Top

International Archives of Occupational and Environmental Health

Published in:

04-07-2023 | Bronchial Asthma | Original Article

Urine 2-hydroxyphenanthrene is associated with current asthma: evidence from NHANES 2007–2012

Authors: Lingyi Lu, Tingfeng Mao, Rui Xu, Lanxia Liu, Jiefeng Qian, Kai Yang, Anjie Yuan, Xinyue Wang, Rong Ni

Published in: International Archives of Occupational and Environmental Health | Issue 8/2023

Abstract

Objective

The current study aims to explore the effects of nine urine monohydroxy PAH metabolites (OHPAH) including 1-hydroxynaphthalene (1-OHNAP), 2-hydroxynaphthalene (2-OHNAP), 3-hydroxyfluorene (3-OHFLU), 9-hydroxyfluorene (9-OHFLU), 1-hydroxyphenanthrene (1-OHPHE), 2-hydroxyphenanthrene (2-OHPHE), 3-hydroxyphenanthrene (3-OHPHE), and 1-hydroxypyrene (1-OHPYR) on current asthma in people in the United States using a variety of statistical techniques.

Methods

A cross-sectional examination of a subsample of 3804 adults aged ≥20 from the National Health and Nutrition Examination Survey (NHANES) was conducted between 2007 and 2012. To investigate the relationship between urine OHPAHs levels and current asthma, multivariate logistic regression, Bayesian kernel machine regression (BKMR), and quantile g-computation (qgcomp) were utilized.

Results

In the multivariate logistic regression model, after controlling for confounders, urine 2-OHPHE was associated with current asthma in both male (AOR = 7.17, 95% CI: 1.28–40.08) and female (AOR = 2.91, 95% CI: 1.06–8.01) smokers. In the qgcomp analysis, 2-OHPHE (39.5%), 1-OHNAP (33.1%), and 2-OHNAP (22.5%) were the major positive contributors to the risk of current asthma (OR = 2.29, 95% CI: 0.99, 5.25), and in female smokers, 9-OHFLU (25.8%), 2-OHFLU (21.5%), and 2-OHPHE (15.1%) were the major positive contributors (OR = 2.19, 95% CI: 1.06, 4.47). The results of the BKMR model basically agreed with qgcomp analysis.

Conclusion

Our results demonstrate a strong association of urine 2-OHPHE with current asthma, and further longitudinal studies are needed to understand the precise relationship between PAH exposure and current asthma risk.

Available only for authorised users

Al-Daghri NM, Alokail MS, Abd-Alrahman SH, Draz HM, Yakout SM, Clerici M (2013) Polycyclic aromatic hydrocarbon exposure and pediatric asthma in children: a case–control study. Environ Health Global Access Sci Sour 12:1. https://doi.org/10.1186/1476-069X-12-1CrossRef

Alshaarawy O, Zhu M, Ducatman AM, Conway B, Andrew ME (2014) Urinary polycyclic aromatic hydrocarbon biomarkers and diabetes mellitus. Occup Environ Med 71(6):437–441. https://doi.org/10.1136/oemed-2013-101987CrossRef

Archibong AE, Inyang F, Ramesh A, Greenwood M, Nayyar T, Kopsombut P, Hood DB, Nyanda AM (2002) Alteration of pregnancy related hormones and fetal survival in F-344 rats exposed by inhalation to benzo(a)pyrene. Rep Toxicol (Elmsford, N.Y.) 16(6): 801–808. https://doi.org/10.1016/s0890-6238(02)00058-8

Aslam R, Sharif F, Baqar M, Nizami AS (2022) Association of human cohorts exposed to blood and urinary biomarkers of PAHs with adult asthma in a South Asian metropolitan city. Environ Sci Pollut Res Int. https://doi.org/10.1007/s11356-022-24445-zCrossRef

Becerra BJ, Arias D, Becerra MB (2022) Sex-specific association between environmental tobacco smoke exposure and asthma severity among adults with current asthma. Int J Environ Res Public Health 19(9): 5036. https://doi.org/10.3390/ijerph19095036

Bobb JF, Valeri L, Claus Henn B, Christiani DC, Wright RO, Mazumdar M, Godleski JJ, Coull BA (2015) Bayesian kernel machine regression for estimating the health effects of multi-pollutant mixtures. Biostatistics (oxford, England) 16(3):493–508. https://doi.org/10.1093/biostatistics/kxu058CrossRef

