Work And Health Review Essay

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IS WORK GOOD FOR YOUR HEALTH AND WELL-BEING?
Gordon Waddell, A Kim Burton

IS WORK GOOD FOR YOUR HEALTH AND WELL-BEING?
Gordon Waddell, CBE DSc MD FRCS Centre for Psychosocial and Disability Research, Cardiff University, UK A Kim Burton, PhD DO EurErg Centre for Health and Social Care Research, University of Huddersfield, UK

The authors were commissioned by the Department for Work and Pensions to conduct this independent review of the scientific evidence. The authors are solely responsible for the scientific content and the views expressed which do not necessarily represent the official views of the Department for Work and Pensions, HM Government or The Stationery Office.

London: TSO

Published by TSO (The Stationery Office) and available from: Online www.tsoshop.co.uk Mail, Telephone, Fax & E-mail TSO PO Box 29, Norwich, NR3 1GN Telephone orders/General enquiries: 0870 600 5522 Fax orders: 0870 600 5533 E-mail: [email protected] Textphone 0870 240 3701 TSO Shops 123 Kingsway, London, WC2B 6PQ 020 7242 6393 Fax 020 7242 6394 68-69 Bull Street, Birmingham B4 6AD 0121 236 9696 Fax 0121 236 9699 9-21 Princess Street, Manchester M60 8AS 0161 834 7201 Fax 0161 833 0634 16 Arthur Street, Belfast BT1 4GD 028 9023 8451 Fax 028 9023 5401 18-19 High Street, Cardiff CF10 1PT 029 2039 5548 Fax 029 2038 4347 71 Lothian Road, Edinburgh EH3 9AZ 0870 606 5566 Fax 0870 606 5588 TSO Accredited Agents (see Yellow Pages) and through good booksellers © Gordon Waddell and Kim Burton 2006 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or byany means, electronic, mechanical, photocopying, recording or otherwise without the permission of the publisher. Copyright in the typographical arrangement and design is vested in The Stationery Office Limited. Applications for reproduction should be made in writing to The Stationery Office Limited, St Crispins, Duke Street, Norwich NR3 1PD. The information contained in this publication is believed to be correct at the time of manufacture. Whilst care has been taken toensure that the information is accurate, the publisher can accept no responsibility for any errors or omissions or for changes to the details given. Kim Burton and Gordon Waddell have asserted their moral rights under the Copyright, Designs and Patents Act 1988, to be identifie as d the authors of this work. A CIP catalogue record for this book is available from the British Library. A Library of Congress CIP catalogue record has been applied for. First published 2006 ISBN 0 11 703694 3 13 digit ISBN 978 0 11 703694 9 Printed in the United Kingdom by The Stationery Office

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Contents
Acknowledgements EXECUTIVE SUMMARY HEALTH, WORK, AND WELL-BEING Aims Definitions REVIEW METHODS Organisation of the evidence Evidence synthesis and rating REVIEW FINDINGS Health effects of work and unemployment Work Unemployment Age-specific findings Re-employment Work for sick and disabled people Mental Health Severe mental illness Common mental health problems Stress Musculoskeletal conditions Cardio-respiratory conditions Social Security Studies DISCUSSION Conclusions REFERENCES EVIDENCE TABLES v vii 1 3 3 6 6 7 9 9 9 10 13 17 20 21 21 22 22 24 27 29 31 36 39 69

Is work good for your health & well-being?

Table 1. Health effects of work vs unemployment Table 1a: Work Table 1b: Unemployment Table 1c: Older workers (> approx. 50 years) Table 2. Health impacts of employment, re-employment, and retirement Table 2a: School leavers and young adults (Age < approx. 25 years) Table 2b: Adults (age ~25 to ~ 50 years) Table 2c: Older workers (> approx. 50 years) Table 3: Work for sick and disabled people. Table 3a: Disability Table 3b: Sickness absence and return to work Table 4: The impact of work on the health of people with mental health conditions Table 4a: Severe mental illness Table 4b: Minor/moderate mental health problems Table 4c-i: Stress: The impact of work on mental health Table 4c-ii: Stress: Management Table 4c-iii: Burnout 109 109 116 126 133 133 136 153 153 157 161 169 182

69 69 85 104

Table 5. The impact of work on the health of people with musculoskeletal conditions 184 Table 6.The impact of work on the health of people with cardio-respiratory conditions 206 Table 6a-i: Cardiac conditions - impact of work 206 Table 6a-ii: Cardiac conditions - management 209 Table 6b: Respiratory conditions 218 Table 7. Health after moving off social security benefits APPENDIX Review Methods The structure of the evidence and literature reviewed Literature searching and selection Data Extraction Evidence Synthesis Quality assurance 222 241 241 241 242 245 245 246

Acknowledgements
We are grateful to Keith Palmer and Christopher Prinz for their careful review of the final draft of the report. We thank the following colleagues for their helpful ideas and comments, and for pointing us to useful material during the course of the project: Kristina Alexanderson, Robert Barth, Jo Bowen, Peter Donceel, Hege Eriksen, Simon Francis, David Fryer, Bob Grove, Bill Gunnyeon, Elizabeth Gyngell, Bob Hassett, Camilla Ihlebaek, Nick Ke ndall, Rachel Lee, Chris Main, Fehmidah Munir, Trang Nguyen, Nick Niven-Jenkins, David Randolph, Justine Schneider, David Snashall, Holger Ursin, Keith Wiley, Nerys Williams, and Peter Wright. Finally, we thank Debbie McStrafick for archiving the data and providing administrative support.

Is work good for your health & well-being?

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Executive summary

BACKGROUND Increasing employment and supporting people into work are key elements of the UK Government’s public health and welfare reform agendas. There are economic, social and moral arguments that work is the most effective way to improve the well-being of individuals, their families and their communities. There is also growing awareness that (long-term) worklessness is harmful to physical and mental health, so the corollary might be assumed – that work is beneficial for health. However, that does not necessarily follow. This review collates and evaluates the evidence on the question ‘Is work good for your health and well-being?’ This forms part of the evidence base for the Health, Work and Well-Being Strategy published in October 2005. METHODS This review approached the question from various directions and incorporated an enormous range of scientific evidence, of differing type and quality, from a variety of disciplines, methodologies, and literatures. It a) evaluated the scientific evidence on the relationship between work, health and well-being; and b) to do that, it also had to make sense of the complex set of issues around work and health. This required a combination of a) a ‘best evidence synthesis’ that offered the flexibility to tackle heterogeneous evidence and complex sociomedical issues, and b) a rigorous methodology for rating the strength of the scientific evidence. The review focused on adults of working age and the common health problems that account for two-thirds of sickness absence and long-term incapacity (i.e. mild/moderate mental health, musculoskeletal and cardio-respiratory conditions). FINDINGS Work: The generally accepted theoretical framework about work and well-being is based on extensive background evidence: • Employment is generally the most important means of obtaining adequate economic resources, which are essential for material wel -being and full participation in today’s society; l • 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 physical and mental health and mortality;

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Is work good for your health & well-being?

• Various physical and psychosocial aspects of work can also be hazards and pose a risk to health. Unemployment: Conversely, there is a strong association between worklessness and poor health. This may be partly a health selection effect, but it is also to a large extent cause and effect. There is strong evidence that unemployment is generally harmful to health, including: • higher mortality; • poorer general health, long-standing illness, limiting longstanding illness; • poorer mental health, psychological distress, minor psychological/psychiatric morbidity; • higher medical consultation, medication consumption and hospital admission rates. Re-employment: There is strong evidence that re-employment leads to improved self-esteem, improved general and mental health, and reduced psychological distress and minor psychiatric morbidity. The magnitude of this improvement is more or less comparable to the adverse effects of job loss. Work for sick and 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 (particularly those with ‘common health problems’) should be encouraged and supported to remain in or to (re)-enter work as soon as possible because it: • is 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 long-term incapacity; • promotes full participation in society, independence and human rights; • reduces poverty; • improves quality of life and well-being. Health after moving off social security benefits: Claimants who move off benefits and (re)-enter work generally experience improvementsin income, socio-economic status, mental and general health, and well-being. Those who move off benefits but do not enter work are more likely to report deterioration in health and well-being.

Executive Summary

Provisos: Although the balance of the evidence is that work is generally good for health and well-being, for most people, there are three major provisos: 1. 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); 2. Beneficial health effects depend on the nature and quality of work (though there is insufficient evidence to define the physical and psychosocial characteristics of jobs and workplaces that are ‘good’ for health); 3. The social context must be taken into account, particularly social gradients in health and regional deprivation. CONCLUSION There is a strong evidence base showing that work is generally good for physical and mental health and well-being. Worklessness is associated with poorer physical and mental health and well-being. Work can be therapeutic and can reverse the adverse health effects of unemployment. That is true for healthy people of working age, for many disabled people, for most people with common health problems and for social security beneficiaries. The provisos are that account must be taken of the nature and quality of work and its social context; jobs should be safe and accommodating. Overall, the beneficial effects of work outweigh the risks of work, and are greater than the harmful effects of long-term unemployment or prolonged sickness absence. Work is generally good for health and well-being.

