A multilevel study of the determinants of area-level inequalities in colorectal cancer survival

Background: In Australia, associations between geographic remoteness, socioeconomic disadvantage, and colorectal cancer (CRC) survival show that survival rates are lowest among residents of geographically remote regions and those living in disadvantaged areas. At present we know very little about the reasons for these inequalities, hence our capacity to intervene to reduce the inequalities is limited. Methods/Design: This study, the first of its type in Australia, examines the association between CRC survival and key area- and individual-level factors. Specifically, we will use a multilevel framework to investigate the possible determinants of area- and individual-level inequalities in CRC survival and quantify the relative contribution of geographic remoteness, socioeconomic and demographic factors, disease stage, and access to diagnostic and treatment services, to these inequalities. The multilevel analysis will be based on survival data relating to people diagnosed with CRC in Queensland between 1996 and 2005 (n = 22,723) from the Queensland Cancer Registry (QCR), area-level data from other data custodians such as the Australian Bureau of Statistics, and individual-level data from the QCR (including extracting stage from pathology records) and Queensland Hospitals. For a subset of this period (2003 and 2004) we will utilise more detailed, individual-level data (n = 1,966) covering a greater range of risk factors from a concurrent research study. Geo-coding and spatial technology will be used to calculate road travel distances from patients’ residence to treatment centres. The analyses will be conducted using a multilevel Cox proportional hazards model with Level 1 comprising individual-level factors (e.g. occupation) and level 2 area level indicators of remoteness and area socioeconomic disadvantage. Discussion: This study focuses on the health inequalities for rural and disadvantaged populations that have often been documented but poorly understood, hence limiting our capacity to intervene. This study utilises and develops emerging statistical and spatial technologies that can then be applied to other cancers and health outcomes. The findings of this study will have direct implications for the targeting and resourcing of cancer control programs designed to reduce the burden of colorectal cancer, and for the provision of diagnostic and treatment services

Psychosocial working conditions in a representative sample of working Australians 2001–2008: an analysis of changes in inequalities over time

Background A number of widely prevalent job stressors have been identified as modifiable risk factors for common mental and physical illnesses such as depression and cardiovascular disease, yet there has been relatively little study of population trends in exposure to job stressors over time. The aims of this paper were to assess: (1) overall time trends in job control and security and (2) whether disparities by sex, age, skill level and employment arrangement were changing over time in the Australian working population. Methods Job control and security were measured in eight annual waves (2000–2008) from the Australian nationally-representative Household Income and Labour Dynamics of Australia panel survey (n=13 188 unique individuals for control and n=13 182 for security). Observed and model-predicted time trends were generated. Models were generated using population-averaged longitudinal linear regression, with year fitted categorically. Changes in disparities over time by sex, age group, skill level and employment arrangement were tested as interactions between each of these stratifying variables and time. Results While significant disparities persisted for disadvantaged compared with advantaged groups, results suggested that inequalities in job control narrowed among young workers compared with older groups and for casual, fixed-term and self-employed compared with permanent workers. A slight narrowing of disparities over time in job security was noted for gender, age, employment arrangement and occupational skill level. Conclusions Despite the favourable findings of small reductions in disparities in job control and security, significant cross-sectional disparities persist. Policy and practice intervention to improve psychosocial working conditions for disadvantaged groups could reduce these persisting disparities and associated illness burdens

Psychosocial job quality in a national sample of working Australians: A comparison of persons working with versus without disability

Objectives: There is growing international policy interest in disability employment, yet there has been little investigation of job quality among people working with disability. This study uses Australian national data to compare the psychosocial job quality of people working with versus without disability. Methods: We used 10 annual waves of data from a large representative Australian panel survey to estimate the proportion of the population experiencing poorer psychosocial job quality (overall and by individual ‘adversities’ of low job control, high demands, high insecurity, and low fairness of pay) by disability status and impairment type. We used logistic regression to examine the pooled cross-sectional associations between disability and job quality, adjusting for age, sex, education and job type. Results: Those working with any disability showed approximately 25% higher odds of reporting one or more adversity at work (OR: 1.23, 95% CI: 1.15, 1.31), and this finding was consistent across impairment types with the exception of intellectual/developmental disability. Estimates were largely unchanged after adjustments. Similar results were found for reporting two or more adversities compared one or more. Conclusions: We observed that working people with a disability in Australia reported systematically poorer psychosocial job quality than those working without disability. These results suggest the need for further research to understand the reasons for these patterns, as well as policy and practice efforts to address this inequity. Keywords: Impairment, Disability employment, Equity, Job stressors, Psychosocial, Working conditions, Epidemiolog

