How much will interventions on physical and psychosocial factors at work contribute to working longer in good health? Alex Burdorf Department of Public Health Erasmus Medical Centre in Rotterdam Working longer: how ? Lecture and key messages 1. How to link working life to life expectancy? Þ large inequalities in life expectancy Þ current retirement schemes do not adjust for life expectancy inequalities 2. How do work, lifestyle, and health influence paid employment? Þ a good health is important to enter and stay in paid employment Þ working conditions and lifestyle matters ! 3. Can interventions increase working life ? Þ strenuous working conditions reduce working life Þ interventions on working conditions may prolong working life 4. What are the challenges in the near future? ..the golden age….life is treating us very well ….. Life is treating us very well …but a little less in Denmark Denmark: 82 yrs (Statistics Denmark) Source: Danielsson et al Scand J Public Health 2012;40:6 78 yrs Proportion of life spent in retirement is rapidly growing Life expectancy at 65 yrs in 2009-2013: Men 17.1 yrs, Women 19.8 yrs ….but some are much better off.... Widening of health disparities through ‘intervention generated inequalities’: - decline in smoking faster in socially advantaged groups - strong social gradient in overweight and obesity Source: Brønnum-Hansen et al BMC Public Health 2012;12:994 What would be a fair retirement age ? Two options for Denmark: A retirement at the same age ? B retirement with similar years of retirement ? What would be a fair retirement age ? A Retirement at the same age; life expectancy at 65 What would be a fair retirement age ? B Age of retirement with similar years of retirement What would be a fair retirement age ? B Age of retirement with similar years of retirement Historical developments in working above 55 yrs Working until 65 yrs of age is already a big challenge ! Anxo et al. Int J Manpower 2012;33:612-28. Take home message 1: * Large differences in life expectancy, working life expectancy, and years spent in retirement * Current retirement arrangements are not very fair, but what is fair? * Enabling and supporting the workforce to remain in paid employment until 65 yrs is already a big challenge 2. How do work, lifestyle & health influence paid employment ? 2. How do work, lifestyle & health influence paid employment ? Who is losing years of working life before 65 yrs of age ? Which factors play a role in premature displacement from the labour market ? 2. Influence of health on working life Disability benefits and lost years of work before 67 yrs in Norway Year of working lost: Knudsen et al. Plos One 2012;7:e42567 Mental disorders 20.9 Nervous system 18.8 Injury 15.8 MSD 12.0 Neoplasms 11.6 Respiratory dis. 11.0 2. Influence of job on working life Exit from paid employment through disability among 325,000 Swedish construction workers 1971 to 2010 (Järvholm et al 2014) 2. Influence of job on working life Exit from paid employment through disability among 325,000 Swedish construction workers 1971 to 2010 (Järvholm et al 2014) Occupational group working years lost due to disability rock workers 3.2 insulator 3.0 roofer 3.0 concrete worker 2.7 … foremen 0.9 office personnel 0.7 Until age 65, up to 45% retires with a disability benefit ! 2. How does health influences paid employment ? 7,00 6,00 Odds Ratio 5,00 less than good health chronic disease 4,00 depressive symptoms mobility problems 3,00 2,00 1,00 unemployed retired homemaker disabled Work status Relative probability of displacement from the labour market during 2 year follow-up 2004 to 2006 in the SHARE study [Van den Berg et al. Occup Environ Med 2010;67:845-52] 2. Influence of work, lifestyle and health Take home message 2: * Various studies have demonstrated the profound effects of ill health on working life expectancy: * - studies on persons with a disability benefit - studies in particular occupational populations - studies in general populations Strenuous working conditions and unhealthy behaviour have direct effects and indirect effects (through ill health) on working life expectancy * Relative contributions of specific determinants difficult to ascertain 3. Can interventions increase working life ? Problems in experimental studies: - RCTs not always possible - too short follow-up to determine consequences for working life Problems in current longitudinal studies: - determinants are usually measured only at baseline - interrelations between health, working conditions and lifestyle seldom addressed - too short follow-up to determine consequences for working life Potential solution: - modelling impact of determinants on paid employment over time (Health Impact Assessment as strategy) Modelling ‘Working Life Expectancy’ (WLE) - WLE: time a person is expected to spend in employment until he or she leaves the labour force (Nurminen, Scand J Work Environ Health 2004;35:339-49.). - Health Impact Assessment model: 1. Participation life table (life expectancy approach) with entering and exiting paid employment (transition probabilities) 2. Effect of work, unhealthy lifestyle and ill health on transition from paid