Social support at work and work changes among cancer survivors in Norway

Transcription

1 Scandinavian Journal of Public Health, 2011; 39(Suppl 6): ORIGINAL ARTICLE Social support at work and work changes among cancer survivors in Norway STEFFEN TORP 1, SÆVAR B. GUDBERGSSON 2, ALV A. DAHL 2, SOPHIE D. FOSSÅ 2 & TONE FLØTTEN 3 1 Department of Health Promotion, Vestfold University College, Norway, 2 National Resource Center for Late Effects, Department of Oncology, Oslo University Hospital and University of Oslo, Norway, and 3 Fafo Institute for Labour and Social Research, Oslo, Norway Abstract Aims: To investigate how cancer survivors (CSs) experience the cancer-related support they get at the workplace, the proportion of CSs who change work due to cancer and the sociodemographic and work-related factors associated with CSs work changes. Methods: CSs of the 10 most common invasive types of cancer for men and women in Norway completed a mailed questionnaire months after primary treatment. All CSs who were working when diagnosed were included in the analyses (n ¼ 1115). Leaving the workforce and making other important changes in paid work were regarded as work changes. Results: When diagnosed with cancer, 84% of the CSs experienced their supervisor as caring vs. 90% for colleagues. At the time of the survey, 84% were still working; 24% had made changes in work due to the cancer. Work changes due to cancer were most common among CSs who reported low supervisor support related to the cancer (odds ratio (OR) 0.78) and high physical (OR 2.48) and psychological job demands (OR 1.39) at the time of diagnosis. Work changes were more common among self-employed CSs than among employees (OR 2.03). CSs with high education (OR 0.59) and medium income (OR 0.66) made fewer work changes than other CSs, but these differences were not significant when controlled for the work factors. Conclusions: Close follow-up by supervisors should be a key element in workplace health promotion programmes for CSs. Further, the programmes should target both physical and psychosocial work factors. Key Words: Cancer survivors, employment, health promotion, return to work, sociodemographic, work changes Introduction Preventing social inequity in health is one of the main aims of health promotion [1], and the Ottawa Charter for Health Promotion [2] emphasises the importance of building healthy public policies, creating supportive environments, and reorienting health services. Staying in work is important for most people of working age in order to maintain a decent standard of living, to uphold social contacts and self-esteem and to keep an identity as a normal and useful individual [3,4], thereby maintaining health and well-being. For society as a whole, keeping as many people in the workforce as possible is important for economic reasons but also to prevent health-related social inequity. The prevalence of cancer is increasing all over high-income countries, and much research has focused on preventing and treating cancer. Fewer studies have focused on the effects of cancer on living conditions in general and on work in particular and on which groups of cancer survivors (CSs) struggle to return to work. Such knowledge is necessary for politicians, social services, managers, trade unions, and occupational health services in their efforts to Correspondence: Steffen Torp, Department of Health Promotion, Faculty of Health Sciences, Vestfold University College, PO Box 2243, N-3101 Tønsberg, Norway. steffen.torp@hive.no (Accepted 4 December 2010) ß 2011 the Nordic Societies of Public Health DOI: /

2 34 S. Torp et al. help cancer survivors back to work and thereby prevent social inequity due to cancer-related impairment. Data from the Cancer Registry of Norway show that about 40% of the 25,000 Norwegians diagnosed with cancer in 2006 were years old [5], and an estimated 80% of these were employed or self-employed when diagnosed [6]. Almost two-thirds of the people diagnosed with cancer in Norway survive the first 5 years. Due to both the increasing prevalence and increasingly effective treatment regimens, more CSs are expected to be able and willing to return to work after treatment in the future. Reviews have concluded that the employment rate among CSs is 60 70% on average [7 10]. However, two recent Nordic registry studies show that 80 90% of CSs return to work [11,12]. Diagnosis, treatment, sociodemographic factors, and work factors influence the employment rates of CSs [7 10,13,14]. Although most CSs return to work, many report reduced physical and mental work ability [7,15 17]. It seems reasonable to assume that many CSs have to change their work situation to cope with the demands of work and everyday life. Most studies investigating the work situation among CSs have examined the employment rate and not investigated other types of changes in their work situation due to cancer such as changing job or position. In addition, most studies have investigated only selected groups of CSs, often treated at only one hospital [14]. According to our knowledge, only one study in Norway has investigated associations between work factors and changes in work among