Is work good for your health & well-being?

Health, work and well-being
Health is fundamental to human well-being, whilst work is an integral part of modern life. Increasing employment and supporting people into work are key elements of the UK Government’s public health and welfare agendas (DH 2004; DWP 2006; HM Government 2005). There are economic, social and moral arguments that, for those able to work, ‘work is the best form of welfare’ (Mead 1997; Deacon 1997; King & Wickam-Jones 1999) and is the most effective way to improve the well-being of these individuals, their families and their communities. There is also growing awareness that (long-term) worklessness is harmful to physical and mental health, so it could be assumed the corollary must be true – that work is beneficial for health. However, that does not necessarily follow. Therefore, the basic aim of this review is to consider the scientific evidence on the question ‘Is work good for your health and well-being?’ This seemingly simple question must be placed in context. There are a number of potential causal pathways between health, work and well-being, with complex interactions and sometimes contradictory effects (Schwefel 1986; Shortt 1996): • In modern society, work provides the material wherewithal for life and well-being • Health and fitness underpin capacity for work (irrespective of whether any health problem bears a causal relationship to work – possible confounding) People’s health may make them more or less likely to seek or obtain work, influence their work performance, and influence whether or not they leave work temporarily or permanently – health selection and the healthy worker effect. • Work can be beneficial for health and fitness • Work can carry risks for physical and mental health Certain jobs may create ill-health. People in certain kinds of work may be unhealthy because of non-work factors – possible confounding. • Sickness and disability can impact on capacity for work Presenteeism, sickness absence, long-term incapacity, ill-health retirement. • Work can be therapeutic. Conversely, (temporary) absence from work can be therapeutic • Worklessness can be detrimental to health and well-being.

Is work good for your health & well-being?

• Physical and mental health are important elements of well-being • Work can have positive or negative effects on well-being. Traditional approaches to occupational health and safety view work as a potential hazard and emphasise the adverse effects of work on health, and of ill health on capacity for work. But it is essential to consider the beneficial as well as the harmful effects of work on health and wellbeing (Figure 1). What ultimately matters is the balance between the positive and negative effects of work and how that compares with worklessness.

Well-being +/– +/–

Health +/–

+/–

Work

Figure 1. Possible causal pathways between health, work and well-being (+/- : beneficial or harmful effects) The main focus of this review is whether the current evidence suggests that work is (directly) beneficial for physical and mental health and well-being, and checking that any apparent relation is not explained by reverse causality or confounding. Whether or how work might cause (i.e. be a risk factor for) ill health is beyond the scope of this review because these are complex questions requiring different search strategies, in different literatures and with a different conceptual focus. However, that issue cannot be ignored when considering work and how it might affect the health of people with health problems (whatever their cause). This becomes important when advising people about continuing work or returning to work, in view of the concern that returning to (the same) work might do (further) harm. Associated questions include the timing of return to work and whether work demands should be modified. Therefore, key reviews of the epidemiological evidence about work as a risk factor are included and used to provide necessary balance when drawing up the evidence statements. This review focuses on the ‘common health problems’ that now account for about two-thirds of sickness absence, long-term incapacity and early retirement - mild/moderate mental health, musculoskeletal and cardio-respiratory conditions (Waddell & Burton 2004). Many of these

Health, work and well-being

problems have high prevalence rates in the adult population, are essentially subjective, and often have limited evidence of objective disease or impairment. That is not to deny the reality of the symptoms or their impact, but these are essentially whole people, their health conditions are potentially remediable, and long-term incapacity is not inevitable. Moreover, epidemiology shows that these conditions are common whether in or out of work, risk factors are multifactorial, and cause-effect relationships ambiguous. Work, activity, and indeed life itself involves physical and mental effort, which imposes demands and is associated with bodily symptoms. Yet that effort is essential (physiologically) for maintaining health and capability. More generally, the relationship between work and health must be placed in a broader social context. Account must be taken of the powerful social gradient in physical and mental health with socio-economic status – which is itself closely linked to work (Saunders 2002b; Saunders & Taylor 2002; McLean et al. 2005; Marmot & Wilkinson 2006). Social security covers diverse groups of people, with different kinds of problems, in very different circumstances. Many people receiving incapacity benefits have multiple disadvantages and face multiple barriers returning to work: older age, distance from the labour market, low skills, high local unemployment rates and employer discrimination (Waddell & Aylward 2005). Finally, social inequalities in work and health have a geographical dimension, with a strong link to deprived areas and local unemployment rates (McLean et al. 2005; Ritchie et al. 2005; Scottish Executive 2005). Analysis must be tempered by compassion for some of the most disadvantaged members of society, living in the most deprived circumstances (Rawls 1999; White 2004). AIMS This review considers the scientific evidence on the health effects of work and worklessness. It seeks the balance of the health benefits of work vs. the harmful effects of work, and of work vs. worklessness. It addresses the following questions: 1. Does the current evidence suggest that work is beneficial for physical and mental health and well being, in general and for common health problems? 2. What is the balance of benefits and risks to health from work and from worklessness? 3. Are there any circumstances (specific people, health conditions, or types of work) where work is likely to be detrimental to health and well-being? 4. Are there specific areas where there is a lack of evidence and need for further research? DEFINITIONS Analysis depends on understanding certain basic concepts. The following definitions will be used in this review, recognising that these and other concepts will require further debate and development as the Health, Work and Well-being Strategy evolves.

Is work good for your health & well-being?

Work: involves the application of physical or mental effort, skills, knowledge or other personal resources, usually involves commitment over time, and has connotations of effort and a need to labour or exert oneself (Warr 1987; OECD 2003). Work is not only ‘a job’ or paid employment, but includes unpaid or voluntary work, education and training, family responsibilities and caring. Worklessness: not engaged in any form of work, which includes but is broader than economic inactivity and unemployment. Economic activity: covers all forms of engagement with the labour market, including: employed; self-employed; subsidised, supported or sheltered employment; and actively seeking work. Economic inactivity: covers all those who are not engaged in the labour market, including those not actively seeking work, homemakers and carers, long-term sick and disabled, and retired (Barham 2002). There are now five times as many economically inactive as unemployed. Employment: a job typically takes the form of a contractual relationship between the individual worker and an employer over time for financial (and other) remuneration, as a socially acceptable means of earning a living. It involves a specific set of technical and social tasks located within a certain physical and social context (Locke 1969; Warr 1987; Dodu 2005). Unemployed: not employed at a job, wanting and available for work, and actively seeking employment (Barham 2002). This is often operationalised as being in receipt of unemployment benefits. There is considerable overlap between ‘health’ and ‘well-being’, with philosophical debate about their relationship (Ryff & Singer 1998). Pragmatically, (Danna & Griffin 1999) suggest that health should be used when the focus is on the absence of physiological or psychological symptoms and morbidity; well-being should be used as a broader and more encompassing concept that takes account of ‘the whole person’ in their context. Health: comprises physical and mental well-being, and (despite philosophical debate) is usually operationalised in terms of the absence of symptoms, illness and morbidity (WHO 1948; Danna & Griffin 1999; WHO 2004). Well-being: is the subjective state of being healthy, happy, contented, comfortable and satisfied with one’s quality of life. It includes physical, material, social, emotional (‘happiness’), and development & activity dimensions (Felce & Perry 1995; Danna & Griffin 1999; Diener 2000).

Health, work and well-being

Quality of life: is ‘individuals’ perception of their position in life in the context of the culture and value system in which they live and in relation to their own goals, expectations, standards and concerns’ (The WHOQOL Group 1995).