Bobb JF, Claus Henn B, Valeri L, Coull BA (2018) Statistical software for analyzing the health effects of multiple concurrent exposures via Bayesian kernel machine regression. Environ Health Global Access Sci Sour 17(1):67. https://doi.org/10.1186/s12940-018-0413-yCrossRef

Busse WW, Lemanske RF, Gern JE (2010) Role of viral respiratory infections in asthma and asthma exacerbations. Lancet (london, England) 376(9743):826–834. https://doi.org/10.1016/S0140-6736(10)61380-3CrossRef

Centers for Disease Control and Prevention (2017) National Center for Health Statistics: National Health and Nutrition Examination Survey. Last modified 18 June 2017. Available at: https://www.cdc.gov/nchs/nhanes/index.htm. Accessed 27 June 2017

Chowdhury NU, Guntur VP, Newcomb DC, Wechsler ME (2021) Sex and gender in asthma. Eur Resp Rev Off J Eur Resp Soc 30(162): 210067. https://doi.org/10.1183/16000617.0067-2021

Crinnion WJ (2012) Do environmental toxicants contribute to allergy and asthma? Alter Med Rev J Clin Ther 17(1): 6–18

de Nijs SB, Venekamp LN, Bel EH (2013) Adult-onset asthma: is it really different? Eur Resp Rev off J Eur Resp Soc 22(127):44–52. https://doi.org/10.1183/09059180.00007112CrossRef

Delfino RJ (2002) Epidemiologic evidence for asthma and exposure to air toxics: linkages between occupational, indoor, and community air pollution research. Environ Health Perspect 110(Suppl 4):573–589. https://doi.org/10.1289/ehp.02110s4573CrossRef

Gale SL, Noth EM, Mann J, Balmes J, Hammond SK, Tager IB (2012) Polycyclic aromatic hydrocarbon exposure and wheeze in a cohort of children with asthma in Fresno, CA. J Expos Sci Environ Epidemiol 22(4):386–392. https://doi.org/10.1038/jes.2012.29CrossRef

Gowers AM, Cullinan P, Ayres JG, Anderson HR, Strachan DP, Holgate ST, Mills IC, Maynard RL (2012) Does outdoor air pollution induce new cases of asthma? Biological plausibility and evidence; a review. Respirology (Carlton, Vic.) 17(6): 887–898. https://doi.org/10.1111/j.1440-1843.2012.02195.x

Guarnieri M, Balmes JR (2014) Outdoor air pollution and asthma. Lancet (london, England) 383(9928):1581–1592. https://doi.org/10.1016/S0140-6736(14)60617-6CrossRef

Hu J, Bao Y, Huang H, Zhang Z, Chen F, Li L, Wu Q (2022) The preliminary investigation of potential response biomarkers to PAHs exposure on childhood asthma. J Expos Sci Environ Epidemiol 32(1):82–93. https://doi.org/10.1038/s41370-021-00334-4CrossRef

Huang X, Zhou Y, Cui X, Wu X, Yuan J, Xie J, Chen W (2018) Urinary polycyclic aromatic hydrocarbon metabolites and adult asthma: a case–control study. Sci Rep 8(1):7658. https://doi.org/10.1038/s41598-018-26021-3CrossRef

Hudson-Hanley B, Smit E, Branscum A, Hystad P, Kile ML (2021) Trends in urinary metabolites of polycyclic aromatic hydrocarbons (PAHs) in the non-smoking U.S. population, NHANES 2001–2014. Chemosphere 276: 130211. https://doi.org/10.1016/j.chemosphere.2021.130211

Jenerowicz D, Silny W, Dańczak-Pazdrowska A, Polańska A, Osmola-Mańkowska A, Olek-Hrab K (2012) Environmental factors and allergic diseases. Ann Agric Environ Med AAEM 19(3): 475–481

Jia L, Wang Y, Li J, Li S, Zhang Y, Shen J, Tan W, Wu C (2017) Detection of IL-9 producing T cells in the PBMCs of allergic asthmatic patients. BMC Immunol 18(1):38. https://doi.org/10.1186/s12865-017-0220-1CrossRef

