Why did middle-aged and older people retire since the first COVID-19 lockdown? A qualitative study of participants from the Health and Employment After Fifty study.

BACKGROUND: Governments of Western countries need people to work to older ages, however the COVID-19 pandemic impacted the workforce by pushing older adults to retire. Socio-demographic factors that influence the decision to retire in the pre-pandemic period were, poor or good health, finances, marital status, and gender. The aim of this study was to explore aspects that contributed to the decision to retire among middle-aged and older people in England who retired during the COVID-19 pandemic. METHODS: In September 2022 semi-structured interviews were conducted with a sample of participants from the Health and Employment After Fifty (HEAF) study who retired since March 2020. Consenting participants were purposively selected to achieve a wide spread of characteristics deemed important in the retirement process. Telephone interviews were conducted, audio-recorded, transcribed and then thematically analysed. RESULTS: 24 interviews were conducted (10 men and 14 women, mean age 65 years). Six themes were identified: four of them were non-COVID-19 aspects while two can be interpreted as impact of COVID-19 on the workforce. Work-related factors were of major importance. A sense of appreciation and attachment in relation to their employer, and conversely high work demands and stress, as well as changes in work responsibilities and work practices since lockdown and/or perception of personal safety in the workplace during the pandemic influenced their retirement decision, as did physical and mental health issues. Another theme suggested that some participants felt they had reached the 'right' age and needed to spend more time with family. Having the financial capacity to retire was widely mentioned but was never the main factor. CONCLUSIONS: The decision to retire during the pandemic was multi-factorial although changes to work during lockdown were of great importance. Post-pandemic, our findings suggest that there are modifiable aspects of work, including appreciation and fair pay and work conditions, that employers and policy makers could encourage to retain their older workers.

Return to work and employment retention after uni-compartmental and total knee replacement: findings from the Clinical Outcomes in Arthroplasty study.

BACKGROUND: Little is known about ability to work after unicompartmental knee replacement (UKR) and total knee replacement (TKR), especially in physically-demanding occupations. This study described rates of return-to-work (RTW) and ability to sustain work by job after arthroplasty. METHOD: Participants from The Clinical Outcomes in Arthroplasty Study (COASt) aged 18-65 were eligible if they underwent UKR or TKR and had at least 5 years' follow-up post-operation. We posted a survey asking about pre-operative occupation, post-operative occupations and associated physical demands, and whether they had quit a job post-surgery due to difficulties with the operated knee (knee-related job loss (KRJL)). We fitted Cox Proportional Hazard Models to investigate the role of demanding physical activities on KRJL. RESULTS: 251 people (143 UKR, 108 TKR) returned a questionnaire, of whom 101 UKR and 57 TKR worked post-operatively. Rates of RTW were highest amongst those in managerial and professional or technical roles, whichever operation they received. RTW was poorest amongst those in elementary occupations. In associate professional/technical occupations, RTW rates were better amongst UKR recipients. Amongst participants who returned to work, 17 reported KRJL (8.5% UKR and 16.7% TKR). Respondents were more likely to have KRJL if their job involved carrying/lifting ≥10 kg (HR:4.81, 95%CI 1.55-14.93) or climbing >30 flights of stairs (HR:4.03, 95%CI 1.36-11.98). CONCLUSIONS: Knee arthroplasty recipients working pre-operatively mostly RTW. RTW may be more difficult after TKR than UKR. Jobs which involve lifting and climbing stairs may be particularly challenging. Surgeons offering knee arthroplasty should counsel patients about workability as well as risk of revision.

Pre-pandemic socio-economic status and changes in employment during the first lockdown (2020) on the health of middle-aged people in England: a longitudinal study.

BACKGROUND: The COVID-19 pandemic markedly disrupted people's lives. It caused higher mortality and morbidity amongst individuals from poorer socio-economic position (SEP). It is well-recognised that job loss has a negative impact on health. We hypothesised that health effects of the pandemic on middle-aged people might be different depending on SEP and changes in employment. METHODS: Data are from the Health and Employment After Fifty (HEAF), a cohort recruited 2013-2014 when aged 50-64 through 24 English general practices. At baseline and annually since, participants completed a questionnaire reporting about demographics, employment, health, lifestyle, and finances. In 2021 we sent an e-survey to all contactable HEAF participants, asking about effects of the first lockdown (March-July 2020). Outcomes were participants' perception of worsening of mental, physical health, and self-rated health (SRH) since lockdown. Associations between SEP, COVID-19 related employment changes and health were explored with Poisson regression with robust standard error, with adjustment for age, sex, and pre-pandemic SRH. RESULTS: In total, 2,469 (53%) returned a usable questionnaire, amongst whom 2,344 provided complete information for these analyses (44% men, mean age 65.7 years). Worsening of mental, physical or SRH since lockdown was reported by 21%, 27% and 17% respectively. Mutually adjusted models showed that reporting struggling financially pre-pandemic (versus living comfortably) was associated with an increased risk of deterioration in: mental (RR = 2.0, 95%CI 1.7-2.5), physical health (RR = 2.0, 95%CI 1.6-2.3), and SRH (RR = 1.6, 95%CI 1.2-2.1). Participants working from home during lockdown and those who lost their job (as opposed to those with unchanged employment) were at increased risk of reporting deterioration in mental health and SRH. CONCLUSION: In a cohort of older workers, working from home, job loss and poorer pre-pandemic SEP were all associated with worsening of mental health and SRH since lockdown.

