Table Of ContentHealth and Safety
Executive
Developing an intervention toolbox for
common health problems in the workplace
Prepared by the Health and Safety Laboratory
for the Health and Safety Executive 2015
RR1053
Research Report
Health and Safety
Executive
Developing an intervention toolbox for
common health problems in the workplace
Dr Nick Kendall and Professor Kim Burton
Kendall Burton Consulting
30 Queen Street
Huddersfield HD1 25P
Dr Jennifer Lunt and Dr Nadine Mellor
Health and Safety Laboratory
Harpur Hill, Buxton
Derbyshire SK17 9JN
Professor Kevin Daniels
University of East Anglia
Norwich Research Park, Norwich
Norfolk NR4 7TJ
The Management Standards (MS) approach is a key component of the HSE’s ‘stress toolbox.’ It was
developed to reduce the levels of work-related stress reported/experienced by working people in Britain.
Although a study by Cox et al, 2009 identified a number of weaknesses and limitations in the current version
of the Management Standards, research suggested that there were good prospects for correcting these and
building on them to evolve a more generic toolbox.
The aim of the project was to look at the feasibility of developing a toolbox for the management of common
health problems in the workplace. Reliable and valid evidence identifies the two most common health
problems at work as musculoskeletal disorders and psychological ill-health (stress, anxiety and depression).
It was anticipated that the tool could bring together work on work-related stress (ie Management Standards)
and musculoskeletal disorders (MSDs) and contribute to HSE’s specific aim of developing the applicability
of the Management Standards to a wider range of health issues in particular, to extend their scope to cover
musculoskeletal disorders.
HSE has concluded that it was not possible to develop the simple health and safety toolbox as envisaged, as
the ‘model’ moved into the ‘wellbeing’ area and away from HSE’s specific remit/responsibilities for workplace
health-related issues. HSE acknowledges the work of the researchers and believes that others involved in this
area of work are better placed to take forward some of the recommendations.
This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents,
including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily
reflect HSE policy.
HSE Books
© Crown copyright 2015
First published 2015
You may reuse this information (not including logos) free
of charge in any format or medium, under the terms of the
Open Government Licence. To view the licence visit
www.nationalarchives.gov.uk/doc/open-government-licence/,
write to the Information Policy Team, The National Archives, Kew,
London TW9 4DU, or email [email protected].
Some images and illustrations may not be owned by the
Crown so cannot be reproduced without permission of the
copyright owner. Enquiries should be sent to
[email protected].
Acknowledgements
The authors would like to thank the various experts from
Government, Academia and Industry for their valuable input
and insights into the development of the toolbox as part of the
stakeholder engagement exercises. The authors would also
like to thank Line Managers from both within the public and
private sectors for their time in evaluating the usability of the
toolbox.
The authors would also like to acknowledge the cooperation of
the University of East Anglia (UEA) in this project. This is on
account of Professor Daniels moving to UEA during the course
of this project.
Thanks are also due to David Fox, HSL, for his help with the
analysis, and to Louise Carter, HSL, in her role of project
manager.
Finally, the authors would like to acknowledge the
appointments of Dr Kendall with the University of Otago, New
Zealand, and of Professor Burton with the University of
Huddersfield.
ii
CONTENTS
1.
EXECUTIVE SUMMARY ....................................................... v
1.1.
Aim v
1.2.
Approach v
1.3.
Findings/outcomes v
1.4.
Implications vii
2. INTRODUCTION ..................................................................... 1
2.1.
What are Common Health Problems? 1
2.2.
Challenges posed by Common Health Problems 1
2.3.
Current approaches for managing Common Health Problems 2
2.4.
Case for a new approach 2
2.5.
Research objectives 3
2.6.
Overall approach 4
2.7.
Caveats 4
3. PHASE ONE: EVIDENCE SYNTHESIS .................................. 7
3.1.
Evidence review: Method 7
3.2.
Evidence review: Key Findings 8
3.3.
Stakeholder survey: Method 16
4. PHASE TWO: DEVELOPMENT OF THE CONCEPTUAL
FRAMEWORK ................................................................................ 19
4.1.
Workshops: Method 19
4.2.
Workshop: Key Findings 20
4.3.
Conceptual framework: Method 21
4.4.
Conceptual framework: Findings 22
5. PHASE THREE: PRODUCTION OF USER-CENTRED
TOOLBOX ...................................................................................... 27
5.1.
Production of user-centred toolbox: Method 27
5.2.
Production of a user-centred toolbox: Findings 28
6. PHASE FOUR: USABILITY TESTING .................................. 35
6.1.
