The Value of Occupational Health Research

History, Evolution and Way Forward

June 2019 THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 3

RECOMMENDATIONS

Recommendation 1: Recommendation 7: There is a requirement for a co-ordinating body in the High quality economic evaluation studies are required UK to provide leadership on OH research, to disseminate across the different OH research areas to establish their research to key stakeholders simply and meaningfully economic value, to help decision makers to make best and to facilitate the translation of research into practice. use of resources and potentially strengthen the business Further functions should be to grow and support the OH case to employers and Government. academic base through training and development, to Recommendation 8: attract research funding to the specialty and to promote The benefits of OH can accrue to a wide range the value of OH research (see recommendations below). of stakeholders hence broad societal perspective Recommendation 2: economic evaluations are required. New guidance on A national co-ordinated OH research strategy is required conducting and reporting economic evaluations are to progress the research agenda and inform policy recommended for this purpose. Economic evaluations of development. Current research priorities have recently OH interventions and services should include a long-term been identified from two UK studies1, 2 and these can time horizon, allow for reporting multiple sector effects be used as a platform. To date, what has been lacking is and report costs and outcomes from a broad societal collaboration with research funding organisations. This perspective along with other perspectives including the would be essential to the success of any strategy, as NHS and the employer. Frameworks such as cost-benefit would their continued engagement with the evolving analyses, return on investment and cost-consequences OH research agenda. analyses are likely to capture the effects beyond the traditional, narrower, cost-effectiveness methods. Recommendation 3: Urgent attention needs to be given to retaining and Recommendation 9: developing the OH academic base; to attract, train and The feasibility and implementation of many of the support new OH researchers with appropriate resourcing recommendations above will only be possible with for this. Unlike other clinical disciplines, there are no funding investment in OH research. Government, established pathways for academic training and careers in employers and industry, as co-beneficiaries of workplace OH research and neither is there a co-ordinated approach health, should lead this investment. Potential gains could across the UK or in its constituent countries. This is a include: healthy working lives with improved workforce AUTHORED BY: CONFLICTS OF INTEREST: fundamental barrier that needs to be addressed. productivity and retention, improved public health and a None thriving national economy. Recommendation 4: Dr Drushca Lalloo Improved dissemination and better ‘marketing’ of key and Additional recommendations for the provision of Consultant Physician in Occupational Medicine, Integral ACKNOWLEDGMENTS relevant OH research findings is required to promote their multidisciplinary OH clinical services as a whole OH Ltd, Honorary Senior Clinical Lecturer, Healthy Working AND DISCLAIMER: ‘value’ among key stakeholders including OH clinicians, (linking to the OH research agenda): Lives Group, University of Glasgow. employers, employees and Government. The SOM is grateful to the Health Recommendation 1: Professor Ewan Macdonald OBE and Safety Executive for their Recommendation 5: The gaps in OH provision should be addressed. There is Head of Healthy Working Lives Group, University of financial support for this report. Its Current research priorities of employers, human resources incomplete OH coverage of the working population due Glasgow, Chair of UK FOM/SOM Academic Forum for contents, including any opinions and worker representatives should be identified. to a system of self-funded and optional provision of OH Health and Work, Director, MacOH Ltd. and/or conclusions expressed, are Addressing their priorities could be an important measure services by employers. Small and Medium Enterprises those of the authors alone. to ‘add’ value. (SMEs) in particular have poor coverage and there is no Dr Sergio Vargas-Prada Figueroa systematic coverage of the unemployed working age Recommendation 6: Consultant Physician in Occupational Medicine, Salus, The authors would like to thank population. Alternative models of OH provision for the There is a need for integration of technological advances Honorary Senior Research Fellow, Healthy Working Lives Professor David Coggon, Professor UK working age population should be investigated and into OH research and incorporation of more innovative Group, University of Glasgow. Damien McElvenny and Professor potential new models assessed with rigorous evaluation methodologies, particularly in the fields of occupational Consuelo Serra-Pujadas for their and research. Dr Evi Germeni external reviews. database development, social media and artificial Lecturer in Qualitative Methods for Health Research, intelligence. This forward thinking and ‘cutting-edge’ Recommendation 2: HEHTA, University of Glasgow. They would also like to extend a approach is likely to increase the OH research profile The numbers of clinical and other staff providing special thanks to the qualitative and attract the attention of funding organisations and OH need to increase, through more training posts Professor Emma McIntosh interview participants and prospective OH researchers. and recruitment. OH remains a poorly publicised and Professor of Health Economics, Nick Pahl (CEO, SOM) for his understood specialty. Much work is still needed to HEHTA, University of Glasgow support of this project. increase its profile and to ‘market’ careers in OH. THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 5

TABLE OF CONTENTS

Recommendations 3 Executive summary 6 1. Defining occupational health research 8 2. The historical background of occupational health research 8 3. The evolution of work 9 4. Recent and current developments in occupational health research 10 5. The burden of health on work and work-related ill health 12 6. Establishing research priorities 12 7. Resourcing in occupational health research 13 8. Translating research into practice and policy changes 14 9. Definition of value 15 10. Scoping review of economic evaluation workplace interventions 15 Methodology of the review 16 Search strategy 16 Data extraction and synthesis 16 Types of interventions: 16 a) Health promotion interventions 15 b) Ergonomic interventions 16 c) Interventions in relation to employability, work adjustments, work rehabilitation and return to work 17 d) Psychosocial interventions 17 Methodology assessment of economic evaluations 17 Summary of scoping review and economic evaluation methodology findings 18 11. Stakeholder perspectives 19 a) What has OH research ever done for us? 20 b) Key challenges in moving forward 20 12. Discussion 22 a) The economic value 22 b) The occupational health, public health and societal value 22 13. Conclusion 26 14. Tables 27 15. References 34 THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 7

Indeed, the impact of this historical OH research has been are a thing of the past. However, this shift in industry, EXECUTIVE SUMMARY much wider in that it has also contributed to the broader technological advances and the global economic drive understanding of disease mechanisms, particularly in the have brought with them new occupational hazards. As a follow-on to the two previous UK and Global reports Systematic reviews to evaluate the cost-effectiveness of fields of toxicology and carcinogenesis, and recognition of With rapidly evolving work situations, new hazards will on the value of occupational health (OH)3, 4, the aim of this OH interventions6-9 have identified poor methodological the significance of environmental exposures. inevitably emerge and, as has been the case historically, it is imperative that there is robust epidemiological evidence report was to assess the value of OH research. quality as a key barrier to drawing meaningful conclusions. Historically, much of what was known about the causes It has been five years since the most recent review7 derived from within the UK, to inform national OH and The reader might wonder why three reports are thought to of cancer was derived from studies undertaken in the so we undertook a brief scope of the literature and its safety policy development and safer work practices. be necessary on the value of this specialty area of medicine workplace. Up until the early 1980’s, almost half of the methodological quality to explore whether there had and health care and it can be argued that it is precisely recognised human carcinogens were occupational in UK and US surveys of the perceived value of health been any improvement since then in the quality of 11,15 21, 22 because OH provision in most countries sits outside nature . Although this may no longer be the case with research by the public have found that they hold a very economic evaluations. We found a relatively low number mainstream medical services. Employers have to purchase the growing number of non-occupational carcinogens, positive view of research, believing that developments in of intervention studies in OH research that incorporated it; it is therefore an overhead cost; and because a large they still represent a substantial proportion. In 2017, there science play a very important role in our health and the economic evaluations. Few were cost-effective or cost- proportion of OH conditions are chronic, with long latency, were 47 established occupational carcinogens compared economy and are essential for improving the quality of beneficial. For the majority, the economic evaluations were 11 21, 22 the perceived value appears to be low. with 28 in 2004 . Although recognition of occupational human lives and society . A UK health and safety study typically of low methodological quality and often from an carcinogens are important for occupational cancer identified that members of the public are more supportive This has been reflected in the serious decline of academic ‘employer’ perspective only. Only a small number included prevention, given that many occupational exposures find of health and safety efforts to promote safer workplaces OH resources in the UK over the past 30 years, at a time a broader societal perspective. The majority of studies their way into the general environment, the potential than interventions out of work and half the respondents when recognition of the interaction between work and did not consider a long-term time horizon nor use any benefit of these discoveries extends beyond the workplace. thought more could be done to protect workers from health has never been higher. Worldwide the costs of work- extrapolation or modelling approaches. 23 16 health and safety risks . related health issues are an estimated 4% of global GDP Waddell and Burton’s pioneering evidence review Nevertheless, although there is a persisting lack of evidence and equivalent to the entire GDP of the UK 5. This figure5 leading to the development of the Faculty of Occupational Although we did not identify any employer data on their to support the economic value, based on our evaluation of refers to work injuries and illnesses only, with the burden Medicine Guidelines for the Management of Low Back perceived value of research, in one UK study of employer the literature and the qualitative interviews we conducted, likely to be considerably higher when accounting for the Pain at Work in 2000, as mentioned in our stakeholder and employee priorities of the required competencies in our view there is a strong case to support the OH (i.e. impact of health on work, and going forward, the ageing interviews, conveys the powerful impact robust research for occupational physicians (OPs), 75% of respondents improving health, wellbeing and functional capacity of the 24 working population with multiple morbidity and longer can have on revolutionising not just risk but clinical and considered research to be an important OP competency . working age population), societal and public health value OH management. It marked the introduction of the first exposures to work environments. It is not difficult to see why we need to continue to of OH research. national OH guidelines in the UK, and brought to the encourage and drive high quality OH research, with the Historically, OH research has meant different things 17,18 Occupational epidemiological research has made an forefront the biopsychosocial model of health . to different people and a single definition is yet to be report providing striking examples of the benefits it has enormously valuable contribution in these areas. established. A potential reason for this could be its growth, Without doubt, one of the most valuable contributions provided to OH, public health and society as a whole. Many diseases and risk factors for diseases were first development and evolution over time. of OH research in current times has been demonstration Modern day OH research has scope to be even broader in discovered in occupational studies10,11, with increased of the health benefits of ‘good work’ and the adverse its role, not just targeting ‘occupational diseases’ but also In its broadest sense, OH research is the scientific recognition of the work setting and occupational health impact of being away from work. This is effectively accessing a wide range of the population to ‘prevent’ and study of the interaction between work and health. It cohorts as remarkably good study populations to assess the underpinning supportive evidence-base for OH as a ‘manage’ broader population health issues. is multidisciplinary and covers a range of study areas exposures10-12. Early epidemiological studies of large scale specialty, and has empowered all those in workplace health Commitment and action is required to continue to including: occupational disease epidemiology, exposure occupational diseases and resulting workplace exposure to confidently promote the benefits of being in work. This innovate and drive the OH research agenda and to actively assessment, toxicology and hygiene, sickness absence limits and descriptions of best practice have led to their triggered a paradigm shift that has not only influenced convey and ‘better market’ this value to key stakeholders management, workplace and worker wellbeing/ reduction (and in some cases elimination) and have Government to act (particularly with the challenges they (e.g. OH clinicians, employers, the HR community, health promotion, evaluation of OH interventions and substantially improved population health, possibly more face with growing benefit dependency) and employers in employees, employee representative organisations and health economics. These different approaches provide than most other population or clinical interventions. The their management of absence (in recognition that “Good Government). Equally, the future maintenance of this complementary insights to the evidence-base, and its morbidity and mortality in relation to work historically was Health is Good Business”19 20) but also public perceptions, potentially ‘valuable’ contribution can only be secured application to practice and policy. very high and this has improved to a substantial degree with broader societal ramifications in reducing health and through retention and development of the OH academic through industry and policy makers paying increasing social inequalities, as highlighted in our interviews. The This report has approached the ‘value’ of OH research from base and attracting research grant funding. a general OH perspective i.e. improving health, wellbeing attention to research on health and the systematic study evidence-base on the health benefits of work has gone and functional capability of the working age population, and developments that followed. a step further in consolidating the concept of work as a In summary therefore, while there is a persisting lack of good quality evidence to demonstrate the economic a societal and public health perspective and an economic These falling trends have been corroborated by early health outcome, in rightful recognition within mainstream value of OH interventions, based on our evaluation of the perspective. 21st century databases on prevalence of and trends healthcare, of the important impact of work on health. research and qualitative study, in our view there is a strong in work-related disease in different occupations This could become even more important with ageing These elements have been addressed by: a brief scoping 19 13,14 demographics and the mental health epidemic where case supporting the OH, societal and public health value of review of workplace interventions with economic internationally and nationally in a number of countries . work may prove to be a positive health intervention. OH research. evaluations, qualitative interviews of key stakeholders in The OH, public health and societal value here has been the field of OH research, and supplemented by an overview the substantial reduction in mortality and morbidity of the Given the decline in heavy manufacturing industry in the We conclude that OH research should be at the core of of related reports and publications, including those on working age population. UK and other developed countries in recent decades, there shaping a healthy workforce and productive economy and occupational epidemiology and other OH research areas. is an overarching perception that occupational diseases should be developed accordingly. THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 9

