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====== Quality of Life (RAND-36) ======

The RAND-36 measures ‘Health Related Quality of Life’, i.e. how health impacts an individual’s ability to function and his or her perceived well-being in physical, mental and social domains of life((Hays RD, Morales LS. The RAND-36 measure of health-related quality of life. Ann Med 2001; 33:350-357)). [[sections|Section]]: [[Wellbeing & subjective health]].\\ 
The RAND-36 is highly similar to the [[https://en.wikipedia.org/wiki/SF-36|Short Form (36) Health Survey]].\\
The full RAND-36 was performed at [[1A|baseline]] and in the additional questionnaire [[EARQ]]. At several other assessments, only the first two items were assessed.\\
Note that [[https://en.wikipedia.org/wiki/Quality_of_life|quality of life]] is also assessed in Lifelines using the [[Life satisfaction (SWLS)|SWLS]] and [[Quality of Life (EQ5D)|EQ5D]] instruments. 


===== Background =====

The RAND-36 is comprised of 36 items selected from a larger pool of items used in the RAND Medical Outcomes Study (MOS).\\
Twenty of the items are administered using a past 4 weeks reporting interval. RAND-36 assesses eight health concepts with multi item scales (35 items): 
 
  * 10x physical functioning (RAND 03A-J, very limited/little limited/not limited)
  * 4x role limitations caused by physical health problems (RAND4A-D, yes/no)
  * 3x role limitations caused by emotional problems (RAND5A-C, yes/no)
  * 2x social functioning (RAND6/10, 5-point Likert scale)
  * 2x pain (RAND7/8, 5-point Likert scale) 
  * 5x emotional well-being (RAND9B/C/D/F/H, 6-point Likert scale)
  * 4x energy/fatigue (RAND9A/E/G/I, 6-point Likert scale)
  * 4x general health perceptions (RAND11A-D, 5-point Likert scale).

The additional items assess the general health perceived by participants (all on a 5-point Likert scale), either at the time of the questionnaire (RAND1), compared to a year ago (RAND2), or compared to the time of the previous questionnaire (RAND2A).

Please note, in assessment 3A, RAND6 and RAND8 were adapted to include the anwer option 'I do not know' (new code rand_social_adu_q_06_v2 / rand_social_adu_q_08_v2) to meet participants' wishes. 
Of note: in assessment 3A, RAND10 (rand_social_adu_q_10_v2) was mistakenly adapted to include the answer option 'often' (and not 'I do not know'). In addition, the variable received wrong enumerations in the data. On August 28th 2025, rand_social_adu_q_10_v2 was removed from the data catalogue and replaced by rand_social_adu_q_10_v2b, which includes the correct enumerations (as shown to participants in the questionnaire). Researchers who received rand_social_adu_q_10_v2 were informed (sept 2025).


===== Scoring =====

Scores between 0-100% can be calculated for each of the eight domains/scales. A higher score is indicative for higher well-being.\\ 
In addition, domains representing physical and mental health can be summarized into a “physical component score” and a “mental component score”.
Standard scoring procedures and syntaxes are available from Lifelines at request. 

===== Validity =====

The reliability and validity of the RAND 36-Item Health Survey 1.0 were investigated in a population sample of 1,063 inhabitants of a Dutch township (Emmen), all age 18 or older. 35% were male and 65% were female and the mean age of the sample was 44.1 years ((Van der Zee K, Sanderman R. Het meten van de algemene gezondheidstoestand met de RAND-36: een handleiding. Groningen: Noordelijk Centrum voor Gezondheidsvraagstukken; 1993)).\\

