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Social Determinants in Asthma: Population-based studies on asthma and respiratory symptoms in relation to occupation, occupational exposure and socioeconomic status
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. (OLIN-studierna)ORCID iD: 0000-0003-1904-7514
2019 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Sociala bestämningsfaktorer och astma : populationsbaserade studier av astma och luftvägssymtom i relation till yrke, yrkesmässig exponering och socioekonomisk status (Swedish)
Abstract [en]

Background: Asthma is one of the most common chronic obstructive airway diseases among children and adults, with a prevalence between 6-11% in European countries. It is also the most common work-related occupational respiratory disease. There are different methods to classify occupational exposure and, even though there is no clear consensus on which method is the most accurate, the single-item question on exposure to the composite measure vapour, gas, dust or fumes (VGDF) is commonly used in epidemiological research. Low socioeconomic status is associated with asthma and also behavioural factors such as smoking and over-weight, which by themselves are risk factors for asthma. Socioeconomic status is, however, truly a multifaceted concept and using only one measure does not encompass its entire effect on health-related outcomes. Asthma does also have a negative impact on the quality of life among adolescents: they report less physical fitness compared to their peers and more school absenteeism due to respiratory symptoms. Still, research on whether childhood asthma has any impact on socioeconomic status in young adulthood is scarce.

Aim: The overall aim is to study social determinants of health such as socioeconomic status, occupation and occupational exposure and their relationship with asthma and respiratory symptoms among adults and further, to evaluate if asthma during childhood or adolescence is associated with social determinants in young adulthood.

Method: This thesis includes four papers based on data from the Obstructive Lung Disease in Northern Sweden (OLIN) studies. Papers I-III are cross-sectional studies among adults; a structured interview from clinical examinations between 2002-04 (paper I, n=4036) and postal questionnaire surveys from 2006 (paper II, n=9992) and 2016 (paper III, n=6854) with the addition of register-based data in paper III. Paper IV is a longitudinal prospective cohort study; the first OLIN paediatric cohort followed from 7 to 19 years of age and a postal questionnaire follow-up at ages 27-28 in 2015 (n=2017). Asthma was defined as physician diagnosis (paper I) together with respiratory symptoms (paper II-IV) or use of asthma medication (paper IV). In paper IV asthma was further categorized based on age of onset and p v and adolescence. Main or longest held occupation was used to categorize occupational and socioeconomic groups. In papers III and IV additional measures of socioeconomic status were included; educational level (papers III and IV) and income (paper III). In all papers, occupational exposure to vapour and/or gas, dust and fumes (VGDF or GDF) were taken into consideration and in paper I further divided into subgroups based on a detailed questionnaire on occupational exposure.

Results: In paper I we found that the association between occupational exposure to VGDF and asthma and rhinitis was driven by the component of chemicals rather than dusts. In paper II, the ISCO-based manual Swedish Standard Classification of Occupations (SSYK) and the manual Socioeconomic classification (SEI), could both identify occupational and socioeconomic groups at risk for respiratory symptoms and asthma, while the older ISCO-based manual Nordic Classification of Occupations (NYK) was not as sensitive.

In paper III, behavioural risk factors for respiratory symptoms and asthma such as smoking and obesity and, occupational exposure to GDF were associated with low educational level. Interaction analyses between income level and sex revealed different patterns among women and men. Among women, low income was associated with all respiratory symptoms as well as asthma, while among men only with productive cough.

In paper IV, early onset asthma was associated with lower educational level in young adulthood, especially not continuing after compulsory school. Further, those with asthma during childhood or adolescence did not seem to refrain from smoking at age 19, nor did they as young adults seem to avoid occupations with known or expected exposure to GDF.