Review Methods
This review had to do two things: (a) evaluate the scientific evidence on the relationship between work, health, and well-being; in order to do that, it also had to (b) make sense of, and impose some order on, the complex set of issues around work and health. It included a wide range of evidence, of differing type and quality, from a variety of disciplines, methodologies, and literatures. Meeting these diverse demands needed a combination of approaches. Developing concepts and organising the evidence required freedom to evolve as the project progressed. This may be described as a ‘best evidence synthesis’, which summarises the available literature and draws conclusions about the balance of evidence, based on its quality, quantity and consistency (Slavin 1995; Franche et al. 2005). This approach offered the flexibility needed to tackle heterogeneous evidence and complex socio-medical issues, together with quality assurance. At the same time, a rigorous approach was required when it came to assessing the strength of the scientific evidence. The detailed methodology, including search strategies, inclusion/exclusion criteria, and evidence sources, is given in the Appendix. Throughout the review, broad and inclusive search strategies were used to retrieve as much material as possible, pertinent to the basic question: ‘Is work good for your health and well-being?’ Exclusion was primarily on the basis of lack of relevance to that question. Existing literature reviews, mainly from 1990 through early 2006, were used as the primary material, as in previous similar projects (Waddell & Burton 2004; Burton et al. 2004). Greatest weight was given to systematic reviews, whilst narrative reviews were used mainly to expand upon relevant issues or develop concepts. Selection inevitably involved judgements about quality: all articles were considered independently by both reviewers, and any disagreements resolved by discussion. Only in the absence of suitable reviews on a key issue was a search made for original studies. The focus was on common health problems, so major trauma and serious disease were included only if the evidence was particularly illuminating. The review covered adults of working age (generally 16-65 years). ORGANISATION OF THE EVIDENCE The structure of this report follows that of the literature searching and the evidence retrieved (Box 1). The obvious and most accessible starting point was reviews of the adverse health effects of unemployment. However, most of that evidence actually compares unemployment with work, so it was logical to expand the search to include the health effects of work and of unemployment. The retrieved literature was mainly about young or middle working-age adults, so a further search was made for material on older workers. All of these reviews considered the health impact of loss of employment, but provided little evidence on reemployment. A specific search was therefore made for individual longitudinal studies on the health impact of re-employment.

Review methods

It then became apparent that that evidence was all about the impact of work or unemployment on people who were healthy. An additional search (in a different, largely clinical literature) was therefore made for reviews about the impact of work for sick and disabled people. The generic material retrieved showed a broad consensus of opinion but provided very little actual scientific evidence, so separate searches were made for condition-specific reviews on the three main categories of common health problems: mental health, musculoskeletal, and cardio-respiratory conditions. Finally, recognising that social security is a special context, a separate search was made for literature on the health impact of moving off benefits and re-entering work. There are few reviews in this area, so original studies were also included. Workers compensation studies were excluded because they are not readily generalisable. Information from the included papers was summarised and inserted into evidence tables (Tables 1 to 7), in chronological order. Box1. The key areas of the review and the related evidence tables Areas of review Health effects of work vs. unemployment Health impacts of re-employment Work for sick and disabled people The impact of work on people with mental health conditions The impact of work on people with musculoskeletal conditions The impact of work on people with cardio-respiratory conditions Health after moving off social security benefits Table Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7

EVIDENCE SYNTHESIS AND RATING Building on the evidence tables and using an iterative process, evidence statements were developed, refined, and agreed in each key area. The strength of the scientific evidence supporting each statement was rated as in Box 2. Where appropriate, the text of the evidence statements was used to expand on the nature or limitations of the underlying evidence, and to offer any caveats or cautions. The strength of the evidence should be distinguished from the size of the effect: e.g. there may be strong evidence about a particular link between work and health, yet the effect may be small. Furthermore, a statistical association does not necessarily mean a causal relationship. Where possible, effect sizes and causality are noted in the text of the evidence statements.

Is work good for your health & well-being?

Box 2. Evidence rating system used to rate the strength of the scientific evidence for the evidence statements Scientific Evidence *** ** * Strong Moderate Weak Definition generally consistent findings provided by (systematic review(s) of) multiple scientific studies. generally consistent findings provided by (review(s) of) fewer and/or methodologically weaker scientific studies. Limited evidence – provided by (review(s) of) a single scientific study, Mixed or conflicting evidence – inconsistent findings provided by (review(s) of) multiple scientific studies. 0

Non-scientific

legislation; practical, social or ethical considerations; guidance; general consensus.

The evidence statements are grouped and numbered under the areas in Box 1, and for ease of future referrence they are identified by the initial letter(s) of the heading concerned. Where the evidence statements were insufficient to convey complex underlying ideas, important issues were discussed in narrative text. Finally, the entire material was progressively distilled into an evidence synthesis to reflect the overall balance of the evidence about work and health. This was used to develop a conceptual framework located in the context of healthy working lives. Quality assurance was provided by peer review of a final draft by two internationally acknowledged experts. Their feedback was used to refine the evidence statements and the evidence synthesis for the final report.

Review Findings

HEALTH EFFECTS OF WORK AND UNEMPLOYMENT Table 1 lays out the retrieved evidence on the health impact of work (Table 1a) and of unemployment (Table 1b). Table 1c includes additional material on older workers. Work Extensive studies and theoretical analyses of work and of unemployment, and comparisons between work and unemployment, support the basic concept that work is beneficial for health and well-being: W1 *** Employment is generally the most important means of obtaining adequate economic resources, which are essential for material well-being and full participation in today’s society Table 1a: (Shah & Marks 2004; Layard 2004; Coats & Max 2005) Table 1b: (Jahoda 1982; Brenner & Mooney 1983; Nordenmark & Strandh 1999; Saunders 2002b; Saunders & Taylor 2002)

W2 *** Work meets important psychosocial needs in societies where employment is the norm Table 1a: (Dodu 2005),Table 1b: (Jahoda 1982;Warr 1987)

W3 *** Work is central to individual identity, social roles and social status Table 1a: (Shah & Marks 2004) Table 1b: (Brenner & Mooney 1983; Ezzy 1993; Nordenmark & Strandh 1999)

W4 *** At the same time, various aspects of work can be a hazard and pose a risk to health Table 1a: (Coggon 1994; Snashall 2003; HSC 2002; HSC 2004)

Logically, then, the nature and quality of work is important for health (WHO 1995; HDA 2004; Cox et al. 2004; Shah & Marks 2004; Layard 2004; Dodu 2005; Coats & Max 2005)). (All references in the following sub-section are to Table 1a). W5 0

For moral, social and legal reasons, work should be as safe as reasonably practicable (WHO 1995; HSC 2002; HSC 2004)

Is work good for your health & well-being?

Pay should be sufficient (though there is no evidence on what is ‘sufficient’) [and the multiple non-health-related factors that influence pay levels must also be acknowledged]. (Dooley 2003; Layard 2004; Coats & Max 2005)

W7 *** There is a powerful social gradient in physical and mental health and mortality, which probably outweighs (and is confounded with) all other work characteristics that influence health. (Acheson et al. 1998; Fryers et al. 2003; Coats & Max 2005)

W8 *** Job insecurity has an adverse effect on health.
(Ferrie 1999; Benavides et al. 2000; Quinlan et al. 2001; Sverke et al. 2002; Dooley 2003)

There is conflicting evidence that long working hours (with no evidence for any particular limit) and shift work have a weak negative effect (Harrington 1994a; Sparks et al. 1997; van der Hulst 2003); limited evidence that flexible work schedules have a weak positive effect (Baltes et al. 1999); and conflicting evidence about any effect of compressed working weeks of 12-hour shifts (Smith et al. 1998; Baltes et al. 1999; Poissonnet & Véron 2000) on physical and mental health.

In summary, there is a strong theoretical case, supported by a great deal of background evidence, that work and paid employment are generally beneficial for physical and mental health and well-being. The major proviso is that that depends on the quality of the job and the social context. Nevertheless, the available evidence is on representative jobs, whatever their quality and defects, and shows that on average they are beneficial for health.Within reason, shift patterns and hours of work probably do not have a major impact on health: what workers choose and are happy with is more important. Most of this evidence is on men.What evidence is available suggests that the benefits of work are broadly comparable for women, though that must be placed in the context of other gender, family and caring roles. W10 *** Paid employment generally has beneficial or neutral effects and, importantly, has no significant adverse effects on the physical and mental health of women. (Klumb & Lampert 2004)

Unemployment This section lays out in logical order the evidence on the association between unemployment and health, on the causal relationship, on possible mechanisms and on modifying influences. (All references in this section are to Table 1b).

Review findings

There is a strong, positive association between unemployment and: U1 *** Increased rates of overall mortality, mortality from cardiovascular disease, lung cancer and suicide. (Brenner & Mooney 1983; Platt 1984; Jin et al. 1995; Lynge 1997; Mathers & Schofield 1998; Brenner 2002)

Poorer physical health (Mathers & Schofield 1998): e.g. cardiovascular risk factors such as hypertension and serum cholesterol (Jin et al. 1995), and susceptibility to respiratory infections (Cohen 1999).