To assure __content validity__ in comparison with accepted definitions of health, multiple dimensions of health were included to the RAND-36 questionnaire. Dimensions of health that were most frequently included in health questionnaires, i.e. physical, social- and role functioning, mental health and general health perceptions were included. Two dimensions were included for which substantial empirical evidence existed, i.e. pain and vitality.\\ 
The __predictive value__ of the RAND-36 has been established using the prevalence of chronic complaints as criterion. Step-wise multiple regression showed that the eight RAND-36-scales explained 41% variance of the number of chronic conditions, 34% of the number of chronic conditions requiring a medical consult and 29% of the conditions for which drugs were prescribed.\\  
__Construct validity__ of the RAND-36 is indicated by:
  * Positive and significant correlations between RAND-36 scales and similar scales of the Nottingham health profile (NHP), Pearson’s r = 0.42-0.69, all p<0.001
  * Correlations of:
     * RAND-36 physical functioning scale and Groninger Activiteiten Restrictie Schaal (GARS), r=0.65, p<0.001
     * RAND-36 mental health scale and 
       * State and Trait Anxiety Inventory (STAI), r=-0.72, p<0.001 
       * Center for Epidemiological Studies Depression Scale (CES-D),r=-0.91, p<0.001 
       * Algemene Gezondheidsvragenlijst (AGV), r=0.76, p<0.001.
     * RAND-36 pain scale and self rated pain on a 0-10 scale, r=-0.55, p<0.001. 
The __internal consistency__ of the RAND-36 was moderate to high. Cronbach’s alpha values for the various scales varied from 0.71 for social functioning to 0.92 for physical functioning.\\ 
__Test-retest correlations__ were based on repeated measurements after two and six months in groups of 159 and 410 persons respectively. Test-retest correlations using a two month time interval varied from 0.58 for social functioning to 0.82 for physical functioning. Using a six months interval, the test-retest correlations varied from 0.40 (role restrictions due to emotional problem) to 0.75 (general health perception). This is acceptable for an instrument that is required sensitive to health changes over time.\\
__Responsiveness__ of the SF-36 (which is highly identical to RAND-36) has been demonstrated in the Whitehall II longitudinal cohort study (n=7267, mean follow-up=36 months)((Hemmingway H et al. Is the SF-36 a valid measure of change in population health? Results from the Whitehall II study. BMJ 1997; 315:1273-9
)). In this study, within-person change in scores on the SF-36 by age, sex, employment grade and disease status were measured. Health functioning, as measured by the SF-36 changed in hypothesized directions with age, employment grade and disease status, suggesting that the SF-36 and RAND-36 are sensitive to changes in health in general populations.\\
See also: ((Ware JE, Koskinski M, Keller SD. SF-36 physical and mental health summary scales: A user's manual 2nd ed. The Health Institute, Boston MA: 1994)) and ((van der Zee K, Sanderman R, Heyink JW, de Haes H. Psychometric qualities of the RAND 36-item Health Survey 1.0: A Multidimensional Measure of General Health Status. Int J Behav Med 1996; 3(2):104-22)).\\ 


