, and income (model two). In model three, we further adjusted for the four other working conditions: influence, possibilities for development, role conflicts, and physical demands at work.
We also analyzed the associations between low influence, low possibilities for development, high role conflicts, or high physical demands, respectively, and future long-term sickness absence risk by fitting the three models. To quantify if the association between high emotional demands and risk of long-term sickness absence was modified by influence, possibilities for development, role conflicts, or physical demands, we tested the inter-action effects defined as a departure from additivity as recommended in STROBE guidelines.24 For each of the four effect modifiers, we analyzed the separate effects of emotional demands and the effect modifier and their joint effects, each relative to no exposure, and calculated the relative excess risk due to interaction (RERI).16 To inform decision-makers about the number of additional cases for the combinations of emotional demands with each of the effect modifiers, we multiplied the estimated HR by the number of cases per 1000 person-years in the reference category and calculated the differences in the number of cases in the reference group versus the exposure groups.
As proposed by Knol and VanderWeele,25 we also present results for high emotional demands and risk of long-term sickness absence across strata of each of the four effect modifiers. In sensitivity analyses, we repeated all analyses with follow-up until Dec 31, 2001 (ie, using a 1-year follow-up), similar to the follow-up duration in previous studies on long-term sickness absence in Denmark.4,26 We further analyzed effect modification without adjusting for other working conditions and dichotomizing working conditions by median split instead of the highest or lowest quartile. All analyses were done using SAS version 9.4. Role of the funding source The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. Results from 1680214 individuals with complete data were identified from the JEMPAD cohort. 158862 individuals had long-term sickness absences between Jan 1, 1998, and Dec 31, 2000, and were excluded. 1521352 employed individuals (789812 [51·9%] men and 731540 [48·1%] women) were included and contributed data between Jan 1, 2000, and Dec 31, 2010 (table 1).
The mean age at baseline was 43·7 years (SD 8·4). During 11919021 person-years (mean follow-up 7·8 years) we identified 480685 new cases of long-term sickness absence. We censored 147863 individuals due to retirement, 27915 due to emigration, and 13151 due to death. After adjustment for age and sex, high emotional demands were associated with an increased risk of long-term sickness absence compared with low emotional demands (HR 1·23 [95% CI 1·23–1·24]; table 2). After further adjustment for cohabitation, migration background, income, and the four other working conditions (effect modifiers), the estimate increased (1·55 [1·53–1·56]). Estimates were similar for men and women (appendix p 8).
The RERI was greater than 0 for possibilities for development (RERI 0·35 [95% CI 0·22 to 0·47], 28·9 additional cases per 1000 person-years) and role conflicts (0·13 [0·11 to 0·15], 22·0 additional cases per 1000 person-years) at work, indicating more than additive interaction (ie, synergism) in the double-exposed.
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