Predictors and Consequences of Not Seeking Healthcare during the COVID-19 Pandemic: Findings from the HEAF Cohort.

The COVID-19 pandemic resulted in a dramatic reduction of routine healthcare availability in many European countries. Among a cohort of English middle-aged adults, we explored pre-pandemic and pandemic factors associated with not seeking healthcare during lockdown, and their effect on subsequent self-reported health measures. Longitudinal data from the Health and Employment After Fifty (HEAF) cohort were used. Pre-pandemic data came from the 5th annual follow-up (2019), when participants were aged 56-71 years, and pandemic data were collected by e-survey in February 2021 and November 2021. Response rates of the two e-surveys were 53% and 79%, respectively. Pre-pandemic predictors of not seeking healthcare were: female gender, higher BMI, higher comorbidity, poorer self-rated health and depression; non-care seekers were also more likely to report that family or friends were affected by COVID-19 and to have been advised to shield. Not seeking healthcare during lockdown was associated with a higher risk of reporting worsening of physical, but not mental, health during the later phase of the pandemic. In this cohort, those with generally poorer health were disproportionately more likely to not seek healthcare during lockdown, which may potentially exacerbate pre-existing inequalities and lead to longer-term health consequences.

A pilot trial investigating the feasibility of a future randomised controlled trial of Individualised Placement and Support for people unemployed with chronic pain recruiting in primary care.

BACKGROUND: We investigated the feasibility of recruiting patients unemployed for more than 3 months with chronic pain using a range of methods in primary care in order to conduct a pilot trial of Individual Placement and Support (IPS) to improve quality of life outcomes for people with chronic pain. METHODS: This research was informed by people with chronic pain. We assessed the feasibility of identification and recruitment of unemployed patients; the training and support needs of employment support workers to integrate with pain services; acceptability of randomisation, retention through follow-up and appropriate outcome measures for a definitive trial. Participants randomised to IPS received integrated support from an employment support worker and a pain occupational therapist to prepare for, and take up, a work placement. Those randomised to Treatment as Usual (TAU) received a bespoke workbook, delivered at an appointment with a research nurse not trained in vocational rehabilitation. RESULTS: Using a range of approaches, recruitment through primary care was difficult and resource-intensive (1028 approached to recruit 37 eligible participants). Supplementing recruitment through pain services, another 13 people were recruited (total n = 50). Randomisation to both arms was acceptable: 22 were allocated to IPS and 28 to TAU. Recruited participants were generally not 'work ready', particularly if recruited through pain services. CONCLUSION: A definitive randomised controlled trial is not currently feasible for recruiting through primary care in the UK. Although a trial recruiting through pain services might be possible, participants could be unrepresentative in levels of disability and associated health complexities. Retention of participants over 12 months proved challenging, and methods for reducing attrition are required. The intervention has been manualised.

Patterns of change of multisite pain over 1 year of follow-up and related risk factors.

BACKGROUND: Multisite musculoskeletal pain is common and disabling. This study aimed to prospectively investigate the distribution of musculoskeletal pain anatomically, and explore risk factors for increases/reductions in the number of painful sites. METHODS: Using data from participants working in 45 occupational groups in 18 countries, we explored changes in reporting pain at 10 anatomical sites on two occasions 14 months apart. We used descriptive statistics to explore consistency over time in the number of painful sites, and their anatomical distribution. Baseline risk factors for increases/reductions by ≥3 painful sites were explored by random intercept logistic regression that adjusted for baseline number of painful sites. RESULTS: Among 8927 workers, only 20% reported no pain at either time point, and 16% reported ≥3 painful sites both times. After 14 months, the anatomical distribution of pain often changed but there was only an average increase of 0.17 painful sites. Some 14% workers reported a change in painful sites by ≥3. Risk factors for an increase of ≥3 painful sites included female sex, lower educational attainment, having a physically demanding job and adverse beliefs about the work-relatedness of musculoskeletal pain. Also predictives were as follows: older age, somatizing tendency and poorer mental health (each of which was also associated with lower odds of reductions of ≥3 painful sites). CONCLUSIONS: Longitudinally, the number of reported painful sites was relatively stable but the anatomical distribution varied considerably. These findings suggest an important role for central pain sensitization mechanisms, rather than localized risk factors, among working adults. SIGNIFICANCE: Our findings indicate that within individuals, the number of painful sites is fairly constant over time, but the anatomical distribution varies, supporting the theory that among people at work, musculoskeletal pain is driven more by factors that predispose to experiencing or reporting pain rather than by localized stressors specific to only one or two anatomical sites.

