(2009) Environmental Scan on Workplace Health in Canada

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Table of Contents

• Methodology
• Format of the Environmental Scan on Workplace Health in Canada
• Current Trends in Workplace Health Research
• The Physical Environment Avenue of Influence on Workplace Health
• The Social Environment Avenue of Influence on Workplace Health
• The Personal Resources Avenue of Influence on Workplace Health
• Needs and Risks of Canadians
• Annex 1
• Annex 2

Health Canada is responsible for helping Canadians maintain and improve their health. One important element of that mandate is to protect the health of Canadians from environmental risks, including where they work. To this end, our goal is provide Canadian employees and employers with knowledge, skills and resources for maintaining and improving their health in the workplace.

To achieve the goal of healthier Canadian workplaces, Health Canada has developed a comprehensive Workplace Health System based on the principle that the workplace is a determinant of health. Canadian employers are using this System to implement health programs and policies, and to integrate health considerations into their normal ways of doing business.

We encourage you to visit our website to get more information on the Workplace Health System and our suite of tools for employees and employers.

Since the workplace was first conceptualized as a determinant of health, workplace health research has become an increasingly evolving field of investigation. While many academics, governments, and non-profit organizations have been studying the various elements of what makes a workplace healthy, there is little offered in terms of a comprehensive analysis of the current research, and what needs and risks are facing Canadians. The objective of the Environmental Scan on Workplace Health in Canada is to fill this gap. Specifically this Scan aims to:

1. identify the current research trends in workplace health issues in Canada;
2. determine the needs of the Canadian population relative to workplace health; and
3. identify interventions that have been proven to address the needs of Canadians.

Methodology

1) Current trends in workplace health research in Canada

To accurately assess the current research trends in workplace health, we identified five sectors relating to workplace health and proceeded with an environmental scan of each. The five are: 1) the academic sector, 2) the voluntary sector, 3) unions and workers’ compensation boards, 4) provincial governments, and 5) the federal government.

First, the academic sector scan searched both peer review publications and the work of university researchers across Canada. This dual approach was employed to provide a comprehensive assessment of the themes under study.

The analysis of peer review publications was conducted using keywords and title words including ‘occupational health’, ‘occupational’, ‘health,’ and ‘Canada’. These words were used to gather results from seven major databases including: JSTOR, EBSCO, SAGE, Web of Science, PubMed, Ingenta and PAIS. Results were restricted to publication dates between 2002 and 2007.

In addition to the peer review literature, a scan of universities provided a snapshot of the work currently under way in Canadian universities that may not have been reflected in the publications. A second methodology was employed to systematically assess this component of the academic sector. Beginning in British Columbia, the university scan included all major universities across the country. By accessing their official web sites, the work of faculty in departments relating to health or the social sciences were reviewed for any research conducted on occupational health.

Second, we executed another scan to identify research themes and publications in non-profit organizations that were not quasi-autonomous non-governmental organizations, such as universities, schools, hospitals, and clinics. In order to focus our scan and identify organizations holding an expertise and credibility in the field, we started by following hyperlinks listed as partners or links on federal and provincial government websites. We were also able to identify organizations by looking at hosts, sponsors and partners of conferences related to occupational health and safety, and organizations listed on workers’ compensation boards and workers’ and union websites.

For each organization, we scanned its website to identify partner organizations to further our scan, and to track down research findings and 2002-2007 publications using the following keywords: ‘workplace health’, ‘occupational health’, ‘emergency preparedness’, and ‘stress’. This enabled us to distinguish trends and common themes in the voluntary sector. Note that based on the definition we employed for the voluntary sector, we did not look at think tanks such as the C.D. Howe Institute or the Fraser Institute.

Third, because occupational health and safety implicates unions and workers’ compensation boards, we carried out a third scan of these organizations. The thematic results for unions and workers’ compensation boards emerged from a scan of their websites to identify research findings and 2002-2007 publications using the keywords ‘workplace health’, ‘occupational health’, ‘emergency preparedness’, and ‘stress’. This enabled us to distinguish current trends and common themes.

Fourth, we continued scanning provincial and territorial government publications in the ministries responsible for occupational health and safety and workplace health. We narrowed our search to research and publications published between 2002 and 2007, and used the keywords: ‘workplace health’, ‘occupational health’, ‘emergency preparedness’, and ‘work’ and ‘stress’.

Finally, we reviewed the ministries responsible for occupational health and safety and workplace health in the federal government. We scanned Health Canada, Human Resources and Skills Development Canada, Industry Canada, the Public Health Agency of Canada, the Canadian Institute for Health Information, Statistics Canada, Status of Women Canada, Policy Research Initiatives, and the Canada School of Public Service to identify research findings and publications from between 2002 and 2007. To focus our search, we used the keywords: ‘workplace health’, ‘occupational health’, ‘emergency preparedness’, and ‘stress’.

