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OBJECTIVE: The Scandinavian Journal of Work, Environment & Health (SJWEH) was established half a century ago. This paper provides an overview of research on musculoskeletal disorders (MSD) published over these 50 years. Three themes are described: risk assessment, interventions to prevent work-related MSD, and interventions to support work participation. Finally, implications for future research are highlighted. METHODS: A systematic literature search was performed for all papers on MSD published in SJWEH. Each paper was coded on several criteria including research topic, type of MSD, risk factor(s), and number of citations. Findings were tabulated, and discussions within the author team defined the main results and future research directions. RESULTS: The search resulted in 1056 papers, of which 474 were included. The most reported-on MSD was low-back pain (LBP, 18%) and the most reported-on work-related risk factors were physically demanding work (14%) and psychosocial factors (12%). Research has contributed to improving case definitions, refining work-related exposure criteria, and recognizing the varying importance of physical and psychosocial factors across different MSD. Research on the association between work-related risk factors and LBP continues to emerge. Effective interventions for prevention of MSD are characterised by sufficient exposure reduction, while supporting work participation requires integrating health care, with multidisciplinary actions directed at factors involving the worker, employer, and workplace. CONCLUSION: Research has provided valuable insights into risk assessment, interventions for preventing work-related MSD, and supporting work participation. Intervention studies remain warranted and new areas include adopting whole-system approaches to prevent work-related MSD and promoting the concept of musculoskeletal health.

Abstract Background With the worldwide rising obesity epidemic and the aging population, it is essential to deliver (cost-)effective care that results in enhanced societal participation among knee arthroplasty patients. The purpose of this study is to describe the development, content, and protocol of our (cost-)effectiveness study that assesses a perioperative integrated care program, including a personalized eHealth app, for knee arthroplasty patients aimed to enhance societal participation post-surgery compared to care as usual. Methods The intervention will be tested in a multicentre randomized controlled trial with eleven participating Dutch medical centers (i.e., hospitals and clinics). Working patients on the waiting-list for a total- or unicompartmental knee arthroplasty with the intention to return to work after surgery will be included. After pre-stratification on medical centre with or without eHealth as usual care, operation procedure (total- or unicompartmental knee arthroplasty) and recovery expectations regarding return to work, randomization will take place at the patient-level. A minimum of 138 patients will be included in both the intervention and control group, 276 in total. The control group will receive usual care. On top of care as usual, patients in the intervention group will receive an intervention consisting of three components: 1) a personalized eHealth intervention called ikHerstel (‘I Recover’) including an activity tracker, 2) goal setting using goal attainment scaling to improve rehabilitation and 3) a referral to a case-manager. Our main outcome is quality of life, based on patient-reported physical functioning (using PROMIS-PF). (Cost-)effectiveness will be assessed from a healthcare and societal perspective. Data collection has been started in 2020 and is expected to finish in 2024. Discussion Improving societal participation for knee arthroplasty is relevant for patients, health care providers, employers and society. This multicentre randomized controlled trial will evaluate the (cost-)effectiveness of a personalized integrated care program for knee arthroplasty patients, consisting of effective intervention components based on previous studies, compared to care as usual. Trial registration Trialsearch.who.int; reference no. NL8525, reference date version 1: 14–04-2020.

Abstract Background This study aimed to quantify the absenteeism costs of knee and hip osteoarthritis in the Netherlands for the Dutch workforce and specific groups of workers. Methods We used a longitudinal, dynamic database from a large occupational health service in which occupational physicians register information about personal information and sick leave of workers with the diagnosis of knee- and/or hip osteoarthritis. We included all employees aged 15 to 75 years performing paid work and diagnosed with knee and/or hip osteoarthritis. Costs were calculated annually and per episode for different subgroups from an employer’s perspective using the Human Capital Approach. In the Netherlands, the employer has to pay 70% of the employee's wage out of pocket for the first two years of sick leave and also for the occupational health care. In this way, employers receive information about the costs of workers on sick leave due to knee or hip osteoarthritis. This might stimulate investments in targeted prevention and work-directed care. Results For the period 2015–2017, 1399 workers fulfilled the inclusion criteria. An average sick leave episode of knee osteoarthritis had a duration of 186 calendar days and was associated with €15,550 in costs. For hip osteoarthritis these data were 159 calendar days and €12,482 in costs. These costs are particularly high among male workers and workers with a higher number of weekly working hours. The average annual costs for the Dutch workforce due to sick leave for knee and hip osteoarthritis were €26.9 million and €13.8 million, respectively. Sick leave costs decreased for hip and not for knee osteoarthritis during 2015–2017. Conclusions Annual sick leave costs due to knee and hip osteoarthritis are about €40 million for the Dutch workforce and approximately twice as high for knee compared to hip osteoarthritis. Average costs per sick leave episode are particularly high among male workers and workers with a higher number of weekly working hours.