Feasibility and sustainability of working in different types of jobs after total hip arthroplasty: analysis of longitudinal data from two cohorts.

OBJECTIVES: To investigate the rates of return to work and workability among working-age people following total hip arthroplasty (THA). METHODS: Participants from the Geneva Arthroplasty Registry and the Clinical Outcomes for Arthroplasty Study aged 18-64 years when they had primary THA and with at least 5 years' follow-up were mailed a questionnaire 2017-2019. Information was collected about preoperative and post-THA employment along with exposure to physically demanding activities at work or in leisure. Patterns of change of job were explored. Survival analyses using Cox proportional hazard models were created to explore risk factors for having to stop work because of difficulties with the replaced hip. RESULTS: In total, 825 returned a questionnaire (response 58%), 392 (48%) men, mean age 58 years, median follow-up 7.5 years post-THA. The majority (93%) of those who worked preoperatively returned to work, mostly in the same sector but higher rates of non-return (36%-41%) were seen among process, plant and machine operatives and workers in elementary occupations. 7% reported subsequently leaving work because of their replaced hip and the risk of this was strongly associated with: standing >4 hours/day (HR 3.81, 95% CI 1.62 to 8.96); kneeling/squatting (HR 3.32, 95% CI 1.46 to 7.55) and/or carrying/lifting ≥10 kg (HR 5.43, 95% CI 2.29 to 12.88). CONCLUSIONS: It may be more difficult to return to some (particularly physically demanding) jobs post-THA than others. Rehabilitation may need to be targeted to these types of workers or it may be that redeployment or job change counselling are required.

Consequences of ignoring clustering in linear regression.

BACKGROUND: Clustering of observations is a common phenomenon in epidemiological and clinical research. Previous studies have highlighted the importance of using multilevel analysis to account for such clustering, but in practice, methods ignoring clustering are often employed. We used simulated data to explore the circumstances in which failure to account for clustering in linear regression could lead to importantly erroneous conclusions. METHODS: We simulated data following the random-intercept model specification under different scenarios of clustering of a continuous outcome and a single continuous or binary explanatory variable. We fitted random-intercept (RI) and ordinary least squares (OLS) models and compared effect estimates with the "true" value that had been used in simulation. We also assessed the relative precision of effect estimates, and explored the extent to which coverage by 95% confidence intervals and Type I error rates were appropriate. RESULTS: We found that effect estimates from both types of regression model were on average unbiased. However, deviations from the "true" value were greater when the outcome variable was more clustered. For a continuous explanatory variable, they tended also to be greater for the OLS than the RI model, and when the explanatory variable was less clustered. The precision of effect estimates from the OLS model was overestimated when the explanatory variable varied more between than within clusters, and was somewhat underestimated when the explanatory variable was less clustered. The cluster-unadjusted model gave poor coverage rates by 95% confidence intervals and high Type I error rates when the explanatory variable was continuous. With a binary explanatory variable, coverage rates by 95% confidence intervals and Type I error rates deviated from nominal values when the outcome variable was more clustered, but the direction of the deviation varied according to the overall prevalence of the explanatory variable, and the extent to which it was clustered. CONCLUSIONS: In this study we identified circumstances in which application of an OLS regression model to clustered data is more likely to mislead statistical inference. The potential for error is greatest when the explanatory variable is continuous, and the outcome variable more clustered (intraclass correlation coefficient is ≥ 0.01).

Capturing the Healthfulness of the In-store Environments of United Kingdom Supermarket Stores Over 5 Months (January-May 2019).