U3 *** Poorer general health, somatic complaints, long-standing illness, limiting longstanding illness, disability [though these self-reported measures of health also correlate with psychological well-being]. (Jin et al. 1995; Shortt 1996; Mathers & Schofield 1998; Lakey 2001)

U4 *** Poorer mental health and psychological well-being, more psychological distress, minor psychological/psychiatric morbidity, increased rates of parasuicide. (Platt 1984; Murphy & Athanasou 1999; Fryers et al. 2003)

Higher medical consultation, medication consumption and hospital admission rates. (Hammarström 1994b; Jin et al. 1995; Mathers & Schofield 1998; Lakey 2001)

Furthermore: U6 *** There is strong evidence that unemployment cancause, contribute to or aggravate most of these adverse health outcomes. (Bartley 1994; Janlert 1997; Shortt 1996; Murphy & Athanasou 1999)

There are a number of possible mechanisms by which unemployment might have adverse effects on health (Bartley 1994; Shortt 1996): U7 *** The health effects of unemployment are at least partly mediated through socioeconomic status, (probably relative rather than absolute) poverty and financial anxiety. (Jahoda 1982; Brenner & Mooney 1983; Bartley 1994; Nordenmark & Strandh1999; Saunders 2002b; Saunders & Taylor 2002; Brenner 2002; Fryers et al. 2003)

Unemployment may affect physical health via a ‘stress’ pathway involving physiological changes such as hypertension and lowered immunity [though there is no direct evidence of this pathway in unemployed people]. (Ezzy 1993; Jin et al. 1995)

Is work good for your health & well-being?

U9 *** The psychosocial impact of being without a job can affect psychological health and lead to psychological/psychiatric morbidity. (Jahoda 1982;Warr 1987; Ezzy 1993)

U10

There is conflicting evidence that unemployment is associated with altered health-related behaviour (e.g. smoking, alcohol, exercise). (Bartley 1994; Hammarström 1994b; Jin et al. 1995)

U11 *** One spell of unemployment may be followed by poorer subsequent employment patterns and increased risk of further spells of unemployment - the ‘life course perspective’. (Lakey 2001; McLean et al. 2005)

There is no clear evidence on the exact nature or relative importance of these causal mechanisms: any of them may play a part, and it appears likely they will vary in different individuals in different contexts for different outcomes (McLean et al. 2005; Bartley et al. 2005) The impact of unemployment on health can be modified by: U12 *** socio-economic status, income and degree of financial anxiety. (Hakim 1982; Brenner & Mooney 1983; Ezzy 1993; Bartley 1994; Shortt 1996; Cohen 1999; Nordenmark & Strandh 1999; Saunders 2002b; Saunders & Taylor 2002)

U13 *** individual factors such as gender and family status, age, education, social capital, social support, previous job satisfaction & reason for job loss, duration out of work, and by desire and expectancy of re-employment. (Warr 1987; Ezzy 1993; Hammarström 1994b; Banks 1995; Nordenmark & Strandh 1999; Lakey 2001; McLean et al. 2005)

U14 *** regional deprivation and local unemployment rates.
(Brenner & Mooney 1983; McLean et al. 2005; Ritchie et al. 2005)

These factors may have positive, negative or sometimes quite complex effects on the health impact of unemployment. Moreover, it is not clear to what extent they a) have a direct impact on health, b) act as mediators, c) moderate the impact of unemployment, or d) act as confounders. U15 *** Despite the generally adverse effects of unemployment on health, for a minority of people (possibly 5-10%) unemployment can lead to improved health and wellbeing. (Warr 1987; Ezzy 1993; Shortt 1996; Nordenmark & Strandh 1999)

Review findings

Overall, there is extensive evidence that there are strong links between unemployment and poorer physical and mental health and mortality. A large part of this appears to be a cause-effect relationship, despite continuing debate about the relative importance of possible mechanisms. However, these adverse effects may vary in nature and degree for different individuals in different social contexts. Not all unemployment is ‘bad’: for a minority of people unemployment may be better for their health than their previous work. Nor does unemployment necessarily mean worklessness. Just as with work, health impacts depend on the quality of worklessness. Age-specific findings Both on a priori grounds and in the available evidence, three broad age groups can be distinguished: school leavers and young adults (16 to ~25 years); middle working age (~25 to ~50 years); and older workers (>50 years to retirement age). School leavers and young adults: Work and unemployment have different financial, social and health consequences for school leavers and young adults. They are at the start of their working lives, entering work for the first time, likely to have lesser financial and social commitments, and often still receiving some degree of parental family support. The majority are likely to be healthier, and health selection effects are therefore likely to be less important. (All references in this sub-section are to Table 1b) A1 *** The mortality rate of unemployed young people is significantly higher (compared with employed young people), mainly due to accidents and suicide. (Hammarström 1994b; Morrell et al. 1998; Lakey 2001)

There is mixed evidence that unemployment is harmful to the physical health of young people though any effect appears to be less than in middle working age or older workers. (Hammarström 1994b; Morrell et al. 1998; Lakey 2001)

A3 *** Unemployment has adverse effects on the mental health of young people (poor mental health and psychological well-being, more psychological distress, minor psychological/psychiatric morbidity) but these effects are generally less severe than in middle working age adults. (Warr 1987; Hammarström 1994b; Morrell et al. 1998; Lakey 2001)

Is work good for your health & well-being?

There is mixed evidence that unemployed young people show worse health behaviour (compared with employed young people) on various measures e.g. eating habits, personal hygiene, sleeping habits, physical activities, alcohol, drugs and smoking. (Hammarström 1994b; Morrell et al. 1998; Lakey 2001)

There is mixed evidence that young unemployed people suffer adverse social consequences including social exclusion and alienation, financial deprivation, criminality and longer-lasting effects on employment patterns (including higher risk of further spells of unemployment) and health into adult life. (Warr 1987; Hammarström 1994b; Lakey 2001)

Young people from disadvantaged backgrounds, those with lower levels of education, or those who lack social support (characteristics which cluster together) are more vulnerable to the adverse health effects of unemployment. (Hammarström 1994b; Lakey 2001)

Failure to enter the world of work and unemployment undoubtedly causes adverse effects on the physical and mental health and social well-being of school-leavers. However, the strength of these effects appears to be less than in adults, perhaps because of the resilience of youth and because their work habits are not yet established. For most, there appears to be relatively little impact on physical health, probably because they are healthier to start with. The impact on mental health is more comparable but still generally less than in adults, though that may depend on the young person’s social context. The short-term social effects are again relatively mild, probably because of different social and family responsibilities, though the consequences of longer-term unemployment may be much more fundamental and important. Middle working age Most of this review and most of the available evidence is about middle working age adults, except where stated otherwise. (All references in this sub-section are to Table 1b). All of the health effects of work and of unemployment are generally most marked in middle working-aged men, especially those with dependent families. (Hakim 1982; Warr 1987). As with work, much of the evidence about unemployment is on men. Nevertheless, most of the available evidence suggests that the adverse health effects of unemployment are broadly comparable in men and women of middle working age, though they may be modified by gender and family roles. Single women with no family responsibilities may be more comparable to men. Women with partners and with family or caring commitments generally have less adverse health effects, possibly because they are financially cushioned and have better alternative social roles. (Warr 1987; Hammarström 1994b)

Review findings

Older workers: Work and unemployment have different financial, social and health consequences for older workers, particularly as they approach retirement. Early retirement may be a consequence of health problems (ill-health retirement), involuntary job loss (redundancy) or voluntary exit from the work force, each of which may have different financial, social and health effects. However, these patterns are often blurred (Aarts et al. 1996). There are methodological problems in separating the health impact of work, unemployment or retirement from that of ageing and from health selection effects (ill-health selection into retirement and the healthy worker effect). (The evidence statements for older workers are developed from both Table 1 and Table 2.) (a) Work for older workers: (References in this sub-section are to Table 1c). A7 *** Physical and mental capability declines with age; thus work ability also declines but the nature and extent of the decline and the effect on work performance varies between individuals. (Tuomi et al. 1997; Shephard 1999; Ilmarinen 2001; Benjamin & Wilson 2005)

There is mixed evidence that older workers have any decline in perceived/reported health (despite increasing disease prevalence). (Tuomi et al. 1997;Wegman 1999; Shephard 1999; Scales & Scase 2000; Ilmarinen 2001)

Older workers do not necessarily have substantially more sickness absence (despite more severe illnesses and injuries). (Tuomi et al. 1997; Benjamin & Wilson 2005)

A10

There is broad consensus that 1) ‘work’ should accommodate the needs and demands of ageing workers and 2) that physical ergonomics and workorganisational issues will contribute to safe participation in the workforce to older age. (Hansson et al. 1997;Wegman 1999; Shephard 1999; Kilbom 1999; Ilmarinen 2001)

Is work good for your health & well-being?