1. DEFINING OCCUPATIONAL 2. THE HISTORICAL BACKGROUND 3. THE EVOLUTION OF WORK HEALTH RESEARCH OF OCCUPATIONAL HEALTH RESEARCH

Since its inception, occupational health (OH) research Scientific investigation and research on work and health Work and concomitantly, OH services have evolved in has meant different things to different people and a clear date back to the 16th and 17th centuries with increasing recent decades with manifest changes in customer and definition has yet to be established. A potential reason for recognition of occupational hazards to health and workforce needs, working population demographics and this could be its growth, development and evolution over disease25. Agricola and Paracelsus described the hazards work practices and patterns. The latter have been largely time. It was initially focussed around occupational hazards and disease associated with metal mining. The harmful driven by a marked shift from heavy manufacturing and work related ill health and, while this has remained health effects of lead, carbon monoxide and arsenic were industry to service based industries, the emergence important, OH research has evolved to also encompass also observed during this early period. A key development of small and medium sized enterprises (doing some the impact of health on work. In recent years, its scope has occurred in 1775 when Percival Pott described scrotal of the work previously undertaken by larger industrial developed even more broadly, to investigate the health of cancer in chimney sweeps, the first occupational cancer corporations) but also regulatory and legislative the working age population and worklessness. recorded in history. Other examples between the late 18th requirements and technological advances. OH problems century and early 19th century include: Thomas Percival’s vary with these dynamics and change and develop In its broadest sense, OH research is the scientific study of study of textile mill workers, Charles Thackrah’s work on accordingly. the interaction between work and health. occupational disease epidemiology and mortality and OH research covers a range of study areas. These Greenhow’s work on dusts/fumes and respiratory disease25. include: occupational disease epidemiology, exposure These scientific reports influenced workplace and assessment, toxicology and hygiene, sickness absence government policy and a continual series of legislation management, workplace and worker wellbeing/health related to working conditions in the 19th century both in promotion, evaluation of OH interventions and health Europe and the UK. The Factory Acts in the UK regulated economics. These study areas can provide important working hours and working age. It also introduced information about occupational disease trends and physician examinations of workers with specific exposures, risk factors, outcomes of work interventions, facilitating factory inspectors, safety processes and notification of early rehabilitation and return to work (RTW), improving industrial disease. In 1898 Thomas Legge was appointed functional capability, patterns of service delivery and the first Medical Inspector of Factories in the UK25. economic evaluation, although this list is not exhaustive. These different approaches to OH research provide The growing body of evidence ultimately led to the complementary insights to the evidence base, and its introduction of trade unions, worker’s compensation application to practice and policy. and increased bargaining power to continually improve working conditions and prevent injuries and disease. In recent years the key focus areas have included: the psychosocial work environment, musculoskeletal disorders The ensuing decades saw research focussed on high (MSD), hazardous substances and occupational safety and incidences of byssinosis, lead poisoning, coal workers health (OSH) services and management. pneumoconiosis, asbestos-related diseases, silicosis, and many other diseases25. Even with its use banned in the UK OH research is multidisciplinary and researchers might for several decades in response to the scientific research, include: physicians, nurses, epidemiologists, hygienists, because of the prolonged latency of disease onset, statisticians, toxicologists, ergonomists, health economists, asbestos remains the single biggest cause of work-related sociologists, geneticists, data managers, clinical scientists, deaths in the UK26. social scientists and market researchers. THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 11

4. RECENT AND CURRENT DEVELOPMENTS Figure 1. Employment rate by age IN OCCUPATIONAL HEALTH RESEARCH

Through the pioneering advances in workplace health Waddell and Burton’s pioneering evidence review16 science described earlier and the developments that leading to the development of the Faculty of Occupational followed, notably establishment of occupational hygiene, Medicine Guidelines for the Management of Low Back Pain workplace exposure limits and description of best practice, at Work in 2000, revolutionised the clinical management substantial improvements in workplace occupational of low back pain. It marked the introduction of the first health and safety in developed countries have occurred. national occupational health guidelines in the UK, and brought to the forefront the biopsychosocial model of Government agencies such as the UK Health and Safety health17,18. Executive (HSE) and professional associations such as International Labour Organisation (ILO) and International The study of biopsychosocial factors in OH has continued Commission on Occupational Health (ICOH) were to grow in importance, an example being the CUPID study developed in the early 20th century to record and monitor which across 18 countries showed large differences in the trends in occupational disease. The mid-20th century prevalence of musculoskeletal pain and related sickness brought further material developments in UK Occupational absence among workers doing similar occupational tasks32. Health and Safety legislation and EU directives. In recent decades, there has been a strong emergent focus The late 20th century saw national OHS organisations on disability management and workplace adjustments to in the US, UK, Italy, EU and Japan develop their research enable workers with chronic diseases to remain at work. agendas. Early 21st century databases looking at The introduction of disability discrimination legislation prevalence and trends of work-related disease in different in the UK33 34 has undoubtedly been a key driver in this occupations have been established on international and trend, as has the recent Government target to see one national levels as a driver for both further clinical research million more disabled people in employment by 202735. and legislative changes. Examples include: ILO– Recording In tandem, the developing evidence base on the adverse & notification of occupational accidents and diseases and health effects of prolonged absence from work (such as ILO list of occupational diseases27, the HSE and THOR28 in poor prognostic outcomes and increased risk of work loss) the UK, NIOSH29 in the US and MODERNET30 in Europe. A has been established, along with a drive toward pro-active Cochrane Work31 Review Group has also been established absence management and rehabilitation and a focus on with over 100 systematic reviews or protocols of reviews on early interventions in sickness absence. Ageing is associated with multiple morbidity, which in turn OH services in the UK are funded by the employer; those topics relevant to OH and safety. is a cause of job loss39. A recent study of 13,000 benefit who have lost their job through ill health generally have There is also an increasing interest in studying sickness Recent decades have seen the growth of new (or perhaps, claimants in the welfare to work programme confirmed no access to OH advice or services, which are currently presenteeism36 (i.e. a person’s decision to go to work only newly recognised) conditions, such as work-related a strong inverse relationship between the number of focussed on the survivor population. Some attention despite feeling ill) and the related factors including work, upper limb (and other musculoskeletal) disorders, medical conditions and the likelihood of return to work is now given to the previously overlooked ‘workless’ personal circumstances and attitudes towards sickness occupational deafness, hand arm vibration syndrome (RTW)39. Much of the current OH research undertaken in population and importantly, modifiable factors that may absence36 but there is still much heterogeneity in how it is (HAVS), occupational asthma and work-related stress/ the UK is still focused on occupational groups and specific prevent these individuals falling out of work in the first assessed. mental ill health. New occupational carcinogens have also clinical areas such as respiratory, musculoskeletal and place. There is a need for much more research in this field. been identified. The changing demographics of an increasing ageing mental health conditions. However, more research on The concept of ‘good’ work and the related health benefit population and pension eligibility changes have made multi-morbidity and maintaining function in an ageing is now established. There is also emerging recognition of At the same time, a shift of emphasis has occurred from it necessary to keep people in work for longer37. population is needed. the workplace as a forum for influencing health behaviours, historical disease prevention to overall worker health and While policy imperative is toward extending working of worklessness as a public health issue, and of work as a wellbeing and the impact of health on work. lives, a 2014 ONS report (see Figure 1) demonstrated a health outcome19,35. substantial proportion of those aged between 50-60 falling out of work38. THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 13