OBJECTIVES: Emerging evidence suggests contrasting health effects for leisure-time and occupational physical activity. In this systematic review, we synthesized and described the epidemiological evidence regarding the association between occupational physical activity and cardiovascular disease (CVD) mortality. METHODS: A literature search was performed in PubMed, Embase, CINAHL, PsycINFO and Evidence-Based Medicine Reviews, from database inception to 17 April 2020. Articles were included if they described original observational prospective research, assessing the association between occupational physical activity and CVD mortality among adult workers. Reviews were included if they controlled for age and gender and at least one other relevant variable. We performed meta-analyses on the associations between occupational physical activity and CVD mortality. RESULTS: We screened 3345 unique articles, and 31 articles (from 23 studies) were described in this review. In the meta-analysis, occupational physical activity showed no significant association with overall CVD mortality for both males [hazard ratio (HR) 1.00, 95% confidence interval (CI) 0.87–1.15] and females (HR 0.95, 95% CI 0.82–1.09). Additional analysis showed that higher levels of occupational physical activity were non-significantly associated with a 15% increase in studies reporting on the outcome ischemic heart disease mortality (HR 1.15, 95% CI 0.88–1.49). CONCLUSIONS: While the beneficial association between leisure-time physical activity and CVD mortality has been widely documented, occupational physical activity was not found to have a beneficial association with CVD mortality. This observation may have implications for our appreciation of the association between physical activity and health for workers in physically demanding jobs, as occupational physical activity may not be health enhancing.

The potential of workplace health promotion Unhealthy behaviors (eg, insufficient physical activity, an unhealthy diet, high alcohol intake and smoking) and obesity are risk factors for adverse health outcomes (1, 2), productivity loss due to presenteeism or sickness absence (3–6), and early exit from paid employment (7, 8). Poor health and unhealthy behaviors are more prevalent among workers from low socioeconomic positions (1, 2, 9), as are unemployment and work disability (10, 11). With a growing challenge in our societies to work longer, reflected in the increasing statutory retirement age in many European countries, an urgent need exists to enhance workers’ health to remain in paid employment. Given the profound socioeconomic inequalities in health behaviors, health, and participation in paid employment, this is particularly pressing among workers in lower socioeconomic positions. The workplace is a promising setting for health promotion as workers spend a lot of time at work, and existing social networks for social support could be used to change behavior and enhance health. In the past decades, numerous workplace health promotion programs have been offered and evaluated regarding their (cost-)effectiveness. Workplace health promotion programs could be a way to improve workers’ health and can for example include elements of support, policies, or environmental changes to encourage healthy behavior. Traditionally, programs have focused on providing workers with advice on how to change their behavior. Such programs have been criticized because they do not take a broader perspective such as the environment (eg, workplace structures and conditions) into account (12). However, still many of these traditional programs are offered to employees and evaluated. The effects of such programs remain disappointing thus far. A recent review of reviews reported only small favorable long-term effects of workplace health promotion programs targeting physical activity and diet to reduce workers’ body weight (13). This is in line with findings from recent individual participant data meta-analyses of Dutch workplace health promotion programs that showed small and statistically non-significant decreases in unhealthy behaviors and body mass index (14, 15). In this editorial, we reflect on the body of research regarding workplace health promotion. Gaps in the literature will be described, most notably regarding (i) the need for more targeted workplace health promotion, (ii) a systems approach for workplace health promotion, and (iii) the delivery of workplace health promotion. We will conclude this editorial with future directions for workplace health promotion research. Gaps in the workplace health promotion literature Targeted workplace health promotion A recent individual participant data meta-analysis showed that the effectiveness of workplace health promotion programs differed across target populations. Those programs focusing on indicated prevention (ie, on workers who are already at risk for unhealthy behavior, obesity or other health problems) were found to be more effective than universal prevention where a program is delivered to all workers within an organization (15). This is in contrast with the Geoffrey Rose paradigm, which implies that universal prevention, aimed at reducing the risk of an entire population, would be more effective from a public health perspective than interventions only targeting high-risk groups (16). However, as unhealthy behaviors and obesity are highly prevalent in the general population, the high-risk group consists of a large share of this population. It could therefore be argued that a targeted approach for workplace health promotion would be effective from a public health perspective as well. In line with this and in an attempt to reduce socioeconomic health inequalities, effective interventions targeting workers in low socioeconomic position are needed. There are no indications that workplace health promotion programs differ in their effectiveness when delivered to different socioeconomic groups (14–16). However, a recent review on workplace health promotion showed that researchers substantially more often conduct studies on workplace health promotion among workers from higher compared to lower socioeconomic groups (17). This is striking because, as mentioned above, there is a particular need among workers in low socioeconomic groups to improve their health and reduce sickness absence and presenteeism. Researchers need to be encouraged to reach out to this group, even though it might be challenging. A systems approach to workplace health promotion As universal behavioral prevention strategies on health behaviors or weight reduction in health promotion programs show little-to-no effect (13–15), it could be questioned whether and – if so – how workplace health promotion programs are justified. As unhealthy behaviors and obesity often coincide with pressing life struggles, including relational, emotional, financial and physical problems, single component interventions are unlikely to result in substantial changes (18). This notion is underlined by study results suggesting that improvements in health and productivity among workers is unlikely solely a behavioral issue. A recent article in this journal indicated that the work itself, rather than characteristics of the worker, account for one third of socioeconomic health differences (19). These recent findings reiterate discussion papers from decades ago arguing that health behavior change can hardly be reached by only providing people information and advice on how to become healthy (20). Approaches that combine individual interventions with changes in the environment and society are the most promising strategies to improve healthy behavior and reduce obesity (21). This means that more research is needed on the interplay between ‘causes of the causes’ of unhealthy behavior by trying to understand the ‘system’ in which people live and work. Only then, the structural determinants of health behavior among workers can be addressed. These so-termed system approaches are lacking within the occupation health setting or occur with only minimal changes in the environment. The delivery of workplace health promotion The ineffectiveness of workplace health promotion programs cannot only be attributed to the target population or the content of the programs, but can also be the result of the lack of a clear implementation strategy and understanding of factors that may hinder or enable adequate uptake of workplace health promotion. In other words, what, why and how programs work in `real world` settings. Even though implementation research receives more and more attention in occupational health, it is still underrepresented in publications, including in this journal. Proper & van Oostrom (13) conclude that more research is needed on the factors that contribute to successful implementation of interventions. A systematic review showed room for improvement as initial participation levels in studies regarding workplace health promotion had a median participation level of only 33% (22). A meta-analysis indicated larger intervention effects among workers with higher program compliance (14), which emphasizes the importance of sustained participation with regard to the effectiveness. It is a particular challenge to reach workers with a lower socioeconomic position who typically work in blue-collar occupations and jobs involving difficult work circumstances such as shift work. A review on shift workers suggested that, to enhance participation, workplace health promotion programs should adopt more flexibility in the time and location of delivery of the program and time off (23). To reduce socioeconomic inequalities, in addition to delivering effective workplace health promotion programs, there is a need to gain more knowledge on implementation strategies to reach specifically workers with lower socioeconomic positions and to implement interventions in their context. Future directions of workplace health promotion research Based on the knowledge gaps mentioned above, we propose the following research agenda concerning workplace health promotion. First, address underlying determinants of unhealthy behavior in workplace health promotion programs for workers with lower socioeconomic positions. Because of the persistent socioeconomic health inequalities and the low number of scientific studies conducted among workers with a lower socioeconomic position, there is undoubtedly a need for high quality studies on targeted interventions for these workers. These interventions should use approaches that go beyond a single behavioral component, for example a systems approach that considers underlying issues that coincide among workers with a low socioeconomic position (eg, unhealthy behaviors, unfavorable working conditions, health problems, and underlying social and financial issues). Second, conduct process evaluations alongside effect evaluations to better understand how and why an intervention is (in-)effective. As aforementioned, although targeted interventions could be highly effective in the context of a research trial, it is important that they reach and retain the target group when implemented in a real-world setting. Designing the intervention and implementation strategies both deserve attention in the development phase of workplace health promotion programs to gain a better insight on what works for whom in which context and to make sure that successful workplace health promotion programs are sustainable in practice. To develop such implementation strategies, structured process evaluations to monitor the implementation alongside effect evaluations are needed (24). Although this suggestion is not new, and the number of process evaluations have increased in the past decades, publications of process evaluation still lag behind the publication of effects evaluations. A review showed that of 307 effect evaluations of workplace health promotion programs, only 27 (7.2%) published a process evaluation, which were moreover often of poor-to-average quality (25). We encourage researchers to conduct process evaluations and submit papers consisting of both a process and effect evaluation. In line with this, editors should also be more willing to publish such studies. In conclusion, workplace health promotion programs thus far show marginal gains, as the effectiveness and implementation of traditional universal preventative workplace health promotion interventions are still disappointing. A drastic turnaround in occupational health research would be needed for us to have a bright future ahead with better tailoring and delivering interventions to the needs of the target group, in particular for workers with low socioeconomic positions. References 1. Schram JL, Oude Groeniger J, Schuring M, Proper KI, van Oostrom SH, Robroek SJ, Burdorf A. Working conditions and health behavior as causes of educational inequalities in self-rated health: an inverse odds weighting approach. Scand J Work Environ Health 2021;47:127-135. https://doi.org/10.5271/sjweh.3918 2. Niedhammer I, Bourgkard E, Chau N; Lorhandicap Study Group. Occupational and behavioural factors in the explanation of social inequalities in premature and total mortality: a 12.5-year follow-up in the Lorhandicap study. Eur J Epidemiol 2011;26:1-12. https://doi.org/10.1007/s10654-010-9506-9 3. 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Available from: https://www.sjweh.fi/index.php?page=show-keyterms&key=80&start=600 [Accessed 30 Sept 2021].

