Healthy Worker Effect (HWE

An annoying methodological aspect in

occupational studies?
Khaldoun Nijem
November 25, 2002

Today I will talk about an occupational

epidemiological phenomena known
as HWE. This phenomena was under
debate and a lot of discussion during
the last years. Some epidemiologist
regard HWE as an ordinary method
problems, while others considered it
as a field of science by itself.

Contents

Definition of HWE
Historical background
Importance of HWE
Core of HWE
Factors affecting HWE
Avoiding HWE
Summary and conclusion

In this lecture I will talk about different

diffeniton of HWE and the historical
back ground. What its important to
understand this phenomena and what
is the core of HWE, by that I mean the
crux of the problem. I will also talk
about the different factors affecting
the phenomena and how to minimize
it then at the end of this lecture I will
make the summay and main
conclusion.

Definition

A phenomenon observed initially in

studies of occupational diseases:
workers usually exhibit lower overall
death rates than the general
population, because the severely ill
and chronically disabled are ordinarily
excluded from employment
Last, 1995

Definition

HWE refers to the consistent

tendency for the actively
employed people to have a more
favorable mortality experience
than the population at large
(McMichael 1987)

Another difinition by Mcmichaelt who

first give its name is (read the slide).
However, other occupational
epidemiologists describe HWE as the
reduction of mortality or morbidity of
occupational cohorts when compared
with the general population. (Next
slide is an example)

Example

Mortality (SMR, all causes) of gas workers

compared with national experience

heavy exposure
105

intermediate
90

no exposu
84

(Doll et al 196

As an example is the study of Doll

and coworkers on gas workers
exposed to carbonised coal. They
measured SMR for groups of
gasworkers with different
exposure. .

What is standardization?

A set of techniques used to remove as

far as possible the effects of
difference in age or other
confounding variables when
comparing two or more populations.
Standardization methods:
1- Direct standardization
2- Indirect standardization (SMR)
Last, 1995

SMR is an example on indirect

standardization where it used to eliminate
possible effect of age differences by
comparing a cohort of workers with the
general population

Standardized mortality ratio

(SMR)

The ratio of the number of deaths

observed in the study group or
population to the number that
would be expected if the study
population had the same specific
rates as the standard population,
multiplied by 100
Last, 1995

The standardized mortality ratio is defined as

the ratio between observed mortality rate
among workers exposed to certain hazards
and expected mortality rate of the same
workers standarized with the general
population.

Example

Mortality (SMR, all causes) of gas workers

compared with national experience

heavy exposure
105

intermediate
90

no exposure
84

Returning to the previous example. The unexposed workers had SMR

less than 100

(Doll et al 1965)

Historical Background

The phenomenon was first

observed by Ogle (1885) who
found that the more vigorous
occupations had relatively lower
mortality rate as compared with
the death-rates in occupations of
an easier character or the
unemployed
(Arrighi & Hertz-Picciotto 1994)

The phenomena was observed in

1885 when William Ogle found that
mortality rates is depending on the
difficulty of the work where some
occupations may repeal, while
others may attract the workers

Historical Background,
contd

The term healthy worker

effect was first used by
McMichael et al in 1974

Almost One hundred years

later Mcmichael coined the
term HWE to describe this
phenomena.

Historical Background,
contd

Goldsmith (1975) pointed out

that most industrially-employed
cohorts should be expected to
have better life expectancy than
unemployed persons

Historical Background,
contd

Fox and Collier examined the

healthy worker survivor effect
in terms of the standardized
mortality ratio (SMR) with the
general population as reference
(Fox & Collier
1976)

Trying to measure the magnitude of HWE, fox and collier

used Standardized Mortality ratio .

Historical Background,
contd

SMRs close to unity (100) was

used as an indication of
absence or a low degree of the
HWE
(Fox & Collier 1976, Doll
1988)

They considered MRS close to unity

as indication of low degree of HWE.

Importance of HWE

A common problem?