CSs, but that study solely included measures of work stress after primary treatment and did not include physical and psychosocial factors in previous work [18]. In general, social support from colleagues and management is important for work-related health, satisfaction and sick leave [19,20]. Supporting workers on sick leave and those in danger of permanently leaving the labour force has therefore been a particular recent focus in Norway s workplace policy, such as in the tripartite Inclusive Working Life Agreement [21]. There is relatively sparse knowledge on how employers and employees follow up the intention of giving such support in general [22], and there are no studies of whether such support affects how CSs specifically manage their return to work. The aim of this study among CSs in Norway with diverse types of cancer was to pinpoint factors that must be kept in mind in helping CSs to stay in the workforce after primary treatment. Hence, the objectives were to investigate: how many CSs changed work after their first cancer diagnosis and how many changed work due to cancer in the first years after primary treatment; how CSs experienced the cancer-related support they got at their workplace; and what sociodemographic and work-related factors were associated with CSs work changes due to cancer. The study was limited to CSs who were working when they were diagnosed with cancer, and work changes were defined as leaving the workforce or other changes in labour force status. Materials and methods Sampling of survivors This retrospective cohort study was part of the Cancer and Living Conditions project investigating the living conditions of CSs of working age in Norway using registry data, qualitative interviews and mailed questionnaires [23,24]. The results presented here are based on data collected from the mailed questionnaires. The Cancer Registry of Norway identified a sample of 2848 people who had been treated at four large hospitals in Norway. The eligibility criteria were: (1) aged years at the time of diagnosis; (2) diagnosed for the first time between 1 January 2005 and 31 December 2006; and (3) diagnosis being one of the 10 most common invasive types of cancer among men and women in Norway. The following 15 types of cancer were included (ICD-10 code in parentheses); colon (C18), rectum (C19 C21), lung (C33 C34), melanoma (C43), breast (C50), cervix (C53), uterus (C54), ovary (C56), prostate (C61), testis (C62), bladder (C66 C68), central nervous system (C70 C72), thyroid (C73), non-hodgkin lymphoma (C82 C85, C96), and leukaemia (C91 C95). To exclude people considered inappropriate to address or not accountable, the doctors responsible for patients at the four hospitals applied the following exclusion criteria: (1) recent death; (2) patients who were unaware that they were diagnosed with cancer; (3) and patients considered too ill to receive the questionnaire. Procedures and response rates The responsible doctors thus excluded 326 patients during autumn The researchers were responsible for sending (and collecting) the questionnaires

3 to the 2522 eligible patients. The data were collected in February and March 2008, months after primary treatment. The participants responded anonymously, so no reminders were possible. Thirty-six questionnaires were returned with unknown addresses, and 29 patients were reported dead. Seven patients responded I do not have cancer. Among the remaining 2486 CSs, 1343 (54%) returned a completed questionnaire. Of these, we defined the CSs who were employed or self-employed when diagnosed with cancer as the study sample (n ¼ 1115). Questionnaire variables Overall, the questionnaire consisted of 73 questions covering health, treatment, rehabilitation, sociodemographic factors, cancer-related changes in income, support from private and public offices, cancerrelated changes in the living conditions of children and spouses, ability to work, sick leave, and employment and work environment factors before diagnosis, immediately after diagnosis, and at the time of the survey. The questions on sociodemographics and income were mostly taken from studies done by Statistics Norway [25] and Fafo [26], and questions on cancer and work were mostly selected from the Nordic Study Group of Cancer and Work Life (NOCWO) [18]. Some questions had to be adapted to fit the scope and design of the study, and some were constructed specifically for this study. Social support and work changes among cancer survivors 35 Employment Labour force status at the time of this survey was measured through a question from Statistics Norway using 11 mutually exclusive response alternatives: employed, self-employed, participating in a job creation programme, unemployed, temporarily laid off, disability benefit, early retirement, rehabilitation benefit, homemaker, student, and other. CSs on sick leave were asked to indicate which of the alternatives they were on leave from. In Norway, job creation programmes and rehabilitation benefit provide public financial and practical support to workers unable to stay in their current profession due to impaired health. Workers unable to return to work after 1 year of sick leave but