The effect of Worklessness on Health and Wellbeing Professor Ewan B Macdonald OBE - Healthy Working Lives Group University of Glasgow - wwdpi

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The effect of Worklessness on Health and Wellbeing Professor Ewan B Macdonald OBE - Healthy Working Lives Group University of Glasgow - wwdpi
The effect of Worklessness on
     Health and Wellbeing

Professor Ewan B Macdonald OBE
    Healthy Working Lives Group
       University of Glasgow
The effect of Worklessness on Health and Wellbeing Professor Ewan B Macdonald OBE - Healthy Working Lives Group University of Glasgow - wwdpi
What is Work?

Oxford English dictionary – “Purposeful Activity”

•   Paid employment
•   Self Employment
•   Voluntary work
•   Carer
•   Homemaker
•   Child rearing
•   Full time/ part-time
•   Community activities, clubs, church
•   Etc

ALL OF THESE ARE BENEFICIAL TO SOCIETY AND THE INDIVIDUAL
PROVIDED THEY HAVE ENOUGH MONEY
The effect of Worklessness on Health and Wellbeing Professor Ewan B Macdonald OBE - Healthy Working Lives Group University of Glasgow - wwdpi
Definition of
                                          “Worklessness”
               ‘Worklessness’ is a fairly new term.
         Is it just a different word for unemployment?

    …….worklessness is not the same as unemployment
              -several different definitions.

        “Worklessness” includes people who are
 unemployed and people who are economically inactive:
people who are sick or disabled, students, people looking
    after the family and home, and retired people…...

Worklessness: not engaged in any form of work, which includes
 but is broader than economic inactivity and unemployment.
The effect of Worklessness on Health and Wellbeing Professor Ewan B Macdonald OBE - Healthy Working Lives Group University of Glasgow - wwdpi
What is Health?

• WHO Definition – “a complete state of physical, mental
  and social wellbeing and not merely the absence of
  disease and infirmity”
• Newer definitions - Healthy Working Lives - “being able
  to do as much as possible for as long as possible in your
  working and non working lives” (HWL, Macdonald 2004)
• Health is about level of functioning, functional capacity
  or capability
The effect of Worklessness on Health and Wellbeing Professor Ewan B Macdonald OBE - Healthy Working Lives Group University of Glasgow - wwdpi
Long Term Health
                                               conditions
Examples of long term health conditions
• Congenital
• Chronic inflammatory joint disease e.g. Rheumatoid arthritis
• Other musculoskeletal conditions e.g. back pain
• Respiratory problems e.g. COPD
• Cardiac disease
• Hypertension
• Stroke
• Cancer
• Diabetes
• Obesity
The effect of Worklessness on Health and Wellbeing Professor Ewan B Macdonald OBE - Healthy Working Lives Group University of Glasgow - wwdpi
Rate of IB receipt by
                                                                         MSP constituency 2008

                                                     Rate of IB receipt 2008
                                                              3.5% - 6.7%
                                                              6.8% - 8.6%
                                                              8.7% - 9.9%
                                                              10% - 14.7%
                                                              14.8% - 20.0%
 .

Scottish Observatory for Work and Health, University of Glasgow (Data source: DWP)
The effect of Worklessness on Health and Wellbeing Professor Ewan B Macdonald OBE - Healthy Working Lives Group University of Glasgow - wwdpi
ESA and Incapacity Benefit
The effect of Worklessness on Health and Wellbeing Professor Ewan B Macdonald OBE - Healthy Working Lives Group University of Glasgow - wwdpi
What do we know about
                                                                        being out of work?

Unemployment is bad for you:
 • Loss of Income¹
 • Destructive on self-respect¹
 • Risks of ill-health²
 • The “psychosocial scar” persists³
 • Trans-generational effects

 1. Winkelmann and Winkelmann 1996; 2. Clark, Georgellis, Samfey 2001;
 3. Clark and Oswald 1996; 4. Aylward 2006
The effect of Worklessness on Health and Wellbeing Professor Ewan B Macdonald OBE - Healthy Working Lives Group University of Glasgow - wwdpi
The new Paradigm
                          Work is good for you

 “Overall the beneficial effects of work outweigh the risks
 of work, and are greater than the harmful effects of long-
term unemployment or prolonged sickness absence. Work
       is generally good for health and well-being”