2) Needs of the Canadian population relative to workplace health

We began our search by sourcing research statistics from reliable sources that identify risk factors relating to workplace health. ‘Risk factors’ were defined as anything that contributes negatively to health in a workplace setting. ‘Reliable’ was defined as government-sponsored or associated sources. These included national surveys, Statistics Canada data and publications, provincial government statistics, workers’ compensation board injury and fatalities rate data, and hospital injury reporting. Overall 52 sources were found.

A secondary approach was also employed by looking at peer review academic studies. Search words included "work" AND "injuries" AND "Canada". These broad words were used to avoid validity conflicts in seeking out specific risk factors. We searched the following databases for relevant articles dating between 2004 and 2007: EBSCO, JSTOR, SAGE, Web of Science, PubMed, Ingenta and PAIS. We chose 2004 as the cut-off for this section to fully capture what risks Canadians are facing now. The peer review scan resulted in 24 relevant sources, which we determined was unsatisfactory for a comprehensive review of needs and risks facing Canadians. The sources obtained from this search are listed in Annex 2, sources (1) to (24).

We thus conducted another peer review search, this time modifying our approach. In collaboration with the Health Canada library we developed an extensive search strategy for the databases Medline, Current Contents, Global Health, PscyhINFO, Scopus, EMBASE, and the Canadian Research Index. Of the 1,384 additional records that emerged from this strategy, we included 113 articles. For more information on this methodology, see Annex 1. The sources obtained from this second search strategy are listed in Annex 2, sources (0.1) to (0.113).

3) Interventions proven to address the needs of Canadians

Due to the high number of risks identified in the second section, a comprehensive review of interventions for each risk would have fallen outside the scope of the scan. We thus chose one sub-risk for each avenue of influence on workplace health, basing our selections on the criteria of severity and frequency.

We wanted to be sure that interventions found for these sections did represent "best practices", i.e. they had undergone an evaluation cycle to prove their efficacy at addressing the risk factors facing Canadians. We therefore only included resources that had evaluated an intervention, or literature reviews of previously evaluated interventions.

Physical Environment search

In this section, we focussed our research on injuries relating to low back pain and musculoskeletal disorders. This was based on the findings from part two, which demonstrated that musculoskeletal disorders and back pain represented a type of high-frequency injury for workers across Canada.

We began by using key words ‘strategies’, ‘initiatives’, ‘interventions’, AND ‘injuries’, ‘injury’, ‘musculoskeletal diseases/disorders (MSD)’, and ‘low back pain (LBP)’ in the databases: Medline, Current Contents, Global Health, PsychINFO, SCOPUS, EMBASE, and the Canadian Research Index. We used Canada as a limiter and confined our results to post-2004.

We also searched through the university researchers identified in section one of the scan using key words: ‘injuries/injury’, and ‘musculoskeletal disorder’, and ‘low back pain’. Once the researchers were identified, we sought publications specific to those researchers, from their websites and peer review journals. Also employing the results of part one, we looked through publications gathered from provincial/territorial and federal governments, workers’ compensation boards, unions and the voluntary sector.

We searched the  CANOSH website, maintained by the Canadian Centre for Occupational Health and Safety (CCOHS), as well as  the CCOHS’ Occupational Health and Safety Links website and the Workplace Health Promotion Resources database.

To complete the scan we searched Google using keywords: ‘musculoskeletal disorder’, ‘low back pain’, ‘strategies’, ‘initiatives’, and ‘interventions’. We included relevant results from the first 10 pages (displaying 10 results per page).

Social Environment search

From the Social Environment, we chose to investigate non-standardized work schedules. This category includes both shift work and part-time work. We chose this section due to the number of Canadians employed in this type of work arrangement. We found from section two of the scan that 30% of Canadians are shift workers, while in some sectors, like protective agencies, this number increases to 55%. In addition to the preponderance of non-standardized work schedules in Canada, we were also concerned by the physical and psychosocial health concerns associated with this type of work arrangement.

We began by searching peer-reviewed sources after 2004 in the databases Medline, Current Contents, Global Health, PsychINFO, SCOPUS, EMBASE, and the Canadian Research Index. We employed the key words ‘strategies’, ‘initiatives’, ‘interventions’ AND ‘non-standardized work schedules’, ‘part time’, and ‘shift work’.

We also searched through the resources that emerged from part one of the scan. For academic researchers, we used the key words: ‘part time’ and ‘shift work’ and subsequently retrieved relevant publications on their faculty websites. Provincial, territorial and federal governments, workers’ compensation boards and unions, and the voluntary sector sources were also searched using the key words ‘part time’ and ‘shift work’.

As well, we searched  the CANOSH website, maintained by the Canadian Centre for Occupational Health and Safety (CCOHS), the CCOHS’  Occupational Health and Safety Links website and Workplace Health Promotion Resources database.