Phase Four: Usability Testing: Method 35
6.2.
Usability Testing: Findings 35
7. SUMMARY, IMPLICATIONS AND CONCLUSIONS ............ 39
7.1.
What does the toolbox do? 39
7.2.
Who is the toolbox for? 39
7.3.
How should the toolbox work? 39
7.4.
How can the toolbox add value? 41
7.5.
Caveats 41
7.6.
Next Steps 42
(cid:76)(cid:76) (cid:76)
8. REFERENCES ...................................................................... 45
9. APPENDIX 1 .......................................................................... 47
9.1.
Best Evidence Synthesis 47
9.2.
Evidence Tables 104
9.3.
Project Glossary 235
10. APPENDIX 2 ........................................................................ 244
10.1.
Stakeholder Survey 244
11. APPENDIX 3 ........................................................................ 292
11.1.
Workshops – expert groups 292
12. APPENDIX 4 ........................................................................ 298
12.1.
Underpinning Framework (‘Expert Backend’) 298
13. APPENDIX 5 ........................................................................ 399
13.1.
Usability Testing of Work↔Health Toolbox 399
14. APPENDIX 6 ........................................................................ 419
14.1.
Website 419
15.
APPENDIX 7 ........................................................................ (cid:24)(cid:23)(cid:22)
15.1.
Evaluation Options 543
i(cid:89)
1. EXECUTIVE SUMMARY
1.1. AIM
The project brief was to develop the content for an intervention toolbox for common health
problems in the workplace - musculoskeletal, mental health and stress complaints. The intention
was to develop a prototype toolbox that can be taken forward to (1) minimise the occurrence of
work-relevant common health problems (CHPs) and (2) reduce avoidable sickness absence,
healthcare use and long-term disability for CHP complaints that inevitably occur in the
workplace1.
1.2. APPROACH
Development of the intervention toolbox was commissioned by the Health and Safety Executive
and undertaken by a consortium comprising KendallBurton Consulting, Loughborough
University, and the Health and Safety Laboratory. The development process spanned five
phases. Phases were designed to attain each of the project’s objectives (page 3). The first phase
provided the toolbox’s evidence base derived from a review of the scientific literature and a
stakeholder survey. It gave rise to an underpinning conceptual model for steering subsequent
development. The second phase entailed developing a conceptual framework that specified
‘what’ (content) should go ‘where’ (structure) and how the toolbox could be implemented.
Expert workshops were also undertaken at the outset of phase two to check the project direction.
Phase three produced a draft user-centred toolbox based on the conceptual framework
comprising information, advice and a suite of tools. In the fourth phase, the draft web-based
toolbox was tested for acceptability and usability with a sample of potential end-users,
following which a functional prototype was produced.
1.3. FINDINGS/OUTCOMES
Current approaches: The scientific evidence on the relationship between CHPs and work
indicates that prevention approaches using the conventional hazard-risk-control model, and
treatment approaches founded on treatment-cure-participate assumptions, have not yielded the
hoped-for outcomes. Underlying dose-response assumptions do not readily translate to CHPs.
Their subjective and ubiquitous nature significantly undermines the potential for risk control in
the workplace to eradicate CHPs. Furthermore, clinical treatments neither fully alleviate all
symptoms nor prevent further episodes. What this means in practice is that current health and
safety regulation and guidance, including the Management Standards for Work-Related Stress,
although useful for their specific purposes, are not sufficient for managing the workplace
consequences of CHPs, and that simply adapting them would be a suboptimal appraoch. The
evidence indicates that this supplementary approach should be more effective than adaptations
to existing material. Consequently this new approach represents an addition to rather than a
change to current approaches such as the Management Standards.
Conceptual model: The underlying principle for this toolbox recognises that the relationship
between employment and health is considered to be close, enduring and multidimensional. A
1 All key terms used in this document are outlined in the section Definitions and Glossary. The term ‘complaint’ is
preferred over ‘symptoms’ due to it being more inclusive of the subjective nature of symptom onset, interpretation,
and behavioural responses. Complaint denotes the point at which CHP symptoms are reported. Work-relevance has
been used on the basis that CHP symptoms affect and are affected by the workplace irrespective of whether work
related factors contributed to their onset.
v
novel conceptual model was developed to support the toolbox, which was based on this
principle and was underpinned by a biopsychosocial approach. A key feature is that it combines
evidence both from primary prevention approaches and the delivery of healthcare. This allows
direct focus on the interface between work and health, and opens up a new zone of opportunity
for proactive initiatives in the workplace. Its primary intent is to facilitate an approach that
enables people with CHP complaints to maintain work participation, measured by ability to stay
at work or return speedily after absence, thus sustaining productive activity.
