A recent high-level symposium suggests it is time to put occupational health research into public health policy. SOM chief executive Nick Pahl reports on the conference and asks if the mismatch between evidence and policy can be addressed.
Occupational health epidemiologists from across the world met at the International Symposium on Epidemiology in Occupational Health (EPICOH) conference in Edinburgh in August to present their latest research and review research needs in the future. One research area was lower back pain.
Professor David Coggon, who received a well-deserved lifetime achievement award from EPICOH at the conference, presented statistics about UK rates of sickness absence and invalidity benefit due to back pain.
During the 40 years from 1955 to 1995, rates increased eight-fold (they have fallen back a little since). This was despite a reduction in the physical requirements of work – with the increase in employment in the service sector reducing the historical risks of loading, heavy lifting and frequent bending or twisting.
Indemnity insurance offer for occupational health nurses who are members of the Society of Occupational Medicine
The Society of Occupational Medicine (SOM) is offering a new medical malpractice indemnity policy for nurses who work in OH and are members of the SOM.
OH nurses have been able to become members of the SOM since 2012, alongside ergonomists, occupational hygienists, physiotherapists, psychologists, research scientists, occupational therapists, toxicologists and epidemiologists who hold a professional qualification.
Among the benefits of the SOM/James Hallam policy are:
- Up to £5 million limit of indemnity.
- Medical malpractice is underwritten on a claim occurrence basis – run-off insurance (where an insurance company pays claims made against a business after it closes and ceases operations) is not necessary and the policy gives perpetual insurance cover for events occurring during the period of insurance.
- Professional indemnity is provided on claims made with automatic run-off for one year in the event of change of status and longer by negotiation.
The policy is only available to SOM members. To join the SOM, go to www.som.org.uk. For more details on the policy, contact: Wai Chan, account executive, Med Mal. Telephone 020 7977 7858. Email: [email protected]
Coggon stated that back pain should be seen as an illness rather than a disease, with psychological factors having a significant impact, due to low mood, a somatising tendency, fear-avoidance beliefs and psychosocial aspects of work.
He reminded delegates of the standard paradigm of occupational health intervention:
- Identify the hazard
- Assess how risk relates to circumstances of exposure
- Implement control on exposure so risks are eliminated or brought down to a risk level that is acceptable
Coggon said using this approach for ergonomic interventions for lower back pain (for example, to reduce the loading on the spine) had achieved disappointing results. “Conclusions from systematic reviews are that ergonomic organisational interventions on lower back pain demonstrated no more effectiveness than no ergonomic interventions,” he said.
So why have ergonomic interventions failed to reduce lower back pain? One possibility is that they do not bring about the changes that are intended – as people may not follow advice or use the equipment given to them.
Another issue is that systematic reviews only look at randomised controlled trials (RCTs), but study designs other than RCTs may be suitable for evaluating the effectiveness of ergonomic interventions in the workplace.
Practitioners must take care to understand the nuances and context when research is cited. Research design is critical because it determines the results.
Coggon asked whether there could be wider factors contributing to back pain than mechanical injury to spinal tissues. These might include the psychological factors influencing lower back pain or issues unrelated to work but which prevent workplace interventions from being effective.
He and his team decided to research culturally determined health beliefs and expectations. The hypothesis is that there are big differences in health beliefs and expectations across nation states.
In the study, 12,500 participants across 18 countries in 47 occupational groups (including nurses and office workers), were asked about the number of anatomical sites, other than the lower back, that were reported as being painful in the year before the baseline.
He found the highest risk factor for lower back pain at follow-up was the extent of prior pain. Data on pain prevalence by country and what happens when people move from places with lower back pain prevalence to higher back pain prevalence was also reviewed.
Results from analysis of data collected by Dr Ira Madan, working with Coggon, on manual and non-manual workers who had moved from India to the UK, indicated significant increases in back pain prevalence after workers moved, even in first-generation migrants.
This might reflect a back pain “contagion”, whereby people are strongly influenced by the beliefs and expectations of those around them and what they complain about. This is great research. But, it creates new uncertainty as there now seems to be a mismatch with current policy, which says we have to put in place risk assessments and make ergonomic changes, and the research findings, which suggest that ergonomic changes have little impact.
The conference reported on other areas where public health policy is not supported by research. A UK study is currently in progress on repeated head injuries during sport and its relationship with cognitive decline and dementia in later life. In the US, public policy has already ruled that children under the age of 10 must not head the ball during soccer training.
Another mismatch between research evidence and public policy relates to retirement and health-related job loss. Evidence suggests people who have manual jobs and are from lower socio-economic groups are more likely to have health-related job loss than those in managerial roles and from a higher socio-economic class.
Yet, government policy is extending the retirement age, giving people less time to enjoy a disease-free later life, which will particularly disadvantage those from lower socio-economic classes.
Related to this, I visited the excellent research unit at Keele University recently. Its work has focused on rates of sickness absence, understanding the impact of health issues on work and the interface between work and health.
Data has found that 4% of GP patients in a year receive a fit note (30% for musculoskeletal and 36% for mental health). The research unit has produced a wide variety of policy-related research, including that there is no evidence that fit notes have a positive clinical benefit. The research finds:
- People may benefit from being in work, even though they may be in pain.
- Workplace issues have more of an impact on work performance than on sickness absence.
It made me think that policy making at the moment should be more research based. I am pleased that at least the Government is listening, with the Society of Occupational Medicine regularly meeting with the Government’s work and health unit officials and with meetings in the diary with the Deputy Chief Medical Office and the relevant minister.
How should researchers promote their results to the public?
An emerging theme, in this era of fake news and post-truth, is the responsibility of researchers to advocate effectively about results to the public, policymakers and practitioners. Scientific journals such as Occupational Medicine have a fundamental role to play in this, too.
Delegates at the EPICOH conference reflected that, as researchers, they should not only publish in academic journals but go further to ensure research is put into practice.
Sitting on scientific advisory boards, linking with other disciplines such as public health and toxicology, and meeting policy makers alongside organisations such as the Society of Occupational Medicine is all important.
Researchers also need to consider the challenges of communicating results effectively (such as around health risk), in particular when there is uncertainty, such as with lower back pain research.
Future priorities for occupational health research
The EPICOH conference also discussed future priorities for occupational health research. Leading researchers from the US, Australia, South Africa, Taiwan, Canada and the UK spoke of the need for occupational health research into cost-effectiveness studies. Other priorities included:
- How the economy is changing – with a move to non-routine manual and non-routine cognitive jobs and a decline of manual work.
- Climate change, such as research on heat exposure and the impact of heat stress.
- Globalisation – a focus on global supply chains and the worker health impacts of any product or service that needs to be distributed worldwide.
- The interface between workplaces and communities.
- The importance of occupational medicine and health in core curricula training.
- Integration of occupational health into the NHS and employer services.
- Communicating occupational health to the public and the media.
- The translation of results relating to health risk to low-income parts of the world.
Overall, I encourage OH practitioners to get research active. Could you do small-scale research as part of your practice? Don’t worry about funding too much either, as I perceive there is currently more funding than researchers – with funding available from a variety of sources such as the Colt Foundation, the Government and industry.
If research isn’t your bag though, read the Journal of Occupational Medicine and put the results into practice.