still not qualifying for disability benefit are entitled to such public support to obtain a new educational qualification or profession that enables them to stay in the workforce. Work changes due to cancer were covered by a question specifically constructed for this study: Have you changed your labour force status since you were diagnosed? The question had four response alternatives: (1) no changes; (2) yes, and the change was mainly due to cancer; (3) yes, and the change was partly due to cancer; and (4) yes, but the change was not due to cancer. In the analysis including work changes as a dependent variable, the responses were dichotomised into no changes or changes not due to cancer (¼0) vs. changes due to cancer (¼1). Cancer-related and sociodemographic factors The types of cancer were self-reported, and so was recurrence. The CSs stated whether they were receiving current treatment or not. The questions on sociodemographic factors registered the situation at the time of the survey except for income, which was for the preceding year, Age and sex were registered. The level of basic education was rated at four levels and grouped into three: primary school (9 years), secondary school (10 12 years), and university or university college (412 years). Family status was grouped into four categories: single without children (single, separated, divorced, widowed without children younger than 18 years in the household), single with children, paired (married or cohabiting) without children, and paired with children. Household income was measured as the household s total gross income per month and grouped into NOK 35,000 (low), NOK 35,001 70,000 (medium), and 4NOK 70,000 (high) (E1 is about NOK 8). Work-related factors All questions on work-related factors serving as independent variables in this study concerned the work situation when the CSs were diagnosed. Work position had the alternatives of worker, supervisor, or top manager. The hours worked per week were rounded off to whole hours. The employment sectors were divided into state employees, municipal and county employees, private employees, or selfemployed. The respondents answered yes or no for each of the alternatives, implying that they could be employed in more than one sector. Physical strain at work was measured by using the question How would you describe the work you had when you were diagnosed with cancer? adapted from the Hordaland Health Study [27]. The response alternatives were sedentary work (such as office work or montage), mostly walking at work (such as shop clerk, light industrial work, or teaching), much walking and heavy lifting (such as nursing and construction work), and heavy manual work (such as lumbering, heavy farming, or heavy

4 36 S. Torp et al. construction work). In the analysis, the two last alternatives were grouped into one category called manual work. Six questions on psychosocial work factors were taken from the Demand Control Support Questionnaire [28,29] and modified to measure the work situation at diagnosis. The questions were changed to statements to fit the style of the rest of the questionnaire. Psychological demands were measured by using two items on work tempo and asking whether the respondent had enough time to complete work tasks. Decision latitude was measured by using two items on the opportunities to learn new things at work and opportunities to decide how to carry out work. Social support was measured by using two items on support in general from supervisor and from colleagues. All questions had five response alternatives ranging from do not agree at all to completely agree. The scores were summed for each item and divided by 2 for each measure. Higher scores indicate higher demands, decision latitude, and social support. Cancer-related support at work Social support at work related to the cancer was measured by using the Structural-Functional Social Support Scale, a multidimensional instrument especially addressing the structural (social network) and functional aspects of the social relationships of people with severe diseases [30,31]. The scale measures the amount of perceived workplace social support given by supervisors and colleagues. Support from supervisors included: (1) maintaining contact while on sick leave; (2) showing care and understanding; (3) giving good advice; and (4) considering the illness. Support from colleagues included: (1) maintaining contact during illness; and (2) showing care and understanding. The scores were 5-point Likert scales: strongly agree (¼1), agree (¼2), neither agree nor disagree (¼3), disagree (¼4), and strongly disagree (¼5). In the descriptive analysis, this variable was recoded into (A) disagree or strongly disagree, (B) neither agree nor disagree, or (C) agree or strongly agree. For each of the six questions the respondents could also say not relevant if they did not have colleagues or a supervisor or regarded the question as irrelevant for another reason. These responses were recorded as missing for each question. For the bivariate and multivariate analysis, two cancer-related support indexes were constructed: supervisor support and colleague support. The scores from 1 