5. THE BURDEN OF HEALTH ON WORK 6. ESTABLISHING RESEARCH 7. RESOURCING IN OCCUPATIONAL AND WORK-RELATED ILL HEALTH PRIORITIES HEALTH RESEARCH

Ill health among the working population has a significant Evolving OH practice has presented new and changing Of note, the 2017 study1 also highlighted disparities Challenges in OH resourcing are two-fold. Firstly, only a societal and economic impact. In 2017, the Labour Force priorities in OH research. Evaluation and establishment of between areas in which research is currently being limited number of organisations specifically fund OH and Survey estimated that 131 million days were lost due to current research priorities is essential to ensure research is undertaken (occupational disease/injury/illness, work-related research in the UK. It is more commonly sickness absence, with an average of 4.1 lost days per relevant and impactful at key levels (academic, policy and occupational hazards to health and risk assessment and funded as part of larger, broader multi-specialty research worker40. Minor illnesses were the commonest absence practice) and to target funding. Numerous countries have sickness absence management) and areas where current projects. Therefore, total research funding allocation to OH reason accounting for 34.3 million days, followed by established national OH research priorities44 including the priorities were identified (economic evaluation/cost- and work-related research is difficult to quantify, particularly musculoskeletal problems and mental health problems USA45 ,46, the Netherlands47, Italy48, 49 Japan50, Malaysia51, effectiveness studies and disability management). Potential in key priority areas. There has also been recognition of an (stress, depression, anxiety)40 with 28.2 million and 14.3 UAE52, Australia53 and the UK54, 55. A global study56 and reasons for this divergence included: increased emphasis important potential influence of research funding scheme million lost days, respectively. European studies57, 58 have also been undertaken. Research on ‘higher profile’ intervention and aetiological studies criteria and specific study types awarded grants. priorities identified from these have included cost– within the established OH research agenda60 and specific Similarly, work-related illnesses present a heavy socio- Concomitantly, a declining OH academic base and benefit studies47, 57, workplace injuries49, 53, occupational criteria of schemes for funding research. economic burden. According to HSE figures in 2017/2018, reduction in the number of OH research centres/groups carcinogenesis49, psychosocial hazards53 and changing an estimated 30.7 million working days were lost due to Another recent UK study of health and safety professionals, 61-63 present significant challenges in progressing the work patterns/workforce50, 58. Musculoskeletal disorders work-related illness or workplace injuries with an estimated younger workers and OPs has identified three sets of health research agenda. For example, in 201137 approximately were the highest priority among OH clinicians in an total annual cost in 2016/17 of £15 billion for work-related conditions as priority for future research: occupational seven specialist occupational physicians held substantive earlier UK study undertaken over 20 years ago54, with injury and new cases of ill health (excluding long latency stress, musculoskeletal disorders (including HAVS) and UK academic appointments, with others undertaking part- musculoskeletal disorders and stress top in a study of illness such as cancer), £5.2 billion for injuries and £9.7 occupational lung disorders2. time teaching/research (totalling around 24 FTEs). Current personnel managers55. billion for new cases of illness41. These figures refer to work estimations are of no full-time posts and less than three injuries and illnesses only, with the burden likely to be These study findings highlight44-59 varying national full-time equivalents (UK Academic Forum for Health and considerably higher when accounting for the impact of priorities between countries44-59 due to differences in work/ Work, Society of Occupational Medicine and Faculty of health on work. workforce demographics, economic development, socio- Occupational Medicine). Lack of funding and opportunity cultural backgrounds, and health and safety legislation. for able young academics63 and the separation of OH In quantifying the burden of work-related illnesses, it is Nevertheless, the importance of their findings is evident from mainstream healthcare61 are reported barriers in OP important to distinguish between the overall incidence from the impact they have had within their countries in research participation. of illnesses that can be caused by work, and the excess attracting research funding59. incidence of such illnesses that are attributable to work. In recent years, the decline in the number of OP academics The latter is much harder to measure, and sources such In a more recent UK study of both occupational has been balanced to some degree by a growth in as self-report of illness that is caused or made worse by physicians (OPs) and occupational health researchers academics from other disciplines who have an interest in work and counts of medically attributed cases are not (OHRs) undertaken in 20171, economic evaluation/cost- the broader aspects of health and work. considered a particularly reliable indicator. effectiveness studies and disability management were identified jointly as the top research priority, followed When the NHS was formed in 1948, OH was not included, by occupational disease/injury/illness. The study results and at that time OH funding and development were also showed a priority emphasis on mental health and primarily driven by health and safety legislation. The socio- psychosocial hazards, supporting the changing landscape economic burden of health on work has been highlighted of disease epidemiology, and mental ill health (including as a ‘powerful incentive’ for the government to fund work-related mental ill health) as a key player1. A need for broader OH service provision, with a proposal to integrate an increase in evidence-based guidance for clinical OH OH into NHS care systems19,42. practice was also identified1. The developing concept of work as a health outcome Although the highest priority in the previous UK study 20 has stimulated growing awareness of the importance years ago54, musculoskeletal issues were absent among of wider provision of OH to all people of working age35. top priorities1. These differences across two decades were Similarly, the Public Health Responsibility Deal in England probably a reflection of evolving OH practice and related aiming to improve public health by addressing workplace legislation. health through public-private partnership ‘health at work’ pledges has initiated the culture changes and ‘big picture’ perspective that is necessary43. THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 15

8. TRANSLATING RESEARCH INTO 9. DEFINITION OF VALUE 10. SCOPING REVIEW OF ECONOMIC PRACTICE AND POLICY CHANGES EVALUATION WORKPLACE NTERVENTIONS

As with research in general64, within OH and safety65, This report completes a trilogy of reports related to While acknowledging the varying and broad definitions We elected to focus our scope of the literature on concerns around research–practice gaps66 and the so- the value of maintaining and improving the health and perspectives held, the scope of this report has workplace intervention studies over other aspects of OH called practitioner–researcher divide67 have been expressed and wellbeing of the working age population. The first, approached the ‘value’ of OH research from a general OH research. This is on the basis that intervention studies in recent years. These pertain to the degree to which Occupational health: the value proposition3, was aimed perspective i.e. improving health, wellbeing and functional evaluate effects of treatment/programmes in real-world researchers address questions they perceive of primary at UK policy makers and commissioners of services and capability of the working age population, a societal and settings. Furthermore, they are often the natural follow-on importance to them, rather than practitioner-focussed provided a narrative synthesis of the evidence from the public health perspective and an economic perspective. from occupational epidemiology studies. research68. scientific and wider literature to help illustrate and publicise These elements have been addressed by: a brief scoping In recent years, several interventions at the workplace the benefits that OH services provide to employees, There has also been debate around the extent to which review of workplace interventions with economic have been developed, implemented and assessed with employers and to the economy. research findings translate into practice or policy changes66, evaluations, assessment of their methodological quality, the aim to modify or improve working conditions, worker 67. It has been reported that, despite multiple decades of The second, Occupational Health: the Global Evidence qualitative interviews of key stakeholders in the field of health and workplace practices. The “effectiveness” of advances in medical knowledge based on high-quality and Value4 provided an extensive global perspective of OH research, and supplemented by an overview of related the intervention focuses on the extent to which an empirical evidence, widespread implementation of the considerable financial and societal benefits. reports and publications, including those on occupational intervention improves health outcomes for individuals. these findings into practice has not been achieved69. epidemiology and other OH research areas. The “cost-effectiveness” refers to cost of the intervention or Both applied a broad meaning to the word ‘value’ as Additionally, in OH, there is increasing recognition of the its economic effect. This includes an analysis of the direct including the financial, legal and moral aspects. importance of even broader dissemination of research and, less frequently, the indirect costs of implementing the findings (beyond academics and practitioners) to Value can be defined as ‘the regard that something is intervention, and considers the effect or consequences of employers, human resources, the business community and held to deserve; the importance, worth or usefulness of an intervention upon economic variables. In other words, Government. Wider public engagement is also necessary something’ (Oxford Dictionary). In a modern consumer it seeks to determine the best “value for money” or the to inform and educate about advancing developments context, it is often associated with economic worth and “financial return” from the intervention in order to maximise and thereby improve both general and occupational cost-benefit, although it can also apply at a personal level individuals’ health, wellbeing and function, given the health and wellbeing. The value clinicians and practitioners or ‘for the greater good’. available resources. place on research has also been debated with re-iteration In an OH context, an applied ‘value’ definition could be The two previous reports3, 4 on the value of occupational that ‘relevant and useful research’ is more likely to draw the improving health, wellbeing and functional capability of health have identified high quality economic evaluations attention of practitioners and influence their practice68. the working population with resultant economic, industry, to be an important gap in the OH evidence base. societal, occupational and public health benefits70. Furthermore, in a recent study1 on the OH research The reader might wonder why three reports are thought to priorities of UK OH physicians and researchers, economic be necessary on the value of this specialty area of medicine evaluation/cost-effectiveness studies were ranked the and health care and it can be argued that it is precisely highest priority jointly, along with disability management. because OH provision in most countries sits outside A number of systematic reviews have been conducted mainstream medical services. Employers have to purchase to evaluate the cost-effectiveness of OH interventions7-9, it; it is therefore an overhead cost; and because a large all of which have identified poor methodological quality proportion of OH conditions are chronic, with long latency, as a key barrier to drawing meaningful conclusions and the perceived value appears to be low. making a value case. As it has been five years since the last 7 This has been reflected in the serious decline of systematic review , we undertook a brief scoping review academic OH resources in the UK over the past 30 years of the literature and its methodological quality to explore as highlighted above, at a time when recognition of the whether there had been any improvement since then in interaction between work and health has never been the quality of economic evaluations. This review focussed higher, and globally the costs of work-related health issues on workplace interventions where an economic evaluation are an estimated 4% of global GDP and equivalent to the had been performed or where economic outcomes had entire GDP of the UK5. Once again, this figure5 refers to been assessed. For the purpose of the review, workplace work injuries and illnesses only, with the burden likely to interventions were defined as all interventions carried out be considerably higher when accounting for the impact of in the workplace, implemented directly or indirectly by the health on work, and going forward, the ageing population employer, including the involvement and participation of and multiple morbidity. a variety of professionals from internal (company/sector occupational health departments) or external occupational health services. THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 17