Computer search
Medline: 59 articles with HWE in
title
Occupational databases: additional
20 articles with HWE in title
General Medline search: more than
400 hits

The first question is HWE is common.

Any occupational study looking for the
worker health could potentially faced
this problem. When we made computer
search in medline from the year 74;
when it was first named-we found 59
articles with HWE in its title. an extra
search in other occupational database
result in additional 20 articles with
HWE in the title. More than 400 articles
contain HWE in the content. So its a
common problem

A serious problem?

Reduce SMR by 20-30%

Example, SMR, all causes of gasworkers

compared with national experience

heavy exposure
105

intermediate
90

no exposure
84

(Doll et al 1965)

Is it a serious bias?. Actually, Most of

the study indicated that HWE will
reduce the association between
exposure and outcome by an average
of 20-30 percent. I will use the same
example as I showed earlier, the
British gasworkers:.(see the slide and
point to no exposure and move to next
slidde next slide is an example).

A serious problem?

Reduce SMR by 20-30%

Example, SMR, all causes of gas workers

compared with national experience

heavy exposure
105

intermediate
90

no exposure
84

(Doll et al 1965)

A serious problem

It may partially or completely

mask excess mortality or
morbidity that is caused by
harmful exposure

So this reduction in SMR could be

described as a negative effect of
exposure-outcome association or
in other terms it might said that
the condition among the workers is
good and no harmful effect was
seen. And of course it is not true..

Core of the HWE

Trying to under stand HWE was not

easy since there was a lot of
explaination and debate about its
nature, a good example could be seen
in Choi 1992 when he described the
differences in opion regarding HWE.
The article included the openion of
nine different participents familiar with
HWE.

Core of the HWE

Although the HWE is well

recognized, it has been
considered to be a poorly
defined phenomenon
(Li & Sung
1999)

Core of the HWE

Selection bias?
Confounding?
Mixture of different biases?
Comparison problem?

Some of them considered HWE as

a source of selection bias, others
considered it as a confounding . A
third group considered it as a
mixture of both. While others
considered it as a coparison
problem

Some of them considered HWE as

a source of selection bias, others
considered it as a confounding . A
third group considered it as a
mixture of both. While others
considered it as a coparison
problem

What is Selection Bias?

Error due to systematic
differences in characteristics
between those who are
selected for study and those
who are not.
Last 1995

Is HWE a Selection Bias?

HWE is the most common

selection bias in occupational
studies and occurs because
relatively healthy individuals
are likely to gain employment
and to remain employed.
(McMicheal 1987; Checkoway et al
1989)

According to this difinition is HWE is a

source of selection bias. McMichael
considered it a source of selection bias
because the characteristic of the
occupational cohort selected to
participate in a work are differ they are
healthy-from the general population
which contains healthy and unhealthy
casescause only healthy workers will
gain and remain employed.

HWE refers to the initial

hiring into the workforce
and the subsequent
factors which influence
continuing employment
(Arrighi & Hertz-Picciotto
1994)

The selection bias occurred from

the initial choosing of workers
(mainly healthy workers) and the
factors that influence the
contineouty of work such as
leaving thework because of
sickness.

Confounding
A situation in which a
measure of the effect of an
exposure on risk is distorted
because of the association
of exposure with other
factor(s) that influence the
outcome under study.
Last 1995

Example of
Confounding
Coffee drinking

disease

Cigarette Smoking

Heart

An example on confounding is the

following diagram. The confounder
should associate with both
exposure and outcome

Is HWE a case of confounding?

Monson (1986) considered

HWE to be an example of
confounding:
The confounding factor is the
(unmeasured) health status of
the group of employees

According to Monson HWE is

considered as a case of confounding.
The confounder is the unmeasured
health status. also He considered the
appearance of selection bias depends
on the action of the investigators,
whereas confounding is a
characteristic of the study population.

HWE as a case of
confounding
Employment in the industry
death

Good health status

Going back to our example GHS is

associated with exposure
(Employment in industry and
associated with outcome death