Jung KH, Yan B, Moors K, Chillrud SN, Perzanowski MS, Whyatt RM, Hoepner L, Goldstein I, Zhang B, Camann D, Kinney PL, Perera FP, Miller RL (2012) Repeated exposure to polycyclic aromatic hydrocarbons and asthma: effect of seroatopy. Ann Allergy Asthma Immunol off Publ Am Coll Allergy Asthma Immunol 109(4):249–254. https://doi.org/10.1016/j.anai.2012.07.019CrossRef

Karimi P, Peters KO, Bidad K, Strickland PT (2015) Polycyclic aromatic hydrocarbons and childhood asthma. Eur J Epidemiol 30(2):91–101. https://doi.org/10.1007/s10654-015-9988-6CrossRef

Keil AP, Buckley JP, O’Brien KM, Ferguson KK, Zhao S, White AJ (2020) A quantile-based g-computation approach to addressing the effects of exposure mixtures. Environ Health Perspect 128(4):47004. https://doi.org/10.1289/EHP5838CrossRef

Kim JH, Yamaguchi K, Lee SH, Tithof PK, Sayler GS, Yoon JH, Baek SJ (2005) Evaluation of polycyclic aromatic hydrocarbons in the activation of early growth response-1 and peroxisome proliferator activated receptors. Toxicol Sci off J Soc Toxicol 85(1):585–593. https://doi.org/10.1093/toxsci/kfi118CrossRef

Klingbeil EC, Hew KM, Nygaard UC, Nadeau KC (2014) Polycyclic aromatic hydrocarbons, tobacco smoke, and epigenetic remodeling in asthma. Immunol Res 58(2–3):369–373. https://doi.org/10.1007/s12026-014-8508-1CrossRef

Koch S, Sopel N, Finotto S (2017) Th9 and other IL-9-producing cells in allergic asthma. Sem Immunopathol 39(1):55–68. https://doi.org/10.1007/s00281-016-0601-1CrossRef

Kuang H, Liu J, Zeng Y, Zhou W, Wu P, Tan J, Li Y, Pang Q, Jiang W, Fan R (2020) Co-exposure to polycyclic aromatic hydrocarbons, benzene and toluene may impair lung function by increasing oxidative damage and airway inflammation in asthmatic children. Environ Pollut (Barking, Essex: 1987) 266(Pt 2): 115220. https://doi.org/10.1016/j.envpol.2020.115220

Låg M, Øvrevik J, Refsnes M, Holme JA (2020) Potential role of polycyclic aromatic hydrocarbons in air pollution-induced non-malignant respiratory diseases. Respir Res 21(1):299. https://doi.org/10.1186/s12931-020-01563-1CrossRef

Lazarevic N, Barnett AG, Sly PD, Knibbs LD (2019) Statistical methodology in studies of prenatal exposure to mixtures of endocrine-disrupting chemicals: a review of existing approaches and new alternatives. Environ Health Perspect 127(2):26001. https://doi.org/10.1289/EHP2207CrossRef

Liu L, Poon R, Chen L, Frescura AM, Montuschi P, Ciabattoni G, Wheeler A, Dales R (2009) Acute effects of air pollution on pulmonary function, airway inflammation, and oxidative stress in asthmatic children. Environ Health Perspect 117(4):668–674. https://doi.org/10.1289/ehp11813CrossRef

Liu H, Xu C, Jiang ZY, Gu A (2016) Association of polycyclic aromatic hydrocarbons and asthma among children 6–19 years: NHANES 2001–2008 and NHANES 2011–2012. Respir Med 110:20–27. https://doi.org/10.1016/j.rmed.2015.11.003CrossRef

Liu J, Chen X, Qiu X, Zhang H, Lu X, Li H, Chen W, Zhang L, Que C, Zhu T (2021) Association between exposure to polycyclic aromatic hydrocarbons and lipid peroxidation in patients with chronic obstructive pulmonary disease. Sci Total Environ 780: 146660. https://doi.org/10.1016/j.scitotenv.2021.146660