METHODOLOGY OF THE REVIEW TYPES OF INTERVENTIONS METHODOLOGY ASSESSMENT OF ECONOMIC EVALUATIONS

Search strategy a) Health promotion interventions c) Interventions in relation to employability, work The majority of the economic studies were conducted in adjustments, work rehabilitation and return to work the United States. The overall rating of these economic An electronic search was carried out using MEDLINE Six health promotion interventions were identified from evaluations was low/moderate quality. The main (Pubmed) database. Our search strategy combined four our search. Two identified papers related to the same 13 interventions were identified in relation to employability, perspective of the studies was the ‘employer’ perspective. blocks of keywords or MEsH terms intended to cover all intervention71, 72 (Strijk 2013, van Dongen 2013). Four work adjustments, work rehabilitation and return to work. In a few of the identified studies were broader perspective different aspects of our review: i) workplace setting ii) studies were performed in the United States73-76 (Palumbo The characteristics and main outcomes of the selected economic evaluations such as cost-benefit analysis occupational exposures and outcomes iii) intervention, 2012, Kuehl 2013, Serxner 2012, Serxner 2001), one in The interventions are presented in Table 3. The Netherlands performed. The majority of the outcomes evaluated randomised controlled trials, clinical trials and systematic Netherlands71,72 (Strijk 2013, van Dongen 2013) and one with five studies is the predominant country publishing within these economic evaluations were productivity review studies and iv) economic evaluation and financial in Taiwan77 (Lin 2018). The workplace settings were very on these types of intervention87-91 (van Holland 2018, and reduced absenteeism. Only one study used a formal outcomes. The detailed search strategy is available from variable, including an aerospace industry77 (Lin 2018), Koolhaas 2015, Meijer 2006, Steenstra 2006, Hlobil 2007), threshold to assess value for money. This study was also the authors upon request. a telecommunications company76 (Serxner 2001), a fire two studies were performed in Sweden92 93 (Karrholm 2006, the only one to include a recommended preference- department73 (Kuehl 2013), a large financial services Jensen 2005), two studies in Canada94 95 (Badii 2006, Loisel Study selection and eligibility criteria based quality of life outcome measure. The highest quality corporation75 (Serxner 2012) and two academic hospitals/ 2002) and one study in Germany96 (Enriquez-Diaz 2012), economic evidence comes from those studies evaluating Randomised controlled trials, controlled trials, cluster- medical centres71, 72, 74 (Palumbo 2012, Strijk 2013, van Denmark97 (Bultmann 2009), United States98 (Maniscalco employability/work adjustments/ rehabilitation/return to randomised trials, before and after studies and systematic Dongen 2013). Table 1 provides a summary of all the health 1999) and Brazil99 (Comper 2017) respectively. Programmes work interventions (n=13). 5/13 of these studies were from reviews published in English or Spanish until April 2019 promotion interventions included in the scoping review. to identify workers at risk for reduced employability, job the Netherlands, two from Canada and two from Sweden. were included if they involved economic evaluation of In general, most of the selected interventions sought to rotation programmes, problem-solving strategies for These latter studies tended to adopt a greater use of cost- workplace interventions or financial outcomes were decrease sedentary activities and to promote physical ageing workers, combined occupational and clinical benefit analyses and other approaches including return on included, such as productivity or indirect cost derived from activities at the workplace, including exercise programmes interventions, workplace programmes to reduce injuries investment. absenteeism. such as yoga, workout, aerobic exercise and Tai Chi classes. due to musculoskeletal disorders, manufacturing methods, 71, 72 A total of 1,333 citations were obtained from the electronic One study included a free fruit programme (Strijk 2013, health assessment programmes and cognitive behavioural search. One reviewer screened titles and, when necessary, van Dongen 2013) and only one intervention was oriented and work rehabilitation programmes were the type of 76 abstracts for eligibility. The reference lists from selected to workers on sick leave (Serxner 2001). From all six health interventions included. Absenteeism, days lost or time loss 87, 90-95, papers were searched by hand and additional studies promotion interventions included, only four seemed to be as a proxy of productivity loss were included in eight 73-76 97 derived from relevant systematic reviews selected in cost-effective or cost-saving (Palumbo 2012, Kuehl 2013, (van Holland 2018, Badii 2006, Karrholm 2006, Bultmann our search were also identified. 123 potentially suitable Serxner 2012, Serxner 2001). 2009, Jensen 2005, Loisel 2002, Steenstra 2006, Hlobil 2007) of the 13 studies. Four workplace interventions87, 93, 95, 98 publications were identified from the electronic search b) Ergonomic interventions and a full text was obtained for all of them. Those 123 (Maniscalco 1999, Karrholm 2006, Loisel 2002, Hlobil 2007) Table 2 describes the ergonomic interventions selected studies were reviewed by two independent reviewers. seemed to be cost-effective and from those, only one in our review. Nine interventions fulfilled our eligibility 98 Disagreements were resolved by discussion and, where study did not include a control group (Maniscalco 1999). criteria. The majority of the interventions included were necessary, by a third reviewer who made the final decision. d) Psychosocial interventions performed in North America, and from those, seven were 33 papers met our inclusion criteria and were considered performed in the United States78-82 (Rempel 2006, Lahiri Only four psychosocial interventions were identified with for this brief scoping review. 2005, Collins 2004, Evannoff 1999, Banco 1997) and one our eligibility criteria. Two studies came from the United Data extraction and synthesis in Canada83 (Chhokar 2004). Only one intervention was States100, 101 (Lavelle 2018, Childs 2014) and two from Nordic 84-86 102, 103 The 33 interventions were classified into four broad implemented in Europe (Driessen 2011, Driessen 2012). countries (Gupta 2018, Anderzen 2005). The study 100 101 categories: a) health promotion interventions b) ergonomic In general, the selected interventions included ergonomic settings were military installations (Lavelle 2018, Childs 103 interventions c) interventions related to employability/ training, workstation modifications, mechanical aides or 2014), manufacturing factories (Gupta 2018) and internal 102 work adjustments/work rehabilitation/return to work d) lifts, participatory ergonomics programmes and a safety revenue service (Anderzen 2005). All interventions psychosocial interventions. Selected information was programme to reduce cutting injuries at the workplace. were educational programmes to map and enhance 79-81, 83 obtained from each of the 33 studies, including author, Six (Lahiri 2005, Collins 2004, Chhokar 2004, Evannoff psychosocial aspects at the workplace. Outcomes assessed 101 publication year, country of origin, intervention setting 1999) out of nine interventions were before-and-after in the selected interventions included mental health 100 and study participants. Likewise, characteristics of assessments and no control group was selected. All the (Lavelle 2018) and musculoskeletal disorders (Childs 101 intervention and control groups, follow-up period and ergonomic interventions seemed to be cost-effective or 2014). From the four included interventions, only one 84-86 primary and secondary outcome measurements were cost-saving, with the exception of one (Driessen 2011, (Lavelle 2018) seemed to be cost-effective. also documented from each paper. This information is Driessen 2012). summarised in Tables 1-4. THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 19

SUMMARY OF SCOPING REVIEW AND ECONOMIC 11. STAKEHOLDER PERSPECTIVES EVALUATION METHODOLOGY FINDINGS

Most of the interventions were implemented in the United Understanding how key stakeholders perceive the value category/role, and (c) their accessibility (mainly in terms States, the Netherlands or in Nordic countries. None of the of OH research and what they think about its current and of time availability). Between March and April 2019, interventions identified within our search criteria came future status is just as critically important as understanding a total of 11 semi-structured, telephone interviews from the United Kingdom and a number were before-and- the scope and quality of published research in the field. were conducted, lasting on average half an hour. With after studies without a control group. participant permission, all interviews were audio-recorded, We supplemented our literature review with insights fully transcribed, and thematically analysed. This section Overall the economic evaluations focussed on measuring from qualitative interview data collected from a range of provides an overview of the qualitative findings, organised and valuing absenteeism and productivity, using a narrow stakeholders, including UK and international academic under two main headings: a) ‘What has OH research ever ‘employer’ perspective. They focussed on cost savings and experts, employer organisations representatives, OH done for us?’ and (b) ‘Key challenges in moving forward’. typically did not include preference-based quality of life providers, and a Government representative (Figure 2). Direct quotes from participants are used throughout outcomes nor utilise thresholds for making assessments of The study was approved by the University of Glasgow to illustrate main points. To ensure anonymity and value. ethics committee. Participants – identified through the confidentiality, participant names have been replaced with professional networks of the research team – were selected Of those minority of studies that were higher quality, there participant numbers; gender and professional category are based on three factors: (a) their substantial experience were however insights to the possible value workplace nonetheless indicated. and expertise in the field of OH (b) their professional interventions could have in society. Economists/health economists have not paid this OH area sufficient attention in regard to the adoption of relevant methodology with a greater use of broad evaluative frameworks, including cost- Figure 2. Number of participants by professional category benefit analysis and/or cost-consequences analysis. There has been an insufficient use of longer-term time horizons and little adoption of modelling methods to assist with this. In the UK, with bodies such as the National Institute for Clinical Excellence (NICE) paying a renewed attention to the economic evaluation of ‘preventive’ population health interventions and an associated rise in the methodological guidance for conducting these complex evaluations, economists should capitalise on this opportunity to explore the economics of OH. THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 21