Conclusions: Increased automation in industries have decreased the number of manual workers in industries with typically dirty tasks, meaning that the interrelationships between the subgroups included in VGDF may have changed. This may also affect the meaning of occupational exposure to VGDF, at least with regard to asthma and rhinitis, and according to our findings exposure to the component of chemicals may be the most important. We also found that the use of an ISCO-based manual (SSYK) as well as socioeconomic classification based on job-title (SEI) can be useful and easily applicable tools to identify occupational and socioeconomic groups at risk for respiratory symptoms and asthma. Further, low socioeconomic status is associated with respiratory vi symptoms and asthma. It seems as these associations relies more on low income than low educational level. Low educational level as well as low income are furthermore related to known behavioural risk factors for respiratory symptoms and asthma such as obesity, smoking and, also potentially modifiable risk factors as occupational exposure to gas dust or fumes. Having a persisting asthma since childhood is associated with lower educational level as a young adult. This may, in turn, be related with behavioural risk factors as discussed above and, there were no indications that those with child or adolescent asthma refrained from smoking at age 19. Neither did they in young adulthood avoid occupations with known or expected exposure to gas, dust or fumes, such as manufacturing, construction and transportation work. To conclude, our results indicate a vicious circle with regard to the relationship between the studied social determinants of health and asthma and respiratory symptoms.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2019. , p. 80
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2034
Keywords [en]
Asthma, Signs and Symptoms, Respiratory, Social Determinants of Health, Socioeconomic Factors, Epidemiology
National Category
Respiratory Medicine and Allergy Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Occupational and Environmental Medicine
Identifiers
URN: urn:nbn:se:umu:diva-159143ISBN: 978-91-7855-068-5 (print)OAI: oai:DiVA.org:umu-159143DiVA, id: diva2:1316926
Public defence
2019-06-13, Konferenscentrum, Sunderby Sjukhus, 954 42, Södra Sunderbyn, Luleå, 09:00 (Swedish)
Opponent
Supervisors
Funder
Swedish Research CouncilSwedish Heart Lung FoundationSwedish Asthma and Allergy AssociationVårdal FoundationNordForskNorrbotten County Council
Note

Ytterligare forskningsfinansiärer:

Avtal om läkarutbildning och forskning (ALF), ett avtal mellan Umeå Universitet och Region Västerbotten

Konsul Th C Berghs Stiftelse

Region Blekinge

Available from: 2019-05-23 Created: 2019-05-21 Last updated: 2019-05-22Bibliographically approved
List of papers
1. Occupational exposure to chemicals drives the increased risk of asthma and rhinitis observed for exposure to vapours, gas, dust and fumes: a cross-sectional population-based study
Open this publication in new window or tab >>Occupational exposure to chemicals drives the increased risk of asthma and rhinitis observed for exposure to vapours, gas, dust and fumes: a cross-sectional population-based study
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2016 (English)In: Occupational and Environmental Medicine, ISSN 1351-0711, E-ISSN 1470-7926, Vol. 73, no 10, p. 663-669Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: Occupational exposure to the composite measure vapours, gases, dusts and fumes (VGDF), contribute to the burden of asthma and rhinitis. The objective was to evaluate occupational exposure to VGDF, which is further divided into the components chemicals, organic and inorganic dust in relation to asthma and rhinitis.

METHODS: Previously examined participants from three population-based cohorts in the Obstructive Lung disease In Northern Sweden (OLIN) studies were re-examined during 2002-2004. In total, 4036 participated in a structured interview and answered a questionnaire on occupational exposures.

RESULTS: Occupational exposure to VGDF increased the risk of asthma, and concomitant asthma and rhinitis. Exposure to chemicals, but not dust, showed a similar pattern. Exposure to chemicals increased the risks (OR, 95% CI) of rhinitis without asthma (1.29, 1.10 to 1.52), asthma without rhinitis (1.42, 1.15 to 1.77) and concomitant asthma and rhinitis (1.60, 1.31 to 1.96) when adjusted for confounders such as age, smoking habits, body mass index and sex. The association between exposure to chemicals and asthma and rhinitis remained independent of exposure to dust and was also so when excluding exposure to isocyanates and welding fumes. The results were similar for women and men, as well as for never-smokers and participants without a history of allergy.

CONCLUSIONS: In this cross-sectional population-based study, occupational exposure to chemicals contributed substantially to the increased risk of asthma and rhinitis observed for occupational exposure to VGDF.