The conceptual model spans three key areas: Good work; Good Jobs; Supportive Workplaces.
The ability to provide and have ‘Good work’ stems mostly from actions at the socio-political
level through enabling legislation and suitable policy frameworks (e.g. the Management
Standards). Work that is both ‘good’ and safe has become an expected minimum standard in
modern societies, but, although necessary, this approach is not sufficient to ensure the health
and well-being of workers. To do so requires additional interventions at different levels.
The toolbox therefore focuses on helping line managers, and senior management, to provide
Good Jobs for when people are well, and Supportive Workplaces for when they are ill or
injured. The core principle is that a Good Job will reduce the likelihood that symptoms of CHPs
will be expressed at work, while a Supportive Workplace will enable those who are struggling
with health at work to more readily maintain work participation.
Good Jobs are characterised by: balanced demands and a safe work environment; effective and
helpful line management; working practices and feedback that lead workers to feel they are
valued and respected members of staff; opportunities to use and develop skills; endorsement and
opportunities for workers to solve their own problems; encouragement to help workers make
their own work better; and, opportunities for social interaction.
Supportive Workplaces are characterised by: commitment from senior management; early
provision of factual information and advice; fostering early reporting of work-relevant health
problems; keeping in touch; adopting a can-do approach; engaging the person in identifying
obstacles to work participation and making a work plan; assessing the job and offering
temporary modified work if needed (just to ease the path to usual work); liaising with healthcare
practitioners if necessary (using a confidentiality waiver); allowing graduated return to work
plans; and, monitoring progress so the plan can be appropriately revised if there are any
setbacks.
Good Jobs differ from Supportive Workplaces in a number of ways. Creating Good Jobs is
intended as a proactive process applied mainly to groups of workers. The emphasis is on
directing coping at demands and resilience, with the intention of reducing the work-relevance of
CHPs. Creating Supportive Workplaces provides ‘just in time’ response for individual workers
starting to struggle with CHP symptoms at work. The emphasis is on providing an environment
where workers can cope with symptoms, so that unnecessary healthcare, sickness absence and
disability can be avoided. The aspiration to Good Jobs and delivering a Supportive Workplace
should run in tandem.
User experience: The intervention toolbox is named the Health ↔ Work Toolbox to convey the
interdependency between health and work, and the transferability of its content to a range of
health at work issues. The key audience is line managers, backed up by senior management buy-
in, since they are pivotal in shaping working conditions. Nonetheless, it has also been designed
to appeal to a range of players so that they can direct line managers toward it. Toolbox users
will initially encounter content under ‘Knowledge’, intended to encourage their ‘buy-in’ (and
this includes the business, moral and legal case), deepen their knowledge of the nature CHPs,
and prompt them to undertake preparatory activities such as learning about and assessing health
v i
and work culture. The content provided under ‘Good Jobs’ and ‘Supportive Workplaces’
broadly splits into knowledge and tools. Two main groups of tools are provided: those to enable
‘identification’ (Good Jobs or Supportive Workplaces) and a suite of tools to provide solutions
and aid their implementation. There are succinct lists of ‘Actions’ for the three key areas:
Knowledge, Good Jobs, and Supportive Workplaces. These are linked to concise explanations
of what to do and how to do it. Mechanisms are built in to facilitate organisational learning and
review both for Good Jobs and Supportive Workplaces.
Process: Being web-based, the toolbox has the benefit of hyperlinks. It has a simple logical
structure, and is set out so that no single part is contingent on another part having already been
accessed. The only exception to this is that implementing targeted actions is always expected to
follow ‘identification’ of what can be done to help provide Good Jobs and Supportive
Workplaces.
The majority of the process for identifying obstacles is in the form of guided questioning. This
process is quite different from assessment of symptoms, and deliberately avoids confounding
obstacle identification with the subjectivity of CHP symptoms. Identification of Good Jobs rests
largely on asking about job characteristics. Identification of Supportive Workplaces is based on
self-report by workers, or others noticing an individual struggling, or a mixture of both: this is
followed by proactive discussion between worker and line manager to identify obstacles to
staying at or returning to work.
The toolbox content is provided in three layers of complexity. This allows for variations in the
user’s time, skill level, interest and resources. Essential information and actions are uppermost
in the structure. Narrative devices such as principles and important ideas are provided
throughout to anchor understanding of key values and messages. Case studies are provided as
exemplars to facilitate application across settings through the use of underlying principles.
