1. Health, work & well-being
Gordon Waddell
Centre for Psychosocial & Disability Research,
University of Cardiff

2. Aims of Review
To collate and evaluate the scientific evidence on the question –
Is work good for your health and well-being?
Does the scientific evidence support promotion of work and RTW?

3. Definitions
Work(lessness)
(Un)Employment
Health
Well-being

4. Definitions
Work : application of physical and mental knowledge & skills; commitment over time; effort, labour & exertion
Employment : contract of employment for pay; set of specific tasks, located in specific physical/social context
Health
Well-being

5. Definitions Work Employment
Health : usually operationalized in terms of absence of physical and mental symptoms, illness and morbidity
Well-being : the subjective state of being healthy, happy, contented, comfortable and satisfied with one’s quality of life

6. Work and health
Possible causal pathways between health, work and well-being

7. Common health problems
Less severe medical conditions
Responsible for 2/3 of absence and long-term incapacity
Common mental health problems
Musculoskeletal conditions
Cardio-respiratory conditions

8. Common health problems
Common features
High prevalence in working age population
Largely subjective - little or no disease or impairment
Multifactorial causation – work usually only one contributory factor
Most episodes settle rapidly – though often persistent or recurrent
Most people remain at work or return to work quite quickly
Essentially whole people, with what should be manageable health conditions
Is work beneficial for people with common health problems?

9. Review Methodology

10. Structure of review Health effects of work
Health effects of unemployment
Health effects of re-employment
original studies
Work for sick and disabled people
Impact of work on people with
mental health conditions
musculoskeletal conditions
cardio-respiratory conditions
Health effects of moving off social security benefits
original studies + reviews

11. Review Findings

12. Work
The generally accepted theoretical framework about work and well-being is based on extensive background evidence:

13. Work
Work provides income: material well-being and participation in today’s society
Work meets important psychosocial needs in societies where employment is the norm
Work is central to individual identity, social roles and social status
Employment and socio-economic status are the main drivers of social gradients in health

14. Work
Work provides income: material well-being and participation in today’s society
Work meets important psychosocial needs in societies where employment is the norm
Work is central to individual identity, social roles and social status
Employment and socio-economic status are the main drivers of social gradients in health
At the same time, various aspects of work can be a hazard and pose a risk to health

15. Unemployment
There is strong evidence that (long-term) unemployment is associated with:
Higher mortality
Poorer general health, somatic complaints, long-standing illness, limiting longstanding illness
Poorer mental health; more psychological distress; minor psychological/psychiatric morbidity, suicide
Higher medical consultation, medication consumption and hospital admission rates.

16. Re-employment There is strong evidence that re-employment:
First comprehensive review of 53 longitudinal studies
Improves physical & general health and well-being
Improves mental health
Magnitude of improvement comparable to the harmful effects of losing a job.
There is strong evidence that re-employment:

17. Re-employment There is strong evidence that re-employment: However:
First comprehensive review of 53 longitudinal studies
Improves physical & general health and well-being
Improves mental health
Magnitude of improvement comparable to the harmful effects of losing a job.
There is strong evidence that re-employment:
However:
That depends on the quality and security of re-employment
There is a persisting risk of poor employment patterns and further unemployment

18. Work for sick & disabled people
There is a broad consensus across multiple disciplines, disability groups, employers, unions, insurers and all political parties,
based on extensive clinical experience AND on principles of fairness and social justice:
When their health condition permits, sick and disabled people should remain in or re-enter work as soon as possible, because -

19. Work for sick & disabled people:
Is (generally) therapeutic
Helps to promote recovery and rehabilitation
Leads to better health outcomes
Minimises the harmful physical, mental and social effects of long-term sickness absence
Reduces the risk of chronic disability and long-term incapacity
Reduces poverty and social exclusion
Improves quality of life and well-being

20. Work for people with common health problems:
Common mental health problems
Musculoskeletal conditions
Cardio-respiratory conditions

21. Moving off social security benefits
Claimants who move off benefits and (re)-enter work generally experience improvements in income, socio-economic status, mental and general health, and well-being.
Claimants who move off benefits but do not enter work are more likely to report deterioration in health and well-being.

22. Is work good for your health?
Theoretical framework
Unemployment is bad for physical and mental health and mortality (c.f. work)
Re-employment reverses the ill effects
Clinical management of common health problems
Benefit leavers – health benefits depend on re-entering work.