Loftus CT, Szpiro AA, Workman T, Wallace ER, Hazlehurst MF, Day DB, Ni Y, Carroll KN, Adgent MA, Moore PE, Barrett ES, Nguyen RHN, Kannan K, Robinson M, Masterson EE, Tylavsky FA, Bush NR, LeWinn KZ, Sathyanarayana S, Karr CJ (2022) Maternal exposure to urinary polycyclic aromatic hydrocarbons (PAH) in pregnancy and childhood asthma in a pooled multi-cohort study. Environ Int 170: 107494. https://doi.org/10.1016/j.envint.2022.107494

LoMauro A, Aliverti A (2021) Sex and gender in respiratory physiology. Eur Resp Rev Off J Eur Resp Soc 30(162): 210038. https://doi.org/10.1183/16000617.0038-2021

Lu L, Ni R (2023) Association between polycyclic aromatic hydrocarbon exposure and hypertension among the U.S. adults in the NHANES 2003–2016: a cross-sectional study. Environ Res 217: 114907. https://doi.org/10.1016/j.envres.2022.114907

Lu L, Ni R (2022) Bibliometric analysis of global research on polycyclic aromatic hydrocarbons and health risk between 2002 and 2021. Environ Sci Pollut Res Int 29(56):84034–84048. https://doi.org/10.1007/s11356-022-23047-zCrossRef

Maharjan L, Kang S, Tripathee L, Gul C, Zheng H, Li Q, Chen P, Rai M, Santos E (2022) Atmospheric particle-bound polycyclic aromatic compounds over two distinct sites in Pakistan: characteristics, sources and health risk assessment. J Environ Sci (china) 112:1–15. https://doi.org/10.1016/j.jes.2021.04.024CrossRef

Mallah MA, Changxing L, Mallah MA, Naveed M, Liu Y, Noreen S, Xi H, Wang W, Feng F, Zhang Q (2022) Association of urinary polycyclic aromatic hydrocarbon metabolites and cardiovascular disease among US population: a cross-sectional study. Environ Res 209: 112775. https://doi.org/10.1016/j.envres.2022.112775

Mattila T, Santonen T, Andersen HR, Katsonouri A, Szigeti T, Uhl M, Wąsowicz W, Lange R, Bocca B, Ruggieri F, Kolossa-Gehring M, Sarigiannis DA, Tolonen H (2021) Scoping review—the association between asthma and environmental chemicals. Int J Environ Res Public Health 18(3):1323. https://doi.org/10.3390/ijerph18031323CrossRef

Mazurek JM, Syamlal G (2018) Prevalence of asthma, asthma attacks, and emergency department visits for asthma among working adults—National Health Interview Survey, 2011–2016. MMWR Morbid Mortal Weekly Rep 67(13): 377–386. https://doi.org/10.15585/mmwr.mm6713a1

Miller RL, Garfinkel R, Lendor C, Hoepner L, Li Z, Romanoff L, Sjodin A, Needham L, Perera FP, Whyatt RM (2010) Polycyclic aromatic hydrocarbon metabolite levels and pediatric allergy and asthma in an inner-city cohort. Pediatr Allergy Immunol off Publ Eur Soc Pediatr Allergy Immunol 21(2 Pt 1):260–267. https://doi.org/10.1111/j.1399-3038.2009.00980.xCrossRef

Mirzababaei A, Daneshzad E, Moradi S, Abaj F, Mehranfar S, Asbaghi O, Clark CCT, Mirzaei K (2022) The association between urinary metabolites of polycyclic aromatic hydrocarbons (PAHs) and cardiovascular diseases and blood pressure: a systematic review and meta-analysis of observational studies. Environ Sci Pollut Res Int 29(2):1712–1728. https://doi.org/10.1007/s11356-021-17091-4CrossRef

Neophytou AM, Hart JE, Cavallari JM, Smith TJ, Dockery DW, Coull BA, Garshick E, Laden F (2013) Traffic-related exposures and biomarkers of systemic inflammation, endothelial activation and oxidative stress: a panel study in the US trucking industry. Environ Health Global Access Sci Sour 12:105. https://doi.org/10.1186/1476-069X-12-105CrossRef

Nguyen HD, Kim MS (2022) Cadmium, lead, and mercury mixtures interact with non-alcoholic fatty liver diseases. Environ Pollut (Barking, Essex: 1987) 309: 119780. https://doi.org/10.1016/j.envpol.2022.119780