a) What has OH research ever done for us? b) Key challenges in moving forward The need to attract high quality people in OH research Last but not least, equally important was seen to be the was a recurring theme across the interviews, with some integration of technological advances into OH research. Participating stakeholders talked extensively about the Notwithstanding the overall positive outlook, informants stakeholders admitting that “occupational medicine has As one of the participants described: “Occupational data ‘value’ of OH research, conceptualised primarily as the identified a number of key challenges that need to be never been very good at marketing itself within academic is not included in any of the routine data collection in development of a solid evidence base for identifying and addressed so that the field of OH research continues to institutions” and others talking about a lack of a culture primary or secondary care in the UK, and that is a big controlling occupational health hazards and creating safer evolve and expand. Among the most commonly reported of research in occupational medicine: “So, I think there’s a limitation. So, trying to kind of improve data and evidence working environments: “Take for instance all the research ones were the lack of a consistent funding stream to few things to that… I think there’s a lack of an academic through electronic systems – they might not necessarily that was done about risk factors and management of back support OH research activities, as well as the steady decline pathway, so that’s one thing. There’s a lack of people who be designed solely for research purposes but they may pain at work. That’s had a huge impact on health at work in the number of OH research centres (and, more broadly, want to do occupational medicine research, so posts have other purposes. So, what I’m saying is that they do not and on managing risks at work. I mean, 20 years ago, you in the number of people choosing an academic pathway). have been advertised and nobody’s applied for them. need to be part of a research project, but we need to kind used to see nurses who did their first shift on the ward A Government representative commented: “I think, at the That’s probably something to do with people that want of develop systems that can collect intelligent evidence of and they’d do something stupid… not stupid, but they’d moment, it all feels to me a little bit ‘hit-and-miss’ in terms to do occupational medicine as a specialty; they’re not as lagging and leading indicators, mainly leading indicators in do some major manual handling activity and they’d end of both resourcing the research and what’s currently being interested in research as perhaps they might be in other occupational health.” (Participant 3 – Male, UK Academic up with back pain, and some of them never got back to done and where. It doesn’t feel like it’s coherent at all and specialties, such as cardiology or respiratory. And the third Expert). work – or, well, certainly never got back to work in nursing. I think there’s definitely a role for central Government thing: there’s just not a culture of research in occupational That almost never happens now.” (Participant 6 – Female, in providing a bit of coherence into what needs to be Similarly, another academic commented: “We are not alone medicine, so that’s our fault, really, that we have not made Employer Organisations Representative). done… I mean, sitting in Scottish Government, we don’t in the world anymore. There’s a big digitalisation occurring it a culture.” (Participant 4 – Female, UK Academic Expert). have resources that we can put into this at the moment at the moment. And I think that’s an opportunity and a Such real-world examples of impact or ‘success stories’ or, at least, the case is not being made well to ministers Doing ‘better’ research and research that is socially relevant challenge at the same time. I think our traditional context, were common in participants’ narratives, with several that they should be thinking about putting resources and can influence policy and practice was also voiced as in which we are seeing patients within a medical setting, highlighting the crucial role that OH research has had into this and I think, possibly, it’s the same with the UK a key priority for moving forward. ‘Better’, in this context, and in which the physician does the examination and gives in reducing traditional occupational diseases, such as Government. I think the other problem is the status of was seen as going beyond the traditional occupational advice, I think that model is not valid anymore. I think we occupational asthma and silicosis: “There have been occupational health within the NHS. It’s not part of core health approaches and finding ways to effectively address need to work much more on shared decision-making kind several success stories over the last decades. You’re NHS services, so provision is patchy. It’s not coherent, it’s the complexity of emerging challenges. According to of consultations and fully make use of the opportunities usually going to find them by looking at surveillance data. not consistent and, therefore, it’s not providing career paths the participants, this could be accomplished through that the digital world is offering us, the data that can be Some diseases are – I don’t know if I can use the word or opportunities for people to develop a career and then, various means, including strengthening interdisciplinary collected, and also artificial intelligence, so that we can ‘disappearing’– markedly going down. An anecdotal therefore, there isn’t the teaching and research base that is collaboration and adopting a more systems-based improve our knowledge and prove the return, actually.” example and I hope this is still true… I remember going to needed to support that. So, it probably needs to be given approach to analysing and intervening on occupational (Participant 5 – Male, International Academic Expert). a scientific conference a few years ago and talking, among a more significant status in terms of what the NHS does.” health problems: “But since 2011, there’s also a new other things, about silicosis. And somebody – one of the (Participant 8 – Male, Government Representative). paradigm shift that is occurring in what is the next presenters – said, ‘you know, in Sweden we have stopped challenge in occupational health. And this is the… you’ve measuring rates of silicosis, because our numbers are so probably heard of the concept of ‘total worker health’. low that we just simply count the cases.’ And I thought ‘Total worker health’ implies an important paradigmatic that was a beautiful example of success, right? Because “I think it has to do with the lack of shift. It has been sometimes portrayed over-simplistically one is too many.” (Participant 9 – Male, International as simply bringing traditional occupational safety and Academic Expert). a sort of reference structure health together with health promotion in the workplace. Participants also discussed how the field of OH has evolved that supports it, that supports It’s not – it’s more than that. It’s a lot more than that, but over the last decades and how the focus of research has occupational medicine as a clinical the shift is, conceptually, from our objective, going from gradually shifted from hazard identification and control discipline that should have research wanting to keep – and this is a little bit euphemistic – the to a broader consideration of the health benefits of work worker as healthy when he or she leaves at the end of the and the importance of ‘good work’: “The most important in the same way as other specialities. work day, as when he or she came in that day. Shifting to, thing we’ve proven beyond reasonable doubt is that being And that’s linked to the lack of again euphemistically, hoping even that their health is at work is better for you – if you’re in good work – than even a little bit better when they leave the workplace. And being away from work and absent from work. And this has national support for it, because it’s to do that, you have to go beyond traditional occupational massively changed Government policy and is beginning seen, at the moment, very much health and safety approaches, such as identifying to move Government policy to the long-term sickness in Government terms, as getting workplace risks and how to control them. And use a much and absence, and people on benefits. And it is one of the more systems-based approach to looking at exposure as most important things that we can do in terms of reducing people back to work, which is a good a much broader thing that includes individual behaviours, health and social inequalities. I don’t think we are very good agenda - it’s absolutely right - but the that includes community exposures, it includes risk factors at blowing that trumpet, I have to say, but I think we’ve got agenda should be wider than that.” inside and outside of the workplace, and how they all to basically choose to use it to demonstrate the important interact to affect the health of the worker in both a positive impact on societal health inequalities.” (Participant 1 – Participant 6 – Female, and a negative sense, because it doesn’t always have to Male, OH Provider). Employer Organisations Representative be negative.” (Participant 9 – Male, International Academic Expert). THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 23