Lastly, we conducted a search on the Google search engine, using key words: ‘shift work’, ‘part time’, ‘strategies’, ‘initiatives’, and ‘interventions’. We included relevant results from the first 10 pages, displaying 10 results per page.

Personal Resources search

Given the recent profile of mental health and illness, and the findings from part two of the scan, we chose to examine interventions related to psychological disorders and anxiety. 

We employed a multi-targeted approach to our strategy. We started with a peer review search using the key words: ‘strategies’, ‘initiatives’, ‘interventions’ AND ‘psychological disorders’, ‘mental health’, ‘mental illness’, ‘depression’ and ‘anxiety’ in databases: Medline, Current Contents, Global Health, PsychINFO, SCOPUS, EMBASE, and the Canadian Research Index. We included articles published after 2004.

We also employed the work from part one of the scan. In the academic sector we reviewed the list of researchers using the key words ‘psychological disorders’, ‘mental health’, ‘mental illness’, ‘depression’, and ‘anxiety’, and retrieved relevant publications on their faculty websites. Provincial, territorial and federal governments, workers’ compensation boards, unions, and the voluntary sector were also searched using the key words ‘psychological disorders’, ‘mental health’, ‘mental illness’, ‘depression’, and ‘anxiety’.

We also searched the CANOSH website, maintained by the Canadian Centre for Occupational Health and Safety (CCOHS), as well as  the CCOHS’ Occupational Health and Safety Links website and Workplace Health Promotion Resources database.

Finally, we used the Google search engine. Relevant sources were retrieved from the first 10 pages of 10 sources per page, using the keywords: ‘psychological disorders’, ‘mental health’, ‘mental illness’, ‘depression’, and ‘anxiety’, ‘strategies’, and ‘initiatives’.

Format of the Environmental Scan on Workplace Health in Canada

The theory underlying the Workplace Health System and Health Canada’s approach to the promotion of workplace health is that three major avenues influence health in the workplace. Throughout this report our findings will be aligned to these three avenues.

The Avenues of Influence on Workplace Health

1) Environment (physical and social):
Factors in the home or work environment that effect employee health, such as air, noise and light conditions, the quality of machinery and equipment, the type of work, responsibilities at work, relations with supervisors and co-workers, and relations with family at home.

2) Personal Resources:
The sense of influence employees feel they have over health and work, how much social support they feel they receive from others, and the degree to which they actively participate in improving their own health.

3) Health Practices:
Practices that effect health, including: physical activity, smoking, drinking, sleeping and eating habits, as well as the use of medication and other drugs.

The Environmental Scan Workplace Health in Canada is divided into five sections:

1. Current trends in workplace health research in Canada
2. The physical environment avenue of influence on workplace health
3. The social environment avenue of influence on workplace health
4. The personal resources avenue of influence on workplace health
5. Needs and risks of Canadians sorted by labour sector and demographic

We regret that the health practices avenue of influence on workplace health was not developed sufficiently to merit its own section. We hypothesize that this avenue of influence on workplace health does not figure as prominently in the minds of researchers, employers, and Canadians due to the personal nature of employees’ health choices. However, it was raised as an associated risk factor and intervention for the other three areas suggesting that there is a role for organizations in promoting healthy practices among their employees.

Current Trends in Workplace Health Research

Academic Sector

Peer Review Publications

Of the 206 articles that emerged from our methodology, 22 different themes surfaced on occupational health. The five themes with the highest frequency of articles include: 1) OHS tools and methodology, 2) changing nature of work, 3) injuries and musculoskeletal disorders, 4) psychological issues and stress, and 5) international and comparative papers.

Themes in Academic Sector Scan
Peer Review Research - Keyords: Occupational Health and Canada

Publication themes across time

The themes that emerged from the peer review literature were also analysed to assess trends within the academic sector. OHS tools had the highest number of publications in 2002/2003. The most frequent theme from publications during 2004/2005 were psychological and stress-related issues; however, in 2006/2007, OHS tools and methodology arose most frequently

In 2007, the most frequent themes after OHS tools and methodology were the changing nature of work, gender/women and reproductive health and ethnicity, diversity, and immigration. In 2006, emphasis was also placed on gender/women and reproductive health, as well as on work-life balance and ‘work and family’ considerations. Top themes from 2004/2005, other than OHS tools, were psychological and stress-related, injuries and musculoskeletal disorders, and gender/women and reproductive health.

Finally, in 2002/2003, a similar trend paralleled the 2007 results. The changing nature of work, gender/women and reproductive health, injuries and musculoskeletal disorders, as well as ethnicity, diversity and immigration were the most frequent themes in the peer review literature for 2002/2003.

Themes by Date in Academic Sector Scan
Peer Review Research - Keyords: Occupational Health and Canada

University Faculty Research

In addition to the peer review literature, a scan of universities provided a snapshot of the work currently under way in Canadian Universities that may not be reflected in the publications.

