Regions, hospitals and health outcomes over time: A multi-level analysis of repeat prevalence among a cohort of health-care workers Donald C. Cole b,c,Ã , Mieke Koehoorn a,b , Selahadin Ibrahim b,c , Clyde Hertzman a,b , Aleck Ostry a , Fan Xu a , Patrick Brown c,d a Department of Health Care & Epidemiology, University of British Columbia, Vancouver, Canada b Institute for Work & Health, 481 University Ave., 8th Floor, Toronto, Ont., Canada M5G 2E9 c Dalla Lana School of Public Health, University of Toronto, Toronto, Canada d Cancer Care Ontario, Toronto, Canada article info Article history: Received 18 September 2008 Received in revised form 9 April 2009 Accepted 5 May 2009 Keywords: Mental disorders Musculoskeletal diseases Regional variation Health personnel Longitudinal study abstract Background: The relative importance of region, workplace, and individual determinants of health burden is debated. Objective: To model the contribution of hospital characteristics to employee mental and musculoske- letal disorders. Methods: We linked employment records of nurses and support services’ staff with health records, neighbourhood census, and hospital administrative data. We conducted multi-level logistic regression analyses with three levels: year (I), employee characteristics (II), and hospital characteristics (III). Results: Northern region hospitals experienced lower disorder prevalences (odds ratios (OR) 0.58, 95% confidence intervals (0.40, 0.82) for mental and 0.56 (0.44, 0.73) for musculoskeletal disorders). Hospitals with yearly workloads of the highest versus lowest quintiles of inpatient days/1000 employee hours (486.0 vs. o42.6) and surgical cases/1000 employee hours (410.5 vs. o3.9) had greater odds of mental (1.29 (1.05, 1.57); 1.22 (1.05, 1.42)) and musculoskeletal (1.38 (1.21, 1.58); 1.21 (1.09, 1.34)) disorders. Conclusion: Opportunities exist for reduction in burden with hospital workload reduction. Further exploration of regional effects is needed. & 2009 Elsevier Ltd. All rights reserved. 1. Introduction Health planners are monitoring an increasingly wide range of factors, at different organizational and geographic levels, that likely impact on the health of populations. In British Columbia, Canada, policy makers and researchers are particularly concerned with better understanding the complex way that living and working conditions affect the health of working populations (BCPHO, 2000, Goal 1, pp. 21–41). However, the relative contribution of individual, neighbourhood, workplace, and regio- nal factors in explaining variations in health status among working populations remains under-researched (Muntaner et al., 2006). There are particular challenges in conducting this type of research in health-care workforces because conditions of work in this sector are constantly changing. The importance of under- standing the relative contribution of individual, neighbourhood, and workplace factors to the health of workers in the health-care sector goes beyond improvement simply in the prevention of injury and illness among health-care providers as it may also impact the accessibility and quality of health services for the general population (OAGBC, 2004). Accordingly this paper focuses on variation in health-care workers’ own health-care utilization across different kinds of work places, nested within regions. Workplace characteristics have been demonstrated to vary across work units (Elovainio et al., 2004) and health outcomes have been shown to vary across workplaces within the same sector (Johns, 1997; Houtman et al., 1998; Warren and Karasek, 1998; Shamian et al., 2002). Workplace factors important for health include: the way services are organized (Cohen et al., 2004), workplace size, unionization, health and safety practices (Shannon et al., 1997), and disability management practices (Hunt et al., 1993). In the health-care sector, mental and musculoskeletal disorders represent significant burdens (Koehoorn et al., 2006a) due to high levels of both psychological strain (Sullivan et al., 1999; Cheng et al., 2000; Ylipaavalniemi et al., 2005) and physical demands (Trinkoff et al., 2003). Hierarchical analyses have distinguished workgroup (Elovainio et al., 2004; Bliese and Jex, 2002) and hospital ward-level effects from individual-level effects ARTICLE IN PRESS Contents lists available at ScienceDirect journal homepage: www.elsevier.com/locate/healthplace Health & Place 1353-8292/$ - see front matter & 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.healthplace.2009.05.004 Ã Corresponding author at: Institute for Work & Health, 481 University Ave., 8th Floor, Toronto, Ont., Canada M5G 2E9. Tel.: +14169272027x2166; fax: +1 416 927 4167. E-mail addresses: dcole@iwh.on.ca, donald.cole416@gmail.com (D.C. Cole). Health & Place 15 (2009) 1046–1057