INTRODUCTION: Numerous environmental factors within supermarkets can influence the healthfulness of food purchases. This research aims to identify the changes in store healthfulness scores and assess the variations by store type and neighborhood deprivation using an adapted Consumer Nutrition Environment tool. METHODS: Between January and May 2019, a total of 104 supermarkets in London were surveyed on 1-3 occasions. The adapted Consumer Nutrition Environment tool included data on 9 variables (variety, price, quality, promotions, shelf placement, store placement, nutrition information, healthier alternatives, and single fruit sale) for 11 healthy and 5 less healthy food items. An algorithm was used to create a composite score of in-store healthfulness and to assess inter-rater reliability. Longitudinal changes in overall store healthfulness and individual variables were investigated using multivariable hierarchical mixed models. Descriptive statistics were used to describe the differences by store type and neighborhood deprivation in each month. All analyses were conducted between January and July 2020. RESULTS: The adapted Consumer Nutrition Environment tool showed acceptable inter-rater reliability. Large stores exhibited healthier environments than small stores (p<0.001), with a similar pattern for each of the 9 individual variables. Within large stores, the overall healthfulness score did not change over the study period. Promotions on more healthful items increased in February (p=0.04), and the availability of healthier alternatives for less healthy foods decreased in March (p=0.01). Within small stores, there was a trend toward increasing healthfulness (p<0.001), primarily owing to more promotions on healthy items (p<0.001). There was no difference in overall healthfulness by neighborhood deprivation. CONCLUSIONS: The adapted Consumer Nutrition Environment tool is sensitive to longitudinal changes in environmental variables that contribute to store healthfulness. A wider application of this tool could be used to map in-store environments to identify targets for interventions to encourage healthier food purchasing.

Older working adults in the HEAF study are more likely to report loneliness after two years of follow-up if they have negative perceptions of their work quality.

BACKGROUND: Loneliness is an important public health issue associated with mortality and morbidity. Often researched amongst older people, less is known about risk factors for loneliness among adults aged 50-64 years who are in work. We investigated (a) if exit from the workforce increases the odds of loneliness; (b) whether adverse psychosocial work factors are associated with increased odds of loneliness over 2 years of follow-up; and (c) whether the association is stronger among subjects still working compared with those who have exited the workforce. METHODS: Data came from the Health and Employment After Fifty (HEAF) study, a large population cohort who provided questionnaire information about work and health at baseline and 2 annual follow-ups. Logistic regression was used to explore the association between psychosocial risk factors and loneliness at follow-up 2, with adjustment for loneliness at baseline, sex, age, self-rated health, living alone, and mental health diagnosis. RESULTS: Of the initial 8134 participants, 4521 were working at baseline and provided data for this analysis. Of those, 507 (11.2%) were defined as lonely at 2 years' follow-up. Exiting the workforce was not significantly associated with loneliness (OR = 1.1, 95%CI: 0.7-1.7). However, negative psychosocial work factors predicted loneliness at follow-up. After mutual adjustment, lack of choice at work (OR: 1.5, 95%CI: 1.1-1.9), often lying awake worrying about work (OR: 1.4, 95%CI: 1.0-1.9) and perceived not coping with physical demands of the job (OR: 1.3, 95%CI: 1.0-1.7) were independent predictors, with associations robust to adjustment for demographic factors and health. Associations were only slightly altered when we restricted the sample to those who remained in work until the end of follow-up. CONCLUSIONS: Loneliness amongst middle-aged working adults is not predicted by permanent work exit but is predicted by individuals' perceptions about their work. Provision of good-quality work, matched to the capacity of the older worker, could prevent loneliness.

A case management occupational health model to facilitate earlier return to work of NHS staff with common mental health disorders: a feasibility study.

