Prolungamento della vita lavorativa: salute e problemi correlati Giuseppe Costa e Angelo d’Errico Servizio di Epidemiologia Università di Torino ASL 5 del Piemonte Labor, 22 novembre 2006

employability retirability workability Competences Knowledge Abilities Health Lifestyles Working conditions Material hazards Psychosocial hazards Believes Values Attitudes Satisfaction

Social inequalities employability retirability workability Believes Competences Knowledge Abilities Health Lifestyles Working conditions Material hazards Psychosocial hazards Believes Values Attitudes Satisfaction employability retirability Social inequalities

Occupational inequalities in mortality in eleven European countries 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 30–64 years in 11 European countries. Soc Sci Med 1998.

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.

large relative occupational inequalities 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.

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: 222–230). 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: 316–326; 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: 295–305). 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): 303–315).

Social inequalities employability retirability workability Believes Competences Knowledge Abilities Health Lifestyles Working conditions Material hazards Psychosocial hazards Believes Values Attitudes Satisfaction employability retirability Social inequalities

societal/neighbourhood context support psychosocial dem/contr eff/rew behaviours material selection phys/chem/ erg hazards income downward mobility Inter-generational through life-course in adult age (healthy w. effect) morbidity health care outcomes

societal/neighbourhood context support psychosocial dem/contr eff/rew behaviours material 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

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): 1563–1574

societal/neighbourhood context support psychosocial dem/contr eff/rew behaviours material selection phys/chem/ erg hazards income downward mobility Inter-generational through life-course in adult age (healthy w. effect) morbidity health care more controversial the question of the size of the contribution of intergenerational and life-course selection to the adult pattern of health inequalities outcomes Singh-Manoux A et al. Social Science and Medicine, 2005, 60

societal/neighbourhood context support psychosocial dem/contr eff/rew behaviours material 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

% exposed to Job Strain Sample of 1479 employees in Torino (797 workers and 682 clerks)

societal/neighbourhood context support psychosocial dem/contr eff/rew behaviours material 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

Smoking by social class– Italian males 2000 %

societal/neighbourhood context support psychosocial dem/contr ff/rew behaviours material 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

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 MEDIUM 1.21 (1.05 - 1.40) 0.93 (0.86 – 1.02) (0.85 – 1.02) 1.12 (1.03-1.22) LOW 1.33 (1.16 - 1.51) 0.83 (0.76 – 0.90) (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

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 MEDIUM 1.21 (1.05 - 1.40) 0.93 (0.86 – 1.02) (0.85 – 1.02) 1.12 (1.03-1.22) LOW 1.33 (1.16 - 1.51) 0.83 (0.76 – 0.90) (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

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 MEDIUM 1.21 (1.05 - 1.40) 0.93 (0.86 – 1.02) (0.85 – 1.02) 1.12 (1.03-1.22) LOW 1.33 (1.16 - 1.51) 0.83 (0.76 – 0.90) (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

societal/neighbourhood context support psychosocial dem/contr ff/rew behaviours material 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

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

Aging (and cohort?) ? workability Competences Knowledge Abilities Health Lifestyles Working conditions Material hazards Psychosocial hazards Believes Values Attitudes Satisfaction employability retirability

Aging (and cohort?) ? workability Competences Knowledge Abilities Health Lifestyles Working conditions Material hazards Psychosocial hazards Believes Values Attitudes Satisfaction employability retirability Context/regulation: Preferences Constraints Opportunities

Aging (and cohort?) ? workability Competences Knowledge Abilities Health Lifestyles Working conditions Material hazards Psychosocial hazards Believes Values Attitudes Satisfaction employability retirability

Education at 1981 males -24.5 -8.6 -15.6 -10.6 females -33.4 -0.6 -3.4 % variation in 1991-2005 mortality among adults (30-59 yrs) that have improved their education btw 1981 and 1991 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

Aging (and cohort?) ? workability Competences Knowledge Abilities Health Lifestyles Working conditions Material hazards Psychosocial hazards Believes Values Attitudes Satisfaction employability retirability

Diseases and aging Injuries Vulnerability to severity 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?

Aging and functional abilities Physical Coordination, mobility, flexibility, strenght, sensorial… Cardiorespiratory Muscoloskeletal Obesity Mental and social Psicomotricity, cognitive, metacognitive, motivational Relational and role

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

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 dall’INAIL (Colombini et al., 2003) Circa il 50% dei soggetti con disturbi muscolo-scheletrici all’arto superiore non ha segni obiettivi (Punnett, 1998, 2000) “Nella maggior parte dei casi, i disturbi muscolo-scheletrici a carico dell’arto superiore non possono essere classificati in specifiche categorie diagnostiche” (Sluiter, 2000)

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)

MALATTIE MUSCOLO-SCHELETRICHE (MSDs) – Frazione attribuibile all’esposizione a rischi fisici sul lavoro Patologie del rachide National Research Council and Institute of Medicine, 2001