Osborne NJ, Alcock I, Wheeler BW, Hajat S, Sarran C, Clewlow Y, McInnes RN, Hemming D, White M, Vardoulakis S, Fleming LE (2017) Pollen exposure and hospitalization due to asthma exacerbations: daily time series in a European city. Int J Biometeorol 61(10):1837–1848. https://doi.org/10.1007/s00484-017-1369-2CrossRef

Patel MM, Chillrud SN, Deepti KC, Ross JM, Kinney PL (2013) Traffic-related air pollutants and exhaled markers of airway inflammation and oxidative stress in New York City adolescents. Environ Res 121:71–78. https://doi.org/10.1016/j.envres.2012.10.012CrossRef

Patel AP, Mehta SS, White AJ, Niehoff NM, Arroyave WD, Wang A, Lunn RM (2021) Urinary polycyclic aromatic hydrocarbon metabolites and mortality in the United States: a prospective analysis. PloS One 16(6): e0252719. https://doi.org/10.1371/journal.pone.0252719

Peters MC, Wenzel SE (2020) Intersection of biology and therapeutics: type 2 targeted therapeutics for adult asthma. Lancet (london, England) 395(10221):371–383. https://doi.org/10.1016/S0140-6736(19)33005-3CrossRef

Pogun S, Yararbas G (2009) Sex differences in nicotine action. Handb Exp Pharmacol 192:261–291. https://doi.org/10.1007/978-3-540-69248-5_10CrossRef

Porsbjerg C, Melén E, Lehtimäki L, Shaw D (2023) Asthma. Lancet (London, England). https://doi.org/10.1016/S0140-6736(22)02125-0

Rahman HH, Niemann D, Munson-McGee SH (2022) Association of chronic kidney disease with exposure to polycyclic aromatic hydrocarbons in the US population. Environ Sci Pollut Res Int 29(16):24024–24034. https://doi.org/10.1007/s11356-021-17479-2CrossRef

Riedl MA, Nel AE (2008) Importance of oxidative stress in the pathogenesis and treatment of asthma. Curr Opin Allergy Clin Immunol 8(1):49–56. https://doi.org/10.1097/ACI.0b013e3282f3d913CrossRef

Schultz TW, Sinks GD (2002) Xenoestrogenic gene expression: structural features of active polycyclic aromatic hydrocarbons. Environ Toxicol Chem 21(4):783–786. https://doi.org/10.1002/etc.5620210414CrossRef

Shahsavani S, Fararouei M, Soveid M, Hoseini M, Dehghani M (2021) The association between the urinary biomarkers of polycyclic aromatic hydrocarbons and risk of metabolic syndromes and blood cell levels in adults in a Middle Eastern area. J Environ Health Sci Eng 19(2):1667–1680. https://doi.org/10.1007/s40201-021-00722-wCrossRef

Sun H, Shen OX, Xu XL, Song L, Wang XR (2008) Carbaryl, 1-naphthol and 2-naphthol inhibit the beta-1 thyroid hormone receptor-mediated transcription in vitro. Toxicology 249(2–3):238–242. https://doi.org/10.1016/j.tox.2008.05.008CrossRef

To T, Stanojevic S, Moores G, Gershon AS, Bateman ED, Cruz AA, Boulet LP (2012) Global asthma prevalence in adults: findings from the cross-sectional world health survey. BMC Public Health 12:204. https://doi.org/10.1186/1471-2458-12-204CrossRef

Torres-Moreno C, Puente-DelaCruz L, Codling G, Villa AL, Cobo M, Klanova J, Johnson-Restrepo B (2022) Polycyclic aromatic hydrocarbons (PAHs) in human breast milk from Colombia: spatial occurrence, sources and probabilistic risk assessment. Environ Res 204(Pt B): 111981. https://doi.org/10.1016/j.envres.2021.111981

Vinggaard AM, Hnida C, Larsen JC (2000) Environmental polycyclic aromatic hydrocarbons affect androgen receptor activation in vitro. Toxicology 145(2–3):173–183. https://doi.org/10.1016/s0300-483x(00)00143-8CrossRef

Wang L, Zhao Y, Liu X, Huang T, Wang Y, Gao H, Ma J (2015) Cancer risk of petrochemical workers exposed to airborne PAHs in industrial Lanzhou City, China. Environ Sci Pollut Res Int 22(24):19793–19803. https://doi.org/10.1007/s11356-015-5203-2CrossRef