Waddell and Burton 2006
The effect of Worklessness on Health and Wellbeing Professor Ewan B Macdonald OBE - Healthy Working Lives Group University of Glasgow - wwdpi
Self-Reported health from
                                                               the British Household Panel
                                                                                    Survey
             Self-Reported Health by Economic Group in Scotland
.8
.6
.4
.2
 0

               Employed                        Workless                Incapacity Benefit
                               Excellent/Good                     Less than Good
     Scottish Observatory for Work and Health, University of Glasgow
     (Data Source: BHPS)
Proportion of deviation from
perfect health by social class
Changing Scotland: Estimated & Projected Age Structure
1901 – 2031 (GROS)
                             Scotland 1911                                                           Scotland 1951
      80 - 84                                                                 80 - 84
                  MALES                           FEMALES                                 MALES                            FEMALES
      70 - 74                                                                 70 - 74

      60 - 64                                                                 60 - 64

      50 - 54                                                                 50 - 54

                                                                        Age
Age

      40 - 44                                                                 40 - 44

      30 - 34                                                                 30 - 34

      20 - 24                                                                 20 - 24

      10 - 14                                                                 10 - 14

        0-4                                                                     0-4

          -300,000 -200,000 -100,000    0     100,000 200,000 300,000             -300,000 -200,000 -100,000    0     100,000 200,000 300,000
                                    Population                                                              Population

                             Scotland 2001                                                          Scotland 2031
      80 - 84     MALES                            FEMALES                    80 - 84                                      FEMALES
                                                                                         MALES
      70 - 74                                                                 70 - 74

      60 - 64                                                                 60 - 64

      50 - 54                                                                 50 - 54
Age

                                                                        Age

      40 - 44                                                                 40 - 44

      30 - 34                                                                 30 - 34

      20 - 24                                                                 20 - 24

      10 - 14                                                                 10 - 14

        0-4                                                                     0-4

          -300,000 -200,000 -100,000    0     100,000 200,000 300,000             -300,000 -200,000 -100,000    0     100,000 200,000 300,000
                                    Population                                                              Population
Prevalence of
chronic disease
ILO Projection for Workers Over 55

      Europe                                 32

North America                            30

                                                       %
         Asia                      21

Latin America       7

                0       10    20        30        40
Source: United Nations, Department of Economic and Social Affairs, Population Division
Over 60’s

• In 1999, 593 million persons were aged 60 or over

• In 2009, 737 million persons

• The UN Population Division - 2 billion in 2050

• Today - 1 :9 is 60 or over.

• 2050 - 1:5

     Source: United Nations, Department of Economic and Social Affairs, Population Division
Over 50’s

• In the UK by 2020 – 47% of the population will be over 50
  years of age.
• They will 32% of the available workforce
Work, Health & Society

    Society needs the maximum number of
   productive years from as many people as
                   possible.

   Childhood     Working life       Retirement

The future population will be composed of longer
 survivors, many with several long-term health
                   conditions.
Labour force
participation
Is work good for
                              your health & well-being?

•   Work meets important psychosocial needs in societies
    where employment is the norm;
•   Work is central to individual identity, social roles and
    social status;
•   Employment and socio-economic status are the main
    drivers of social gradients in physical and mental health
    and mortality;
•   Various physical and psychosocial
    aspects of work can also be hazards
    and pose a risk to health.
Unemployment

•   Conversely, there is a strong association between
    worklessness and poor health.
•   Possibly due to a health selection effect, but also
    possibly a large extent cause and effect.
•   There is strong evidence that unemployment is
    generally harmful to health, including:
     - higher mortality;
     - poorer general health, long-standing illness, limiting
       longstanding illness;
     - poorer mental health, psychological distress, minor
       psychological/psychiatric morbidity;
     - higher medical consultation, medication consumption
       and hospital admission rates.
Re-employment

•   There is strong evidence that re-
    employment leads to improved
    self-esteem, improved general
    and mental health, and
    reduced psychological distress
    and minor psychiatric
    morbidity.
•   The magnitude of this
    improvement is more or less
    comparable to the adverse
    effects of job loss.
Do labour market status
                                          transitions predict changes
                                         in psychological well-being?

British Household Panel
Survey 1991-2007
• Positive effect of moving into
  work not as large as the
  negative effect of job loss.