Abstract Background Many cancer survivors experience physical and/or psychosocial problems affecting return to work (RTW) and work retention. Current interventions on RTW lack evidence regarding effectiveness, while interventions for work retention are missing. Partners of cancer survivors may also experience work- and health-related outcomes; yet, these consequences are not well understood. Here, the protocol of the STEPS study is described. The study aims are to: 1) evaluate the (cost-)effectiveness of a rehabilitation program for RTW and work retention in cancer survivors, and 2) assess health- and work-related outcomes among cancer survivors’ partners. Methods In a multicentre Randomized Controlled Trial (RCT), 236 working-age cancer survivors with an employment contract will be randomly allocated to a usual care group or an intervention group receiving a multidisciplinary rehabilitation program, combining occupational therapy facilitating work retention (e.g., energy management and self-efficacy training) and reintegration consultation addressing work-related issues (e.g., RTW planning and discussing workplace or task modifications with the supervisor). Alongside the RCT, a prospective cohort study will be conducted among cancer survivors’ partners (n = 267). Participants in the RCT and cohort study will be asked to complete questionnaires at baseline, and after six and 12 months, assessing work- and health-related outcomes. Generalized estimating equations will be used to assess intervention’s effectiveness, compared to usual care, regarding primary (i.e., working hours per week) and secondary outcomes. Also economic and process evaluations will be performed. For the cohort study, logistic or linear regression modelling will be applied assessing work- and health-related outcomes (primary outcome: working hours) of cancer survivors’ partners, and what factors predict these outcomes. Results The study is planned to start in September 2021; results are expected in 2023. Conclusion Compared to usual care, the STEPS intervention is hypothesized to be (cost-)effective and the intervention could be a valuable addition to standard care helping cancer survivors to sustain employment. Further, it is expected that living with a cancer survivor has a substantial impact on work and health of partners, while specific groups of partners that are at particular risk for this impact are likely to be identified. Trial registration Dutch Trial Register ( NTR;NL9094 ; 15-12-2020).