National Category
Occupational Health and Environmental Health
Identifiers
urn:nbn:se:umu:diva-125059 (URN)10.1136/oemed-2016-103595 (DOI)000384079100005 ()27466615 (PubMedID)
Available from: 2016-09-05 Created: 2016-09-05 Last updated: 2019-05-21Bibliographically approved
2. Job titles classified into socioeconomic and occupational groups identify subjects with increased risk for respiratory symptoms independent of occupational exposure to vapour, gas, dust, or fumes
Open this publication in new window or tab >>Job titles classified into socioeconomic and occupational groups identify subjects with increased risk for respiratory symptoms independent of occupational exposure to vapour, gas, dust, or fumes
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2018 (English)In: European Clinical Respiratory Journal, ISSN 2001-8525, Vol. 5, no 1, article id 1468715Article in journal (Refereed) Published
Abstract [en]

Objectives: To evaluate the ability of three different job title classification systems to identify subjects at risk for respiratory symptoms and asthma by also taking the effect of exposure to vapours, gas, dust, and fumes (VGDF) into account.

Background: Respiratory symptoms and asthma may be caused by occupational factors. There are different ways to classify occupational exposure. In this study, self-reported occupational exposure to vapours, gas, dust and fumes was used as well as job titles classifed into occupational and socioeconomic Groups according to three different systems.

Design: This was a large population-based study of adults aged 30–69 years in Northern Sweden (n = 9,992, 50% women). Information on job titles, VGDF-exposure, smoking habits, asthma and respiratory symptoms was collected by a postal survey. Job titles were used for classification into socioeconomic and occupational groups based on three classification systems; Socioeconomic classification (SEI), the Nordic Occupations Classification 1983 (NYK), and the Swedish Standard Classification of Occupations 2012 (SSYK). Associations were analysed by multivariable logistic regression.

Results: Occupational exposure to VGDF was a risk factor for all respiratory symptoms and asthma (odds ratios (ORs) 1.3–2.4). Productive cough was associated with the socioeconomic groups of manual workers (ORs 1.5–2.1) and non-manual employees (ORs 1.6–1.9). These groups include occupations such as construction and transportation workers, service workers, nurses, teachers and administration clerks which by the SSYK classification were associated with productive cough (ORs 2.4–3.7). Recurrent wheeze was significantly associated with the SEI group manual workers (ORs 1.5–1.7). After adjustment for also VGDF, productive cough remained significantly associated with the SEI groups manual workers in service and non-manual employees, and the SSYK-occupational groups administration, service, and elementary occupations.

Conclusions: In this cross-sectional study, two of the three different classification systems, SSYK and SEI gave similar results and identified groups with increased risk for respiratory symptoms while NYK did not give conclusive results. Furthermore, several associations were independent of exposure to VGDF indicating that also other job-related factors than VGDF are of importance.

Place, publisher, year, edition, pages
Taylor & Francis, 2018
Keywords
asthma, occupational exposure, socioeconomic status
National Category
Occupational Health and Environmental Health
Identifiers
urn:nbn:se:umu:diva-147961 (URN)10.1080/20018525.2018.1468715 (DOI)000432538500001 ()29785256 (PubMedID)
Available from: 2018-05-23 Created: 2018-05-23 Last updated: 2019-05-21Bibliographically approved
3. Low socioeconomic status is associated with asthma and respiratory symptoms in northern Sweden, especially among women: The OLIN and Nordic EpiLung studies
Open this publication in new window or tab >>Low socioeconomic status is associated with asthma and respiratory symptoms in northern Sweden, especially among women: The OLIN and Nordic EpiLung studies
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(English)Manuscript (preprint) (Other academic)
National Category
Respiratory Medicine and Allergy Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-159141 (URN)
Available from: 2019-05-20 Created: 2019-05-20 Last updated: 2019-05-22
4. Childhood asthma affects educational level in young adults: a prospective cohort study
Open this publication in new window or tab >>Childhood asthma affects educational level in young adults: a prospective cohort study
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Respiratory Medicine and Allergy Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-159142 (URN)
Available from: 2019-05-20 Created: 2019-05-20 Last updated: 2019-05-22

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