(b) The health impact of early retirement: (References in this sub-section are to Tables 1 and 2.) A11 *** Early retirement can have either positive or negative effects on physical and mental health and mortality. Table 1a: (Acheson et al. 1998),Table 1b: (Scales & Scase 2000) Table 2c: (Ekerdt et al. 1983; Crowley 1986; Mein et al. 2003)

A12

Workers in lower and middle socioeconomic groups, those who are compulsorily retired or those who face economic insecurity in retirement (characteristics which cluster together) can experience detrimental effects on health and well-being and survival rates. Table 1b: (Scales & Scase 2000),Table 2c: (Crowley 1986; Gallo et al. 2000; Gallo et al. 2001; Gallo et al. 2004;Tsai et al. 2005)

A13

Workers in higher socio-economic groups, those who retire voluntarily or those who are economically secure in retirement(characteristics which cluster together) may experience beneficial effects on health and well-being Table 1b: (Scales & Scase 2000),Table 2c: (Crowley 1986; Mein et al. 2003)

but there is some conflicting evidence.
(Morris et al. 1992).

A14

Early retirement out of unemployment may lead to improvement of the depression associated with unemployment. Table 2c: (Frese 1987; Reitzes et al. 1996)

Demographic trends mean that older workers form an increasing proportion of the workforce. Some reduction in physical and mental capability and workability is probably inevitable with age, but chronological age is not a reliable marker. Many older workers are not only capable of continuing to work (Tsai et al. 2005) but want to do so (WHO 2001; AARP 2001). There is a conceptual argument, and broad consensus, that matching work circumstances to the changing capabilities and needs of older workers will help to maintain their health and safety at work. That has yet to be tested, because most of the available evidence is from pragmatic studies of current practice without age-specific risk assessment or control. Nevertheless, it seems an entirely reasonable principle that would be simple and inexpensive to test. The available evidence suggests that continuing to work, at least up to state retirement age, is not harmful to health or mortality in older workers (Gallo et al. 2004; Tsai et al. 2005; Pattani et al. 2004). This may, however, at least to some extent, reflect a health selection effect whereby those

Review findings

with more serious or chronic health problems leave the labour force. People who are happy with their current role (whether continuing to work or early retired) also have better affective wellbeing (Warr et al. 2004). Conversely, early retirement can be either harmful or beneficial to physical and mental health and mortality, apparently depending largely on social determinants. Socio-economic group is not only a matter of financial and social status, but also reflects education, work type, social capital, lifestyle and behaviour. Other key determinants are (a) whether early retirement is by choice or involuntary and (b) financial (in)security in retirement: these tend to cluster with socio-economic group. Whether early retirement is good or bad for health appears to reflect powerful social gradients in health that continue after leaving work (Acheson et al. 1998; Scales & Scase 2000; Marmot 2004). RE-EMPLOYMENT The concept of re-employment for working age adults is relatively straightforward – moving from unemployment back into employment. In principle, it could also include moving from other forms of economic inactivity into employment, but this search did not retrieve any such studies. School leavers have not been employed before, so the closest equivalent is entering employment. Alternatively, they may move into some other form of ‘work’ such as further education or training. So, ‘re-employment’ for school leavers was taken here to be any ‘work’ option other than unemployment.Older workers,j st like working age adults,may be re-employed u out of unemployment. Alternatively, they may move into (early) retirement, following which some may undertake other forms of ‘work’. Unemployment and retirement may then have different effects on health and well-being and must be considered separately (Warret al. 2004). Table 2 presents the characteristics and key findings of the 53 retrieved longitudinal studies on the health impact of re-employment. The most common health outcomes were based on psychometrics, e.g. the General Health Questionnaire (GHQ), but a few studies gave clinical parameters such as blood pressure or mortality rates. R1 ** Aggregate-level studies of employment rates show that increased employment rates lead to lower mortality rates. Table 1b: (Brenner 2002)

Is work good for your health & well-being?

School leavers and young adults (References in this sub-section are to Table 2a unless stated otherwise.) R2 *** School leavers who move into employment or training, or return to education, show improvements in somatic and psychological symptoms compared with those who move into unemployment. (Banks & Jackson 1982; Donovanet al. 1986; Feather & O'Brien 1986; O'Brien & Feather 1990; Hammarström 1994a; Mean Patterson 1997; Bjarnason & Sigurdardottir 2003)

R3 *** School leavers who move into ‘unsatisfactory’ employment can experience a decline in their health and well-being. (Patton & Noller 1984; Feather & O'Brien 1986; O'Brien & Feather 1990;Patton & Noller 1990; Hammarström 1994a; Dooley & Prause 1995; Schaufeli 1997)

After re-employment, there is a persisting risk of subsequent poor employment patterns and further spells of unemployment. Table 1b: (Lakey 2001)

Adults (References in this sub-section are to Table 2b unless stated otherwise.) R5 *** Re-employment of unemployed adults improves various measures of general health and well-being, such as self-esteem, self-rated health, self-satisfaction, physical health, financial concerns. (Cohn 1978; Payne & Jones 1987;Vinokur et al. 1987; Caplan et al. 1989; Kessler et al. 1989; Ferrie et al. 2001)

R6 *** Re-employment of unemployed adults improves psychological distress and minor psychiatric morbidity. (Layton 1986b; Payne & Jones 1987; Iversen & Sabroe 1988; Kessler et al.1989; Lahelma 1992; Hamilton et al. 1993; Claussen et al. 1993; Burchell 1994; Hamiltonet al. 1997; Nordenmark & Strandh 1999; Liira & Leino-Arjas 1999;Vuori & Vesalainen 1999; Ferrie et al.2001; Ferrie et al.2002)

R7 *** The beneficial effects of re-employment depend mainly on the security of the new job, and also on the individual’s motivation, desires and satisfaction. (Kessler et al. 1989; Hamilton et al. 1993; Claussen et al. 1993; Burchell 1994; Wanberg 1995; Halvorsen 1998; Ferrie et al. 2001; Ferrie et al. 2002; Ostry et al. 2002)

Review findings

There is conflicting evidence that visits to health professionals are reduced by re-employment. (Virtanen 1993; Ferrie et al. 2001)

Even after re-employment, there is a persisting risk of subsequent poor employment patterns and further spells of unemployment. Table 1b: (Saunders 2002b),Table 2b: (Liira & Leino-Arjas 1999)

Older workers (References in this sub-section are to Table 2c.) R10 ** Re-employment in older workers can improve physical functioning and mental health. (Frese & Mohr 1987; Gallo et al. 2000; Pattani et al. 2004)

The studies in Table 2 provide strong evidence that re-employment leads to improved health in all age groups. However, the next question is whether that reflects cause and effect or could be explained by a health selection effect (the corollary of the healthy worker phenomenon). Three studies suggest that it is at least partly due to health selection (Hamilton al. 1993; Claussen et al. et 1993; Mean Patterson 1997). However, eight other studies that tested this hypothesis in various ways failed to demonstrate any health selection effect (Tiggemann & Winefield 1984; Warr & Jackson 1985; Layton 1986b; Kessler et al. 1989; Patton & Noller 1990; Graetz 1993; Schaufeli 1997; Vuori & Vesalainen 1999). Thus, the balance of the evidence is that health improvements are (at least to a large extent) a direct consequence of re-employment. Moving into employment, continued education or training is clearly better than unemployment for the mental health, general well-being and longer-term social development of school leavers. That evidence is generally consistent but some studies show a smaller effect, perhaps reflecting different social and cultural contexts (e.g. (Patton & Noller 1990; Schaufeli 1997)). However, health benefits depend on the job or the training being ‘satisfactory’ while ‘unsatisfactory’ jobs may be little better than unemployment. That is consistent with Evidence Statements W5 – W9 about the importance of job quality. In adults of middle working age, re-employment leads to clear benefits in psychological health and some measures of well-being, though there is a dearth of information on physical health. The magnitude of the improvement is more or less comparable to the adverse effects of job loss. The benefits of re-employment can be seen within the first year, and are generally sustained in those studies with a follow-up of some years.

Is work good for your health & well-being?