The results of the second methodology located 360 researchers in universities across Canada. The primary interests of researchers, taken from their biographies and publications listed on their personal web pages, provided the platform for themes to emerge. From the 360 researchers, 48 themes surfaced. The top five include: 1) psychological and stress-related, 2) injuries and musculoskeletal disorders, 3) organizational analysis, 4) gender/women, and 5) work-life balance and ‘work and family.’ Only two of these themes overlap with the peer review results: psychological and stress, and injuries and musculoskeletal disorders.

Themes in Academic Sector University Faculty Member Research across Canada: Highest Ranking (Based on 360 Researchers in Canadian Universities)

Themes in Academic Sector University Faculty Member Research across Canada: Lowest Ranking (Based on 360 Researchers in Canadian Universities)

Themes by Universities

These top five themes were further broken down to the university level to assess which universities were studying them in the greatest number. Psychological and stress related research is overwhelmingly being studied in Quebec universities, with Université de Montréal, HEC Montréal and Université de Laval representing the top three. Collectively, these schools have 33 researchers studying psychological and stress-related issues in occupational health.

Top Universities Across Canada Researching Psychological / Stress (Based on Number of Researchers)

Academics researching injuries and musculoskeletal disorders are more dispersed across Canada. The top five universities are Université de Laval, University of Toronto, the University of Manitoba, Waterloo, and the University of Saskatchewan. Together these schools have 23 researchers who focus on injuries or musculoskeletal disorders in occupational health.

Top Universities Across Canada Researching Injuries / Musculoskeletal Disorders / Ergonomics (Based on Number of Researchers)

The organizational analysis theme includes organizational culture, change, and behaviour. This category is again dominated by Quebec universities. All told, 23 Quebec researchers at Université de Laval, HEC Montréal, Université de Montréal and Concordia study organizational analysis.

Top University Across Canada Researching Organizational Analysis (Based on Number of Researchers)

The theme of gender/women, in the context of occupational health, is primarily the focus of two universities, the University of Toronto and McMaster University. The University of Toronto has nine researchers in this field of study, while McMaster has five. Overall, there are 24 researchers in Ontario studying women and gender in occupational health.

Top University Across Canada Researching Gender / Women (Based on Number of Researchers)

Work-life balance and work and family issues are being researched in Ontario, Saskatchewan and British Columbia. Guelph University leads the universities studying this area, with five researchers. University of Toronto and Saskatchewan each have three, while York, Carleton and the University of Victoria each have two. Combined, there are 17 researches from the top universities studying work-life balance and work and family issues.

Top University Across Canada Researching Work and Family / Work Life Balance Based on Number of Researchers

Themes by Provinces

In addition to the most frequent themes, university research on occupational health was also grouped by province. Not surprisingly, based on the number of universities found in Ontario, this province had the most (156) researchers studying occupational health. Of these, gender/ women, followed by injuries and musculoskeletal disorders, were the most frequent themes.

Themes in Academic Sector University Faculty Member Research in Ontario (Based on 156 Researchers in Ontario Universities)

Of Quebec's 106 researchers on occupational health, 40 focused on psychological and stress related issues, and just under 30 emphasized organizational analysis.

Themes in Academic Sector University Faculty Member Research in Quebec (Based on 106 Researchers in Quebec Universities)

The most-studied theme in British Columbia is chemical exposure and WHMIS, followed by psychological and stress-related issues, and disability management. Thirty-seven researchers study occupational health in the province.

Themes in Academic Sector University Faculty Member Research in British Columbia (Based on 37 Researchers in British Columbia Universities)

In Manitoba, five of the 20 university researchers studying occupational health focus on injuries and musculoskeletal disorders, while six researchers consider psychological and stress-related issues, mental illness and rehabilitation.

Themes in Academic Sector University Faculty Member Research in Manitoba (Based on 20 Researchers in Manitoba Universities)

Alberta, Saskatchewan, Nova Scotia and New Brunswick all have fewer than 15 researchers looking at the issue of occupational health.

Themes in Academic Sector University Faculty Member Research in Alberta (Based on 13 Researchers in Alberta Universities)

Themes in Academic Sector University Faculty Member Research in Saskatchewan (Based on 11 Researchers in Saskatchewan Universities)

Themes in Academic Sector University Faculty Member Research in Nova Scotia (Based on 10 Researchers in Nova Scotia Universities)

Themes in Academic Sector University Faculty Member Research in New Brunswick (Based on 7 Researchers in New Brunswick Universities)

The two methodologies: Publications and Universities

The two-step methodology for the academic scan suggests that, although ‘OHS tools and methodology’ is the theme most frequently published in peer review databases, it is not the theme that university faculty members use to identify as their research area. Based on the self-identification of researchers, the top theme that emerged is psychological and stress-related issues. Interestingly, this theme in the peer review publications peaked in 2004/2005 and was followed by a steady decline in 2006 to a virtual silence in 2007 publications.