BACKGROUND: The NHS is the biggest employer in the UK. Depression and anxiety are common reasons for sickness absence among staff. Evidence suggests that an intervention based on a case management model using a biopsychosocial approach could be cost-effective and lead to earlier return to work for staff with common mental health disorders. OBJECTIVE: The objective was to assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of an early occupational health referral and case management intervention to facilitate the return to work of NHS staff on sick leave with any common mental health disorder (e.g. depression or anxiety). DESIGN: A multicentre mixed-methods feasibility study with embedded process evaluation and economic analyses. The study comprised an updated systematic review, survey of care as usual, and development of an intervention in consultation with key stakeholders. Although this was not a randomised controlled trial, the study design comprised two arms where participants received either the intervention or care as usual. PARTICIPANTS: Participants were NHS staff on sick leave for 7 or more consecutive days but less than 90 consecutive days, with a common mental health disorder. INTERVENTION: The intervention involved early referral to occupational health combined with standardised work-focused case management. CONTROL/COMPARATOR: Participants in the control arm received care as usual. PRIMARY OUTCOME: The primary outcome was the feasibility and acceptability of the intervention, study processes (including methods of recruiting participants) and data collection tools to measure return to work, episodes of sickness absence, workability (a worker's functional ability to perform their job), occupational functioning, symptomatology and cost-effectiveness proposed for use in a main trial. RESULTS: Forty articles and two guidelines were included in an updated systematic review. A total of 49 of the 126 (39%) occupational health providers who were approached participated in a national survey of care as usual. Selected multidisciplinary stakeholders contributed to the development of the work-focused case management intervention (including a training workshop). Six NHS trusts (occupational health departments) agreed to take part in the study, although one trust withdrew prior to participant recruitment, citing staff shortages. At mixed intervention sites, participants were sequentially allocated to each arm, where possible. Approximately 1938 (3.9%) NHS staff from the participating sites were on sick leave with a common mental health disorder during the study period. Forty-two sick-listed NHS staff were screened for eligibility on receipt of occupational health management referrals. Twenty-four (57%) participants were consented: 11 (46%) received the case management intervention and 13 (54%) received care as usual. Follow-up data were collected from 11 out of 24 (46%) participants at 3 months and 10 out of 24 (42%) participants at 6 months. The case management intervention and case manager training were found to be acceptable and inexpensive to deliver. Possible contamination issues are likely in a future trial if participants are individually randomised at mixed intervention sites. HARMS: No adverse events were reported. LIMITATIONS: The method of identification and recruitment of eligible sick-listed staff was ineffective in practice because uptake of referral to occupational health was low, but a new targeted method has been devised. CONCLUSION: All study questions were addressed. Difficulties raising organisational awareness of the study coupled with a lack of change in occupational health referral practices by line managers affected the identification and recruitment of participants. Strategies to overcome these barriers in a main trial were identified. The case management intervention was fit for purpose and acceptable to deliver in the NHS. TRIAL REGISTRATION: Current Controlled Trials ISRCTN14621901. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 12. See the NIHR Journals Library website for further project information.

Anxiety and depression are common causes of sickness absence in the NHS. This can harm patient care. Previous research has shown that offering early support to NHS staff on sick leave with a common mental health disorder is important to aid recovery and rehabilitation. However, it is not currently known how best to support staff in returning to work. The purpose of this research was to test the feasibility of a large-scale study to see if specially trained occupational health nurses would be effective in getting NHS staff with these problems back to work quicker. We reviewed the recent scientific literature and did a survey of NHS occupational health departments to find out what was currently offered to such staff. We developed a new work-focused case management intervention and trained six occupational health nurses to deliver it. We recruited 24 NHS staff who were on sick leave with a common mental health disorder (such as depression or anxiety) and allocated 11 to receive the new intervention and the rest to receive usual support. Participants were invited to complete three questionnaires and we collected information from the participating occupational health sites. We also interviewed participants, managers, human resource staff and occupational health nurses to find out what they thought about being involved in the study. We found that the new case management intervention had potential benefits. However, it would not be possible to run a trial to evaluate the intervention until a better way can be found to encourage the early referral of sick staff to occupational health.

Sickness absence after carpal tunnel release: a multicentre prospective cohort study.

OBJECTIVES: To describe when patients return to different types of work after elective carpal tunnel release (CTR) surgery and identify the factors associated with the duration of sickness absence. DESIGN: Multicentre prospective observational cohort study. SETTING AND PARTICIPANTS: Participants were recruited preoperatively from 16 UK centres and clinical, occupational and demographic information were collected. Participants completed a weekly diary and questionnaires at four and 12 weeks postoperatively. OUTCOMES: The main outcome was duration of work absence from date of surgery to date of first return to work. RESULTS: 254 participants were enrolled in the study and 201 provided the follow-up data. Median duration of sickness absence was 20 days (range 1-99). Earlier return to work was associated with having surgery in primary care and a self-reported work role involving more than 4 hours of daily computer use. Being female and entitlement to more than a month of paid sick leave were both associated with longer work absences. The duration of work absence was strongly associated with the expected duration of leave, as reported by participants before surgery. Earlier return to work was not associated with poorer clinical outcomes reported 12 weeks after CTR. CONCLUSIONS: There was wide variation in the duration of work absence after CTR across all occupational categories. A combination of occupational, demographic and clinical factors was associated with the duration of work absence, illustrating the complexity of return to work decision making. However, preoperative expectations were strongly associated with the actual duration of leave. We found no evidence that earlier return to work was harmful. Clear, consistent advice from clinicians preoperatively setting expectations of a prompt return to work could reduce unnecessary sickness absence after CTR. To enable this, clinicians need evidence-informed guidance about appropriate timescales for the safe return to different types of work.

Individualised placement and support programme for people unemployed because of chronic pain: a feasibility study and the InSTEP pilot RCT.