Re-employment seems to have similar health benefits for older workers, but this is based on few studies. Moreover, the most important comparison may not be with continued unemployment but with (early) retirement, which can have either positive or negative effects on health (Evidence Statements A11 – A14). It is therefore not possible to predict which older workers will benefit from re-employment or under what circumstances, or whether re-employment will be better than other alternatives. Re-employment generally leads to improved health, so efforts to seek a job are advisable. However, if these attempts to get work are unsuccessful, that failure can then have a further negative effect on mental health (Vinokur et al. 1987). Moreover, even if unemployed people do manage to get back to work, they remain at risk of further unemployment and subsequent poor employment patterns, which can have a longer-term impact on their health and well-being. Unemployment, like social disadvantage and deprivation, is best viewed across a life course perspective (Acheson et al. 1998; Bartley 1994). WORK FOR SICK AND DISABLED PEOPLE Table 3 shows a broad consensus across multiple disciplines and also, importantly, among disability groups, employers, unions, insurers, and the main political parties. It is widely accepted that job retention or (return to) work are desirable goals to maintain or improve quality of life and well-being. There is also general consensus that people should receive accurate, consistent information and advice, along with clinical and occupational management that reflects these goals (Coulter et al. 1998; Department of Health 2000; Detmer et al. 2003). SD1 0

There is a broad consensus that, when possible, sick and disabled people should remain in work or return to work as soon as possible because it: • is therapeutic; • helps to promote recovery and rehabilitation; • leads to better health outcomes; • minimises the deleterious physical, mental and social effects of long-term sickness absence and worklessness; • reduces the chances of chronic disability, long-term incapacity for work and social exclusion; • promotes full participation in society, independence and human rights; • reduces poverty; • improves quality of life and well-being. (Table 3)

Review findings

The policy statements and guidance in Table 3 are based upon and reflect the available evidence, yet they are essentially expert opinions. Several refer to the evidence on the health benefits of work and the detrimental effects of unemployment in healthy people. Others discuss in general terms the harmful effects of prolonged sickness absence and avoidable incapacity, and the beneficial effects of work for sick people. However, there is little direct reference or linkage to scientific evidence on the physical or mental health benefits of (early) (return to) work for sick or disabled people. MENTAL HEALTH Table 4 presents the evidence on severe mental illness (Table 4a), common mental health problems (Table 4b) and ‘stress’ (Table 4c). Severe mental illness Severe mental illness was not the main focus of the present review but was included because it provides some of the best available evidence on work and mental illness. It may be argued that if work is good for people with severe mental illness that is likely to apply to a greater or lesser extent to people with mild/moderate problems. (References in this sub-section are to Table 4a). M1 *** Supported Employment programmes are effective for vocational outcomes in competitive employment (and more effective than Pre-Vocational Training). (Crowther et al. 2001a; Bond 2004).

Supported Employment, Pre-vocational Training and Sheltered Employment do not produce any significant effect (positive or negative) on health outcomes such as the psychiatric condition, severity of symptoms, or quality of life. (Schneider 1998; Barton 1999; Crowther et al. 2001a; Schneider et al. 2002)

There is a correlation between working and more positive outcomes in symptom levels, self-esteem, quality of life and social functioning, but a health selection effect is likely and a clear causal relationship has not been established. (Schneider et al. 2002; Marwaha & Johnson 2004)

Many people with severe mental illness want to work and 30-50% are capable of work, though only 10-20% are working (Schneider 1998; Schneider et al. 2002; Marwaha & Johnson 2004). The current review shows that work is not harmful to the psychiatric condition or mental health of people with severe mental illness although, conversely, it has no direct beneficial impact on their mental condition either. However, the balance of the indirect evidence is that it is beneficial for their overall well-being (Schneider 1998; RCP 2002; Twamley et al. 2003).

Is work good for your health & well-being?

Common mental health problems (References in this sub-section are to Table 4b). M4 *** Emotional symptoms and minor psychological morbidity are very common in the working age population: most people cope with these most of the time without health care or sickness absence from work (Ursin 1997; Glozier 2002)

M5 *** People with mental health problems are more likely to be or to become workless (sickness, disability, unemployment), with a risk of a downward spiral of worklessness, deterioration in mental health and consequent reduced chances of gaining employment. (Merz et al. 2001; RCP 2002; Seymour & Grove 2005)

There is a general consensus that work is important in promoting mental health and recovery from mental health problems and that losing one’s job is detrimental. (RCP 2002;Thomas et al. 2002; Seymour & Grove 2005)

There is limited evidence about the impact of (return to) work on (people with) mild/moderate mental health problems, despite their epidemiological and social importance. However, there is much more evidence on ‘stress’, which may be the best modern exemplar of common mental health problems. Stress HSE defines stress as ‘the adverse reaction people have to excessive pressure or other types of demand placed on them’ (HSE Stress homepage www.hse.gov.uk/stress accessed 24 January 2006). However, there are many other definitions of stress and no generally agreed scientific definition (Wainwright & Calnan 2002; Palmore 2006). The term ‘stress’ is often used for both psychosocial characteristics of work (stressors) and adverse health outcomes (stress responses). To avoid fragmentation and duplication of the review, this section includes evidence on both stressors and/or stress responses: these constructs should be distinguished. (References in this sub-section are to Table 4c). M7 *** Cross-sectional studies show an association between various psychosocial characteristics of work (job satisfaction, job demands/control, effort/reward, social support) and various subjective measures of general health and psychological well-being (van der Doef & Maes 1999;Viswesvaranet al.1999;de Lange et al.2003;Tsutsumi & Kawakami 2004; van Vegchel et al. 2005; Faragher et al. 2005)

Review findings

The strongest associations are with job satisfaction (Faragher et al. 2005), and the weakest with social support (Viswesvaran et al. 1999; Bond et al. 2006). The associations are stronger for subjective perceptions of work than for more objective measures of work organization. M8 *** Longitudinal studies support a causal relationship between certain psychosocial characteristics of work (particularly demand and control) and mental health (mainly psychological distress) over time but the effect sizes are generally small. (Viswesvaran et al. 1999; de Lange et al. 2003;Tsutsumi & Kawakami 2004; van Vegchel et al. 2005; Faragher et al. 2005; Bond et al. 2006)

The conceptual problem is the circularity in stimulus-response definitions: stressors are any (job) demands associated with adverse stress responses; stress responses are any adverse (health) effects attributed to stressors. The practical problem is that stressors and stress responses and the relationship between them are subjective perceptions, self-reported, open to modulation by the mental state identified as ‘stress’ (whatever its cause), and with confounding of cause and effect. There are no objective or agreed criteria for the definition or measurement of stressors or stress responses, or for the diagnosis of any clinical syndrome of ‘stress’ (Lazarus & Folkman 1984; Rick & Briner 2000; Rick et al. 2001; IIAC 2004; Wessely 2004). These conceptual and methodological problems create considerable uncertainty about psychosocial hazards, about psychosocial harms, and about the relationship between them (Rick & Briner 2000; Rick et al. 2002; Mackay et al. 2004; IIAC 2004; HSE/HSL 2005) The underlying problem is the fundamental assumption that work demands/stressors are necessarily a hazard with potential adverse mental health consequences (Cox 1993; Cox et al. 2000a; Cox et al. 2000b; Mackay et al. 2004), ignoring or failing to take sufficient account of the possibility that work might also be good for mental health (Lazarus & Folkman 1984; Edwards & Cooper 1988; Payne 1999; Salovey et al. 2000; Briner 2000; Adisesh 2003; Nelson & Simmons 2003; Wessely 2004; HSE/HSL 2005; Dodu 2005). It is sometimes argued that this is a matter of quantitative exposure: ‘Pressure is part and parcel of all work and helps to keep us motivated. But excessive pressure can lead to stress which undermines performance’ (HSE Stress homepage www.hse.gov.uk/stress : accessed 24 January 2006). However, there is little evidence for such a dose-response relationship or for any threshold for adverse health effects (Rick & Briner 2000; Rick et al. 2001; Ricket al.2002).Rather,work involves a complex set of psychosocial characteristics with which the worker interacts to experience beneficial and harmful effects on mental health. Other non-work-related issues can influence how the worker interacts with and copes with work stressors. Positive and negative work characteristics, positive and negative jobworker interactions, and positive and negative effects on the worker’s health then all occur simultaneously. The final impact on the worker’s health depends on the complex balance between them.

Is work good for your health & well-being?