12. DISCUSSION These falling trends have been corroborated by early 21st Interestingly, this product of OH research i.e. making century databases on prevalence of and trends in work- workplaces safer and provision of a solid evidence-base related disease in different occupations internationally for OH practice and risk management was perceived as (ILO – Recording and notification of occupational accidents being of greatest value to the stakeholders interviewed. As a follow-on to the two previous UK and Global evaluations in these other areas should also and diseases and ILO list of occupational diseases) and Remarkably economic benefit, which arguably could 13,14 reports on the value of OH3, 4, the aim of this report was be encouraged. nationally in a number of countries . The OH, public be a high priority for employers and industry, was not a to assess the value of OH research. As highlighted health and societal value here has been the substantial key ‘value’ concept theme to emerge from the stakeholder In current times when recognition of the economic previously, this report has approached ‘value’ from a reduction in mortality and morbidity of the working age interviews. burden of work related ill health has never been higher5, general OH perspective i.e. improving the health, population. Furthermore, although not formally quantified, there is a need for an increase in economic evaluation Establishment of the health benefits and importance of wellbeing and functional capability of the working age the consequent improvement in workforce and public studies (at individual, employer, NHS, Government and ‘good work’ and the adverse health effects of prolonged population, a societal and public health perspective and health is bound to have inferred cost savings from a economy levels) and importantly, for these to be of good work absence an economic perspective. healthcare, employer and government perspective with methodological quality. These can help decision makers to ultimate benefits to the economy. Without doubt, one of the most valuable contributions of a) The economic value make the best use of resources106, 107, 109 and to consolidate OH research in current times has been demonstration of 110 Several ‘real-world’ success story examples in reducing 3, 4 the business case for OH. A 2017 survey of 500 UK the health benefits of work and the importance of ‘good The two previous reports on the value of OH highlighted traditional occupational disease prevalence were described employers reported that 54% of businesses were not clear work’. The concept in its simplest term is described by one a paucity of high quality economic evaluations as an by key stakeholders participating in our qualitative study, on how much absence was costing them and only 46% stakeholder: “that being at work is better for you – if you’re important gap in the OH evidence base. notably in relation to silicosis. It also highlights anecdotally believed that the absence reduction measures they had in in good work– than being away from work and absent that in some countries, for example silicosis rates in Given that intervention studies evaluate effects of place have clear benefits. from work.” This is effectively the underpinning supportive treatment/programmes in real-world settings and are often Sweden, levels have been so low that the need to actively Addressing this persisting gap in the evidence could be evidence-base for OH as a specialty, and has empowered the natural follow-on from occupational epidemiology monitor trends is no longer deemed necessary. a powerful tool to increasing the perceived value of OH all those in workplace health to confidently promote the studies, we elected to undertake a scope of the literature research among employers, businesses and funders. The wider significant contribution of historical OH research benefits of being in work. on workplace intervention economic evaluations over other aspects of OH research. b) The occupational health, public health The impact of this historical OH research has been much Demonstration of the adverse health effects of prolonged and societal value wider in that it has also contributed to the broader absence from work (including poor prognostic outcomes Systematic reviews on the cost-effectiveness of OH understanding of disease mechanisms particularly in the and increased risk of falling out of work) has in turn driven a 6-9 interventions have identified poor methodological While to date, there is a persisting lack of good quality fields of toxicology and carcinogenesis and recognition of large body of research on pro-active rehabilitation, sickness quality as key barriers to drawing meaningful conclusions. evidence on the economic value of OH intervention the significance of environmental exposures. Historically, absence management and a focus on early interventions in 7 As it has been five years since the last systematic review research, based on our evaluation of the literature and much of what was known about the causes of cancer was sickness absence to facilitate return to work (RTW). so we undertook a brief scoping review of economic the qualitative interviews we conducted, in our view derived from studies undertaken in the workplace. Up Establishment of the health benefits of ‘good work’ and the evaluation workplace intervention studies and their there is a strong case to support the OH (i.e. improving until the early 1980’s, almost half of the recognised human adverse health impact of being away from work, triggered methodological quality, to explore if there had been any health, wellbeing and functional capacity of the working carcinogens were occupational in nature11, 15. Although a paradigm shift that has not only influenced Government improvement in the quality of the economic evaluation age population), societal and public health value of this may no longer be the case with the growing number to act (particularly with the challenges they face with evidence-base over that time. OH research. of non-occupational carcinogens, they still represent a growing benefit dependency) and employers in their Our findings identified a relatively low number of The significant contribution of historical substantial proportion. management of absence (in recognition that “Good Health economic evaluation intervention studies in OH research occupational disease research Although recognition of occupational carcinogens are is Good Business”19, 20) but also public perceptions, with and rarely were economists involved in these evaluations. Occupational epidemiology research (the primary important for occupational cancer prevention, given broader societal ramifications in reducing health and social Few were cost-effective or cost-beneficial. A number methodology used in OH to investigate and identify that many occupational exposures find their way into inequalities, as highlighted in our interviews. were before-and-after studies with no control group. For work-related health hazards) has made an enormously the general environment, the potential benefit of these the majority, the economic evaluations were typically of Evaluation of the effectiveness of workplace interventions valuable contribution in these areas. Many diseases and risk discoveries extends beyond the workplace. The number of low methodological quality and often with an ‘employer’ factors for diseases were first discovered in occupational established occupational carcinogens has increased over The body of evidence on effective workplace interventions perspective only. Only a small number included a studies10, 11, with increased recognition of the work setting time with 47 agents in 2017 compared with 28 in 200411. identified from research over the decades is too broad broader societal perspective. The majority of studies and occupational cohorts as remarkably good study These are a likely underestimate with a number of ‘yet to describe within the scope of this report. Common did not consider a long-term time horizon nor use any populations to assess exposures10-12. undiscovered’ carcinogenic agents present in workplaces12. outcome measures include: prevention and reduction of extrapolation or modelling approaches. In summary disease prevalence, sickness absence reduction and early Early epidemiological studies of large scale occupational A key example of research translating into and therefore, our updated findings confirm a persisting lack of RTW. high-quality economic evaluation evidence. diseases and resulting workplace exposure limits and revolutionising clinical OH practice descriptions of best practice have led to their reduction Two systematic reviews111, 112 have concluded that there is One reason why there are not more economic evaluations Waddell and Burton’s back pain management guidelines16 (and in some cases elimination) and have substantially strong evidence that workplace interventions reduce the of OH interventions may be that such research is expensive example, as mentioned in our stakeholder interviews, improved population health, possibly more than most duration of sickness absence, with early contact between and often the information generated is not expected to conveys the powerful impact robust research can other population or clinical interventions. The morbidity the employee and their workplace and offers of work represent value for money. have on revolutionising not just risk but clinical and and mortality in relation to work historically was very high accommodation as important contributing factors111. OH management. Their pioneering work also initiated On the other hand, other types of OH research, for example and this has improved to a substantial degree through an important shift toward self-management and the using observational data for decision analysis104, 105, service industry and policy makers paying increasing attention biopsychosocial model of health17, 18. needs assessments and quality105-108 may provide much to research on health and the systematic study and better return on investment, and high quality economic developments that followed. THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 25

While a body of evidence on improved outcomes from Establishment of new and emerging occupational To our knowledge no formal study of the value placed by There is a need to ‘market’ and make OH research attractive interventions to prevent and manage musculoskeletal hazards and diseases the public on OH research has been undertaken. However, and to train new generations of researchers. Access to disorders is established113, for mental ill health the of relevance, a 2015 OSHA report on the changing training and support is a key factor to achieving this. Given the decline in heavy and manufacturing industry in evidence to date is limited with reviews reporting mixed legitimacy of health and safety at work118 identified that the UK and other developed countries in recent decades, Beneficiaries of OH research (OH providers, employers, results114. There is evidence for disability case management negative perceptions of health and safety were more there is an overarching perception that occupational human resources, employee representatives and interventions8, notably those that include early contact associated with ‘public’ than ‘workplace’ issues and that diseases/work-related ill health are a thing of the past. Government) should all take responsibility for supporting, with employees on sickness absence and specific members of the public are more supportive of efforts to However this shift in industry, technological advances resourcing and driving OH research. agreements around work modifications, resulting in earlier promote safer workplaces than interventions out of work. and the global economic drive have brought with RTW and demonstrated cost-benefit111. The study also found that almost 50% of respondents While academics are up to date with current research them new occupational hazards which merit in-depth thought more could be done to protect workers from findings, dissemination to beyond the academic The effectiveness of case management interventions has study. Organisational changes in the labour market and health and safety risks23. community is inconsistent. There is a fundamental need been demonstrated. One such example in the UK was the psychosocial hazards at the workplace include: work to quickly and simply translate research findings and new EASY study115 which established a day 1 biopsychosocial exposure intensification, double burden, high emotional We have not been able to identify any studies on the knowledge into practical guidance for key users, including intervention for individuals going off sick. It demonstrated load, violence and harassment at work, flexibility of value placed by employers on OH or health research. OH clinicians, employers and employees. Advances in a 21% reduction in sickness absence (compared to other the labour market, ageing workers and presenteeism. However, in a study of employer and employee priorities social media can drive this agenda. Employers need to traditional interventions), cost-effectiveness and high Emerging risks at work related to dangerous agents, of the required competencies for OPs, 75% of respondents understand the benefits to their business and society as a levels of worker satisfaction. This effect was sustained over substances or technologies include: engineered considered research to be an important OP competency24. whole, beyond the legal and statutory requirements. The a four year follow up. Another UK study116 which entailed nanomaterials and nanotechnologies, emerging chemicals Identified factors and challenges on how the value of OH stronger the evidence and value case presented, the more intensive case management and a biopsychosocial and composite substances and new biological hazards. research is perceived and demonstrated and potential likely both employers and Government are to engage. approach for staff with over four week sickness absence With rapidly evolving OH practice, newly recognised solutions was associated with a 10.7% reduction two years later hazards will inevitably emerge and, as has been the Issues around the research-practitioner gap have already compared to a control site. The intervention was also cost- case historically, it is imperative that there is robust In the context of OH research, a number of factors and been described but as highlighted earlier, the current effective116. epidemiological evidence derived from within the UK to challenges have been identified in relation to how value research priorities of employers, human resources and inform national OH and safety policy development and is perceived and demonstrated. The first is a lack of worker representatives, should be formally studied. This Work as a health outcome safer work practices. Future research needs to be ambitious, coherence in resourcing and undertaking research. As a is an essential step to understand what is important to The shift of emphasis from historical occupational disease interdisciplinary and inclusive. Government representative observed in our qualitative these key research users and an important opportunity prevention (i.e. the impact of work on health) to the study, “it all feels to me a little bit ‘hit-and-miss’ in terms of to ‘add’ value. Worker health of small and medium sized Positive public perceptions of the value of health research impact of health on work and overall worker health and both resourcing the research and what’s currently being enterprises (SMEs) and the self-employed has been poorly wellbeing, was also raised in our stakeholder interviews. American surveys have been conducted to assess the done and where”. Concerns around a lack of leadership studied and merits particular attention. Participants described the concept of ‘total worker perceived value of health research by the public 21, 22. A high and dissemination among the OH community has The need for integration of technological advances into health’ and the aspiration of ultimately achieving worker majority of respondents had a positive view of medical previously been highlighted in Dame Carol Black’s 2008 OH research has also been highlighted. While big data and health that is ‘even a little bit better when they leave the research, believing that developments in science have report19. artificial intelligence are current key players in information workplace’ than when they arrived at work that day. This made society better and that it is essential for improving Poor resourcing of OH research through lack of funding technology, the substantial ‘lag’ of OH has been highlighted was developed further by another stakeholder proposal the quality of human lives21, 22. In two surveys, nearly 80% and a reduction in the OH academic base and expertise by the fact that occupational data is not included in any of a broader approach to exposure assessment, including of respondents were interested in health research findings, have also been highlighted in the interviews. Additionally, routine data collection in primary or secondary care in individual behaviours, community exposures, i.e. risk factors with a similar proportion reporting that science plays a current research governance frameworks and related the UK. The lack of routine collection of occupational inside and outside of the workplace, and how they all very important role in our health22. A very high proportion challenges gaining ethics and governance approvals, data in the NHS not only inhibits important research, interact to affect the health of the worker, both positively felt that health research was important to the economy, have been barriers described among the OH academic but also prevents investigation of potentially important and negatively. These innovative and more ‘holistic’ and supported the education and training of healthcare community. As previously recognised, a key hindrance to occupational risks. approaches are areas where future potential value may be researchers21. OH research funding has been attributed to the practice demonstrated, not just in OH but public health and society These current shortfalls in the development of OH research Similar results were found in a UK study117 with of OH out with the NHS (and predominantly in private as a whole. highlight a fundamental requirement for a co-ordinating very positive views on healthcare research and over industry). Consequently, OH is excluded from NHS targeted body in the UK to provide leadership on OH research and The evidence-base on the health benefits of work has gone 90% believing that medical research will lead to an funding opportunities from ‘patient-centred’ funding publishing, to disseminate and promote research to key a step further in consolidating the concept of work as a improvement in the quality of life for people in the UK organisations and charities and is also overlooked by stakeholders (while establishing engaging networks with health outcome, in rightful recognition within mainstream in the next 20 years. Concerns were expressed that not Government. Importantly though, it has been observed them), to build research capacity and to attract research healthcare of the important impact of work on health. enough money is being spent (40%) and that research is (by a Government representative in our interviews) that funding to the specialty. This could become even more important with ageing not progressing fast enough (17%). A majority of adults and a strong enough case is not being made to Government demographics and the mental health epidemic19 where young people said that they were fairly or very interested in ministers that they should be thinking about putting work may prove to be a positive health intervention. medical research117. resources into workplace health research and initiatives. This could be a result of a lack of leadership19, the absence of a national co-ordinated OH research strategy and a lack of coherence in consolidating, disseminating and presenting OH research findings19. THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 27