BACKGROUND: Chronic pain is a common cause of health-related incapacity for work among people in the UK. Individualised placement and support is a systematic approach to rehabilitation, with emphasis on early supported work placement. It is effective in helping people with severe mental illness to gain employment, but has not been tested for chronic pain. OBJECTIVE: To inform the design of a definitive randomised controlled trial to assess the clinical effectiveness of individualised placement and support for people unemployed because of chronic pain. METHODS: A mixed-methods feasibility study comprising qualitative interviews and focus groups with key stakeholders, alongside a pilot trial. STUDY PARTICIPANTS: Primary care-based health-care professionals, employment support workers, employers, clients who participated in an individualised placement and support programme, and individuals aged 18-64 years with chronic pain who were unemployed for at least 3 months. INTERVENTION: An individualised placement and support programme integrated with a personalised, responsive pain management plan, backed up by communication with a general practitioner and rapid access to community-based pain services. OUTCOMES: Outcomes included stakeholder views about a trial and methods of recruitment; the feasibility and acceptability of the individualised placement and support intervention; study processes (including methods to recruit participants from primary care, training and support needs of the employment support workers to integrate with pain services, acceptability of randomisation and the treatment-as-usual comparator); and scoping of outcome measures for a definitive trial. RESULTS: All stakeholders viewed a trial as feasible and important, and saw the relevance of employment interventions in this group. Using all suggested methods, recruitment was feasible through primary care, but it was slow and resource intensive. Recruitment through pain services was more efficient. Fifty people with chronic pain were recruited (37 from primary care and 13 from pain services). Randomisation was acceptable, and 22 participants were allocated to individualised placement and support, and 28 participants were allocated to treatment as usual. Treatment as usual was found acceptable. Retention of treatment-as-usual participants was acceptable throughout the 12 months. However, follow-up of individualised placement and support recipients using postal questionnaires proved challenging, especially when the participant started paid work, and new approaches would be needed for a trial. Clients, employment support workers, primary care-based health-care professionals and employers contributed to manualisation of the intervention. No adverse events were reported. CONCLUSION: Unless accurate and up-to-date employment status information can be collected in primary care health records, or linkage can be established with employment records, research such as this relating to employment will be impracticable in primary care. The trial may be possible through pain services; however, clients may differ. Retention of participants proved challenging and methods for achieving this would need to be developed. The intervention has been manualised. TRIAL REGISTRATION: Current Controlled Trials ISRCTN30094062. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 5. See the NIHR Journals Library website for further project information.

Chronic pain is a common cause of disability and unemployment. Individualised placement and support is a package of care that aims to rehabilitate people and get them back into paid employment. It is effective for people with severe mental health conditions, but no one knows if it works for patients with chronic pain. This research aimed to determine the feasibility of a future randomised trial to test if individualised placement and support improves quality of life or other health outcomes in this group. We conducted in-depth interviews with patients, doctors, nurses, employment support workers and employers, as well as a small-scale pilot trial. All of the groups interviewed supported the value of the intervention and the pilot trial. The Patient Advisory Group helped review trial documentation and produced a standardised treatment-as-usual booklet for comparison with individualised placement and support. However, despite experimenting with a range of methods, recruiting patients proved challenging, particularly from general practices, where employment status is not recorded systematically. More efficient recruitment was achieved through pain services. Overall, we recruited and randomised 50 participants, 22 of whom received individualised placement and support and 28 of whom received treatment as usual. There were no adverse events and both groups found their 'intervention' acceptable. Returned questionnaires were completed well by all participants; however, we experienced significant levels of non-returns, particularly among those receiving the individualised placement and support, possibly related to starting work. Overall, we believe that a trial would not be feasible if recruiting through general practices, but may be feasible via pain services. Challenges would be complex clients, retention over 12 months in both arms, integrating individualised placement and support with pain services and ensuring that the intervention was delivered as intended across multiple sites. The full report comments on how such challenges might be addressed.

How does job dissatisfaction interact with self-rated health in determining the risk of health-related job loss? Prospective findings from the Health and Employment After Fifty (HEAF) study.