Abstract Background Although it is generally accepted that physical activity reduces the risk for chronic non-communicable disease and mortality, accumulating evidence suggests that occupational physical activity (OPA) may not confer the same health benefits as leisure time physical activity (LTPA). It is also unclear if workers in high OPA jobs benefit from LTPA the same way as those in sedentary jobs. Our objective was to determine whether LTPA and leisure time sedentary behaviour (LTSB) confer the same health effects across occupations with different levels of OPA. Methods Searches were run in Medline, Embase, PsycINFO, ProQuest Public Health and Scopus from inception to June 9, 2020. Prospective or experimental studies which examined the effects of LTPA or LTSB on all-cause and cardiovascular mortality and cardiovascular disease, musculoskeletal pain, diabetes, metabolic syndrome, arrhythmias and depression among adult workers grouped by OPA (low OPA/sitters, standers, moderate OPA/intermittent movers, high OPA/heavy labourers) were eligible. Results were synthesized using narrative syntheses and harvest plots, and certainty of evidence assessed with GRADE. Results The review includes 38 papers. Across all outcomes, except cardiovascular mortality, metabolic syndrome and atrial fibrillation, greater LTPA was consistently protective among low OPA, but conferred less protection among moderate and high OPA. For cardiovascular mortality and metabolic syndrome, higher levels of LTPA were generally associated with similar risk reductions among all OPA groups. Few studies examined effects in standers and none examined effects of LTSB across OPA groups. Conclusions Evidence suggests that LTPA is beneficial for all workers, but with larger risk reductions among those with low compared to high OPA jobs. This suggests that, in our attempts to improve the health of workers through LTPA, tailored interventions for different occupational groups may be required. More high-quality studies are needed to establish recommended levels of LTPA/LTSB for different OPA groups. Protocol registration PROSPERO # CRD42020191708 .

Background and purpose: Recommendations concerning the return to daily life activities, including work and sport, after knee arthroplasty (KA) are essential for setting realistic patient expectations. Fulfillment of these expectations contributes to more satisfaction and enhanced recovery after KA. However, scientific evidence for such recommendations is limited, and recommendations are often based only on healthcare professionals’ expert opinions. We summarized the current recommendations regarding return to daily life activities provided by Dutch hospitals and clinics to KA patients. Material and methods: Recommendations of 43 Dutch hospitals and clinics were identified, representing the advice provided to 70% of the total Dutch KA patients. Recommendations were retrieved from content from websites (n = 8), brochures (n = 40), and mobile phone applications (n = 9). Results: Recommendations for 24 daily life activities were identified. Individual hospitals and clinics provided recommendations for, on average, 9 (0–15) of these activities. Recommendations varied greatly. For example, recommendations regarding when to resume cycling after KA were provided by 36 of the 43 hospitals and clinics and varied from 3 weeks to 3 months. Interpretation: Recommendations for return to daily life activities are often missing and vary considerably between Dutch hospitals and clinics. These findings show the need for more uniformity across healthcare providers regarding recommendations for postoperative return to daily life activities.

Abstract Background This individual patient data (IPD) meta-analysis aimed to investigate socioeconomic inequalities in effectiveness on healthy behavior of, and compliance to, workplace health promotion programs. Methods Dutch (randomized) controlled trials were identified and original IPD were retrieved and harmonized. A two-stage meta-analysis was conducted where linear mixed models were performed per study (stage 1), after which individual study effects were pooled (stage 2). All models were adjusted for baseline values of the outcomes, age and gender. Intervention effects were assessed on physical activity, diet, alcohol use, and smoking. Also, we assessed whether effects differed between participants with low and high program compliance and. All analyses were stratified by socioeconomic position. Results Data from 15 studies (n = 8709) were harmonized. Except for fruit intake (beta: 0·12 [95% CI 0·08 0·15]), no effects were found on health behaviors, nor did these effects differ across socioeconomic groups. Only participants with high compliance showed significant improvements in vigorous and moderate-to-vigorous physical activity, and in more fruit and less snack intake. There were no differences in compliance across socioeconomic groups. Conclusions Workplace health promotion programs were in general not effective. Neither effectiveness nor compliance differed across socioeconomic groups (operationalized by educational level). Even though stronger effects on health behavior were found for participations with high compliance, effects remained small. The results of the current study emphasize the need for new directions in health promotion programs to improve healthy behavior among workers, in particular for those in lower socioeconomic position.