===== Variables =====

| **Label English**                                                                                                                                                                  | **Label Dutch**                                                                                                                                                                          | **Code**                        | **Variable**  | **Assessment**                                                                                                                                                                            | **Age**  |
| How would you rate your health, generally speaking?                                                                                                                                | Wat vindt u, over het algemeen genomen, van uw gezondheid?                                                                                                                               | rand_generalhealth_adu_q_01     | RAND1         | [[1A Questionnaire 1|1A]] [[1B]] [[1C]] [[2A Questionnaire 1|2A]] [[2B]] [[3A Questionnaire 1|3A]] [[3B]] [[4A Questionnaire Health 1| 4A]] [[ACTQ]] [[COVQ]] [[EARQ]] [[MAWQ]] [[NEXT]]  | 18+      |
| Compared to a year ago, how would you rate your health, generally speaking?                                                                                                        | In vergelijking met een jaar geleden, hoe zou u nu uw gezondheid in het algemeen beoordelen?                                                                                             | rand_generalhealth_adu_q_02     | RAND2         | [[1A Questionnaire 1|1A]] [[1B]] [[1C]] [[2A Questionnaire 1|2A]] [[2B]] [[3A Questionnaire 1|3A]]  [[3B]] [[4A Questionnaire Health 1| 4A]] [[EARQ]] [[NEXT]]                            | 18+      |
| compared to the time you filled in [lifelines questionnaire 2a-1], how would you rate your health, generally speaking?                                                             | in vergelijking met de keer dat u [lifelines vragenlijst 2a-1] invulde, hoe zou u nu uw gezondheid in het algemeen beoordelen?                                                           | rand_generalhealth_adu_q_02_v2  | RAND2A        | [[ACTQ]]                                                                                                                                                                                  | 18+      |
| Does your health now limit you in the following activities?                                                                                                                        | Wordt u door op dit moment beperkt bij deze bezigheden? Zo ja, in welke mate?                                                                                                            |                                 |               |                                                                                                                                                                                           |          |
| Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.                                                                                    | Forse inspanning zoals hardlopen, zware voorwerpen tillen, inspannend sporten/                                                                                                           | rand_physical_adu_q_03_a        | RAND3A        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Moderate activities, such as moving a table, pushing a vacuum cleaner, bicycling.                                                                                                  | Matige inspanning zoals het verplaatsen van een tafel, stofzuigen, fietsen                                                                                                               | rand_physical_adu_q_03_b        | RAND3B        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Lifting or carrying groceries.                                                                                                                                                     | Tillen of boodschappen dragen                                                                                                                                                            | rand_physical_adu_q_03_c        | RAND3C        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Climbing several flights of stairs.                                                                                                                                                | Een paar trappen oplopen                                                                                                                                                                 | rand_physical_adu_q_03_d        | RAND3D        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Climbing one flight of stairs.                                                                                                                                                     | Een trap oplopen                                                                                                                                                                         | rand_physical_adu_q_03_e        | RAND3E        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Bending, kneeling or stooping.                                                                                                                                                     | buigen, knielen of bukken                                                                                                                                                                | rand_physical_adu_q_03_f        | RAND3F        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Walking more than a kilometer.                                                                                                                                                     | meer dan een kilometer lopen                                                                                                                                                             | rand_physical_adu_q_03_g        | RAND3G        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Walking half a kilometer.                                                                                                                                                          | een halve kilometer lopen                                                                                                                                                                | rand_physical_adu_q_03_h        | RAND3H        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Walking one hundred meters.                                                                                                                                                        | honderd meter lopen                                                                                                                                                                      | rand_physical_adu_q_03_i        | RAND3I        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Bathing or dressing yourself.                                                                                                                                                      | uzelf wassen of aankleden                                                                                                                                                                | rand_physical_adu_q_03_j        | RAND3J        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your Physical state?                           | Had u, ten gevolge van uw lichamelijke gezondheid, de afgelopen 4 weken een van de volgende problemen bij uw werk of andere dagelijkse bezigheden?                                       |                                 |               |                                                                                                                                                                                           |          |
| Cut down the amount of time you spent on work or other activities.                                                                                                                 | U hebt minder tijd kunnen besteden aan werk of andere bezigheden                                                                                                                         | rand_limitations_adu_q_04_a     | RAND4A        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Accomplished less than you would like.                                                                                                                                             | U hebt minder bereikt dan u zou willen                                                                                                                                                   | rand_limitations_adu_q_04_b     | RAND4B        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Were limited in the kind of work or other activities.                                                                                                                              | U was beperkt in het soort werk of het soort bezigheden                                                                                                                                  | rand_limitations_adu_q_04_c     | RAND4C        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Had difficulty performing the work or other activities (for example, it took extra effort).                                                                                        | U had moeite met het werk of andere bezigheden (het kostte u bijvoorbeeld extra inspanning)                                                                                              | rand_limitations_adu_q_04_d     | RAND4D        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Cut down the amount of time you spent on work or other activities.                                                                                                                 | U hebt minder tijd kunnen besteden aan werk of andere bezigheden                                                                                                                         | rand_limitations_adu_q_05_a     | RAND5A        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Accomplished less than you would like.                                                                                                                                             | U hebt minder bereikt dan u zou willen                                                                                                                                                   | rand_limitations_adu_q_05_b     | RAND5B        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Didn't do work or other activities as carefully as usual.                                                                                                                          | U hebt het werk of andere bezigheden niet zo zorgvuldig gedaan als u gewend bent                                                                                                         | rand_limitations_adu_q_05_c     | RAND5C        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| During the past 4 weeks, to what extent has your Physical state or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?    | In hoeverre heeft uw lichamelijke gezondheid of hebben uw emotionele problemen u de afgelopen 4 weken belemmerd in uw normale sociale bezigheden met gezin, vrienden, buren of anderen?  | rand_social_adu_q_06(_v2) *     | RAND6         | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| How much bodily pain have you had during the past 4 weeks?                                                                                                                         | Hoeveel pijn had u de afgelopen 4 weken?                                                                                                                                                 | rand_pain_adu_q_07              | RAND7         | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?                                                   | In welke mate heeft pijn u de afgelopen vier weken belemmerd bij uw normale werkzaamheden (zowel werk buitenshuis als huishoudelijk werk)?                                               | rand_pain_adu_q_08(_v2) *       | RAND8         | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| How much of the time during the past 4 weeks                                                                                                                                       | Hoe heeft u zich de afgelopen 4 weken gevoeld?                                                                                                                                           |                                 |               | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              |          |
| Did you feel full of pep?                                                                                                                                                          | Voelde u zich levenslustig?                                                                                                                                                              | rand_energy_adu_q_09_a          | RAND9A        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Have you been a very nervous person?                                                                                                                                               | Voelde u zich erg zenuwachtig?                                                                                                                                                           | rand_emotional_adu_q_09_b       | RAND9B        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Have you felt so down in the dumps that nothing could cheer you up?                                                                                                                | Zat u zo erg in de put dat niets u kon opvrolijken?                                                                                                                                      | rand_emotional_adu_q_09_c       | RAND9C        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Have you felt calm and peaceful?                                                                                                                                                   | Voelde u zich kalm en rustig?                                                                                                                                                            | rand_emotional_adu_q_09_d       | RAND9D        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Did you have a lot of energy?                                                                                                                                                      | voelde u zich erg energiek?/ Hoe heeft u zich de afgelopen 4 weken gevoeld?                                                                                                              | rand_energy_adu_q_09_e          | RAND9E        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Have you felt downhearted and blue?                                                                                                                                                | Voelde u zich neerslachtig en somber?                                                                                                                                                    | rand_emotional_adu_q_09_f       | RAND9F        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Did you feel worn out?                                                                                                                                                             | Voelde u zich uitgeblust?                                                                                                                                                                | rand_energy_adu_q_09_g          | RAND9G        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Have you been a happy person?                                                                                                                                                      | Voelde u zich gelukkig?                                                                                                                                                                  | rand_emotional_adu_q_09_h       | RAND9H        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Did you feel tired?                                                                                                                                                                | Voelde u zich moe?                                                                                                                                                                       | rand_energy_adu_q_09_i          | RAND9I        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| Did you feel control over your life?                                                                                                                                               | Voelde u controle over uw leven?                                                                                                                                                         |                                 | EQRAND9J      | [[EARQ]]                                                                                                                                                                                  | 18+      |
| During the past 4 weeks, how much of the time has your Physical state or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?  | Hoe vaak hebben uw lichamelijke gezondheid of emotionele problemen gedurende de afgelopen 4 weken uw sociale activiteiten (zoals bezoek aan vrienden of naaste familieleden) belemmerd?  | rand_social_adu_q_10(_v2b)*     | RAND10        | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| True or False?                                                                                                                                                                     | Waar of niet waar?                                                                                                                                                                       |                                 |               |                                                                                                                                                                                           |          |
| I seem to get sick a little easier than other people.                                                                                                                              | Ik lijk gemakkelijker ziek te worden dan andere mensen                                                                                                                                   | rand_perception_adu_q_11_a      | RAND11A       | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| I am as healthy as anybody I know.                                                                                                                                                 | Ik ben net zo gezond als andere mensen die ik ken                                                                                                                                        | rand_perception_adu_q_11_b      | RAND11B       | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| I expect my health to get worse.                                                                                                                                                   | Ik verwacht dat mijn gezondheid achteruit zal gaan                                                                                                                                       | rand_perception_adu_q_11_c      | RAND11C       | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
| My health is excellent.                                                                                                                                                            | Mijn gezondheid is uitstekend                                                                                                                                                            | rand_perception_adu_q_11_d      | RAND11D       | [[1A Questionnaire 1|1A]] [[3A Questionnaire 1|3A]] [[EARQ]]                                                                                                                              | 18+      |
* See remark in Background