OBJECTIVES: Health and job satisfaction are key independent determinants of ability to work to older ages. We investigated the interaction of these two important factors on health-related job loss (HRJL) over 2 years of follow-up comparing male and female older workers. METHODS: A population sample of adults aged 50-64 years, recruited from 24 English general practices in the Health and Employment After Fifty (HEAF) study, completed questionnaires at baseline with follow-ups at 12 and 24 months. Multiple-record Cox proportional hazards models were performed to explore the main effects of, and potential interactions between, job satisfaction and self-rated health (SRH) as predictors of time to first HRJL. RESULTS: Of the initial 8134 participants, 5143 were ever in work in the study period. Among men, 5.7% and 14.3% reported job dissatisfaction (those in good and poor SRH, respectively), while among women these percentages were 4.6 and 12.9. HRJL was reported by 106 men and 176 women. Men in good health dissatisfied with their job had a sixfold (HR=6.4; 95% CI 3.3 to 12.4) increased risk of HRJL compared with men satisfied with their job (significant multiplicative interaction). Women dissatisfied with their job were more likely to have an HRJL within 2 years of follow-up irrespective of their SRH. CONCLUSIONS: SRH and job dissatisfaction have important individual effects on the risk of stopping work for health among older workers. These findings point to the importance of job satisfaction in reducing health-related exit from paid work among older workers.

Work participation and risk factors for health-related job loss among older workers in the Health and Employment after Fifty (HEAF) study: Evidence from a 2-year follow-up period.

INTRODUCTION: Rapidly increasing population old age dependency ratios create a growing economic imperative for people to work to older ages. However, rates of older worker employment are only increasing slowly. Amongst a cohort of contemporary older workers, we investigated risk factors for health-related job loss (HRJL) over 2 years of follow-up. METHODS: HEAF is a population based cohort study of adults in England (aged 50-64 years at baseline) who provided information about socio-demographic characteristics, lifestyle, and work at baseline and annual follow-ups. Exits from paid work were mapped and risk factors for HRJL explored in a multiple-record survival dataset by Cox proportional hazards models. RESULTS: 2475 (75%) men and 2668 (66%) women were employed; 115 (4.6%) men and 182 (6.8%) women reported HRJL. Employment as road transport drivers/in vehicle trades (men), or as teaching/education/nursing/midwifery professionals or in caring personal services (women), was more frequent among people exiting work for health-related versus non-health-related reasons. Principal socio-demographic and lifestyle risk factors for HRJL were: struggling financially (men and women); low physical activity (men); being overweight or obese, and current smoking (women). Mutually adjusted work-related risk factors for HRJL were job dissatisfaction, and not coping with the physical (hazard ratio [95% confidence interval]: men 5.34[3.40,8.39]; women 3.73[2.48,5.60]) or mental demands (women only, 2.02[1.38,2.96]) of work. CONCLUSIONS: Employment characteristics of contemporary older workers differ by sex. Job satisfaction and perceived ability to cope with the physical and mental demands of work are key determinants of HRJL which employers could potentially influence to enable work to older ages.

A systematic review of the influences of food store product placement on dietary-related outcomes.

CONTEXT: Product placement strategies have been used to influence customers' food purchases in food stores for some time; however, assessment of the evidence that these techniques can limit unhealthy, and promote healthy, food choices has not been completed. OBJECTIVE: This systematic review aimed to determine how product placement strategies, availability, and positioning, in physical retail food stores located in high-income countries, influence dietary-related behaviors. DATA SOURCES: From a search of 9 databases, 38 articles, 17 observational studies, and 22 intervention studies met the study inclusion criteria. DATA EXTRACTION: Two reviewers independently extracted data relating to study design, study population, exposures, outcomes, and key results. Each study was also assessed for risk of bias in relation to the research question. DATA ANALYSIS: Meta-analysis was not possible owing to heterogeneous study designs and outcomes. As recommended by Cochrane, results were synthesized in effect direction plots using a vote-counting technique which recorded the direction of effect and significance level according to the expected relationship for health improvement. CONCLUSIONS: The majority of studies showed that greater availability and more prominent positioning of healthy foods, or reduced availability and less prominent positioning of unhealthy foods, related to better dietary-related behaviors. A large number of results, however, were nonsignificant, which likely reflects the methodological difficulties inherent in this research field. Adequately powered intervention studies that test both the independent and additive effects of availability and positioning strategies are needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. 42016048826.

Levels and Determinants of Fine Particulate Matter and Carbon Monoxide in Kitchens Using Biomass and Non-Biomass Fuel for Cooking.

To assist interpretation of a study in rural Pakistan on the use of biomass for cooking and the risk of coronary heart disease, we continuously monitored airborne concentrations of fine particulate matter (PM2.5) and carbon monoxide (CO) for up to 48 h in the kitchens of households randomly selected from the parent study. Satisfactory data on PM2.5 and CO respectively were obtained for 16 and 17 households using biomass, and 19 and 17 using natural gas. Linear regression analysis indicated that in comparison with kitchens using natural gas, daily average PM2.5 concentrations were substantially higher in kitchens that used biomass in either a chimney stove (mean difference 611, 95% CI: 359, 863 µg/m3) or traditional three-stone stove (mean difference 389, 95% CI: 231, 548 µg/m3). Daily average concentrations of CO were significantly increased when biomass was used in a traditional stove (mean difference from natural gas 3.7, 95% CI: 0.8, 6.7 ppm), but not when it was used in a chimney stove (mean difference -0.8, 95% CI: -4.8, 3.2 ppm). Any impact of smoking by household members was smaller than that of using biomass, and not clearly discernible. In the population studied, cooking with biomass as compared with natural gas should serve as a good proxy for higher personal exposure to PM2.5.