OBJECTIVES: This study aimed to determine the extent of both multimorbidity and work productivity loss among young adults with paid work and to analyze their association. METHODS: We included 604 participants from a follow-up of the Raine Study that comprised a cohort who were 22 years at the time (Gen2-22). Information on 36 health conditions, grouped into 10 condition categories, was collected through questionnaires and physical assessments (for body mass index only). Quarterly questionnaires about work productivity, including total absenteeism, sickness absenteeism, and total presenteeism, were distributed electronically over the subsequent 12 months. Descriptive statistics were used to determine the prevalence of health conditions, condition categories, multimorbidity, and work productivity. Zero-inflated negative binomial regression analyses were used to assess the association of multimorbidity with productivity loss. RESULTS: Multimorbidity prevalence was substantially higher in females (63%) compared to males (41%). Productivity loss increased as the number of condition categories increased. For example, total absenteeism was associated with an increase in the number of health condition categories in males [incidence rate ratio (IRR) 1.20, 95% confidence interval (CI) 1.05–1.36] and females (IRR 1.13, 95% CI 1.04–1.24). Similar results were found for sickness absenteeism and presenteeism. The highest burden of productivity loss was found for musculoskeletal disorders (42 444 hours/1000 workers/year), sleep problems (33 581 hours/1000 workers/year), mental and neurological conditions (15 650 hours/1000 workers/year), and ‘other’ medical conditions (22 519 hours/1000 workers/year). CONCLUSIONS: Multimorbidity appears to be highly prevalent among young adults with paid work and is strongly related to work productivity loss. Therefore, young workers should be targeted in interventions aiming to reduce multimorbidity and its impact on work productivity.

OBJECTIVE: Emerging evidence suggests that excessive sitting has negative health effects. However, this evidence largely relies on research using self-reported sitting time, which is known to be biased. To correct this bias, we aimed at developing a calibration model estimating "true" sitting from self-reported sitting. METHODS: Occupational sitting time was estimated by self-reports (the International Physical Activity Questionnaire) and objective measurements (thigh-worn accelerometer) among 99 Swedish office workers at a governmental agency, at baseline and 3 and 12 months afterwards. Following compositional data analysis procedures, both sitting estimates were transformed into isometric log-ratios (ILR). This effectively addresses that times spent in various activities are inherently dependent and can be presented as values of only 0−100%. Linear regression was used to develop a simple calibration model estimating objectively measured "true" sitting ILR (dependent variable) from self-reported sitting ILR (independent variable). Additional self-reported variables were then added to construct a full calibration model. Performance of the models was assessed by root-mean-square (RMS) differences between estimated and objectively measured values. Models developed on baseline data were validated using the follow-up datasets. RESULTS: Uncalibrated self-reported sitting ILR showed an RMS error of 0.767. Simple and full calibration models (incorporating body mass index, office type, and gender) reduced this error to 0.422 (55%) and 0.398 (52%), respectively. In the validations, model performance decreased to 57%/62% (simple models) and 57%/62% (full models) for the two follow-up data sets, respectively. CONCLUSIONS: Calibration adjusting for errors in self-reported sitting led to substantially more correct estimates of "true" sitting than uncalibrated self-reports. Validation indicated that model performance would change somewhat in new datasets and that full models perform no better than simple models, but calibration remained effective.

OBJECTIVES: Evidence on the effect of smoking on sickness absence could guide workplace smoking cessation interventions and encourage employers to promote smoking cessation among their employees. This systematic review and meta-analysis aimed to summarize evidence on the association between smoking and sickness absence and determine whether there are differences in this association for study design, methodology, and sample characteristics. METHODS: We searched for studies that reported on smoking status and sickness absence, used empirical data, were published in a peer-reviewed journal in the last 25 years, and written in English. We conducted pooled analyses in which uni- and multivariate generalized linear regression models were applied. RESULTS: After screening 2551 unique records, 46 articles from 43 studies were included, of which 33 studies (with 1 240 723 participants) could be included in the pooled analyses. Smoking was associated with an 31% increase in risk of sickness absence compared to non-smoking (95% confidence interval (CI) 1.24–39). We did not find statistically significant different effect sizes for study location, gender, age, occupational class, study design, assessment of sickness absence, short- versus long-term sickness absence, and adjustment for relevant confounders. Furthermore, smoking was associated with 2.89 more sickness absence days per year compared to non-smoking (95% CI 2.08–3.70). CONCLUSIONS: We found robust evidence showing that smoking increases both the risk and number of sickness absence days in working populations, regardless of study location, gender, age, and occupational class. Encouraging smoking cessation at the workplace could therefore be beneficial for employers and employees.

Abstract Background Previous research has shown contrasting effects on hypertension for occupational and leisure-time physical behaviors—physical activity and sedentary behavior and time in bed. However, (a) none of these studies have addressed the compositional property of the physical behaviors and (b) most knowledge on the association between domain-specific physical behaviors and hypertension relies upon self-reported physical behaviors information primarily on white-collar worker study samples. We aimed to be the first to disentangle the relationship between technically measured 24-h time-use behaviors in work and leisure domains and blood pressure among blue-collar workers using a compositional data analysis approach. Methods Workers (n = 669) wore accelerometers to measure daily minutes of work and leisure sedentary time, light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA), and time in bed which were isometrically log-transformed. Cross-sectional linear association between time-use composition and systolic (SBP) and diastolic (DBP) blood pressure were determined using compositional isotemporal substitutions models. Results The time-use composition at the work and leisure domains was significantly associated with SBP (F = 4.98, p

