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PubMed1983

Anatomy of the healthy worker effect: a critical review.

The healthy worker effect is the composite result from factors such as (1) selection of the work force, (2) changes in lifestyle accompanying employment, and (3) methodological characteristics of the standardized mortality ratio (SMR). While the choice of the general population as the comparison population is the underlying reason for this effect, no more feasible, widely accepted or "better" alternative is yet available. Much of the current understanding of the healthy worker effect has been limited to an examination of selection of the work force. The purpose of this report is to illustrate, using examples from a large cohort study, the importance of many factors other than selection. They include employment-associated benefits such as economic gain, medical insurance and lifestyle changes, the proportion of active workers, the calculation method, data completeness, length of follow-up and certain characteristics of SMR methodology. It is shown that some of the healthy worker effect is characteristic of SMR methodology and that the strength of the healthy worker effect depends on the proportion of active workers in the cohort. Furthermore, the disappearance of the healthy worker effect may be due to factors such as aging of the cohort and can be totally unrelated to the true increase in the mortality risk. In other words, its disappearance, in many instances, may be an artifact of SMR methodology.

Adult↗
PubMed1987

The healthy worker effect. Selection of workers and work forces.

The favorable health status of employed populations in comparison to that of the general population is often called the "healthy worker effect," and most researchers feel that it results from the selection of healthy individuals during the hiring process. However, other mechanisms may also contribute to the healthy worker effect. In particular, the healthy worker effect may reflect the selection, for epidemiologic study, of relatively advantaged workforces in terms of socioeconomic status and health. Evidence of differential health by socioeconomic status within the workforce is reviewed, and its possible role in the healthy worker effect is discussed.

Employment↗
PubMed1992

Definition, sources, magnitude, effect modifiers, and strategies of reduction of the healthy worker effect.

This article summarizes, compares, and contrasts the definition, sources, magnitude, effect modifiers, and strategies of reduction of the healthy worker effect (HWE), based on the opinion expressed in the papers of nine contributors who responded to the request of the Industrial Disease Standards Panel (IDSP), Ontario, Canada. It provides an insight into the complex issues relating to the HWE. In addition, the catalog of 15 strategies to reduce the HWE is deemed to be useful for investigators in occupational epidemiology.

Age Factors↗
PubMed1988

Components and modifiers of the healthy worker effect: evidence from three occupational cohorts and implications for industrial compensation.

The authors examined the components and modifiers of the healthy worker effect using mortality data from three occupational cohorts: the employees of Atomic Energy of Canada Limited followed between 1950 and 1981, a 10% sample of the Canadian labor force followed between 1965 and 1979, and workers at the Eldorado Resources Limited Beaverlodge uranium mine followed between 1950 and 1980. Two important components of the healthy worker effect have been identified in these cohorts, namely, initial selection of and continuing employment of healthy individuals. There is less evidence for a contribution from the existence of differential risk factors among employed individuals as compared with the general population. The healthy worker effect is, however, substantially modified by time since employment, sex, age, specific cause of death, and specific occupation. Because of this variation, it is inappropriate to account for the healthy worker effect by a single parameter, and all of the above factors must be taken into account in any appropriate analysis. When the only available comparison group for an occupational cohort is the general population, the healthy worker effect is unlikely to have any substantial influence on the process of assessing causality for any observed association or attributing cause in an individual case. This would be particularly true for cancer, and even more so for lung cancer, a disease often associated with industrial compensation cases.

Adolescent↗
PubMed1987

The healthy worker effect in actively working communications workers.

The healthy worker effect is examined in a large population of actively working communications workers. The mortality experience of 338,306 white male workers at the American Telephone and Telegraph Company grouped by age, duration of service, and general cause categories is compared with the mortality experience of US white males in 1976. Observed were statistically significant and often substantial deficits in mortality among these active workers in almost all categories. For cancers and cardiovascular diseases, mortality ratios tended to decrease across age in the subgroups with longer service durations; these ratios consistently increased across duration of service in older ages. In subgroups with long service durations, the secondary selection of the healthy worker effect in this active worker population appears to increase with increasing age.

Adult↗
PubMed1996

The influence of study characteristics on the healthy worker effect: a multiple regression analysis.

The so-called 'healthy worker effect' (HWE) describes a reduced mortality rate in occupational populations. From 85 occupational cohorts of workers exposed to organic solvents, we have previously found a low weighted standardized mortality ratio (SMR) for all causes (SMR = 89.5, 95 per cent confidence interval [Cl] = 89.0-90.2). Characteristics of the cohorts were examined for association with the HWE. A multiple regression analysis revealed that, for overall deaths, the closer the comparison group, the smaller the HWE (p = 0.001); the more hazardous the potential exposures, the higher the SMR (p = 0.02); the higher the social class, the greater the HWE (p = 0.02); and the higher the rates of loss to follow up, the greater the HWE (p = 0.04). These results have shown that, in addition to time-related modifiers, the comparison group, type of occupational exposure, social class and rates of loss to follow-up significantly influence the size of the so-called HWE. Differences in the HWE related to gender and race were probably attributable to different rates of loss to follow-up.