Associations of sickness absence for pain in the low back, neck and shoulders with wider propensity to pain.

OBJECTIVES: To explore the association of sickness absence ascribed to pain at specific anatomical sites with wider propensity to musculoskeletal pain. METHODS: As part of the CUPID (Cultural and Psychosocial Influences on Disability) study, potential risk factors for sickness absence from musculoskeletal pain were determined for 11 922 participants from 45 occupational groups in 18 countries. After approximately 14 months, 9119 (78%) provided follow-up information about sickness in the past month because of musculoskeletal pain, including 8610 who were still in the same job. Associations with absence for pain at specific anatomical sites were assessed by logistic regression and summarised by ORs with 95% CIs. RESULTS: 861 participants (10%) reported absence from work because of musculoskeletal pain during the month before follow-up. After allowance for potential confounders, risk of absence ascribed entirely to low back pain (n=235) increased with the number of anatomical sites other than low back that had been reported as painful in the year before baseline (ORs 1.6 to 1.7 for ≥4 vs 0 painful sites). Similarly, associations with wider propensity to pain were observed for absence attributed entirely to pain in the neck (ORs up to 2.0) and shoulders (ORs up to 3.4). CONCLUSIONS: Sickness absence for pain at specific anatomical sites is importantly associated with wider propensity to pain, the determinants of which extend beyond established risk factors such as somatising tendency and low mood. Better understanding of why some individuals are generally more prone to musculoskeletal pain might point to useful opportunities for prevention.

Acute coronary syndrome and use of biomass fuel among women in rural Pakistan: a case-control study.

OBJECTIVES: Three billion people use biomass fuel for cooking and heating globally. We assessed the association between acute coronary syndromes (ACS) and use of biomass fuel for cooking. METHODS: We conducted a case-control study among women living in defined areas that were served by two tertiary care hospitals. A total of 364 women admitted to cardiac care units with ACS were compared with 727 controls, individually matched for age, who were inpatients at the same hospitals with a miscellany of diagnoses. Exposure to biomass fuel and other risk factors was ascertained through a questionnaire and assessed by conditional logistic regression. RESULTS: After adjustment, risk of ACS was elevated in women who had ever used biomass for cooking. In comparison with never users, the odds ratio for those who currently cooked with biomass was 4.8 (95% confidence interval 1.7, 13.8). However, among those who had ever used biomass, there was no decline in risk with time since last exposure. CONCLUSIONS: The study found increased risk of ACS from use of biomass for cooking. However, full benefits from interventions may not accrue in short term.

Is radiographic lumbar spondylolisthesis associated with occupational exposures? Findings from a nested case control study within the Wakayama spine study.

BACKGROUND: To explore the relationship between radiographic spondylolisthesis and occupational factors in a case-control study nested within the Wakayama Spine Study (WSS). METHODS: The WSS is a cross-sectional observational study amongst Japanese adults. All participants completed a lifetime occupational history and underwent X-rays of the lumbar spine (L1-S1) according to a pre-defined protocol. One trained surgeon graded the presence of a spondylolisthesis based upon ≥5% anterior or posterior slip at one or more levels. Cases, with lumbar spondylolisthesis, were compared with controls without, for their principal occupation and occupational exposures. RESULTS: In total, data were available for 722 adults (245 men and 477 women), mean age 70.1 (range 53-93) years. According to the pre-defined radiographic criteria, 117 were defined with spondylolisthesis (cases), leaving 605 controls. Cases were not significantly different from controls for age, gender, BMI, smoking or alcohol intake. However, cases were more than twice as likely to report occupational driving ≥4 h/day (OR 2.39, 95% CI 1.08-5.27) after adjustment for age, gender and BMI. Additionally, after stratification by age using 75 years as a cut-point, cases were more than 3-fold more likely to report having worked in the agricultural/ fishing industries (OR 3.47, 95% CI 1.29-9.29) among those aged < 75 years. A reduced risk of being a case was associated with climbing slopes/steps and walking. CONCLUSIONS: A history of occupational driving and working in the agricultural/fishing industry were associated with radiographic spondylolisthesis in this cross-sectional population study. This finding requires further evaluation in longitudinal studies.