===== Papers using Lifelines RAND-36 data =====

  * Elderson, M.F., Pham, S., Eersel, M.E.A. van, Study, L.C., Wolffenbuttel, B.H.R., Kok, J., Gansevoort, R.T., Tucha, O., Klauw, M.M. van der, Slaets, J.P.J., et al. (2016). Agreement between Computerized and Human Assessment of Performance on the Ruff Figural Fluency Test. PLOS ONE 11, e0163286.
  * Janssens, K.A.M., Zijlema, W.L., Joustra, M.L., and Rosmalen, J.G.M. (2015). Mood and Anxiety Disorders in Chronic Fatigue Syndrome, Fibromyalgia, and Irritable Bowel Syndrome: Results From the LifeLines Cohort Study. Psychosom. Med. 77, 449–457.
  * Joustra, M.L., Janssens, K.A.M., Bültmann, U., and Rosmalen, J.G.M. (2015). Functional limitations in functional somatic syndromes and well-defined medical diseases. Results from the general population cohort LifeLines. J. Psychosom. Res. 79, 94–99.
  * Klaver, E.I., van Loon, H.C.M., Stienstra, R., Links, T.P., Keers, J.C., Kema, I.P., Kobold, A.C.M., van der Klauw, M.M., and Wolffenbuttel, B.H.R. (2013). Thyroid hormone status and health-related quality of life in the LifeLines Cohort Study. Thyroid Off. J. Am. Thyroid Assoc. 23, 1066–1073.
  * Klijs, B., Mendes de Leon, C.F., Kibele, E.U.B., and Smidt, N. (2017). Do social relations buffer the effect of neighborhood deprivation on health-related quality of life? Results from the LifeLines Cohort Study. Health Place 44, 43–51.
  * Müller, F., Hagedoorn, M., and Tuinman, M.A. (2017). Chronic multimorbidity impairs role functioning in middle-aged and older individuals mostly when non-partnered or living alone. PLOS ONE 12, e0170525.
  * Nigatu, Y.T., Reijneveld, S.A., Jonge, P. de, Rossum, E. van, and Bültmann, U. (2016). The Combined Effects of Obesity, Abdominal Obesity and Major Depression/Anxiety on Health-Related Quality of Life: the LifeLines Cohort Study. PLOS ONE 11, e0148871.
  * Peters, L.L., Boter, H., Burgerhof, J.G.M., Slaets, J.P.J., and Buskens, E. (2015). Construct validity of the Groningen Frailty Indicator established in a large sample of home-dwelling elderly persons: Evidence of stability across age and gender. Exp. Gerontol. 69, 129–141.
  * Slagter, S.N., van Vliet-Ostaptchouk, J.V., van Beek, A.P., Keers, J.C., Lutgers, H.L., van der Klauw, M.M., and Wolffenbuttel, B.H.R. (2015). Health-Related Quality of Life in Relation to Obesity Grade, Type 2 Diabetes, Metabolic Syndrome and Inflammation. PloS One 10, e0140599.
  * Wouters, H.J.C.M., van Loon, H.C.M., van der Klauw, M.M., Elderson, M.F., Slagter, S.N., Kobold, A.M., Kema, I.P., Links, T.P., van Vliet-Ostaptchouk, J.V., and Wolffenbuttel, B.H.R. (2016). No Effect of the Thr92Ala Polymorphism of Deiodinase-2 on Thyroid Hormone Parameters, Health-Related Quality of Life, and Cognitive Functioning in a Large Population-Based Cohort Study. Thyroid 27, 147–155.
  * van Zon, S.K.R., Bültmann, U., Mendes de Leon, C.F., and Reijneveld, S.A. (2015). Absolute and Relative Socioeconomic Health Inequalities across Age Groups. PloS One 10, e0145947.
  * van Zon, S.K.R., Reijneveld, S.A., Mendes de Leon, C.F., and Bültmann, U. (2017b). The impact of low education and poor health on unemployment varies by work life stage. Int. J. Public Health.