Another area that emerges from both publications and university researchers’ interest is gender/women and reproductive health. Out of 360 researchers, this theme was fourth overall in research interests. Likewise, it placed third overall for publications dated in 2007. Although there has been a consistent decrease from 2002/2003 to 2007 in the theme ‘gender/women and reproduction’, this may reflect a larger trend in the peer review publications that indicates publications on occupational health in general have been declining over the last five years. 

This trend in the volume of publications is evident when looking at the number of publications loaded from the database search. Of 206 articles, 43% are from 2002/2003 compared to 28% from 2004/05. Similarly, 29% of the articles on occupational health were published during 2006/2007. This difference, although significant, should be considered in light of the fact that the academic peer review scan was conducted in August 2007, after 2/3rd of 2007 had elapsed.

Voluntary Sector

The thematic results for the voluntary sector emerged from a scan of non-profit organizations involved in researching or advocating issues regarding workplace health. The organizations identified excluded QUANGO sector organizations (universities, schools, hospitals and clinics).

Overall Results

Between 2002-2007, the five recurrent voluntary sector themes, from most- to least-common, were: 1) perception of work as a determinant of health, 2) changing nature of work, 3) psychological/stress in the workplace, 4) organizational analysis of workplaces, 5) employer incentives for workplace health.

Themes in the Voluntary Sector Scan Based on links posted on voluntary sector websites

Results over time

In 2007, the most researched theme in the voluntary sector was psychological/stress in the workplace, followed by work-life balance. However, this was not the case from 2004 to 2006. During that time the voluntary sector focused on the perception of work as a determinant of health and organizational analysis, while psychological/stress in the workplace came in third.

This may represent a growing awareness of psychological and stress-related issues in the voluntary sector, seeing that between 2002-2003, this category ranked fourth. It should also be noted that the number of publications in the psychological/stress category peaked in 2006. The cut-off for 2007 was August, so it is unclear if this trend will continue.

Themes by Date in Voluntary Sector (Based on links posted on voluntary sector websites)

Unions and Workers’ Compensation Boards Sector

The thematic results for unions and workers’ compensation boards (WCBs) emerged from a scan of their websites to identify research findings and publications published between 2002 and 2007.

Overall Results

Between 2002-2007, ranking from the most common theme to the least, the five recurrent themes identified in the union and worker compensation board sector were: 1) changing nature of work, 2) perception of work as a determinant of health, 3) disability management, 4) organizational analysis of workplaces, and 5) occupational health and safety (OHS) tools/methodology. These results appropriately reflect the mandate of the organizations reviewed. Particularly from the perspective of workers’ compensation boards, disability management and occupational health and safety are logical research avenues.

Themes in the Unions and Worker's Compensation Board Sector Scan Based on links posted on union and WCB sector websites

Results over time

The most frequent themes in the unions and workers’ compensation board publications in 2007 were the changing nature of work, international and comparative analysis, and work-life balance. In 2006, disability management, injuries and perceptions of work as a determinant of health represented the majority of publications. Between 2004 and 2005, disability management and injuries were also in the top three, along with the changing nature of work. Finally, in 2002 and 2003, the workers’ compensation boards and unions focused their research efforts on psychological/stress in the workplace.

The five emerging themes in 2002-2003 and 2004-2005 were easily perceived, compared to the search for five themes in 2006 and 2007. In 2006 and 2007, there were more themes that emerged than previous years, but because of this variability, there was no noticeable dominance of themes as in 2002/2003 or 2004/2005.

Themes by Date in Union and WCB Sector Scan (Based on links posted on union and WCB sector websites)

Federal Government Sector
The thematic results for the federal government emerged from a scan of websites of federal ministries and agencies. We scanned Health Canada, Human Resources and Social Development Canada, Industry Canada, the Public Health Agency of Canada, the Canadian Institute for Health Information, Statistics Canada, Status of Women Canada, Policy Research Initiatives, and the Canada School of Public Service, to identify research findings and publications published between 2002 and 2007.

Overall Results

Between 2002 and 2007, ranking from the most common theme to the least, the five recurrent themes identified in the federal government were: 1) changing nature of work, 2) perception of work as a determinant of health, 3) occupational health and safety (OHS) tools/methodology and psychological/stress in the workplace (tied), 4) work and family/work-life balance, and 5) emergency preparedness.

Themes in Federal Government Scan (Based on Publications and Research on Federal Government Websites)

Results over time

In 2007, the most researched theme by the federal government was occupational health and safety tools and methodology, followed by psychological/stress in the workplace, and emergency preparedness. These areas of investigation reflect the mandate of the federal government with respect to workplace health. These three areas were also the top researched in 2004/2005. In 2006, the federal government changed its focus to the changing nature of work, the perception of work as a determinant of health, and Canadian policy relative to workplace health. Finally, in 2002/2003, publications were predominantly about the changing nature of work, work-life balance and psychological/stress in the workplace.