Flint et Al Soc J Epid Com Health 2013
Employment Status,
                                         employment conditions
                                              & limiting illness:
 Prospective evidence from the
 British Household Panel Survey 1991-2001

• Secure employment in favourable
  working conditions greatly reduces
  the risk of healthy people
  developing limiting illness.
• Secure employment increases
  the likelihood of recovery.

Flint et Al Soc J Epid Com Health 2013
Health effects
                                         of employment

A systematic review of prospective studies

• 33 Prospective studies
• 23 High Quality
• Strong evidence for
  protective effect of
  employment on
  depression and
  general mental health

Flint et Al Soc J Epid Com Health 2013
Unemployment
                                      and ill health

A connection through inflammation
• Increased inflammatory
  markers more common
  among the unemployed than
  employed

• Five fold greater odds for
  having an elevated
  inflammatory status

Hintikka – BMC Public Health 2009
Long term unemployment
                                         - short telomeres

• Northern Finland Birth
  cohort – 5620 men and
  women
• Men: unemployment > 500
  days associated with
  having shorter leukocyte
  telomere length (LTL)
• OR 2.61 (95% C1 1.16 -
  5.85)
• No effect on women

Alla-Mursula - PLOS ONE 8 (11)
Impact on Health of
                                                 Re-employment in
                                        disability benefit recipients

• Compared to those who
  remained on Benefits
• SF12 Mental Health
  improvement 5.94 (CI
  3.53-8.36)
• Physical Health
  improvement 2.83 (CI
  0.85-4.81u

Curnock et Al Soc sc and Med 162 (2016) 1-10
Work for Sick and
                                             Disabled People

Broad consensus across multiple
disciplines, e.g. disability groups,
employers, unions, insurers and all
political parties, based on extensive
clinical experience and on principles of
fairness and social justice. When their
health condition permits, sick and
disabled people (particularly those with
‘common health problems’) should be
encouraged and supported to remain in
or to (re)-enter work as soon as possible
Work for Sick and
                                       Disabled People

because it:
• is therapeutic;
• helps to promote recovery and rehabilitation;
• leads to better health outcomes;
• minimises the harmful physical, mental and social effects
   of long-term sickness absence;
• reduces the risk of long-term incapacity;
• promotes full participation in society, independence and
   human rights;
• reduces poverty;
• improves quality of life and well-being.
Work is generally
                                         good for you

• Strong evidence base showing work is generally good
  for physical and mental health and well-being.
• Worklessness is associated with poorer physical and
  mental health and well-being.
• Work can be therapeutic and can reverse the adverse
  health effects of unemployment.
• That is true for healthy people of working age, for
  many disabled people, for most people with common
  health problems and for social security beneficiaries.
Work is generally
                                          good for you

BUT….
• account must be taken of the nature and quality of
  work and its social context;
• jobs should be safe and accommodating.
• Overall, the beneficial effects of work outweigh the
  risks of work, and are greater than the harmful effects
  of long-term unemployment or prolonged sickness
  absence.
• Work is generally good for health and well-being
Jimmy
                            aged 45

•   Contractor
•   Minimal Health & Safety
•   No eye protection/ear muffs
•   Early noise induced hearing loss
•   Vibration white finger
•   Several Eye injuries in past
Jimmy
                               aged 45

• Irritant dermatitis
• Back injury in past
• Osteoarthritis of spine, shoulders,
  elbows and knees
• 6 visits to accident and emergency
• One hand fracture
• Getting a bit past it
Jimmy

• Old housing                  • Left school with no
                                 qualifications
• Poor diet, not much fruit,
  veg or fish                  • Jobs on building sites
• 4 pints of beer a night      • Frequently does overtime
  (occasional drink at         • Sometimes in informal
  lunchtime)                     economy
• 20 Cigarettes a day          • Few of his employers have
                                 occupational Health &
• No leisure exercise            Safety resource
Jimmy

•   Separated lives with partner and two stepchildren
•   Two children by ex wife
•   Financial problems
•   Child care issues
•   Has been on courses to use power tools
•   No other education
•   Reads paper occasionally
•   Has home computer - on internet
Jimmy

• He has an accident - pipe rolled on leg fracture of right tibia
  and fibula
• Taken to hospital –transferred to orthopaedics – surgery,
  plated, discharged on crutches after two days (superb
  treatment)
• No record of job in the hospital notes
• No physiotherapy
• Attends GP
  given certificate (“Fit Note”)
• No guidance about rehabilitation
Jimmy