13. CONCLUSION 14. TABLES

The establishment of a Centre for Work and Health was first In summary, although there is a lack of good quality proposed by Dame Carol Black in 200819 and is a policy of evidence to demonstrate the economic value of OH the UK Academic Forum for Health and Work, with the goal interventions research (and further high quality research is of achieving some of the aims described above. needed in this and other areas of OH research), in our view there is a strong case supporting the OH (i.e. improving The proposal is for a multi-disciplinary institute that will health, wellbeing and functional capability of the working provide leadership, co-ordination of UK OH research population) societal and public health value of OH together with training for early career researchers, OH research. clinicians, employers and employees. A further objective is to network and collaborate with academic institutes, Modern day OH research has scope to be even broader in research funders, businesses and public and third sector its role, not just targeting ‘occupational ‘diseases’ but also organisations to ‘market’ OH research and generate impact, accessing a wide range of the population to ‘prevent’ and to drive the research agenda and facilitate translation of ‘manage’ broader population health issues. Significant reduction in the intervention in claims rates Significant of the cost savings Total with controls. compared group was $2,765 programme PHLAME Significant improvements in self-regulation for in self-regulation improvements Significant walking, waist weight, more, sitting less and moving and insulin in the intervention group circumference, loss was not Productivity with the controls. compared groups between different reduction in a significant showed chi group Tai in work productivity. and improvement absenteeism interventionThe seems cost saving work in engagement, differences No significant vitality and work-related general vitality, sick leave, productivity between groups was neither cost-effective nor cost- programme The €2.21 was lost invested, euro Per saving. All participation cost increase categories yielded a lower nonparticipation to oncompared return and a positive in a 2.45:1 return 2 and 3, resulting years for investment years the combined programme for of investment from Non-participant lost increased net days average net the participant average 38.1, whereas 33.2 to group 27.8 29.2 to from lost decreased days research into practice. Main Outcomes Commitment and action is required to continue to In recognition of similar challenges within Europe i.e. of innovate and drive the OH research agenda and to actively very limited coordination and promotion of European convey and ‘better market’ this value to key stakeholders 2 years 1 year 15 weeks 1 year 1 year 3 years 2 years health research on occupation and employment, a COST (e.g. OH clinicians, employers, the HR community, Follow-up (European Cooperation in Science and Technology) employees, employee representative organisations and funded project has recently been established, with some Government). common objectives and functions to that proposed Equally, the future maintenance of this ‘valuable’ for the UK Centre for Work and Health. The Network contribution can only be secured through retention and No intervention Educational newsletters about benefits of activitiesphysical No intervention Written about information lifestyle a healthy Written aboutinformation lifestyle a healthy not Employees participating in programme any during the years programme who Employees did not complete a health risk assessment on the Coordination and Harmonization of European Control development of the OH academic base and attracting Occupational Cohorts (OMEGA-NET)119 – in addition to research grant funding. creating a network to optimise the use of occupational, industrial, and population cohorts at European level – We conclude that OH research should be at the core of also aims to connect scientific communities on shaping a healthy workforce and productive economy and should be developed accordingly. occupational health in Europe and beyond and to provide networking, leadership, and training opportunities for early career researchers in occupational epidemiology and exposure assessment. A UK Centre for Work and Health could gain valuable Comprehensive medical testing, medical testing, Comprehensive individualised counselling, health promotion and a team-based (PHLAME) programme Increase participants’ Increase participants’ self-efficacy in and self-regulation activity physical promoting and sitting prolonged reducing Chi classes once Tai On-site and practice for a week on their own each day 10 minutes (yoga, Program Vitality Exercise workout, exercise), aerobic visits, Vitality Coach Personal fruit and free Program, Vitality Exercise visits, Vitality Coach Personal fruit and free on a health and enrolled Employees productivity management (HPM) health which addressed programme: and conditions, and chronic acute risks, disorders psychosocial health promotion A comprehensive reduce to was developed programme employee improve costs, health care satisfaction, and enhance image the employer’s insights from this European model in its set up and Intervention development. Other nationally established example models include: The Finnish Institute of Occupational Health (FIOH) and the Institute for Work & Health (IWH) in Canada. fire-fighters 101 office workers101 office nurses 14 female old 49-54 years 730 workers > 45 oldyears 730 workers > 45 old years 1,369 49,793 employees medicalin enrolled plans 1,628 workers on short-term disability Population

Aerospace Aerospace industrial Academic medical centre Academic hospitals Academic hospitals Fire departments A large financial services corporation Large telecoms company Setting

Taiwan USA Nether- lands Nether- lands USA USA USA Country 2018 2012 2013 2013 2013 2012 2001 Year

71 73 75 75 74 77

72 Serxner et al. Palumbo Palumbo et al. Strijk et al. van Dongen et al. Kuehl et al. Serxner et al. Lin et al. Author Table 1. Health Promotion Interventions (n=7) Interventions 1. Health Promotion Table THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 29 Intervention neck/ support to reduced the forearms shoulder and right upper extremity pain and prevented in comparison to incident neck/shoulder disorders model A return-on-investment training alone. ergonomics and installation costs of arm a full return board predicted within 10.6 months. reported the intervention,After no cases of LBP were oftotal net savings was a There of 100%). (effectiveness in a as a whole and it resulted the company $76,872 for of $625 per worker. savings after the back pain was lower of low prevalence The intervention was reported the due to and no sick leave $96 by was reduced medical care discomfort. Net cost for $70,441 with after intervention. were per year Net savings per workersavings of $111 of An annual average reduced. back pain was greatly Low of one sick with an annual average cases occurred, 3.3 acute per $2,334,409, with savings were per year Net savings day. worker of $1,556. in group than the control effective PE was not more pain intensity and duration of LBP the prevalence, reducing of LBP and in the prevention PE was not effective and NP. in the effective PE was more NP. NP or the recovery from Decision latitude and decision authority LBP. recovery from PE was not effective in PE workers. However, increased were risk and physical psychosocial to the exposure in reducing (CEA) and cost-benefit analyses Cost-effectiveness factors. performed. costs and Health care were analyses (CBA) higher in the interventionof productivity group losses were cost difference (the mean total group than in the control was neither cost-effective PE programme The was €127). measures. of the effect on any nor cost-beneficial Reduction in handling injury workers’ incidence, injuries and lost workdays due to aftercompensation costs, of $158 556 for initial investment The the intervention. in less lifting equipment and worker training was recovered based on post-intervention of $55 years savings than three compensation costs. 000 annually in workers’ Analysis of injury pre-intervention spanning 3 years trends and a significant post-interventionand 3 years found compensation lost, workers’ in days sustained decrease with patient handling and direct costs associated claims, (0.82 period in the year payback was estimated The injuries. intervention. preceding immediately years) post-intervention period 2-year was markedThe by and injury risks lost time injury, of work injury, decreased workers’ Total of time lost. days or more with three was $24,443 pre- orderlies compensation expenses for intervention ($237 per FTE) and $34,207 post-intervention in expenses a 41% decrease ($139 per FTE), representing can savings These of $22,758. savings or total per worker, 2 years. over the $5,000 costs incurred to be compared seen were in health and safety Substantial improvements implementation of a participatoryfollowing ergonomics programme. injuryCutting 3.5/100,000 man-hours in decreased rates and B stores 1.5 in Group to compared A stores, Group savings Estimated stores. 1.6/100,000 man hours in control and $29,413 per store $245 per year were A stores Group for less were B stores for Group the chain. Benefits for per year the chain. of $12,773 for net savings dramatic with total Main Outcomes Main Outcomes 1 year 3 years 12 years 4 years 1 year 6 years 6 years 2 years 4 years Follow-up Follow-up Ergonomics training only No control group No control group No control group shortThree educative movies about the of prevention LBP and NP No control group No control group No control group C Group stores the were control Control Control

(1) Ergonomics train-ing only, (2) train-ing only, (1) Ergonomics training plus a trackball, (3) training plus a fore-arm support, or (4) training support. and forearm plus a track-ball and workstation controls Engineering modifications (adjustable chairs, anti-fatigue lift tables, conveyors, and catwalks). grabbers, matting, Officeprogramme: ergonomic and backrests were lumbar pads, employees. to made available also Back school workshops were conducted. implemented. controls Engineering lift and dollies redesigned, Ergonomic tilt tables installed and mechanical lift and risers and various platforms assists, introduced. Participatory Ergonomics Stay@Work (PE): prioritised ergonomic programme low prevent aimed to measures back pain and neck plus three short about the movies educative back pain (LBP) and of low prevention neck pain (NP). musculoskeletal injury “Best practices” consisting of program prevention aids, mechanical lifts and repositioning training employee and lift policy, a zero on lift usage. Introduction of mechanical ceiling lifts and training. Introduction of a participatory team. ergonomics using a less programme A safety combined with case cutter hazardous worker A stores, education: Group case new safety received employees B with education; in Group cutters education received employees stores, using old cutters. Intervention Intervention

nursing staff 182 customer service182 customer / computer call centre operators 123 workers: forklift, and machine crane, technicians, operators, and utility /general workersproduction 637 workers: engineers, secretaries, engineering managers, technicians, & salespersons 1,500 workers from assembly lines 3047 workers (37 depts) 1728 staff Health care 100–110 On average, orderlies groceryAdolescent workers store Population Pop’n

Customer Customer service centre of large healthcare company Wood processing plant Automotive supplier Worker automobile and truck body plant Dutch Four companies: railway company., an airline company, a university including its medical hospital, and a steel company. Six nursing homes Extended facility care A 1,200- bed urban hospital Nine stores belonging a singleto chain of supermarkets Setting Setting USA USA USA USA Nether- lands USA Canada USA USA Country Country 2006 2005 2005 2005 2011 2012 2004 2004 1999 1997 Year Year