MALATTIE MUSCOLO-SCHELETRICHE (MSDs) – Frazione attribuibile all’esposizione a rischi fisici sul lavoro Patologie dell’arto superiore National Research Council and Institute of Medicine, 2001

MALATTIE MUSCOLO-SCHELETRICHE (MSDs) – Diffusione dell’esposizione – 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

MALATTIE MUSCOLO-SCHELETRICHE (MSDs) – Stima del numero di casi attribuibili all’esposizione 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 un’incidenza del 4.5% alla popolazione occupata e i valori della AF al limite inferiore del range: 8.000 nuovi casi all’anno 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

MALATTIE MUSCOLO-SCHELETRICHE (MSDs) – Stima del numero di casi attribuibili all’esposizione a fattori ergonomici in Piemonte - Patologie dell’arto 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 all’arto superiore Assumendo un’incidenza del 6% alla popolazione occupata e i valori della AF al limite inferiore del range: 53.000 nuovi casi all’anno a movimenti ripetuti 78.000 a sforzi molto intensi 44.000 a vibrazioni trasmesse all’arto superiore

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 l’esperienza 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 dell’organizzazione 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 dell’esposizione a ripetitività, forza, posture incongrue e impatti ripetuti Indicazioni per la sorveglianza sanitaria

Scelta di priorità Assegnazione di punteggi da 0 a 3 ad una serie di caratteristiche del rischio all’interno di ogni settore produttivo: · frequenza e gravità delle patologie considerate nella popolazione generale, · forza dell’associazione tra esposizione professionale e occorrenza delle patologie, · diffusione e livello dell’esposizione nei diversi settori, · proporzione di addetti impiegati in ogni comparto sul totale degli occupati sul territorio regionale, · prevenibilità dell’esposizione, · fattibilità dell’effettuazione di interventi preventivi nel settore.

Tabella 11 – Ranghi di priorità dei più rappresentati settori produttivi, totali e per patologia  

Commitment to adapt working conditions to aging? workability Competences Knowledge Abilities Health Lifestyles Working conditions Material hazards Psychosocial hazards Believes Values Attitudes Satisfaction employability retirability

Low physical exercise by social class - Italian males 2000 %

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)

Core Periphery employability retirability workability Believes Values Competences Knowledge Abilities Health Lifestyles Working conditions Material hazards Psychosocial hazards Believes Values Attitudes Satisfaction employability retirability Core Periphery

Aging (and cohort?) ? workability Competences Knowledge Abilities Health Lifestyles Working conditions Material hazards Psychosocial hazards Believes Values Attitudes Satisfaction employability retirability

Healthy life expectancy by occupation, males

Healthy life expectancy by occupation, females

Differences in life expectancy at 35 yrs by social class, Turin males 2000 - 2005

Anticipating retirement age? Differences in life expectancy at 35 yrs by social class, Turin males 2000 - 2005 Anticipating retirement age?

Mortality 1991-99 by social class among healthy retired 1981-91 High class Clerks Self employed Working class males 1,14 1,38 1,13 females 0,95 1,54 1,08 1,34 RRs age adjusted ; reference : still employed

Differences in life expectancy at 35 yrs by income deciles, Turin males 2000 - 2005

Adjusting benefits according Differences in life expectancy at 35 yrs by income deciles, Turin males 2000 - 2005 Adjusting benefits according to life expectancy?

societal/neighbourhood DIRECT RESPONSIBILITY context support psychosocial dem/contr ff/rew behaviours material 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

societal/neighbourhood CONTRIBUTING RESPONSIBILITY context support psychosocial dem/contr ff/rew behaviours material 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

societal/neighbourhood INDIRECT RESPONSIBILITY context support psychosocial dem/contr ff/rew behaviours material selection phys/chem/ erg hazards income downward mobility Inter-generational through life-course in adult age (healthy w. effect) morbidity INDIRECT RESPONSIBILITY health care outcomes

societal/neighbourhood context support psychosocial dem/contr ff/rew behaviours material 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

societal/neighbourhood context support psychosocial dem/contr ff/rew behaviours material selection phys/chem/ erg hazards income downward mobility Inter-generational through life-course in adult age (healthy w. effect) ADVOCACY morbidity health care outcomes

societal/neighbourhood context support SUPPORT IN SOCIETY behaviours psychosocial material 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

Turin Longitudinal Study Master data file social-health events/status Socio-economic status Turin Longitudinal Study Causes of death cod. A.S.L. 1981-2003 cod. Istat 1970-1991 Census 1971 Census 1981 Population registry identification key Hospital discharges 1995-2005 Master data file 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) Population registry identification key Life status migration Reproductive history ... Drug addiction treatments 1979-1994 income deprivation … Area indices Census tracts and their aggregations Occupational injuries, dyalisis treatments, diabete diagnoses…

TLS population: cohorts 1991 census 1971 census 1981 census 2001 emigration death birth immigration Causes of death Cancer incidence Hospitalization Diabetes Drug prescriptions

TLS census-population registry linkage * Population registry uncomplete update

TLS longitudinal dimension