• Rests at home, watches TV (gets depressed)
• Progresses to walking with a stick
• Wasting of quadriceps (50%) and reduction in
  power both legs, pain at fracture site
• After 2 months GP organises physio - once
  per week for six weeks
• Pain and weakness still a problem,
  GP says job will be too much for him
• Follow up hospital appointment- no
  discussion about work
If we treated our professional footballers and
athletes the same way we treat our workers…

   there would be no sport any weekend
How does the system fail Jimmy?
Problems for Jimmy

•   Lack of rehabilitation
•   Lack of systematic health promotion
•   Employer has no occupational Health & Safety advice
•   No system to advise about planned career change and life
    long learning
•   Employee/medical staff do not know how to get vocational
    advice
•   Employee care and development is not holistic
•   Employer not participating fully in process of return to work
•   Culture of tolerance of absence
•   All leading to long term incapacity
Jimmy - Options

Friendly with the
 boss- given job
driving the dump    Sacked – goes on to
      truck           benefits after 6
                         months
Working for a Healthier
                                    Tomorrow: Conclusions
• Annual economic costs of sickness-absence and
  worklessness associated with ill-health are over
  £100bn, greater than the current NHS budget, an
  unsustainable burden in a competitive global
  economy.
• Left unchecked this will diminish quality of life in
  Britain, undermine efforts to reach full
  employment, and deny business the talent and
  contributions of a potential workforce.
• It will condemn workless families to a cycle of
  poverty and dependency that will widen
  inequalities, perpetuate social injustice in our
  most deprived communities, and obstruct efforts
  to eradicate child poverty.
                                                         Black Review, 2008
Factors that Influence
        Work Participation

      Disease

External    Personal
Reason on IB

           Total IB/SDA claimants by main disabling condition (expressed as % of total claimants) in
                                                Glasgow City

    60.0

    50.0

    40.0
%

    30.0

    20.0

    10.0

     0.0
             Mental &       Diseases of the    Diseases of the      Diseases of the    Injury, Poisoning   Other
            Behavioural     Nervous System      Circulatory or      Musculoskeletal    and certain other
             Disorders                        Respiratory System      System and       consequences of
                                                                   Connective Tissue    external causes

                                                 Main disabling condition

                                              June 99 - August 99     Dec 05 - Feb 06
Age standardised mortality
        (Men) per 100,000
Relationship between
mortality (age/sex
standardised rates per
100,000 population
and deprivation (as
measured by the Scottish
Index of Multiple
Deprivation-SIMD)
)
So…what were the consequences of Jimmy’s
     “expert” Medical treatment?
Worklessness is the single most important cause
of health inequality, social exclusion, deprivation,
                  and mortality
Impact on the next
                                                generation
                                Working for a healthier tomorrow, 2008
There is evidence that :
• Families with no-one working are more likely to suffer persistent
  low income and poverty
• Lower parental income correlates with
  poor health in children
• Child deaths from injury correlate with
  low employment status and worklessness
• Behavioural and conduct disorders
  are more likely where no parent is working
• Children of workless households are
  more likely to experience worklessness
  themselves when adult.
Long-term worklessness
                  ……is one of the greatest known risks to public health

• Health Risk = smoking 10 packs of cigarettes per day (Ross
  1995)
• Suicide in young men > 6 months out of work is increased
  40 x (Wessely, 2004)
• Suicide rate in general increased 6x in longer-term
  worklessness (Bartley et al, 2005)
• Health risk and life expectancy greater than many “killer
  diseases” (Waddell & Aylward, 2005)
• Greater risk than most dangerous jobs
  (construction/Fishing)
The Process of
                                      becoming Workless
•  Failure of the Education and Skill development sector
•  Lifestyle factors not addressed systematically
•  Lack of Occupational Health & Safety
•  NHS doesn’t bother about return to work
  - GP:“its not my job to get people back to work”
  - Surgeon: “we are far too busy to take that on as well”
• The NHS does not have maximisation of functional capacity as
   a treatment outcome measure
Biopsychosocial Model

Biopsychosocial model recognises
that biological, psychological and
social factors all affect human
response to disease or illness.