Wang IJ, Karmaus WJ, Yang CC (2017a) Polycyclic aromatic hydrocarbons exposure, oxidative stress, and asthma in children. Int Arch Occup Environ Health 90(3):297–303. https://doi.org/10.1007/s00420-017-1198-yCrossRef

Wang Y, Meng L, Pittman EN, Etheredge A, Hubbard K, Trinidad DA, Kato K, Ye X, Calafat AM (2017b) Quantification of urinary mono-hydroxylated metabolites of polycyclic aromatic hydrocarbons by on-line solid phase extraction-high performance liquid chromatography–tandem mass spectrometry. Anal Bioanal Chem 409(4):931–937. https://doi.org/10.1007/s00216-016-9933-xCrossRef

Wang J, Zhang Y, Li B, Zhao Z, Huang C, Zhang X, Deng Q, Lu C, Qian H, Yang X, Sun Y, Sundell J, Norbäck D (2021) Asthma and allergic rhinitis among young parents in China in relation to outdoor air pollution, climate and home environment. Sci Total Environ 751: 141734. https://doi.org/10.1016/j.scitotenv.2020.141734

Wenzel SE (2012) Asthma phenotypes: the evolution from clinical to molecular approaches. Nat Med 18(5):716–725. https://doi.org/10.1038/nm.2678CrossRef

Wong TH, Lee CL, Su HH, Lee CL, Wu CC, Wang CC, Sheu CC, Lai RS, Leung SY, Lin CC, Wei YF, Wang CJ, Lin YC, Chen HL, Huang MS, Yen JH, Huang SK, Suen JL (2018) A prominent air pollutant, Indeno[1,2,3-cd]pyrene, enhances allergic lung inflammation via aryl hydrocarbon receptor. Sci Rep 8(1):5198. https://doi.org/10.1038/s41598-018-23542-9CrossRef

Wu D, Zhou J, Bi H, Li L, Gao W, Huang M, Adcock IM, Barnes PJ, Yao X (2014) CCL11 as a potential diagnostic marker for asthma? J Asthma off J Assoc Care Asthma 51(8):847–854. https://doi.org/10.3109/02770903.2014.917659CrossRef

Yang B, Shi Y, Xu S, Wang Y, Kong S, Cai Z, Wang J (2022) Polycyclic aromatic hydrocarbon occurrence in forest soils in response to fires: a summary across sites. Environ Sci Process Impacts 24(1):32–41. https://doi.org/10.1039/d1em00377aCrossRef

Zhang Y, Cheng D, Lei Y, Song J, Xia J (2022) Spatiotemporal distribution of polycyclic aromatic hydrocarbons in sediments of a typical river located in the Loess Plateau, China: influence of human activities and land-use changes. J Hazard Mater 424(Pt D): 127744. https://doi.org/10.1016/j.jhazmat.2021.127744

Title: Urine 2-hydroxyphenanthrene is associated with current asthma: evidence from NHANES 2007–2012
Authors: Lingyi Lu
Tingfeng Mao
Rui Xu
Lanxia Liu
Jiefeng Qian
Kai Yang
Anjie Yuan
Xinyue Wang
Rong Ni
Publication date: 04-07-2023
Publisher: Springer Berlin Heidelberg
Keyword: Bronchial Asthma
Published in: International Archives of Occupational and Environmental Health / Issue 8/2023
Print ISSN: 0340-0131
Electronic ISSN: 1432-1246
DOI: https://doi.org/10.1007/s00420-023-01994-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Urine 2-hydroxyphenanthrene is associated with current asthma: evidence from NHANES 2007–2012

Abstract

Objective

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 8/2023

The impact of ambient air pollutants on childhood respiratory system disease and the resulting disease burden: a time-series study

Influence of indoor volatile organic compounds and its relative respiratory effects among children living in rural biomass cooking households of Tamil Nadu and Andhra Pradesh

The effect of preference and actual days spent working from home on stress and musculoskeletal pain in older workers

How does the distribution of work tasks among home care personnel relate to workload and health-related quality of life?

Job demands and job control and their associations with disability pension—a register-based cohort study of middle-aged and older Swedish workers

Outcome assessment of a complex mental health intervention in the workplace. Results from the MENTUPP pilot study