79 83 80 78 81 81 81 82 Rempel et al Collins et al. Lahiri et al. Lahiri et al. Lahiri et al. Driessen (3 papers) Chhokar et al. Evanoff et al. Banco et al. 84-86 Author Author Table 2. Ergonomic Interventions (n=9) Interventions 2. Ergonomic Table THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 31 Sickness work ability absence, and productivity values were group in the control better per days had substantially less sick leave study group The economic benefitThe month than the comparison group. of the intervention €1,278 per month and to was estimated €2,405 per month and to person based on the whole group, sick leave and person based on those with more Both groups showed an increase in working an increase showed hours and days Both groups musculoskeletallost due to disorders. in productivitygroups. between both No differences intervention no positive problem-solving The showed vitalityworkability and on productivity, effects to compared business as usual Time-loss (TL) musculoskeletalincreased due to disorders the programme in the intervention However, site. work in a shorter back to employees injured returned historical data, reduced with average compared time and, with costs associated compensation costs and healthcare musculoskeletaltime loss due to disorders. Chaku-Chaku a successful assembly lines might represent workers time on spent more However, strategy. production activities than before number of all typesThe including back injuries, of injuries, betweensuggest a 1991 and 1995. Calculations decreased of on investment $800,000 and a return of over cost savings of pain and injury. as avoidance $2.51, as well number of sicknessThe absence hours was significantly in the CTWR lower group. the control to as compared group In terms of productivitythe intervention loss, be seems to in CTWR costs saved total The the society. for cost saving at $1,366 estimated were participants controls to compared and $10,666 per person per person at 6 months follow-up at 12 months follow-up in the intervention in 201 days was reduced (BM) Sick leave medicine behavioural Full-time controls. to compared health and decreasing in increasing is effective programme results The spinal pain. from suffering women costs for the full-time group the control to that compared reveal (BM) is the most cost-effective programme, programme about 137,509€ per the costs by since it decreased after during the first 3-years group subject in the female rehabilitation. benefits was in from saved number of days largest The it was the most the Sherbrooke model arm. Moreover, worker. of $18,585 per with a mean saving cost-beneficial was no there amounts saved, of the large in spite However, four arms. between the difference statistically significant cost towards All experimental a trend study arms showed benefit and cost effectiveness. Main Outcomes Main Outcomes 3 years 3 years 1 year 1 year 1 year Not available 1 Year 1 year 3 years Mean up follow period was 6.4 years Follow-up Follow-up Regular occupational healthcare Conventional rehabilitation Ergonomic training Usual business activity Usual occupational health and safety management Line-based assembly lines No control group Conventional case management Usual treatment care Standard Control Control Comprehensive workers’ health workers’ Comprehensive surveillance identify to designed workers reduced at risk for employability co- multi-professional Systematic (the rehabilitation ordinated Stockholm Co-operation Project) Chaku-Chaku (Japanese: Manufacturing Method based on assembly cells) Job rotation programme plus programme Job rotation training ergonomic increasing for strategy Problem-solving of ageing workers ofthe awareness and responsibility in living their role working healthy sustainable, lives workplace-basedIntegrated musculoskeletal reduce to programme Injuries, including ergonomic early workplaceassessments, work therapy, physical modifications, an and access to accommodations, physician onsite Health assessment, fitness education programmes programmes, nutrition, smoking(back care, cessation), and incentives work and tailored Coordinated (CTWR): program rehabilitation work an disability by screening the by interdisciplinary followed team of a RTW development collaborative plan G1: behaviour-oriented physiotherapy (PT), therapy behavioural G2: cognitive (CBT), medicine G3: behavioural consisting of rehabilitation (BM) PT + CBT G1: occupational arm: study occupational medicine physician and a participatory ergonomics intervention G2: clinical arm: clinical examination a back pain medical specialist,by participation and in a back school, G3: Sherbrooke model (combined interventions)clinical and occupational Intervention Intervention

986 meat processor 986 meat processor workers 64 rehabilitees a public by employed in Stockholmemployer C: Gearbox) of blue- collar workers and leaders team 491 workers from four 491 workers four from production sectors: finishing socks, finishing underwear, sewing socks and sewing underwear 125 nurse and administrative personnel (workers and supervisors) with 348 employees or work-related non-work-related musculoskeletal in whom the disorders ability perform to job demands is affected samples (A: Three B: Handbrake lever, Exhaust Pipe, 147 Offshore Employees Petroleum 200 workers on sick 4–12 weeks for leave musculoskeletaldue to disorders 214 persons 18-60 blue-collar old, years and service/care workers, on sick leave > 1 month and < 6 months 104 workers absent than four more weeks Population Pop’n Meat processing plants Public employer Stockholm Co-operation Project) Textile factory Textile University and University Medical Centre Hospitals Automotive industry Offshore petroleum unit Four participating municipalities: Kolding, Vejle, and Egtved, Give A nationwide health insurance scheme 31 workplaces than more 175 workers in alocated radius of 30 km the from study back pain clinic Setting Setting Nether- lands Sweden Brazil Nether- lands Canada Germany USA Denmark Sweden Canada Country Country 2018 2006 2017 2015 2006 2012 1999 2009 2005 2002 Year Year

94

93 88 96 98 97 92 95

91 99 van Hollandvan et al Karrholm et al. Comper et Comper al. Bultmann et al. Koolhaas et al. Badii et al. Enríquez- Díaz et al. Maniscalco et al. Jensen et al. Loisel et al. Author Author Table 3. Interventions related to Employability / Work Adjustments / Work rehabilitation / Return to Work Interventions (n=13) Interventions Work / Return to rehabilitation Work / Adjustments Work / Employability to related 3. Interventions Table THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 33 Physical disabilities, kinesiophobia disabilities, functioning and physical Physical as in the intervention significantly group improved in It effective usual care. was also more to compared the severity inreducing of complaints and equally effective Multidisciplinary work than usual care. to return treatment no significant but shows individuals positively affects on the societal level as effectiveness (cost-) in difference usual care to compared earlier work 30.0 days than UC at slightly to WI returned WI*CI group higher direct costs (ratio of 1 day: €19). WI*UC group. than later work 50.9 days to returned than UC*UC. later work 21.3 days to UC*CI returned in the is lower on sick leave days mean number of total The A workplace than intervention effective WI group. was more in RTWusual care at slightly higher costs and was equally at equal costs on other outcomes. as usual care effective andA clinical intervention than usual care was less effective with higher costs. associated investment average year an follow-up the end of first At only €83 more the GA interventionfor of €475 per worker, yielded utilisation costs in UC group, than health care a reduction in of at least €999 due to savings an average an were savings cumulative potential The productivity loss. period. follow-up of €1,661 per workera 3-year over average in the severity of PTSD improvements moderate Small to (productivity lost days and fewer symptoms and depression costly intervention a 58% gain of $1255). However, probability of being cost-effective at a $100,000/QALY threshold. recovery for work and ability, improvements No significant work demands and physical mental health, well-being, between groups. found productivity were soldiers costs for health care LBP-related median total The the intervention LBP-related and incurred who received group. than the control $26 per soldier lower costs were in performanceImprovements feedback, participatory skills efficiency, development, management, employeeship, and work-related well-being, employee leadership, identified. exhaustion were and productivity decreased improved. Absenteeism Main Outcomes Main Outcomes 1 year 1 year 3 years 1 year 1 year 2 years 1 year Follow-up Follow-up Usual care Usual care by provided occupational health service G3: Usual care and clinical intervention (UC + CI). G4: only usual provided care anby occupational (UC)physician Usual care (UC) Standard integrated mental health approach: access to mental health specialists and by follow-up nurse care manager No intervention Exercise programme No control group Control Control Psychological and physical sessions and physical Psychological a medical specialist, by provided and an a physiotherapist psychologist, occupational therapistG3: Sherbrooke occupational andmodel (combined clinical interventions) G1: Only occupational intervention (WI):Workplace assessment, work modifications and case Management G2: Occupational intervention and clinical intervention (WI + CI): based on operant physiotherapy principlesbehavioural Graded activity intervention: (GA) twice a 60-min physical a week session with a cognitive exercise under the approach behavioural supervision of specifically trained physiotherapists tele- collaborative assisted Centrally treatment including psychosocial care mental health team and routine monitoring plus standard medical health integrated map positive workshops to Three aspects andand negative of physical and work environment psychosocial action and implemented developed the highlighted plans addressing issues education programme Psychosocial of LBP and threat fear reduce aimed to programme plus exercise Individualised intervention programme assessment each worker’s to targeted work psychosocial of the prevailing conditions Intervention Intervention 38 sick-listed workers38 sick-listed with non-specific upper extremity musculoskeletal complaints 196 workers sick-listed a period of 2 for LBP due to 6 weeks to 134 blue-collar workers, LBP due to sick-listed 629 active-duty service members with Post Stress Traumatic or (PTSD) Disorder depression 415 industrial workers 4295 soldiers who training to attended become a combat medic 383 white-collar in 22 work employees units Population Population Bank employees and workers at one of the two inuniversities Amsterdam Industry, health and office care work Royal AirlinesDutch primaryArmy clinics care at military installations large Three Danish industrial workplaces (manufacturing work) US Army Swedish Internal Revenue Service Setting Setting Nether- lands Nether- lands Nether- lands USA Denmark USA Sweden Country Country 2006 2006 2007 2018 2018 2014 2005 Year Year

95 90 87 101 103 100 102 Steenstra Steenstra et al. Hiobil et al. Gupta et al. Childs et al. Anderzen et al. Meijer et al. Lavelle et al. Author Author Table 3 continued: Interventions related to Employability / Work Adjustments / Work rehabilitation / Return to Work Interventions (n=13) Interventions Work / Return to rehabilitation Work / Adjustments Work / Employability to related Interventions 3 continued: Table (n=4) Interventions 4. Psychosocial Table THE VALUE OF OCCUPATIONAL HEALTH RESEARCH: HISTORY, EVOLUTION AND WAY FORWARD 35

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