Indeed, health is best understood
in terms of a combination of
biological, psychological, and
social factors rather than purely
in biological terms (Engel 1977)
Ageing is a process

  An “accumulation of deficits taking place in different individuals
           in different ways, with a variety of rates for
                     different organ systems”
• Ageing is not solely a passive
  degenerative process.
• Actively regulated by genetic pathways.
• Understanding the molecular basis of
  ageing is a necessary step for
  therapeutic manipulation of these
  pathways to combat age-related
  disorders such as cancer and CKD.
• Essential for good health in old age
Complex variations in health and functional status are not
fully understood, highlighting the need for translational age-
related research
With respect to ageing and health:
How are different organ systems interlinked?
How does this relate to the whole organism?
How do these play out through the life course?
How are these influenced by socioeconomic status,
 psychological, nutritional and lifestyle factors?
Ageing across
                                    the life course

      Antagonistic Pleiotropy

Positive effects Negative effects

                                    Shiels PG, Ritzau-Reid K. Curr Aging Sci. 2015;8(2):123-
                                    30.
Homeostasis implies that an organism remains
      within a certain range of physiological parameters
      to maintain stable function.

                                                                                    Telomere attrition
                                                                                    Deficient response to DNA damage
                                                                                    Epigenetic changes
                                                                                    Metabolic shift
       Allostasis implies that an organism constantly                               Mitochondrial dysfunction
                                                                                    Defective ER stress responses
       varies and adjusts physiological parameters
                                                                                    Decline in autophagy
       to maintain stable function.                                                 Defective proteostasis
                                                                                    Decline in regenerative capacities
                                                                                    Stem cell exhaustion
       Accounts for environmental stimuli                                           SASP (Low grade chronic inflammation)
                                                                                    Cellular senescence
                                                                                    Accumulation of damaged cells
                                                                                    Damage to nuclear envelope (lamina)
                                                                                    Decline in renal function
                                                                                    Impaired immune defence
                                                                                    Low Klotho expression
Age                                                                                 Calciprotein particle (CPP) toxicity

                                                           Shiels PG, Ritzau-Reid K. Curr Aging Sci. 2015;8(2):123-30.
                                                           Shiels PG et al Nature Rev.Neph. 2017
Re-employment, job quality,
                                               health and allostatic load
                                                            bio-markers
Prospective evidence from UK Longitudinal study

 • Allostatic load measured
   by bio-markers
 • Allostatic load increased:
   Unemployed → poor
   quality job

Chandola & Zhang, Int J of Epid 47:1:47-57
4 major elements to
                                        premature Ageing in disease
General increase in the allostatic load
   Oxidative stress
   Persistent inflammation
   Sympathicovagal imbalance
   Disturbances in circadian rhythm
Activation of the ‘stress resistance response’
due to unfavorable conditions in the internal
environment,
   Inactivation of anabolic pathways
   Activation of catabolic pathways.
Disease-specific age-promoting mechanisms
   Hyperphosphatemia
   Hyperhomocysteinemia
   Gut dysbiosis
Impaired activity of anti-aging defense
mechanisms (e.g. Klotho)

                                                 Koomans, Kotanko, Schols, Shiels and Stenvinkel.
                                                 Nat Rev Nephrol. 2014, 10(12):732-42.
Glasgow

• Scotland is ‘sick man’ of Europe

• Glasgow is ‘sick man’ of
  Scotland

• Why?
   - Ill health tied to steep SE
   gradient
   - May impact upon age
   related health
Extremes of ageing
                  in Glasgow

East end
Relation Between Longevity
      and Serum Phosphate
               in Mammals
The Method of Dealing
                           With Workers with
                            Multiple Chronic
                                   Diseases
      Social reinforcers

        Psychological
          distress

        Attitudes and
            beliefs

          Disability

Biopsychosocial model of disability
IOSH / IOM
                                          study 2015

Reviewed evidence on:

•   Ageing and physical changes
•   Psychological and mental well-being
•   Work organisation factors
•   Accidents and ill health
•   Intervention studies
Factors explored in relation to age – physical,
 psychological, sensory and organisational

                                            Source: IOSH
Ageing and
                                     Physical Changes
• Reduced aerobic capacity,
  increased body weight
• Muscle strength generally reduces
  with age (1% per annum over age
  35 years)
• Self-reported musculoskeletal
  disorders increases with age
• Limited evidence that chronic neck
  and shoulder pain increases with
  age
• Moderate evidence that need for
  recovery is greater in older workers

                                                 Source: IOSH
Ageing & psychological
                           or mental well-being factors
• Reactions Slower –but offset by experience
• Regular intellectual stimulation and
  cognitive exercise, maintain and
  improvement ability.
• Majority of workers over the age of 65 show
  no sign of cognitive impairment. (increases
  over 70)
• Limited research on mental wellbeing in
  older workers
• Older workers want to maintain and update
  their skills and have access to training, just
  as workers in general do.