Cohort Studies↗
PubMed1985

The 'healthy worker effect' on morbidity rates.

Studies relating mortality and occupation are difficult to interpret because of the "healthy worker effect." That effect is primarily due to the fact that individuals entering the labor force are in reasonably good health. A similar phenomenon might be expected in a comparison of morbidity among members of an occupational group with that of the general population. A comparison of morbidity among different population and occupation groups is made possible through the Household Interview Survey (HIS) of the National Center for Health Statistics. Data from the HIS for the years 1969 through 1974 were combined to form a sample classified according to race, sex, age, occupation, and occurrence of various health conditions. Among subjects between 25 and 59 years of age, age-specific morbidity ratios and standardized morbidity ratios were computed for blue-collar and professional/managerial employees and for unemployed who were either seeking or not seeking employment. There appears to be a "healthy worker morbidity effect" for chronic, but not for acute, conditions just as there is for mortality. The healthy worker effect for chronic morbidity maintains itself and, in fact, appears to increase throughout the 35-year period of stable employment. The age-specific morbidity ratio may have considerable theoretical importance for evaluating the related mortality experience of employed populations.

Adult↗
PubMed1989

Occupational cohort studies: the influence of design characteristics on the healthy worker effect.

A cross-sectional analysis of the relation between the estimated healthy worker effect (HWE), as measured by a total Standardized Mortality Ratio (SMR) less than 100, and relevant design characteristics in 270 published retrospective occupational cohort studies is presented. The majority of the reviewed studies showed a HWE, varying in SMR from 50 to 99 (mean: 84). The estimated HWE seemed to influence the final outcomes of the studies to a great extent. A tendency for a positive relation between the study size in terms of the number of exposed workers, total number of person-years of follow-up, and the HWE emerged. Studies with a comparatively short follow-up period had an increased chance of resulting in a HWE. Cross-sectional cohorts did not show a stronger HWE than open cohorts. Studies of chemical exposures revealed a fivefold excess of having a HWE compared with other studies.

Cohort Studies↗
PubMed1984

Mobility of diesel versus non-diesel coal miners: some evidence on the healthy worker effect.

Workers who are particularly susceptible to the effects of their occupational exposure, from the perspective of the healthy worker effect, soon leave the workplace. The result of this mobility, called survival bias, is that cross sectional studies based on the survivors underestimate the true risk of occupational exposures. Two questions are addressed in this empirical study of the "survival bias" component of the "healthy worker" effect. Do miners with respiratory impairment or symptoms disproportionately leave jobs that have a potentially harmful respiratory exposure? And does the presence of an additional potentially harmful respiratory exposure, in this case diesel emissions, accelerate the rate of mobility for miners with respiratory impairment or symptoms? No confirmation was found for the survival effect in a study of 738 diesel and 420 non-diesel US underground coal miners. No additional increment in mobility was associated with exposure to both coal mine dust and diesel emissions.

Adolescent↗
PubMed1988

Mortality odds ratio, proportionate mortality ratio, and healthy worker effect.

The standardized proportionate mortality ratio (PMRi) and the mortality odds ratio (MORi) are two statistics used to approximate the cause specific standardized mortality ratio (SMRi) when death data are available but the population at risk is not known. When there is a healthy worker effect, the MORi will always overestimate the SMRi and will always be greater than the PMRi. The PMRi is influenced by the relative frequency of the cause of death. For rare causes, such as brain cancer or leukemia, the PMRi will overestimate the SMRi to essentially the same degree as the MORi. For more common conditions, such as lung cancer, the PMRi will overestimate or underestimate the SMRi depending on the magnitude of the healthy worker effect. When the SMRi = 1 and there is a healthy worker effect, both the PMRi and MORi are in excess of one (1) regardless of the disease rate. As the SMRi increases it is more likely to be bounded by the PMRi (lower) and the MORi (upper). We therefore recommend that each statistic be derived when death certificates are the only source of data used to assess risk due to occupational exposures.

Environmental Exposure↗
PubMed1980

Healthy worker effect in the total Finnish population.