1.4. IMPLICATIONS
The Health ↔ Work Toolbox approach differs from existing approaches, including the
Management Standards, for a number of reasons: positioned between conventional risk
management and healthcare, it is a supplementary approach; it also emphasises positive factors
over and above the prevention of harm; it uses a combination of proactive and responsive
elements; it encourages dual responsibility for health between the employer and employee; and,
it has scope in enabling people with less than perfect health to remain productive and at work.
As such, it provides a ‘comprehensive resource to enable line managers more effectively to
tackle the challenges created by work-relevant CHPs.
The expert and end-user feedback, albeit from a relatively small sample, was positive and
endorsed the overall direction and approach. There were no significant negative comments,
though most respondents expressed a desire for improved design and navigability that future
development should take into account. Further professional development around the
presentation fell outside of the project scope, but the present results suggest that end users
would be receptive to a toolbox of this type.
In principle, the Health ↔ Work Toolbox holds considerable potential to augment existing
primary prevention strategies and healthcare delivery, thus providing a more comprehensive
approach to constraining sickness absence. However, more work will be needed to determine its
overall effectiveness during application.
(cid:89) (cid:76)(cid:76)
2. INTRODUCTION
The following introduction summarises current knowledge about Common Health Problems.
More detailed supporting information is provided in the appendices.
2.1. WHAT ARE COMMON HEALTH PROBLEMS?
Common health problems (CHPs) refer to health complaints that occur most frequently across
the population. They include musculoskeletal, mental health and stress2 complaints. The main
contribution to long-term sickness absence and work disability comes not from serious injury or
disease, but from CHPs. Collectively CHPs account for most loss of productivity, sickness
absence, suffering, care-seeking and health-related benefit claims (e.g. Waddell & Burton,
2004). Self-reported survey data indicates that an estimated 7.6 million working days were lost
to musculoskeletal disorders whilst 10.8 million were lost to stress in Great Britain in 2010/11
(HSE, 2011a). These figures account for 70% overall of the lost days attributed to health and
safety at work issues (HSE, 2011b).
2.2. CHALLENGES POSED BY COMMON HEALTH PROBLEMS
CHPs are characterised by recurrent symptoms of variable frequency and severity, which tend to
co-exist. For example, mental health problems and musculoskeletal pain can occur at the same
time. CHPs involve the report of one or more symptoms, yet in most instances there is limited
objective evidence of injury, disease or impairment (Waddell & Burton, 2004; Waddell, Burton,
& Kendall, 2008).
CHPs have a multi-factorial aetiology, and are influenced by both work and non-work factors.
For example, musculoskeletal symptoms may be experienced at work or not, or may be
influenced by certain work activities and not others. Similarly, stress symptoms may be
experienced at work and also at home to varying degrees. Mental health problems (e.g. anxiety,
depression) can arise from diverse sources, many of which are unrelated to work, but they are
experienced by workers and non-workers alike (Foresight Project, 2008). Evidence for
exclusive occupational causation of most CHPs is contentious, inconsistent or lacking. While
work may not directly or soley cause the majority of episodes of CHPs, disadvantageous aspects
of job design lead to symptoms being more pronounced and bothersome, and may temporarily
reduce the person’s ability to work. In this sense, CHPs can manifest as work-relevant
complaints. That is, health complaints which, irrespective of cause (work or non-work), are
experienced at the workplace to a greater or lesser extent, and which in turn impact on the
performance of a worker (Waddell & Burton, 2004).
The ubiquity and subjective nature of CHPs, along with frequently co-existing symptoms and
complaints, pose a major challenge for CHPs’ accurate identification and treatment.
Nevertheless, the successful management of CHPs should be achievable, and long-term
problems are not inevitable. In occupational terms, the consequences are more important than
any (assumed) pathology: With the right support, most people can remain active and stay at
work or achieve early and sustained return from sickness absence (Waddell & Aylward, 2010;
Seymour & Grove, 2005). Defining and effectively delivering that ‘right support’ has proved a
substantial challenge (Waddell et al, 2008).
2 In this report the term ‘stress’ is used to describe the subjective experience of ‘feeling stressed’. It is recognised that
‘stress’ lacks case definition, is not a diagnosis per se, and current taxonomies do not contain clinical criteria.
1
Description:problems at work as musculoskeletal disorders and psychological ill-health (stress, anxiety and depression). As such, it provides a 'comprehensive resource to enable line managers more effectively to (HPWSs) as integrated human resource management interventions, in conjunction with high.
