Because of its substantial personal social and economic costs, workforce participation among individuals with rheumatic diseases has received considerable research attention. This chapter reviews non-pharmacological employment interventions for people with rheumatic diseases, focussing on the comprehensiveness of interventions, whether they have been targeted to those groups identified as most at risk, and intervention outcomes and effectiveness. Findings highlight that early diagnosis and treatment of rheumatic diseases may not be enough to keep individuals employed and that comprehensive work interventions may have positive psychological effects, as well as result in increased work participation. However, we lack data addressing the optimum time to intervene and subgroup analyses to determine whether some groups are at increased risk for poor work outcomes. Consistent inclusion of behavioural and psychological outcomes to evaluate interventions and compare studies is also needed, along with cost-benefit studies, to determine the long-term feasibility of work interventions.
Workforce participation among individuals with rheumatic diseases has received considerable research attention. Work disability, sick leave, absenteeism and presenteeism are reported to be substantial, with short- and long-term work disability often ranging from one-third to over 50% of individuals who report functional limitations related to their disease . Disability and productivity costs are also high, estimated at 2–4 times greater than direct health care costs . This is of particular concern as rheumatic diseases such as osteoarthritis are projected to increase in prevalence, in part because of the ageing of the population, but also due to lifestyle factors such as lack of physical activity and obesity .
The importance of addressing the workplace needs of those with rheumatic conditions has resulted in a number of interventions aimed broadly at vocational rehabilitation. Several reviews have evaluated this literature . However, there has been little discussion of whether interventions have been targeted to those groups identified as being most at risk or whether interventions address the health, job, personal and environmental factors identified in research as problematic. The outcomes used to evaluate interventions also deserve attention, especially as studies have begun to include presenteeism (i.e., at-work productivity losses) in addition to absenteeism, sick leave and long-term disability as important outcomes. Finally, it is unclear what types of interventions or what components within an intervention are most useful and when an intervention should be delivered to maximise success.
This chapter reviews non-pharmacological work interventions for individuals with rheumatic diseases. It pays particular attention to the components targeted in interventions, the study samples and the effectiveness of the intervention to address the current state of intervention efforts and identify potential gaps. Prior to reviewing work interventions, research related to rheumatic diseases and employment is summarised.
Rheumatic diseases and employment
Research on rheumatic diseases and employment has examined demographic, health, work-context, psychological and social factors. Findings are not always consistent. Demographic variables frequently studied include age, education and gender. To date, a relatively consistent body of evidence points to older age and lower education as significantly related to leaving the labour force . Less evidence exists examining outcomes such as absenteeism and presenteeism, although some research suggests that older working adults with rheumatic diseases may be less likely to take sick days than younger adults . Findings are mixed for gender with some studies finding no differences and others suggesting that women are less likely to be employed or more likely to need workplace accommodations than men . Other research finds that, although men with arthritis were more likely to remain working, they reported more negative job experiences such as being passed over for a promotion than women .
Health factors associated with employment problems include greater pain, fatigue, number of joints involved and functional limitations . Interestingly, although clinical disease activity and damage indices have been examined across different rheumatic conditions, many are not significant in multivariate models once functional limitations and work-context variables are included . Recent research has also examined health factors such as unpredictable symptoms or episodic workplace activity limitations. Findings indicate that intermittent disability is common but that only high levels of workplace limitations are associated with disruptions at work, absenteeism and difficulties with managers and co-workers .
Job context factors are also critical to understanding workforce participation. Jobs with high physical demands and work pace; those involving the hands; where there are few adaptations or accommodations available; low control over work tasks or scheduling; and commuting difficulties are associated with greater employment difficulties for many people . Job disruptions, absenteeism, permanently reducing work hours and sick leave can also predict future job difficulties, including leaving employment .
Although they are gaining attention, personal or psychological factors such as job stress, perceived work-health conflict, social support and coping have been studied less extensively . Those reporting high job stress or work-health conflict report more negative employment outcomes . Some coping strategies such as limiting activities and pacing have been associated with giving up employment , although they are commonly used both at home and work along with modifying activities, accommodations and getting help from others . Studies also report benefits with the use of different self-management strategies . A difficulty when studying the impact of coping strategies is that greater amounts of coping often signal that an individual has greater needs (e.g., more pain) or that a strategy is not working and is being used repeatedly, making analysis of coping as a contextual factor complex. Finally, support at home and work has been associated with better employment outcomes .
A range of work outcomes has been examined in research on rheumatic diseases. Much of the emphasis has been on short- and long-term disability, absenteeism and giving up employment altogether . Increasingly however, studies are assessing presenteeism . Costs related to rheumatic diseases and their management are a third type of outcome examined . Finally, a wide range of additional behavioural outcomes such as work transitions (e.g., reduced hours and changing jobs) and psychosocial outcomes (e.g., work stress and workplace interpersonal relationships) have begun to garner attention .