to 5 were recoded so that a higher score indicates higher support. The scores for the four supervisor support questions were summed and divided by 4, and the scores for the two colleague support variables were summed and divided by 2. One question asked whether the CSs had been in contact with the occupational health service in relation to the cancer. The response alternatives were no (¼0) and yes (¼1). Statistical analysis Descriptive analysis was performed for all the variables included. The associations between all the independent variables and work changes were analysed by using bivariate logistic regression analysis. The independent variables significantly associated with work changes were included in a multivariate logistic regression analysis. The strengths of associations are presented as odds ratios (OR) with 95% confidence intervals (95% CI). Student s t-test was used to measure differences between men and women regarding work changes and cancer-related support. McNemar s test was used to measure differences between the support received from supervisors and colleagues. All the cancer patients had not answered all the questions included in the questionnaire. The reported percentages and means are all based on the number of valid responses and not on the total number of CSs included. Most of the percentages therefore differ slightly from a percentage calculated by use of a total n ¼ Likewise, the bivariate and multivariate analyses are based on the number of valid responses for each analysis. No missing substitution was performed when constructing indexes. The significance level was set at p < 0.05, and all tests were two-sided. PASW Statistics 18 [32] was used for the statistical analyses. Ethics The Regional Committee for Medical Research Ethics of South-Eastern Norway and the Norwegian Data Inspectorate approved the study. All invited CSs received written information about the study from their treating hospital and agreed to participate by returning the questionnaire. Results Description of the respondents Of the 1115 participating CSs, 765 (69%) were women, 338 (31%) were men, and 12 (1%) did not report their sex. The most common diagnoses among women were breast cancer (64%, 490) and cancer of

5 the female genital organs (18%, 138) and, among men, prostate and testicular cancer (46%, 155) and lymphoma (14%, 46). In total 15% (168) were being treated at the time of the survey, and 14% (149) reported that they had had metastases. We do not know whether the CSs were free from their cancer or had any tumour activity. The mean age of the respondents was 52 years (28 64, SD 8.3): 11% (117) were <40 years, 22% (245) were years, 47% (515) were years, and 20% (222) were years. Nineteen per cent (209) had 9 years of formal education, 31% (337) years, and 51% (557) 12 years. Eighteen per cent (199) lived alone without children, 4% (46) lived alone with children, 52% (578) lived together with a partner without children, and 26% (284) lived with a partner and children. Thirty-nine per cent (438) had a monthly household income of NOK 35,000, 36% (402) NOK 35,001 70,000, and 25% (278) 4NOK 70,000. Table I shows the work-related characteristics of the CSs. Changes in work A total of 1073 CSs responded to the question on labour force status at the time of the survey. Of these, 84% (905) reported that they still were employed or self-employed. Of those who had not returned to work, most were receiving rehabilitation benefit (9%, 93), disability benefit (4%, 44), and early Table I. Work characteristics of cancer survivors (n ¼ ). Characteristic % (n) Mean standard deviation Social support and work changes among cancer survivors 37 retirement (1%, 12). Only between one and six people reported any of the other six alternatives for labour force status. Thirty-six per cent (395) of the 1086 CSs who responded to the question on changes in work confirmed making such changes after being diagnosed (Table II). Twenty-four per cent (258) had made the work changes mainly or partly due to cancer. There was no significant sex difference regarding work changes due to cancer. Cancer-related social support at the workplace Seventy-seven per cent (720) of the 933 CSs who regarded the question to be relevant reported that the supervisor kept in touch with them while they were on cancer-related sick leave and 17% (160) did not. The remaining 6% (53) responded that they neither agreed nor disagreed with the statement on whether the supervisor maintained contact or not. Eightyfour per cent (812) had perceived the supervisor as caring and understanding and 9% (82) had not. Sixty-four per cent (517) reported that the supervisor had considered the disease when planning work tasks upon return to work and 24% (263) said that the supervisor had given useful advice on the possibilities of staying in work. Compared with the supervisors, more colleagues kept contact (83%, 816) and showed care and understanding (90%, 909) (p < 0.001). The average score on the colleague support index was significantly higher among the women than among the men (p < 0.001). Only 7% (73) of the CSs had been in contact with the occupational health service after they got