Abstract Background The use of mobile touch screen devices, e.g. smartphones and tablet computers, has become increasingly prevalent among adolescents. However, little is known about how adolescents use these devices and potential influences on their use. Hence, this qualitative study explored adolescents’ perceptions on their patterns of use and factors influencing use, and perceptions and concerns from parents. Methods Semi-structured interviews were conducted with adolescents (n = 36; 11 to 18 years) and their parents/caregivers (n = 28) in Singapore recruited to represent males and females across a range of ages from different socioeconomic groups. Prompts covered weekday and weekend use patterns, types of activities, perspectives on amount of use, parental control measures and concerns. Interviews were recorded and transcribed. Transcripts were coded and thematic analysis was carried out. Results Smartphone was the most common mobile device owned and used by many of the adolescents, while only some used a tablet. Many adolescents and their parents felt that adolescents’ MTSD use was high, frequent and ubiquitous, with frequent checking of device and multitasking during use. Reported influences of use included functional, personal and external influences. Some of the influences were irresistibility of mobile devices, lack of self-control, entertainment or relaxation value, and high use by peers, family and for schoolwork that contributed to high use, or school/parental control measures and lack of internet availability that limited use. Most adolescents were generally unconcerned about their use and perceived their usage as appropriate, while most parents expressed several concerns about their adolescents’ use and perceived their usage as excessive. Conclusions This study has provided rich insights into the patterns and influences of contemporary mobile device use by adolescents. Mobile device use has become an integral part of adolescents’ daily routines, and was affected by several functional, personal and external influences which either facilitated or limited their use. There also seemed to be a strong inclination for adolescents to frequently check and use their mobile devices. There is an urgent need to understand the implications of these common adolescent behaviours to inform advice for wise mobile device use by adolescents.

Summary: Background: Studies suggest that high occupational physical activity increases mortality risk. However, it is unclear whether this association is causal or can be explained by a complex network of socioeconomic and behavioural factors. We aimed to examine the association between occupational physical activity and longevity, taking a complex network of confounding variables into account. Methods: In this prospective cohort study, we linked data from Norwegian population-based health examination surveys, covering all parts of Norway with data from the National Population and Housing Censuses and the Norwegian Cause of Death Registry. 437 378 participants (aged 18–65 years; 48·7% men) self-reported occupational physical activity (mutually exclusive groups: sedentary, walking, walking and lifting, and heavy labour) and were followed up from study entry (between February, 1974, and November, 2002) to death or end of follow-up on Dec 31, 2018, whichever came first. We estimated differences in survival time (death from all causes, cardiovascular disease, and cancer) between occupational physical activity categories using flexible parametric survival models adjusted for confounding factors. Findings: During a median of 28 years (IQR 25–31) from study entry to the end of follow-up, 74 203 (17·0%) of the participants died (all-cause mortality), of which 20 111 (27·1%) of the deaths were due to cardiovascular disease and 29 886 (40·3%) were due to cancer. Crude modelling indicated shorter mean survival times among men in physically active occupations than in those with sedentary occupations. However, this finding was reversed following adjustment for confounding factors (birth cohort, education, income, ethnicity, prevalent cardiovascular disease, smoking, leisure-time physical activity, body-mass index), with estimates suggesting that men in occupations characterised by walking, walking and lifting, and heavy labour had life expectancies equivalent to 0·4 (95% CI −0·1 to 1·0), 0·8 (0·3 to 1·3), and 1·7 (1·2 to 2·3) years longer, respectively, than men in the sedentary referent category. Results for mortality from cardiovascular disease and cancer showed a similar pattern. No clear differences in survival times were observed between occupational physical activity groups in women. Interpretation: Our results suggest that moderate to high occupational physical activity contributes to longevity in men. However, occupational physical activity does not seem to affect longevity in women. These results might inform future physical activity guidelines for public health. Funding: The Norwegian Research Council (grant number 249932/F20).

The aim of the current study was to evaluate whether workplace health promotion programs improve self-perceived health of employees with a low socioeconomic position (SEP), and whether differential effects exist between individuals with a low SEP for gender, marital status or age. Individual participant data from six Dutch intervention studies aiming at promoting healthy behavior and preventing obesity in the work setting, with a total of 1906 participants, were used. The overall intervention effect and interaction effects for gender, marital status and age were evaluated using two-stage meta-analyses with linear mixed regression models. In the first stage effect sizes of each study were estimated, which were pooled in the second stage. Compared to control conditions, workplace health promotion programs did not show an overall improvement in self-perceived health of employees with a low SEP (β0.03 (95%CI: −0.03 to 0.09)). Effects did not differ across gender, marital status and age. Future research could be focused on the determinants of self-perceived health next to health behavior to improve the health of employees with a low SEP.

Objectives Orthopaedic surgery is primarily aimed at improving function and pain reduction. Additional integrated care may enhance patient’s participation in sports and work, possibly improving performance of physical activities and quality of life (QoL). We aimed to assess the effectiveness of integrated care among orthopaedic surgery patients.Design Systematic review with meta-analysis.Data source Medline, EMBASE and CINAHL (until 17 June 2019).Eligibility for selecting studies We searched for controlled studies on integrated care interventions consisting of active referral to case managers, rehabilitation with participation-based goals and/or e/mHealth, with outcomes of sports and work participation, performance of physical activities and/or QoL. Outcomes were normalised to 0–100 scales and statistically pooled.Results Seventeen articles (n=2494) of moderate quality were included reporting on patients receiving back, upper limb, knee or hip surgery. Only one study reported on return to sports and found no significant benefit. For return to work, one study did (90% vs 82%) and one did not (relative risk=1.18 (0.80 to 1.70)) observe significant benefits. Integrated care showed small effects for improving performance of physical activities (2.69 (–0.20 to 5.58); eight studies, n=1267) and QoL (2.62 (1.16 to 5.05); nine studies, n=1158) compared with usual care.Summary/Conclusion We found insufficient and inconsistent evidence for the effectiveness of integrated care for orthopaedic surgery patients regarding sport and work participation. Small effects were found for performance of physical activities and QoL. High quality research on integrated care focusing on sports and work participation is needed before integrated care can be implemented for orthopaedic surgery patients.