The selection due to the "healthy worker effect" was estimated from a random sample of the total Finnish population. The sample of 20 000 people was followed for changes in occupations from 1960 to 1970 and for deaths in 1971-5. Those entering the active work force had a standard mortality ratio of 70, indicating a healthy population selection effect. Those staying in the same occupational category from 1960 to 1970 had a 20% lower mortality than those who did not. This survivor population effect was due to changes to another occupational group and to early retirement. These factors had an inverse effect on the survival history of an occupational group.

Adult↗
PubMed1987

Models of the healthy worker effect in industrial cohorts.

The patterns of standardized mortality ratios (SMRs) with duration of follow-up and duration of service which are characteristic of the healthy worker effect in occupational cohort studies have been simulated using models of selection and survivor effects. The models support current theories about the population dynamics which underlie the selection effect but highlight inadequacies in our understanding of the survivor effect. Several possible models were tested and methods of generating appropriate data are discussed. It is important that the healthy worker effect should be better understood as it can present so large a problem in the interpretation of occupational risk estimates.

Adolescent↗
PubMed1976

Standardized mortality ratios and the "healthy worker effect": Scratching beneath the surface.

The age-standardized mortality ratio (SMR) is a relative index of mortality, expressing the mortality experience of the study population relative to that of a comparison ("standard") population. With the general population as the "standard", the SMR for an occupational population will underestimate the mortality experience of that latter population (since it comprises individuals necessarily healthy enough to be employable --and whose mortality risk is therefore initially lower than the general population average). However, this "healthy worker effect" does not equally to all groups within the study population. Therefore, if one attempts to adjust for this effect, the summary nature of the SMR must be recognized, and allowance must be made for variation in the healthy worker effect between different age groups, different races, different work-status groups, different causes of death, and different elapsed-time periods of observation.

Adult↗
PubMed1986

Observations on the healthy worker effect.

Follow-up mortality data from ten groups of employed persons are compared to the mortality rates of the United States general population. Comparisons related to the healthy worker effect (HWE) are computed. As measured by a relative comparison, the standardized mortality ratio (SMR), the HWE is seen to have a dynamic phase and a plateau phase in relation to length of follow-up. In contrast, the HWE as measured by an absolute comparison has little relationship to length of follow-up. Age at entrance into follow-up is strongly related to the absolute risk of mortality, but has little or no relation to the relative risk (SMR). Issues related to the evaluation and minimization of the healthy worker effect are discussed.

Adult↗
PubMed1989

[Healthy worker effect on Japanese industry workers: a commentary from the viewpoint of industrial health management].

Healthy worker effect (HWE), which can be described as a lower death rate within a work force when compared to the general population, has been observed in many epidemiological mortality studies on industrial work populations free of significant life-shortening hazards. The purpose of this report is to evaluate this effect on the active work populations engaged in large scale manufacturing companies in Japan, and to appreciate the possible attributable factors to this phenomenon. Standardized mortality ratios (SMRs) were calculated for workers in the member companies of The Japan Iron and Steel Federation (JISF) and The Japan Chemical Fibers and Textile Association (JCFTA), where mortality surveillance systems have been established. SMRs for all causes of death from 1969 to 1981 were within the range of 50 to 81 in JISF, and 34 to 41 in JCFTA. These results point to the existence of strong HWE, equal to or even lower than the reported values in some industrial populations in the United States. An evident HWE for cancer was also observed in the study populations, but it was reported to be of little significance, if at all, in the United States. HWE can be considered as a composite result of factors such as: (1) selection of healthier work force, (2) risk reduction due to life style modification during employment, and (3) methodological characteristics of the SMR, which are dependent on the percentage of active workers.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

Healthy worker effect in a longitudinal study of one-second forced expiratory volume (FEV1) and chronic exposure to granite dust.

BACKGROUND: Low level effects of granite dust on one-second forced expiratory volume (FEV1) are estimated in 618 Vermont granite workers followed for 5 years with annual pulmonary function tests. Reduced pulmonary function has already been reported for the subset of subjects lost to follow-up (dropouts) suggesting possible bias in analyses based only on survivors. METHOD: Healthy worker selection bias is directly assessed by comparing the dose-response associations between survivors who remained in the study for the full 5-year observation period and the dropouts. RESULTS: The 353 survivors had an FEV1 of 96% of predicted at baseline and were losing FEV1 at an average rate of 44 ml/yr. No association was found in this group between the rate of FEV1 decline and lifetime dust exposure. However, the 265 workers with incomplete follow-up, 'dropouts', had a lower FEV1 at baseline (94%) and were losing FEV1 at an average rate of 69 ml/yr. The dose-response parameter in this group was estimated to be 4 ml/yr loss per mg/m3-year and was statistically significant. CONCLUSIONS: These results provide an illustration of bias due to the healthy worker effect and an example of the failure to detect a true work-related health effect in a study based only on a 'survivor' population.

Adult↗