cancer. Sector State 25 (274) Municipality or county 23 (252) Private sector 45 (494) Self-employed 9 (98) Hours worked per week Position Worker 68 (732) Supervisor 20 (216) Top manager 12 (133) Physical work environment Sedentary work 51 (557) Mostly walking at work 26 (280) Manual work 23 (251) Psychosocial work environment Psychological demands Decision latitude Social support Cancer-related support Supervisor Colleagues Contact with occupational 7 (73) health service Effect of sociodemographic and work factors on work changes due to cancer In the bivariate analysis (Table III), age, sex, and family status were not significantly related to change in work due to cancer. CSs with more than 12 years of education less often made changes than CSs with less education (OR 0.59, 95% CI ). CSs with medium household income less often made changes compared with CSs with low income (OR 0.66, 95% CI ). The number of work hours per week and whether the respondent was a supervisor or top manager were not significantly associated with work changes due to cancer (Table III). Work changes did not differ significantly between public-sector and privatesector employees, but self-employed people more frequently made changes than the other groups (OR 2.03, 95% CI ). Workers experiencing a higher physical workload (OR 2.48, CI 1.75

6 38 S. Torp et al. Table II. Cancer survivors (CSs) changes in work (n ¼ 1086). All CSs CSs who changed work (n ¼ 395) n % % Did not change work Changed work: Mainly due to the cancer Partly due to the cancer Not due to the cancer Total ), higher psychological demands (OR 1.39; 95% CI ), lower decision latitude (OR 0.78; 95% CI ), and lower social support (OR 0.71; 95% CI ) when diagnosed changed work more frequently than workers with lower physical workload, lower demands, and higher decision latitude and social support. CSs who had perceived their supervisor (OR 0.78; 95% CI ) and colleagues (OR 0.80; 95% CI ) as being supportive after getting cancer made changes less frequently than the CSs who had experienced their supervisor or colleague as being less supportive (Table III). In the multivariate analysis (Table III), manual work (OR 2.49, 95% CI ), psychological demands (OR 1.68, 95% CI ), and cancerrelated supervisor support (OR 0.81, 95% CI ) remained significant. Stepwise analysis (data not shown) showed that the relationship between being self-employed and work changes was reduced to nonsignificance when cancer-related supervisor support was added to the regression model. Discussion More than one-third of those active in the labour force made changes in work after being diagnosed and before the survey, and two-thirds of these changes were due to cancer. Immediately after being diagnosed, 84% (812) of the CSs in paid work perceived the supervisor as caring and understanding vs. 90% (909) for the colleagues. Work changes due to cancer were significantly most prevalent among CSs who had manual work and high psychological job demands at diagnosis. CSs who perceived the supervisor as being supportive while on sick leave and when returning to work made significantly fewer changes than other CSs. Self-employed people made significantly more changes than employees working in the private sector or public sector. Methodological limitations It was necessary to let the present vulnerable group of cancer patients respond anonymously to get this study approved by the Norwegian Data Inspectorate and the Regional Committee for Medical Research Ethics of South-Eastern Norway. Anonymous studies tend to get higher response rates than studies in which the participants are not anonymous, and the respondents may also respond more honestly to sensitive questions. The disadvantage of anonymous studies is that reminders and attrition analysis are not possible. Response rates between 50% and 60% are common in studies similar to the present one (response rate ¼ 54%), but such response rates may limit the external validity of the results. We do not know whether the respondents differed from the total group invited to participate but the distribution of diagnoses is similar to the group of cancer patients treated at the participating hospitals. Compared with national data, breast cancer patients were over-represented in the four hospitals and also in our data material [24]. If the respondents are skewed on some sociodemographic variables, this may affect the descriptive analysis, but such skewness will probably reduce variance and ultimately result in conservatively estimated relationships. We do not know the physical status of the CSs or when they returned to work after treatment. These factors may influence how the participants regarded their physical and psychosocial work environment and thereby affect the relationships found for work changes. The strengths of our study are including all the most common cancer diagnoses, since most other studies focus on one or a few types of cancer, and including CSs treated at four hospitals in different regions. Recall bias may limit the reliability of the data, but since the study was performed shortly after the respondents were diagnosed, we do not consider this a major limitation.