OBJECTIVES: Spinal (ie, back and neck) pain often develops as early as during adolescence and can set a trajectory for later life. However, whether early-life spinal-pain-related behavioral responses of missing school/work are predictive of future work absenteeism is yet unknown. We assessed the association of adolescent spinal-pain-related work or school absenteeism with early adulthood work absenteeism in a prospective population-based cohort. METHODS: Six year follow-up data from the Western Australian Pregnancy Cohort (Raine) study were used (N=476; with a 54% response rate). At age 17, participants reported spinal pain (using the Nordic questionnaire) and adolescent spinal-pain-related work/school absenteeism (with a single item question). Annual total and health-related work absenteeism was assessed with the Health and Work Performance questionnaire distributed in four quarterly text messages during the 23rd year of age. We modelled the association of adolescent spinal-pain-related absenteeism with work absenteeism during early adulthood, using negative binomial regression adjusting for sex, occupation and comorbidities. RESULTS: Participants with adolescent low-back or neck pain with work/school absenteeism reported higher total work absenteeism in early adulthood [148.7, standard deviation (SD) 243.4 hours/year], than those without pain [43.7 (SD 95.2) hours/year); incidence rate ratio 3.4 (95% CI 1.2–9.2)]. Comparable findings were found when considering low-back and neck separately, and when considering health-related absenteeism. CONCLUSIONS: We found a more than three-fold higher risk of work absenteeism in early adulthood among those with adolescent spinal-pain-related absenteeism, compared to those without. These findings suggest that, to keep a sustainable workforce, pain prevention and management should focus on pain-related behaviors as early as in adolescence.

OBJECTIVES: Work-related musculoskeletal disorders (MSD) are highly prevalent and put a large burden on (working) society. Primary prevention of work-related MSD focuses often on physical risk factors (such as manual lifting and awkward postures) but has not been too successful in reducing the MSD burden. This may partly be caused by insufficient knowledge of etiological mechanisms and/or a lack of adequately feasible interventions (theory failure and program failure, respectively), possibly due to limited integration of research disciplines. A research framework could link research disciplines thereby strengthening the development and implementation of preventive interventions. Our objective was to define and describe such a framework for multi-disciplinary research on work-related MSD prevention. METHODS: We described a framework for MSD prevention research, partly based on frameworks from other research fields (ie, sports injury prevention and public health). RESULTS: The framework is composed of a repeated sequence of six steps comprising the assessment of (i) incidence and severity of MSD, (ii) risk factors for MSD, and (iii) underlying mechanisms; and the (iv) development, (v) evaluation, and (vi) implementation of preventive intervention(s). CONCLUSIONS: In the present framework for optimal work-related MSD prevention, research disciplines are linked. This framework can thereby help to improve theories and strengthen the development and implementation of prevention strategies for work-related MSD.