The five emerging themes in 2002/2003 and 2004/2005 were easily perceived. In 2006 and 2007, there were more themes that emerged than previous years. Because of this variability, there was no noticeable dominance of themes as in the two earlier periods. In 2007, there was a resurgence of publications pertaining to OHS methodology and tools.

Themes by Date in Federal Government Sector Scan (Based on Publications and Research on Federal Government Websites)

Provincial Government Sector

The thematic results for the provincial governments emerged from a website scan of each provincial and territorial ministry responsible for occupational health and safety and workplace health. We narrowed our search to research and publications between 2002 and 2007.

Overall Results

Between 2002 and 2007, ranking from the most common theme to the least, the five recurrent themes identified in the provincial/territorial governments were: 1) occupational health and safety (OHS) tools/methodology, 2) emergency preparedness, 3) work and family/work-life balance, 4) changing nature of work, and 5) (Three-way tie) legal perspectives/human rights; gender/women; perception of work as a determinant of health.

Themes in Provincial Government Scan Based on Publications and Research on Provincial Government Websites

Results over time

In 2007, the most frequent research themes in the provinces and territories across Canada included occupational health and safety tools and methodology, emergency preparedness, and the changing nature of work. This was mirrored in the results from 2006. Between 2004 and 2005, occupational health and safety tools and methodology remained the dominant research theme; however work-life balance and perceptions of work as a determinant of health were also areas of investigation that received a lot of attention. Finally, in 2002 and 2003, occupational health and safety tools and methodology remained on top, but other areas emerged including research on addictions and gender/women issues.

The first two dominant themes in 2004/2005 were very perceptible compared to themes in other years.

Themes by Date in Provincial government Sector Scan (Based on Publications and Research on Provinicial Government Websites)

Definitions of the top research themes

1. The changing nature of work category includes research on changes to the economy, labour industries and the impact of technology (such as nanotechnology).
2. The disability management category includes research on return to work and accommodation, as well as individual employee coping strategies.
3. The emergency preparedness category includes research on proactive measures relating to emergency management.
4. The employer incentives for workplace health category include return on investment and increased productivity studies.
5. The injuries and musculoskeletal disorders category includes physical injuries, compensation claim studies, claims management, musculoskeletal disorders, and ergonomic concerns.
6. The international and comparative papers category includes studies that have compared Canadian policy, trends and/or incident rates with other countries. It also includes studies that did not have a Canadian focus.
7. The OHS tools and methodology category includes validity and reliability studies of questionnaires and surveys, biomarkers, recommendations to the research community on study design and improvements on research.
8. The organizational analysis of workplaces category includes studies on organizational change, knowledge, and theory.
9. The perception of work as a determinant of health category includes studies on employees’ perception of their work environment as contributing to their health status, and the relationships between perception of health and the work environment.
10. The psychological health and stress category includes articles on stress, psychological distress and health, depression, and mental health.
11. The work and family/work-life balance category includes studies on home-to-work and work-to-home conflicts, work and family reconciliation, role overload and family-friendly policies at work.

The Physical Environment Avenue of Influence on Workplace Health

We found the following five physical environment sub-risk categories, in our scan of workplace health needs and risks that are facing Canadians: 1) injuries, 2) traumatic brain injury, 3) cancer, 4) asbestos, and 5) motor vehicle accidents. Each category has descriptive statistics that describe the risk category itself. This is followed by risk indicators and relationships found in the literature, categorized by the avenues of influence on workplace health.

Please note that the numbers in brackets located at the end of each statistic indicate its source, as numbered in Annex 2.