                                                   Source: IOSH
Ageing and work
                                   organisation factors

• Limited evidence to show that working excessive overtime in
  physically demanding jobs has an adverse effect on older
  workers.

• Limited evidence that work ability reduced sooner in female
  healthcare workers carrying out shiftwork than in male
  healthcare workers

                                                     Source: IOSH
Ageing and accidents
                                          and ill health
• Older male workers were less of an accident risk but
  females over 55 were found to have the highest estimated
  incident rate.
• The risk of non-fatal serious injury was lowest in the older
  worker group but the injuries sustained were more severe
  and recovery took longer.
• There is an increased risk of developing chronic diseases
  with age, but this doesn’t necessarily mean that work
  shouldn’t be allowed.
• Short-term non-certified absence is the largest recorded
  category of sickness absence. Workers over 55 take more
  days off through self-reported ill health relating to work.

                                                       Source: IOSH
Intervention studies

• No interventions found relating specifically to safety and
  older workers
• OH interventions, e.g. health checks, rehabilitation and
  mental health support, are viewed positively
• Action plans involving various professionals working
  together can reduce the likelihood of sickness absence and
  early retirement for health reasons
• Improvements to health promotion activities,
  1.encouraging    workers of all ages,
  2.allowing   time to attend during the working day,
  3.consider   the views of older workers on age-specific interventions.

                                                                   Source: IOSH
Occupational
                                              Health Role

• Health checks useful
• Influence medical management
• Vocational rehabilitation - maximise function
• Physiotherapy
• Counselling
• Assessment of functional ability
• Career advice
• Recommend work adjustments
• Health surveillance of older workers
• Workplace health promotion programmes
                                                    Source: IOSH
Predicting job loss
                                                                  in those off sick

•   1. Patient’s prediction of likelihood of return to work
•   after current sick leave –
    Do you think you will be able to return to work after your current sick
•   leave?
•   2. Patient’s prediction of ability to do current job in 6
•   months’ time –
•   Do you believe that from the standpoint of your health you will be able to do
•   your current job in 6 months’ time?
    3. The number of weeks off sick in the past year.
•   4. Whether they were waiting for a consultation or treatment
•   for their health condition.
•   5. Age (more likely to return to work if younger in univariate
•   model).
•   (C-index 0.90)
                                  Wilford , Macdonald Occup Med 2008;58:99–106
The process for maintaining the workability of the ageing worker with
                         multiple diseases
             (developed from Juhani E Ilmarinen Occup Environ Med 2001;58:546)

       Health              Education     Psychosocial Work Organisation
 Maintaining & improving    New skills   Adaptations   Adaptations

                                                                           WORKABILITY
Interventions

• Political – sick note to a fit note in the UK- Fit for
  work Service

• Denmark intervention Project
1. RTW coordinator
2. Multidisciplinary support to sick leave cases
1.   Better coordination between employer , Health Care,
       Social system
3. Early and regular content with employees during
 sickness absence
Adapting work and
                                 work environment
                                worker perspective
• Job design and rotation
• More frequent short breaks
• Improved organisation of shift work eg fast forward
  rotation (2-3 days)
• Good lighting and noise control
• Imprved ergonomics and human factors
Workability

• Health and functional capability
• Values attitudes and motivation
• Work environment and community
• Content, demands and organisation of work
• Workability Index
Practical approach

• Health improvement programmes specifically
  designed for older workers
• Specific risk assessments
• Job adaptation and adjustments
• Reduced hours and regular breaks
• Targeted Health checks and FCE
• Case management of the older worker with health
  problems
• Older worker apprenticeships and retraining
What to do about the
                                     growth of NCD and
                                         workers’ health
•   It is not normal to be normal
•   Implement the process for maintaining workability
•   Use the biopsychosocial approach
•   Maximise functional ability
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