In their recent letter to the Editor of the Scandinavian Journal of Work, Environment & Health, Winkel & Westgaard reflected on our earlier paper (2), where we described a research framework for the development and implementation of interventions preventing work-related musculoskeletal disorders (MSD). Winkel & Westgaard argue that interventions described in our paper, such as manual handling advise, ergonomic workplace design, or job rotation, “… are unlikely to have much impact” since rationalization of production systems has a larger potential in the causal pathway to health effects. Furthermore, they stress that ergonomic interventions realized as spin-off from the ‘all-embracing process’ of rationalization of production systems should be evaluated by using either observational or quasi-experimental research designs rather than randomized controlled trials (RCT). We agree with Winkel & Westgaard that effects of system changes induced by company management generally go beyond those from standalone ergonomic adjustments in the workplace and that implementation of interventions largely occurs at company level. We disagree, however, that our research framework would not be suitable for the continuous process of rationalization resulting in ever-changing work environments, with a substantial part of these changes being the introduction of ergonomic interventions. When appraising the effects of such ergonomic spin-offs obtained from changes in the production system, a decent scientific funding of the underlying working mechanisms of the intervention (as described in steps 2–3 of our framework) remains imperative. In their conceptualization of the relation between rationalization at societal level and (musculoskeletal) health effects at individual worker level, Westgaard & Winkel themselves (3) illustrate that the rationalization process at the end of the causal pathway results in changes in exposure to occupational physical and psychosocial risk factors that eventually affect MSD. Moreover, we also agree that policy measures and interventions at the level of companies or populations may need to be evaluated in ways other than an RCT. In fact, the latter was discussed in the Scandinavian Journal of Work, Environment & Health (4), where we have listed several alternative observational research designs that may be suitable to evaluate various workplace interventions, such as interrupted time series, regression discontinuity, or multiple baseline design. Laestadius and colleagues (5) have published an illustrative example of a quasi-experimental research design in the context of MSD prevention. This study evaluated the move of approximately 1500 International Monetary Fund employees to a new office with an improved ergonomics design. In the study, workers who changed offices − which might be called rationalization − were compared to a similar group of World Bank workers that did not move. The study showed a reduction in awkward working postures as well as musculoskeletal pain and eye strain as a result of the change in workplace and individual workstation assessment. We believe that our model is well applicable to a broad range of interventions, such as the one mentioned in this example, as well as adequate methods evaluating the effectiveness of these interventions. In our framework, step 4 (development of intervention(s)), step 5 (evaluation of intervention(s)) and step 6 (implementation of effective intervention(s)) are suitable to do so and certainly not limited to traditional ergonomic interventions and/or evaluations using RCT only. Despite this, we do believe that, in case an intervention cannot be tested by performing an RCT, we should not neglect the scientific quality limitations of the alternative research designs used. Or as phrased eloquently by Kristensen (6): “There may be many good reasons for not performing a randomized controlled trial in an occupational setting. But there are no good reasons for ignoring the problems created by not applying such a design.” As a minimum requirement, we believe that evaluation studies should be longitudinal and should enable the comparison of participants receiving the intervention to an appropriate reference group not receiving the intervention. In conclusion, we thank Winkel & Westgaard for their suggestion that a production system’s approach, which goes beyond standalone adjustments in the workplace introduced by researchers or ergonomists, can be used to prevent work-related MSD and that we may need alternative research designs to evaluate this approach. We agree with these statements. However, we argue that a further development of our research framework, also accommodating interventions introduced by management and other stakeholders in real working life, is unnecessary as our framework already accommodates for this process. Therefore, we invite researchers and ergonomists to fully benefit from the input of corporate stakeholders who aim at organizational sustainability when designing interventions. Researchers should use alternative designs when testing the effectiveness of such interventions if an RCT is not possible and should also prioritize supporting relevant stakeholders in the implementation of effective interventions for the prevention of work-related MSD. 1. Winkel J, Westgaard RH. Development and implementation of interventions managing work-related musculoskeletal disorders: Inadequacy of prevalent research framework and future opportunities. Scand J Work Environ Health 2019;45(3):316-317. https://doi.org/10.5271/sjweh.3815. 2. van der Beek AJ, Dennerlein JT, Huysmans MA, Mathiassen SE, Burdorf A, van Mechelen W, et al. A research framework for the development and implementation of interventions preventing work-related musculoskeletal disorders. Scand J Work Environ Health 2017 Nov 1;43(6):526–39. https://doi.org/10.5271/sjweh.3671. 3. Westgaard RH, Winkel J. Occupational musculoskeletal and mental health: significance of rationalization and opportunities to create sustainable production systems - A systematic review. Appl Ergon 2011 Jan;42(2):261–96. https://doi.org/10.1016/j.apergo.2010.07.002. 4. Schelvis RM, Oude Hengel KM, Burdorf A, Blatter BM, Strijk JE, van der Beek AJ. Evaluation of occupational health interventions using a randomized controlled trial: challenges and alternative research designs. Scand J Work Environ Health 2015 Sep;41(5):491–503. https://doi.org/10.5271/sjweh.3505. 5. Laestadius JG, Ye J, Cai X, Ross S, Dimberg L, Klekner M. The proactive approach--is it worthwhile? A prospective controlled ergonomic intervention study in office workers. J Occup Environ Med 2009 Oct;51(10):1116–24. https://doi.org/10.1097/JOM.0b013e3181bae19d. 6. Kristensen TS. Intervention studies in occupational epidemiology. Occup Environ Med 2005 Mar;62(3):205–10. https://doi.org/10.1136/oem.2004.016097.

OBJECTIVES: Physical exposures (eg, lifting or bending) are believed to be risk factors for low-back pain (LBP), but the literature is inconsistent. Exposure and LBP prevalence differ considerably between occupations, and exposure–outcome associations could be severely modified by the presence of particular occupational groups. We aimed to investigate the influence of such outlying groups on the properties of associations between exposure and LBP. METHODS: Lifting and trunk flexion were observed for 371 of 1131 workers within 19 groups. LBP was obtained from all workers during three follow-up years. Both exposure variables were associated with LBP (P

The use of mobile touch screen devices (MTSDs) has increased rapidly over the last decade, and there are concerns that their use may have negative musculoskeletal consequences; yet evidence on the association of MTSD use with musculoskeletal symptoms and exposures is currently dispersed. The aim of this study was to systematically review available literature on musculoskeletal symptoms and exposures associated with MTSD use. The synthesised information may facilitate wise use of MTSDs and may identify areas in need of further research.EMBASE, Medline, Scopus, PsycINFO and Proquest electronic databases were searched for articles published up to June 2016, using keywords describing MTSD, musculoskeletal symptoms (e.g. pain, discomfort) and musculoskeletal exposures (e.g. posture, muscle activity). Two reviewers independently screened the articles, extracted relevant data and assessed methodological quality of included studies. Due to heterogeneity in the studies, a meta-analysis was not possible and a structured narrative synthesis of the findings was undertaken.A total of 9,908 articles were screened for eligibility with 45 articles finally included for review. Included articles were of cross-sectional, case-control or experimental laboratory study designs. No longitudinal studies were identified. Findings were presented and discussed in terms of the amount, features, tasks and positions of MTSD use and its association with musculoskeletal symptoms and musculoskeletal exposures.There is limited evidence that MTSD use, and various aspects of its use (i.e. amount of usage, features, tasks and positions) are associated with musculoskeletal symptoms and exposures. This is due to mainly low quality experimental and case-control laboratory studies, with few cross-sectional and no longitudinal studies. Further research is warranted in order to develop guidelines for wise use of MTSDs.