Does disability status modify the association between psychosocial job quality and mental health? A longitudinal fixed-effects analysis

BACKGROUND: People with disabilities have difficulties in obtaining work. However, evidence suggests that those with disabilities derive substantial mental health benefits from employment. This paper assesses how the relationship between work and mental health is influenced by psychosocial job quality for people working with a disability. METHODS: The study design was a longitudinal cohort with 13 annual waves of data collection, yielding a sample of 122,883 observations from 21,848 people. Fixed-effects within-person regression was used to control for time invariant confounding. The Mental Component Summary (MCS) of the Short Form 36 (SF-36) measure was used as the primary outcome measure. The main exposure was a six-category measure of psychosocial job quality and employment status (including \u27not in the labour force\u27 [NILF] and unemployment). Disability status (\u27no waves of disability reported\u27 and \u27all contributed waves with reported disability\u27) was assessed as an effect modifier. We also conducted a secondary analysis on respondents contributing both disability and non-disability waves. RESULTS: For those with no disability, the greatest difference in mental health (compared to optimal employment) occurs when people have the poorest quality jobs (-2.12, 95% CI -2.48, -1.75, p < 0.001). The relative difference in mental health was less in relation to NILF and unemployment (-0.39 and -0.66 respectively). For those with consistent disability, the difference in mental health when employed in an optimal job was similar between the poorest quality jobs (-2.25, 95% CI -3.84, -0.65, p = 0.006), NILF (-2.84, 95% CI -4.49, -1.20, p = 0.001) or unemployment (-2.56, 95% CI -4.32, -0.80, p = 0.004). These results were confirmed by the secondary analysis. CONCLUSIONS: Efforts to improve psychosocial job quality may have significant mental health benefits for people with disabilities. This will contribute to the economic viability of disability employment insurance schemes in Australia and other high-income countries

Does disability status modify the association between psychosocial job quality and mental health? A longitudinal fixed-effects analysis

Background: People with disabilities have difficulties in obtaining work. However, evidence suggests that those with disabilities derive substantial mental health benefits from employment. This paper assesses how the relationship between work and mental health is influenced by psychosocial job quality for people working with a disability. Methods: The study design was a longitudinal cohort with 13 annual waves of data collection, yielding a sample of 122,883 observations from 21,848 people. Fixed-effects within-person regression was used to control for time invariant confounding. The Mental Component Summary (MCS) of the Short Form 36 (SF-36) measure was used as the primary outcome measure. The main exposure was a six-category measure of psychosocial job quality and employment status (including 'not in the labour force' [NILF] and unemployment). Disability status ('no waves of disability reported' and 'all contributed waves with reported disability') was assessed as an effect modifier. We also conducted a secondary analysis on respondents contributing both disability and non-disability waves. Results: For those with no disability, the greatest difference in mental health (compared to optimal employment) occurs when people have the poorest quality jobs (-2.12, 95% CI -2.48, -1.75, p < 0.001). The relative difference in mental health was less in relation to NILF and unemployment (-0.39 and -0.66 respectively). For those with consistent disability, the difference in mental health when employed in an optimal job was similar between the poorest quality jobs (-2.25, 95% CI -3.84, -0.65, p = 0.006), NILF (-2.84, 95% CI -4.49, -1.20, p = 0.001) or unemployment (-2.56, 95% CI -4.32, -0.80, p = 0.004). These results were confirmed by the secondary analysis. Conclusions: Efforts to improve psychosocial job quality may have significant mental health benefits for people with disabilities. This will contribute to the economic viability of disability employment insurance schemes in Australia and other high-income countries

Spatial inequalities in colorectal and breast cancer survival: Premature deaths and associated factors

This study examines the influence of cancer stage, distance to treatment facilities and area disadvantage on breast and colorectal cancer spatial survival inequalities. We also estimate the number of premature deaths after adjusting for cancer stage to quantify the impact of spatial survival inequalities. Population-based descriptive study of residents aged <90 years in Queensland, Australia diagnosed with primary invasive breast (25,202 females) or colorectal (14,690 males, 11,700 females) cancers during 1996-2007. Bayesian hierarchical models explored relative survival inequalities across 478 regions. Cancer stage and disadvantage explained the spatial inequalities in breast cancer survival, however spatial inequalities in colorectal cancer survival persisted after adjustment. Of the 6,019 colorectal cancer deaths within 5 years of diagnosis, 470 (8%) were associated with spatial inequalities in non-diagnostic factors, i.e. factors beyond cancer stage at diagnosis. For breast cancers, of 2,412 deaths, 170 (7%) were related to spatial inequalities in non-diagnostic factors. Quantifying premature deaths can increase incentive for action to reduce these spatial inequalities