A more comprehensive model of mental health at work should embody the following principles: • Safety at work should be distinguished from health and well-being. Safety is freedom from dangers or risks (Concise Oxford Dictionary). Health and well-being are much broader and more positive concepts. • Personal perceptions, cognitions and emotions are central to the experience of ‘stress’ (Cox et al. 2000b; Rick et al. 2001; Rick et al. 2002; Ursin & Eriksen 2004). • ‘Stress’ is both part of and reflects a wider process of interaction between the person (worker) and their (work) environment (Lazarus & Folkman 1984; Payne 1999; Cox et al. 2000b) • Work can have both positive and negative effects on mental health and well-being (Lazarus & Folkman 1984; Edwards & Cooper 1988; Payne 1999; Briner 2000; Adisesh 2003; Nelson & Simmons 2003; HSE/HSL 2005) This review did not retrieve any direct evidence on the relative balance of beneficial vs. harmful effects of work (of whatever psychosocial characteristics) on mental health and psychological well-being. Any adverse effects of work stressors appear to be comparable in magnitude to those of job insecurity (Ferrie 1999; Quinlanet al. 2001; Sverke et al. 2002).Any such effects are smaller than the adverse effects of unemployment (Jinet al. 1995; Mathers & Schofield 1998; Murphy & Athanasou 1999; Briner 2000; Glozier 2002), social gradients in health (Kaplan & Keil 1993; Acheson et al. 1998; Saunders 2002b) and regional deprivation (Saunders 2002b; Ritchieet al. 2005) on physical and mental health and mortality (Platt 1984; Lynge 1997; Mathers & Schofield 1998; Brenner 2002). There is no direct evidence on (a) how any adverse/beneficial effects of continuing to work compare with the adverse/beneficial effects of moving to sickness absence; (b) the balance of adverse or beneficial effects of return to work in people with stress-related health complaints; or (c) how any risk of adverse effects from returning to work compares with the adverse effects of prolonged sickness absence. On balance, any adverse effects of work on mental health appear to be outweighed by the bene ficial effects of work on well-being and by the likely adverse effects of (long-term) sickness absence or unemployment. MUSCULOSKELETAL CONDITIONS Much of the literature retrieved on musculoskeletal conditions (Table A5) concerns low back pain, reflecting its occupational importance. However, many of the issues raised about back pain are common to other musculoskeletal conditions, particularly neck pain and arm pain (NIOSH 1997; Buckle & Devereux 1999; National Research Council 2001; Schonstein et al. 2003; National Health and Medical Research Council 2004; Helliwell & Taylor 2004; Waddell & Burton 2004; Punnett & Wegman 2004; Walker-Bone & Cooper 2005). (References in this section are to Table 5).

Review findings

MS1 *** There is a high background prevalence of musculoskeletal conditions, yet most people with musculoskeletal conditions (including many with objective disease) can and do work, even when symptomatic. (Burton 1997; De Beek & Hermans 2000;Waddell & Burton 2001; de Buck et al. 2002; Helliwell & Taylor 2004; de Croon et al. 2004;Walker-Bone & Cooper 2005; Henriksson et al. 2005; Burton et al. 2006)

MS2 *** Certain physical aspects of work are risk factors for the development of musculoskeletal symptoms and specific diseases. However, the effects sizes for physical factors alone are only modest, and tend to be confined to intense exposures. (NIOSH 1997; National Research Council 1999; Buckle & Devereux 1999; Hoogendoorn et al. 1999; National Research Council 2001; Punnett & Wegman 2004; IIAC 2006)

MS3 *** Psychosocial factors (personal and occupational) exert a powerful effect on musculoskeletal symptoms and their consequences. They can act as obstacles to work retention and return to work; control of such obstacles can have a beneficial influence on outcomes such as pain, disability and sick leave. (Burton 1997; Ferguson & Marras 1997; Davis & Heaney 2000;Abenhaim et al. 2000; National Research Council 2001;Waddell & Burton 2004; Helliwell & Taylor 2004;Woods 2005; Walker-Bone & Cooper 2005; Henriksson et al. 2005)

MS4 *** Activity-based rehabilitation and early return to work (or remaining at work) are therapeutic and beneficial for health and well-being for most workers with musculoskeletal conditions. [There is an underlying assumption that significant physical hazards should be controlled]. (Fordyce 1995; Frank et al. 1996;Abenhaim et al. 2000; de Buck et al. 2002; Staal et al. 2003; Carter & Birrell 2000; Schonstein et al. 2003;Waddell & Burton 2004; National Health and Medical Research Council 2004; COST B13 working group 2004; Helliwell & Taylor 2004; ARMA 2004; Staal et al. 2003; Cairns & Hotopf 2005)

MS5

Control (reduction) of the physical demands of work can facilitate work retention for people with musculoskeletal conditions, especially those with specific diseases. (Frank et al. 1996;Westgaard & Winkel 1997;ACC and the National Health Committee 1997; Frank et al. 1998; RCGP 1999; de Buck et al. 2002; Staal et al. 2003;Waddell & Burton 2004; COST B13 working group 2004; Helliwell & Taylor 2004; de Croonet al. 2004;ARMA 2004; Franche et al. 2005; Loisel et al. 2005)

Is work good for your health & well-being?

MS6

Organisational interventions, such as transitional work arrangements (temporary modified work) and improving communication between health care and the workplace, can facilitate early and sustained return to work. (ACC and the National Health Committee 1997; Frank et al. 1998; Staal et al. 2003; Waddell & Burton 2004; COST B13 working group 2004; Henriksson et al. 2005; Franche et al. 2005; Loisel et al. 2005)

Four main themes emerged from the evidence: (a) the high background prevalence of musculoskeletal symptoms in the general population; (b) work can be a risk factor for musculoskeletal conditions; (c) the important modifying influence of psychosocial factors; and (d) the need to combine clinical and occupational strategies in the secondary prevention of chronic disability. Together, these themes are central to the relationship between work and health for people with musculoskeletal conditions. The high background prevalence of musculoskeletal symptoms means that a substantial proportion of musculoskeletal conditions are not caused by work. Most people with musculoskeletal conditions continue to work; many patients with severe musculoskeletal diseases such as rheumatoid arthritis remain at work and experience health benefits (Fifield al. et 1991). Thus, musculoskeletal conditions do not automatically preclude physical work. Musculoskeletal symptoms (whatever their cause) may certainly make it harder to cope with physical demands at work, but that does not necessarily imply a causal relationship or indicate that work is causing (further) harm. Biomechanical studies and epidemiological evidence show that high/intense exposures to physical demands at work can be risk factors for musculoskeletal symptoms,‘injury’and certain musculoskeletal conditions. However, causation is usually multifactorial and the scientific evidence is somewhat ambivalent: much depends on the outcome of interest. Physical demands at work can certainly precipitate or aggravate musculoskeletal symptoms and cause ‘injuries’ but, viewed overall, physical demands of work only account for a modest proportion of the impact of musculoskeletal symptoms in workers. The physical demands of modern work (assuming adequate risk control and except in very specific circumstances) play a modest role in the development of actual musculoskeletal pathology. In contrast, there is strong epidemiological and clinical evidence that (long-term) sickness absence and disability depend more on individual and work-related psychosocial factors than on biomedical factors or the physical demands of work (Walker-Bone & Cooper 2005).

Review findings

More fundamentally, it is wrong to view physical demands from a purely negative perspective as ‘hazards’ with potential only to cause ‘harm’. Different physical activities may either load or unload musculoskeletal structures. Physical activity is fundamental to physiological health and fitness and an essential part of rehabilitation from injury or illness. Work can be therapeutic. Thus, modern clinical management for most musculoskeletal conditions emphasises advice and support to remain in work or to return as soon as possible. People with musculoskeletal conditions who are helped to return to work can enjoy better health (level of pain, function, quality of life) than those who remain off work (Westman et al. 2006; Lötters et al. 2005). Importantly, physical activity and early return to work interventions do not seem to be associated with any increased risk of recurrences or further sickness absence (Staal et al. 2005; McCluskey et al. 2006). The return to work process may need organisational interventions: risk reassessment and control, and modified work if required. The duration of modified work depends on the condition: for common musculoskeletal conditions such as back, neck or arm pain it should be temporary and transitional, although for chronic musculoskeletal disease such as rheumatoid arthritis it may be permanent. This approach is about accommodating the musculoskeletal condition (whatever its cause) rather than implying that work is causal or harmful. CARDIO-RESPIRATORY CONDITIONS Cardio-respiratory conditions can be severe and life-threatening yet, following appropriate treatment, recovery is often good with manageable residual impairment. Any persisting or recurring symptoms may then fit the description of a ‘common health problem’. Cardiorespiratory conditions have a high prevalence in the general population (Perk & Alexanderson 2004; Tarlo & Liss 2005); whilst certain characteristics of work can be risk factors, cardiorespiratory conditions are often multifactorial in nature. Table 6a presents the evidence on common cardiovascular conditions (myocardial infarction, heart failure and hypertension), arranged in two sections covering work as a risk factor (Table 6a-i) and management (Table 6a-ii). Table 6b presents the evidence on common respiratory conditions, particularly chronic obstructive pulmonary disease and asthma. Most of this literature was about the prevention, treatment or control of disease, rather than the impact of work on the health of people with cardio-respiratory conditions. CR1 0

Returning workers with cardiovascular and respiratory conditions to work is a generally accepted goal that is incorporated into clinical guidance. Table 6a: (Wenger et al. 1995;Thompson et al. 1996; van der Doef & Maes 1998; Thompson & Lewin 2000;Wozniak & Kittner 2002; Reynolds et al. 2004) Table 6b: (Hyman 2005; Nicholson et al. 2005; HSE 2006)

Is work good for your health & well-being?