employment to unemployment, early retirement, and disability benefit (Markov model with yearly transitions) 3. Potential effects of determinants on working life expectancy Theoretical benefits of prevention Population attributable fraction: Proportion among the persons with labour force displacement in the total population that can be attributed to a particular risk factor PAF = p * (RR – 1) p * (RR-1) + 1 where p = proportion of subjects with that risk factor RR = relative risk Real benefits of prevention Potential impact fraction: Proportion among persons with labour force displacement in the total population that can be prevented by a specific intervention that reduces exposure to a specific determinant PIF = (po - pp ) * (RR – 1) = S (po - pp ) * RR po * (RR-1) + 1 S po * RR Key question: How much reduction in exposure can be achieved by a specific intervention ? Effects of interventions ‘Working Life Expectancy’ (WLE) 1) Exposure to strenuous working conditions (statistics Netherlands) 2) Relation between strenuous working conditions and routes of exit from paid employment (meta-analyses, secondary data-analyses) 3) Effectiveness of existing interventions (literature) 4) Calculate potential impact fraction (PIF; using info from 1-3) 5) PIF is used to calculate new transition probabilities (exit/re-enter paid employment) 6) Intervention WLE can be calculated as difference with reference WLE (% gain in WLE) Working years lost in the Netherlands For more information: presentation of Suzan Robroek Health, work, and lifestyle as risk factors for quitting paid employment SHARE-study European countries, persons aged 50 - 65 years Theoretical gain in working life expectancy due to complete elimination of unfavourable factors in the total workforce (population attributable fraction): Men Women » 0.4 yr » 0.5 yr High physical load » 0.3 yr » 0.4 yr ill health » 0.9 yr » 0.9 yr Lack of job control & effort-reward imbalance Source: Burdorf A, Mackenbach PJ. The influence of health on early displacement from the labour market. Zoetermeer, Council for Public Health and Care, 2006 [in Dutch] Interventions on working conditions * no universal intervention applicable to all occupational populations * experimental evidence on effects of specific interventions on working conditions in most occupations is completely absent * patterns of physical and psychological factors at work in most occupations not well described (recent JEM-studies: Rijs et al Ann Occup Hyg 2014; Solovieva et al. PlosOne 2012) Health Impact Assessment of assistive devices among nursing personnel – example of HIA Looking for evidence 1. (Yassi et al 2001) One RCT study with 1 yr follow-up 2. Seven pre-post studies (see Burdorf et al 2013) Þ large differences in: * exposure to manual * proportion of LBP * effect of lifting devices lifting of patients attributable to lifting on exposure Health Impact Assessment of assistive devices among nursing personnel Looking for good counsel ! Findings: Without assistive devices: 76% of nurses regularly lift patients manually With assistive devices: 21% of nurses regularly lift patients manually Health Impact Assessment of assistive devices among nursing personnel The six step in the HIA: 1. Exposure: 76% of nursing population (Andersen et al 2014) 2. Exposure-response: WLE loss LBP nurses: 2.33 years (Burdorf 2006) 3. Effect intervention: assistive devices 76% to 21% (Andersen et al 2014) 4. Population attributable fraction (PAF): 0.38 (Andersen et al 2014) Potential impact fraction (PIF): 0.27 5. WLE loss due to manual lifting: 2.33 * 0.38 = 0.88 6. WLE gain due to assistive devices: 2.33 * 0.27 = 0.64 Þ real benefit in WLE = 0.64 years = 33.3 weeks ! Take home message 3: * Contribution of physical working conditions (0.3-0.4), psychosocial factors at work (0.4-0.5) and ill health (0.9) in the total workforce to working years lost is substantial * empirical evidence on impact of interventions is limited * health impact assessment can demonstrate the impact of specific interventions in specific groups on working life expectancy * improvement in working conditions is paramount for prolonging working life From HIA to policy and practice The invisible success of prevention: 1. Success is often a silent victory 2. Primary prevention has no pressure groups 3. Prevention must demonstrate its contribution to population health (HIA!) 4. What are the challenges in the near future? What to do ? 4. What are the challenges in the near future? Need for a tailored approach in our interventions in specific occupations! 4. What are the challenges in the near future? 1. The cost-effectiveness of interventions on work participation Þ understand what will work when (populations, context) 2. Health impact assessment approaches are required to evaluate (long-term) benefits of interventions Þ development of ‘disease models’ as tool for research and practice 3. How to create an inclusive labour market for workers during their life course Þ a life-course approach on loss of working years Þ evaluation of national policy, best practices in organisations and specific interventions [email protected] at www.erasmusmc.nl/mgz Erasmus