Avenue of influence on workplace health : 1 - Physical Environment

Sub-risk category	1.1 - Physical injuries / diseases
Descriptive Indicators	Top injuries: sprains and strains Canada-wide: sprains and strains (11)(0.87) Manitoba: sprains, strains and tears (21) Ontario: 47.6% of time loss injuries are due to sprains and strains (23) Nova Scotia: 60.8% of injuries are sprains and strains (22) Annual prevalence of neck pain in Quebec is 47.8% Top three disabilities at work: 74% pain, 56% mobility, 53% agility (20) Body part affected: hands and back 36.8% of injuries involve the hand or wrist (5) 28% of injuries at work involve the hand (11)(0.87) 16% of injuries at work involve the back (11)(0.87) Manitoba 20% of injuries are in the hand (21) Nova Scotia 31% of injuries are in the back (22) Quebec’s most common musculoskeletal injury for men and women was in the back (0.51) High risk groups: Blue collar men Carpal tunnel syndrome in Ontario average worker profile: 40-years-old and at job for 9 years (0.106) Four times more likely in blue collar than in business, finance, administration (11) Men suffer from more injuries than women; twice as many in manufacturing, business, transportation, etc (11) Men in white and blue collar twice as likely to experience an injury at work compared to women (0.87) Manual or mixed jobs coupled with low education associated with increased risk of disability absence (0.14) Women suffer from more neck pain than men (0.51) More women have repetitive strain injuries than men (5)
Risk Indicators and Relationships	Physical Environment 49% of injuries are due to over-exertion and falls (11) 32% of injuries are due to sharp object, tool or machine (11) In Alberta, top reason for fatality between 1997 and 2006 is contact with object or equipment 34.1% (3) Injury rates decrease when lower physical demands (17) Over-exertion and falls account for half of all injuries reported (0.87) 32% of all injuries are due to sharp objects, tools or machines or being struck or crushed by an object (0.86) Back pain associated with heavy lifting (0.51) Physical Environment - workplace design: computer use Self-reported computer, mouse and keyboard use associated positively with musculoskeletal disorders, especially if exceed 20 hours/week (19) Risk of musculoskeletal disorders increases with years of computer use (19) Office and computer workers have the highest incidence of neck disorders in cohort studies (0.94) Social Environment - overworking Positive association between hours worked and injury absence (0.19) Men who work more than 35 hours per week have increased chance of injury (0.87) Social Environment - job strain Back pain associated with high job strain (0.51) High job strain increases neck and shoulder symptoms in white collar workers (0.52) Personal Resources - decision latitude and job control Low decision latitude increases neck and shoulder symptoms in white collar workers (0.52) Job control and workload associated with increased risk of MSI resulting in increased compensation (0.102) Workers in the first month on the job are four times more likely to have a time-lost claim than workers with more than one year experience (0.16) Personal Resources - psychological disorder and anxiety Emotional or depressive symptoms in workers put them at a higher risk for developing neck pain (0.94) Back pain associated with high psychological distress and a traumatic event (0.51) Health Habits Workers who smoke daily, consume alcohol heavily more likely to be injured (0.87) Men who consume at least five alcoholic drinks per occasion at least once a week more likely to be injured at work (0.87) Obese women twice as likely to be injured at work (0.87) Obesity increases risk of neck pain (0.94) Current smoking or a history of smoking increases the risk of neck pain (0.94)
Sub-risk category	1.2 - Traumatic brain injury (TBI)
Descriptive Indicators	Most likely to result in death and disability than any other injury (18)
Risk Indicators and Relationships	Physical Environment 45.5% of female TBI in Ontario caused by vehicles, 27.3% from falls (10) Leading cause of TBI in Ontario are falls from ladders, scaffolds and buildings with 45.3%; 21% of all TBIs are from vehicles (10) Motor vehicles cause the most severe TBI across all sub-groups of workers and sectors; increased risk of injury when new on the job (4)
Sub-risk category	1.3 - Cancer
Descriptive Indicators	24% of bladder cancers in Canada are due to occupational factors (0.111)
Risk Indicators and Relationships	High risk sectors: agriculture, automotive, forestry and logging, metal workers and machinists, plumbing, firefighting Women who have worked in agricultural industry are three times more likely to have breast cancer (0.20) Women who have worked in agriculture and then in the automotive sector have four times the increased risk of breast cancer (0.20) Increased risk of non-Hodgkin lymphoma in forestry and logging industry workers, metal workers and agricultural workers (0.1) Positive correlation between machinists, farmers, pulp and paper workers for soft tissue sarcoma (0.39) Bladder cancer chemical associations found predominantly in logging, construction and jobs involving motor vehicles (0.111) After 20 years in bricklaying industry, workers are at a higher risk of lung and stomach cancer (0.30) After 30 years in plumbing and pipe-fitting industry, higher mortality rates due to cancer than the population average (0.29) Increased risk of bladder cancer for male metal workers and auto-mechanics (0.33) Increased risk of stomach, pancreatic, lung and bladder cancer in long-term aluminium smelt workers (0.34) Machinists working more than 30 years six times more likely to be diagnosed with soft tissue sarcoma compared to the general population (0.39) Increased risk for kidney cancer after 20 years as a firefighter (0.88) After 40 or more years of firefighting, increased risk of colon cancer, kidney cancer and bladder cancer (0.88) Physical Environment: chemical exposure Increased risk of bladder cancer for workers in industries that work with metals, paint, solvents, diesel engine emissions and textiles (0.2) Bladder cancer associated with derivatives or combustion products of fossil fuels, lubricating oils and grease, solvents and paints, soap detergent and natural gas (0.111) Stomach cancer in men associated to organic lead (0.69) Occupational asphalt and welding fume exposures increase risk for brain cancer (0.67)
Sub-risk category	1.4 - Asbestos
Descriptive Indicators	In B.C., second-highest fatality rate is in construction industry, majority due to asbestos (24) In Alberta, highest cause of occupational disease is asbestos with 50.2% between 2002 and 2006 (3) In Manitoba, 39% of fatalities between 1995 and 2005 due to occupational disease mostly in construction sector; 2/3rd of occupational disease fatalities due to asbestos - 44% in construction (21)
Risk Indicators and Relationships	n/a
Sub-risk category	1.5 - Motor vehicle accidents
Descriptive Indicators	In B.C., the primary sector suffers the most fatalities, most involve vehicles (24) in Saskatchewan, top causes for fatalities in 2006 are from vehicles; 11 of 22 (14) in Manitoba, 30% of fatalities were caused by vehicles (21)
Risk Indicators and Relationships	Physical Environment - traumatic brain injuries Motor vehicles cause the most severe TBI across all sub-groups of workers and sectors; increased risk of injury when new on the job (4) in Ontario, 21% of all TBIs are from vehicles (10)