23. Is work good for your health?
Theoretical framework
Unemployment is bad for physical and mental health and mortality (c.f. work)
Re-employment reverses the ill effects
Clinical management of common health problems
Benefit leavers – health benefits depend on re-entering work.
Strong case that work is good for health

24. Conclusions
Employment is generally good for physical and mental health and well-being
Unemployment and unnecessarily prolonged sickness absence are generally bad for physical and mental health and well-being
That is true for healthy people of working age, for many disabled people, for most people with common health problems, and for social security recipients

25. Provisos
These findings are about average or group effects and should apply to most people to a greater or lesser extent; however, a minority of people may experience contrary health effects from work(lessness);
Beneficial health effects depend on the nature and quality of work
Account must be taken of the social context, particularly social inequalities in health and regional deprivation.

26. Some Implications

27. Occupational health paradigm
Trauma
Injury / disease
Hazard
Worker
Harm
Objective, assessable
Passive (susceptible)
Medically diagnosable
Proof of causal relationship

28. Health & Safety
Safety: identify, assess and control hazards & risks - primary prevention of injury & disease
A healthy working life is:
‘one that continuously provides working-age people with the opportunity, ability, support and encouragement to work in ways and in an environment which allows them to sustain and improve their health and well-being’ (Scottish Executive 2004)
‘Work should be comfortable when we are well and accommodating when we are ill’ (Hadler 1997)

29. Work & Health Distinguish health and safety
Beneficial and harmful health effects
Interactions between worker and work
Common health problems usually not a simple consequence of work – multifactorial + context
Perceptions – the more subjective the condition, the more central the role of psychosocial factors
Must consider the worker, their health problem and their (work) environment (A biopsychosocial model)

30. Work & Health +/- +ve -ve Worker strengths & vulnerabilities
Job demands & rewards
Worker strengths & vulnerabilities
+/-
Harm
+ve
Benefits
Health & well-being
Ill-health
-ve

31. Implications
Clinical management Information & advice Sick certification Rehabilitation
Health at work ‘Risk’ assessment & control Sickness absence management Return to work process
Social policy Employment / ‘Good jobs’ Health & Safety Social security

32. Information and advice
Avoid false attribution to work
Advice on staying active and continuing ordinary activities as normally as possible – including work
Talk about their job & duties
Help plan return to work process
Occupational outcomes

33. Sick certification
Sick certification is a major therapeutic intervention
Is sickness absence really necessary?
Are there any other (better) options?
What are the risks and do they outweigh the benefits?
For how long? - The longer someone is off work, the lower the chances of returning.
Have you thought about how/when they will get back to work? - before you issue the certificate

34. Therapy
Treating symptoms
Restoring function

35. Rehabilitation
Principles of rehab integrated into clinical and occupational management
Every health professional has a responsibility for rehabilitation
Treat symptoms AND restore function
Address bio–psycho–social obstacles to recovery and return to work
All players onside: communication
Focus on occupational outcomes

36. Good jobs Possible characteristics: As safe as reasonably practicable
Fair pay
Social gradients in health
Job security
Personal development & fulfilment: investing in human capital
Accommodating, supportive, non-discriminatory
Control/autonomy
Job satisfaction
Good communication

37. Social context Worklessness Poverty Social exclusion
Social gradients in health
Regional deprivation
Local unemployment rate
Sickness, disability and incapacity
Multiple disadvantages
% ‘poor health
% on benefits

38. Changing the culture of work & health
Culture: The collective attitudes, beliefs and behaviours that characterise a particular social group over time
Benefits culture – e.g. South Wales valleys where 2 and even 3 generations of family not worked

39. Shifting attitudes to work & health
Current:
Shift to:
Work is a ‘risk’ and (potentially) harmful to physical and mental health.
Work is healthy, therapeutic & the best form of rehab.
vs.
Risks of long-term sickness absence
therefore
Advice to stay off / sickness absence / sick certification ‘protects’ from work
Advice and support to remain in or (early) return to work
The key idea is that work is therapeutic and the best form of rehabilitation

40. Long-term worklessness is one of the greatest risks to health
Loss of fitness
2-3X risk of poor health
Depression, 2-3X risk mental illness
20% excess deaths
Greater risk than many “killer diseases”
Greater risk than most dangerous jobs e.g. construction, North Sea
Trapped on benefits to retirement age
Social exclusion, poverty

41. Health, work & well-being
The beneficial effects of work on physical and mental health and well-being generally outweigh the risks of work and the harmful effects of worklessness.