Fig. 3.1
The effects of different measures of ill health in 2004 on unemployment and work-related disability in 2006 in 11 European countries, expressed by adjusted odds ratios (Based on Ref. [4])
In Western countries, ill health is an important determinant of becoming or staying unemployed. Ill health is largely responsible for displacement from the labour force due to disability. Loss of paid employment may cause chronic disease, such as depression and cardiovascular disease.
The SHARE study clearly demonstrates the importance of health for labour force participation. However, an increased risk of displacement from the labour market during the 2-year follow-up period does not present sufficient insight into the consequences of ill health on paid employment during the life course of a person. In the past few years, new approaches have been developed that capture the long-term consequences of ill health for a sustained working life. One of the most promising new metrics is the work life expectancy (WLE) measure, which reflects how many years a person at a given age is expected to work in a paid job. A linked measure is the number of working years lost due to being out of paid employment, for example, due to work-related disability. A recent study on the Norwegian disability pension registry estimated that subjects with a permanent disability benefit lost about 15 years of their working life. Mental disorders contributed most to the total working years lost (33.8 %), followed by musculoskeletal disorders (29.4 %). Individuals with a mental disorder were awarded a disability benefit on average at much younger age than individuals awarded for a musculoskeletal disorder (46 years vs. 55 years, respectively) [6]. In a Canadian study, it was reported that working life of individuals with arthritis was reduced with about 4 years among men and 3 years among women [7].
Working life expectancy equals the number of years a person at a given age is expected to work in a paid job. Working years lost equal number of years out of paid employment. Individuals with arthritis will lose 3–4 years of paid employment due to their disease. Individuals with mental disorder may lose up to 15 years of paid employment.
The metric WLE can be adapted to construct a disease-work participation model that describes for each age, stratified by sex, the transitional probabilities from paid employment to disability and unemployment and the particular contribution of ill health to this displacement from the work force. Such models are extremely useful to estimate the total loss of working years across the life course of the workforce and the relative contribution of ill health to the working years lost. The aforementioned SHARE study was used to evaluate the hypothetical impact of health promotion by assuming that the particular role of ill health in the displacement from the workforce can be completely eliminated. This disease-work participation model starts with a reference population of persons at age 50 years all in paid employment. During the 2-year follow-up, the proportion of workers with paid employment is calculated for each following year, stratified by age and sex, as well as the proportion of workers who exit paid employment through possible exit routes such as work-related disability, unemployment, retirement, and becoming homemaker. Subsequently, the relative contribution to ill health to disability and unemployment can be calculated by the population attributable fraction of ill health. This analysis was conducted for one definition of ill health (less than good health), without taking into account possible additional effects of other measures of ill health, such as presence of chronic disease or limitations in activities in daily life. Figure 3.2 presents the potential impact of prevention of ill health on labour force participation among men. For women a similar pattern was observed. It is estimated that the average age of quitting paid employment could increase from 60.4 to 61.5 years (13.2 months) among men and from 59.2 to 60.5 years (16.2 months) among women. Thus, tackling ill health among workers may prolong WLE by at least 1 year [8]. This example illustrates that new metrics, such as working life expectancy and working years lost, may convey a powerful message to stakeholders, such as policymakers and health professionals, about the need to develop interventions and policies that support workers to remain in paid employment and delay unwanted health-related retirement.
Fig. 3.2
Theoretical effect of elimination of health problems through preventive efforts aimed at important health determinants on the labour force participation among men who have paid employment at the age of 50 year (Based on Ref. [8])
3.3 Consequences of Chronic Disease for Optimal Participation at Work
An important consequence of having a chronic disease is disability, ranging from limitations in executing a simple task to restrictions in societal roles. As stated before, there is a growing interest in the influence of chronic disease on the performance of social roles, i.e. participation, and especially paid employment. Restriction in work participation strongly represents the indirect costs of illness, defined by productivity losses of a person due to sickness absence or less productivity at work because of health problems. This domain is not covered in the ICF, whereas it is very important in cost-effectiveness evaluations. Traditionally, studies among persons with chronic diseases have focused on work-related disability, but comparability across countries is hampered by the strong influence of legal and socio-economic determinants on eligibility for a disability benefit. In recent years, sickness absence has received more attention as a key parameter of restriction in work capacity, since sickness absence is regarded as an important source of productivity loss, which largely accounts for the indirect costs of illness. The latest development is the appreciation that persons with a chronic disease who do go to work may experience a decreased productivity due to their health problems. The phenomenon where workers turn up at work despite health problems is sometimes referred to as sickness presenteeism, but in economic terms, it is better described as productivity loss at work [9]. It has been hypothesised that being less productive at work is an alternative choice to sickness absence for workers with chronic diseases, with both acting as alternative choices for a worker. However, several studies have shown that both measures of reduced productivity are strongly associated, clearly suggesting that productivity loss at work may precede or follow a spell of sickness absence [10].