CR2 *** Many workers with cardiovascular and respiratory conditions do manage to return to work, but the rates vary and return to work may not be sustained. Table 6a: (Shanfield 1990;Thompson et al. 1996; Dafoe & Cupper 1995; NHS CRD1998; de Gaudemaris 2000;Wozniak & Kittner 2002; Perk & Alexanderson 2004) Table 6b: (Malo 2005; Nicholson et al. 2005;Asthma UK 2004)

CR3

The return to work process for workers with cardio-respiratory conditions is generally considered to require a combination of both clinical management and occupational risk control. Table 6a: (Wenger et al. 1995; Dafoe & Cupper 1995) Table 6b: (Hyman 2005; Nicholson et al. 2005)

CR4

There is limited evidence that rehabilitation and return to work for workers with cardio-respiratory conditions can be beneficial for general health and well-being and quality of life. Table 6a: (Brezinka & Kittel 1995; Dafoe & Cupper 1995) Table 6b: (Gibson et al. 2003; Lacasse et al. 2003; Hyman 2005)

CR5 *** Prevention of further exposure is fundamental to the clinical management and rehabilitation of occupational asthma. Table 6b: (Asthma UK 2004;Tarlo & Liss 2005; Malo 2005; IIAC 2006; HSE 2006)

There is an extensive literature on the rehabilitation of patients with cardiovascular conditions, though there is less on respiratory conditions. Workers who have experienced severe and potentially life-threatening illness face perceptual, work-related and social obstacles in returning to work, whether or not they have any continuing medical impairment. Nevertheless, of particular importance for the purpose of the present review, many of them can and do successfully return to work. Multimodal rehabilitation with control of workplace demands and exposures may facilitate that goal. However, there are significant difficulties in engaging patients in rehabilitation programmes (Newman 2004; Witt et al. 2005) which is partly a matter of service provision but also of motivation. There remains the issue of work retention, because patients often leave work again (Thompson et al. 1996; NHS CRD 1998). The overall thrust of this literature is that return to (suitably controlled) work is an appropriate and desirable goal for many people with cardio-respiratory conditions. There is some evidence on the effectiveness of this approach for occupational outcomes, but there is little direct evidence about the impact of (return to) work on cardio-respiratory health. There is some indication that early return to work is safe for myocardial infarction patients stratified as low risk (Kovoor et al. 2006), and that patients with cardiopulmonary disease are rarely harmed by return to work recommendations (Hyman 2005). Furthermore, the limited evidence that is available suggests there may be some general health benefit (Brezinka & Kittel 1995) and this may extend to remaining in work (Gallo et al. 2004).

Review findings

SOCIAL SECURITY STUDIES There is a theoretical argument that moving off benefits and into work is likely to increase income, reduce poverty, increase human/social capital, and improve self-esteem and social status. In principle, that should move claimants up the social gradient in health, and thus improve their physical and mental health, quality of life and well-being (Acheson et al. 1998; Waddell & Aylward 2005). However, moving off benefits does not necessarily mean (re)-entering work, and the two must be distinguished. The further caveat is that any impact may depend on the nature and the quality of the job (Mowlam & Lewis 2005). (All references in this section are to Table 7). SS1 *** Improvements in health and well-being from coming off benefits are associated with (re-)entering work, not simply with leaving the benefits system. (Bound 1989; Caplan et al. 1989; Proudfoot et al. 1997; Dorsett et al. 1998;Watson et al. 2004; Mowlam & Lewis 2005)

SS2

Claimants who move off benefits and (re-)enter work generally have increased income. (Moylan et al. 1984; Caplan et al. 1989; Garman et al. 1992; Dorsett et al. 1998)

SS3

Moving off benefits and (re-)entering work is generally associated with improved psychological health and quality of life. (Caplan et al. 1989; Erens & Ghate 1993;Vinokur et al. 1995; Rowlingson & Berthoud 1996; Proudfoot et al. 1997; Dorsett et al. 1998;Watson et al. 2004; Mowlam & Lewis 2005)

There is conflicting evidence on the extent to which this is a health selection effect or cause and effect: probably both occur. (Vinokur et al. 1995; Proudfoot et al. 1997; Bloch & Prins 2001;Watson et al. 2004)

SS4 *** After leaving benefits, many claimants go into poorly paid or low quality jobs, and insecure, unstable or unsustained employment. Many go on to further periods of unemployment or sickness, and further spell(s) on the same or other social security benefits. (Daniel 1983;Ashworth et al. 2001; Hedges & Sykes 2001; Juvonen-Posti et al. 2002; Bacon 2002; Bowling et al. 2004)

SS5 *** Claimants whose benefit claims are disallowed often do not return to work but cycle between different benefits and often report a deterioration in mental health, quality of life and well-being. (Dorsett et al. 1998; Rosenheck et al. 2000;Ashworth et al. 2001)

Is work good for your health & well-being?

Because the English-language literature in this area is mainly from the UK and the US, these conclusions relate to the social security systems in these countries. Moving off benefits might imply something different in other countries with different benefit systems and benefit levels. Moving off benefits can have either positive or negative effects on health and well-being, depending mainly on how claimants leave benefits and whether or not they (re)-enter work. Of those claimants who leave benefits voluntarily, the majority (re)-enter work and have increased income, and many report that their health is completely recovered or much better. Of those claimants who are disallowed benefits, a minority (re)-enter work and their income generally falls, and many feel that their health remains unchanged or gets worse. Of those who are disallowed and appeal, very few (re)-enter work, and most feel that their health remains unchanged or gets worse. There are obvious (self)-selection effects in these divergent paths, which are also linked to social inequalities, multiple disadvantage and regional deprivation. The net result is that interventions which encourage and support claimants to come off benefits and successfully get them (back) into work are likely to improve their health and well-being; interventions which simply force claimants off benefits are more likely to harm their health and well-being (Dorsett et al. 1998; Ford et al. 2000; Rosenheck et al. 2000; Ashworth et al. 2001; Waddell 2004b; Waddell & Aylward 2005).

DISCUSSION
So, is work good for your health and well-being? This review found much more evidence than originally anticipated, even if it was of widely varying source, type and quality. Basically, there is a limited amount of high quality scientific evidence that directly addresses the question. However, there is a strong body of indirect evidence that can be built into a convincing answer: Yes, work is generally good for your health and well-being, with certain important provisos. There is a generally accepted theoretical framework about work and well-being, based on extensive background evidence: • Employment is generally the most important means of obtaining adequate economic resources, which are essential for material wel -being and full participation in today’s society; l • 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 p...

Keywords

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longer-last longer-term longitudin longman longstand longterm lonsdal look loosen lose loss loss.journal lost lot lothian low low-back low-paid low-status lower lowest lr ltd lubin lung lunt lupus lusk luxembourg lyng lötter m m1 m2 m3 m4 m5 m6 m60 m7 m8 ma macdonald mackay maclean macleod macro macro-econom made mae maetzel magnitud mail main maintain mainten maj majesti major make maker makers.the male malo man manag manageri manchest mani manifest manifesto manifold manner manual manual/nonmanual manufactur march marit mark marker market marmot marra marri marsh marshal martikainen martin marwaha maslach mass massiv masteri match materi matern mather matter max maxim may mayhew mayou mccaig mcclune mccluskey mchugo mckay mclean mcmanus mcmichael mcpherson mcstrafick md mead mean meaning meant measur measurement.research mechan mechelen med med25 median mediat medic medicalis medicin medicine/royal medicine60 medicophi meet mein melhorn melzer member membership men men.what mental merg merrigan merz messag met meta meta-analysi meta-analysis.eur meta-analyt metaanalyt metaphor method methodolog methodologically-sound metric mg mh mhw michi micro micro-level middl middle-ag might migrant mild mild/moderate mileston millar millennium miln mind miner mini mini-seri minim minimis minimum ministri minor minor/moderate misconcept misfit mismatch miss mital mix mj ml mnm mobil modal model model.journal models.clinical moder modern modest modif modifi modul moerman mohr money monitor monninkhof monograph monoton month mood mookadam mooney moonlight moor moral morbid moreov morrel morri morrison mortal mortality.bmj most motiv motor move movement mowlam moylan mp mr ms ms1 ms2 ms3 ms4 ms5 ms6 mu/06/03 much much-quot multi multi-mod multidimension multidisciplinari multifacet multifactori multimod multipl multivari mulvihil munir murphi muscl muscular musculoskelet must mutran mutual mw myocardi myth møller mûller n nagl narrat narrow nation natur navig ndall neal near 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