7 Social support and work changes among cancer survivors 39 Table III. Logistic regression of change in work due to cancer by sociodemographic, work-related and cancer-related support factors (n ¼ ). Bivariate Multivariate Factor Odds ratio 95% CI Odds ratio 95% CI Sociodemographic factors Age (years) <40 (reference) Sex Male (reference) 1.00 Female Education Primary school (9 years) (reference) Secondary school (10 12 years) University or university college (412 years) Family status Single without children (reference) 1.00 Single with children Paired without children Paired with children Household income per month a NOK 35,000 (reference) 1.00 NOK 35,001 70, NOK 70, Work factors Sector State Municipality or county Private sector Self-employed Hours worked Hours worked per week Position Worker (reference) 1.00 Supervisor Top manager Physical work environment Sedentary work (reference) Mostly walking at work Manual work Psychosocial work environment Psychological demands Decision latitude Social support Cancer-related support at work Cancer-related support Supervisor Colleagues Contact with occupational health service No (reference) 1.00 Yes Constant 0.12 Significant relationships in bold. a E1 is about NOK 8. Social support and changes in work The proportion of CSs staying in paid work (84%, 905) in this study is similar to that in other Nordic studies on returning to work [12,33]. Nevertheless, this study shows that as many as 24% (258) change their labour force status because of cancer and that an additional 13% (137) make such changes due to other reasons (Table II). That is, CSs make

8 40 S. Torp et al. important changes in work that are not captured if only employment status is measured. In our study, we do not know exactly the kind of work changes the employed and self-employed people made, but other Nordic studies [18,34] have shown that changing occupation, employer, or work tasks is common. Since other studies have shown that many CSs struggle with fatigue and consequently reduced physical and mental working capacity [15,17,35], most cancer-related changes in work are probably due to this. Supervisors and colleagues seem to provide care and understanding to working CSs in Norway. Nevertheless, 9% (82) of the workers did not perceive this. We do not know whether this is due to lack of knowledge about CSs needs or due to discrimination. Even though health-related workplace discrimination may not be a major problem [8], this may occur among CSs [36 38]. Since support from supervisors and colleagues immediately after getting cancer seems to reduce the probability of work changes later in the cancer trajectory (Table III), this should still be a focus of occupational health services, managers, and health and safety personnel concerned with rehabilitation and health promotion among CSs. Sociodemographic and work-related factors In accordance with Nordic studies [12,33] investigating the effects of sociodemographic factors on CSs returning to work, our study showed that more highly educated CSs were less likely to change work (Table III). Medium income also negatively affected work changes, as Carlsen et al. [12] showed for unemployment among CSs in Denmark. However, the effects of the sociodemographic factors did not reach significance when entered simultaneously with workrelated factors in the multivariate regression analysis. This indicates that the work-related factors moderate the effects of sociodemographic factors on changes in work. One might expect differences in work changes between employees in the public sector and the private sector since work tasks and attitudes towards accommodation of work might differ, but work changes did not differ between these groups. Nevertheless, self-employed CSs more often reported changes in work than employed CSs (Table III). The reasons why the self-employed CSs made more work changes than other CSs may be that the strain of being self-employed is particularly high and that running a business while having a lifethreatening disease may be risky. Other reasons may be that self-employed people have different insurance arrangements and rights than employees or that self-employed people do not have close colleagues and managers that draw them back to work. We do not know of any studies investigating the reasons for work changes among self-employed CSs in depth, but our results differ from those of a study in Canada showing no reduction in the number of self-employed breast CSs 3 years after primary treatment [39] and a study in Denmark showing less unemployment among self-employed CSs than among employed CSs [12]. CSs with a heavy physical workload changed work more frequently than CSs with less demanding work (Table III). This is in accordance with studies on returning to work [7,8] and with a recent Nordic study on work changes [34] that found that the physical demands of previous work were the most important reason for changing employers among working CSs. In accordance with our results, that study found that changing employers was associated with cancer-related support from supervisors. Gudbergsson et al. [40] found that working CSs did not report more occupational stress when returning to work than controls. Nevertheless, our results show that having high psychological demands, low control, and low general social support at work when getting cancer may increase the propensity to change work later in the trajectory. Only 7% (73) (Table I) of the CSs had been in contact with the occupational health service. In a comparative study of breast CSs, Norwegians were less satisfied than Finns with the support received from the occupational health service [30]. This indicates that occupational health services in Norway have potential to improve their efforts to rehabilitate CSs. The supervisor is a key person [41], should closely collaborate with the occupational health services in rehabilitating workers and should be an important partner in the future rehabilitation of CSs as they are for workplace health promotion in general. In addition to occupational health services, supervisors and employers focusing more attention on the specific needs of CSs, closer follow-up by social workers at an early stage might help these workers to return to work more smoothly. The results of our study on work changes and of studies on returning to work [14,33,42] indicate that CSs with lower socioeconomic status (low education and income and high physical and psychological strain) leave the workforce or have to make other important changes in work significantly more often than other CSs. Johansen [42] argues that future rehabilitation programmes for people with cancer must include the perspective of social inequity in the health of CSs. He maintains that current

9 rehabilitation practice is based on intellectual literacy, middle-class values, and individual responsibility for health. He does not mention the importance of work factors and rehabilitation in the workplace as a setting, but we assert that the workplace is one of the most important settings for identifying workers needing special attention and for performing effective rehabilitation to reduce social inequity. Conclusions This study shows that work factors such as physical and psychological demands and cancer-related support from supervisors are important for changes in work in a sample of CSs in Norway. These work factors seem to moderate the effects of education and income on work changes. Public authorities, employers, unions, and health services concerned with workplace health promotion should have this in mind when planning follow-up programmes for CSs. 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