Taking rheumatoid arthritis (RA) patients as an example, several studies have demonstrated the considerable impact of RA on all measures of work participation. In a systematic review, several participation categories were selected from the Comprehensive Core Set for RA, resulting in 30 studies on remunerative employment, 17 studies on recreation and leisure, and 3 studies with combined measures of participation. RA patients had an increased risk of being without paid employment (odds ratios varied from 1.2 to 3.4). Restrictions in employment occurred already within the early phase of RA, but varied greatly among studies. Two years after diagnosis, in some European cohort studies, up to 30 % of the RA patients had already enrolled in the disability benefit system while being without paid employment [11].
While many studies have focused on permanent work disability among patients with established RA, there is emerging evidence that RA will also contribute to temporary absence from work due to illness and a reduced performance while at work due to illness. However, there is scarce information on the work-related factors that prompt workers with RA to take sickness absence or to have reduced productivity at work. Recently, a systematic review was conducted on the occurrence and magnitude of workplace productivity loss and sick leave in patients with inflammatory arthritis (IA), which encompasses primarily patients with early RA as well as established RA. In total, 47 original studies were identified with 44 studies reporting on sickness absence and 20 studies describing productivity loss at work. The occurrence of sickness absence varied from 3.7 % in the past 4 days to 84 % in the past 2.5 years and the total duration of sickness absence ranged from 0.1 to 11 days in the past month. The large variation in sickness absence across studies was also observed for productivity loss at work. About 17–88 % of patients experienced any workplace productivity loss, and productivity was reduced by 4.9 % to over 35 % in the past weeks. In general, increased levels of pain and decreased functional abilities were consistently associated with sickness absence and productivity loss at work. The evidence on the particular role of working conditions that hampered or supported patients with RA to remain productive was poorly developed. There were some indications that heavy physical work, frequent manual material handling, high time pressure, low job control, and poor social support were work-related risk factors for sickness absence [12].
These studies on RA patients clearly demonstrate that RA will impact quantity and quality of work activities performed, frequency and duration of sickness absence, and exit from paid employment through work-related disability. Similar conclusions can be drawn for different patient groups, emphasising the need to study the influence of chronic diseases and all measures of work participation. The systematic reviews on RA and work performance also point at a clear lack of insight into the interplay between working conditions and chronic diseases, which will hamper the development of effective rehabilitation programmes.
3.4 Interplay Between Work Conditions and Chronic Diseases
In interviews with patients with a chronic disease about facilitators and barriers for an optimal performance at work, often, specific work-related factors are mentioned. Among patients with chronic musculoskeletal pain, adjustment latitude and job control were mentioned as success factors for staying at work [13]. In a study among patients with RA and patients with diabetes mellitus, the main factors at work that enabled employees to continue working were adequate working conditions and support from management and colleagues [14]. These qualitative studies strongly suggest that work-related factors modify the effect of ill health on sickness absence, but interestingly there is little quantitative evidence in the scientific literature on how work-related factors interfere with disease.
In order to better understand the effect of work on the influence of ill health on sickness absence, a longitudinal study was conducted among employed persons aged 46–64 years as part of the ongoing Study on Transitions in Employment, Ability, and Motivation (n = 8,984) [15]. The presence of common chronic health problems and work-related factors was determined at baseline and self-reported sickness absence at 1-year follow-up by questionnaire. Multinomial multivariate logistic regression analyses were conducted to assess associations between presence of a chronic health problem and sickness absence and the effect modification of these associations by work-related factors. The effect modification was expressed by the relative excess risk due to interaction (RERI), whereby values above 0 indicate that an additive interaction is present. In Table 3.1, the core findings are reported for high cumulative sickness absence of 10 days or more per year.
Table 3.1
Interaction effects of work-related factors and health on sick leave over 10 days in the follow-up period of 1 year, after adjustment for age, education, and sex, among 6,534 workers aged 45–65 years in the Netherlands (Based on Ref. [15])
Health problem | Work-related factor | N | Odds ratio | 95 % confidence interval | Relative excess risk due to interaction | 95 % confidence interval |
|---|---|---|---|---|---|---|
Psychological complaints
Related posts: State of Vocational Rehabilitation and Disability Evaluation in Chronic Musculoskeletal Pain Conditions
Serious Mental Illness, Vocational Rehabilitation, and Employment
Critical Issues for Mental Health Management in Vocational Rehabilitation: DSM-5, ICD-10-CM, and Implementing the WHODAS
 Applying the ICF in Disability Evaluation: A Report Based on Clinical Experience
Challenges and Opportunities
 Applying the Work Rehabilitation Questionnaire WORQ: A Case Illustrating Its Use in Evaluating Functioning of a Person After a Traumatic Brain Injury in an Interprofessional Vocational Rehabilitation Setting
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