Physical Environment Intervention Case Study:

Sub-risk categories: 1.1 Physical injuries (Low Back Pain and Musculoskeletal Disorder)

Interventions that address the needs and risks associated to sub-risk categories Low Back Pain (LBP) and Musculoskeletal Disorders (MSD) in the Physical Environment at work are categorized by objective: prevention, mitigation and rehabilitation

These objectives are more formally defined as: primary, secondary and tertiary. Primary interventions are proactive measures that attempt to prevent the causes of LBP and MSD in the workplace. These strategies address the sources of such physical distress in an organization. Secondary interventions seek to provide employees with tools that enable them to adjust their responses to factors in the workplace that might be the cause of the physical complaints. Finally, tertiary interventions are reactionary, often involving rehabilitation and return to work initiatives. Ideally, these three strategies should operate collaboratively. Issues identified from secondary and tertiary interventions should feed into the primary prevention strategies.

It must be noted that, initially, this section on the physical environment was also seeking interventions relating to ‘Motor Vehicle Accidents’ (MVA) and ‘Traumatic Brain Injury’ (TBI). However, while there were statistics and studies on occurrences of workplace accidents using motor vehicles, particularly on farms, as well as workplace occurrences of traumatic brain injuries, these search terms produced so few evaluated interventions that the review of these was removed from this paper. We additionally extended all search terms, initially set at up to 2004, to an earlier date of 2001 in order to incorporate a larger number of findings.

Low Back Pain

Low back pain in workers is a rampant problem in today’s workplace. One study suggested that low back pain is “an unavoidable consequence of life”¹. Consequently, there has been a large quantity of studies completed on the subject. Some have focussed on the characteristics of those prone to developing low back pain, or the physical characteristics of those who have developed it.

Most of the material found on evaluated interventions of low back pain was found in the secondary category; that is, what action to take once a worker has been diagnosed with it. It is not known whether the fact that there is a fewer number of primary intervention studies - that is, aimed at preventing low back pain altogether, is because it is not believed to be possible. Or, whether the large number of secondary intervention articles speak to the preponderance of this condition.

It is interesting to note how there were several findings linking a positive outcome if a worker had a positive attitude or supportive and understanding manager. This supports our findings in the personal resources section that the physical and psychological avenues of health are closely linked.

Primary Interventions

As stated above, primary interventions are proactive measures aimed at reducing the risk of low back pain developing in the workplace. One researcher we reviewed felt that the prevention of low back pain is futile because such pain is an unavoidable consequence of life. ² Despite this conclusion, there were several primary interventions that when evaluated proved to be an effective way of avoiding low back pain, notably exercise and cognitive behavioural therapies.

Health Practices - Exercise

Physical exercise and activity interventions are supported in the literature to prevent the onset of low back pain. In fact, McGill has found that people with a history of back troubles are more likely to have lower muscle endurance than those who are free of LBP.³

In a literature review on interventions for preventing low back pain in workers, Burton found six studies that found positive effects from exercise, while one had mixed results. Positive evidence was found in the outcome indicators of sick leave and new incidences. Exercise had no effect on the level of pain experienced. ⁴

In the series ‘Back to Basics’, the Workers’ Compensation Board of Alberta provided information for employees about what they themselves could do to prevent LBP. It stated that maintaining good posture while sitting, standing, and sleeping, and using proper lifting and carrying techniques, are helpful. Finally, it recommended exercise to build muscles that will support the spinal column. ⁵

In a further review of 27 controlled trials on low back pain interventions, the authors found strong evidence that exercise is effective.⁶ Likewise a literature review of controlled trials by Linton and van Tulder found that exercise did have an effect on the prevention of LBP. ⁷

Mirroring these findings was another literature review of randomized control trials for LBP, with 13 trials meeting methodology requirements for inclusion in the study. ⁸ The results showed that exercise is effective in preventing LBP.

Contrary to the above studies, exercise had no effect in the review by Shaw and Linton. ⁹ This study, amidst the positive effects found above, indicates the need for further research of whether this intervention has an effect and whether organizations should employ it.

Personal Resources - Training and Cognitive Behavioural Therapy

The prevention literature on low back pain suggests that training does not have a significant effect on the introduction of new incidents. However, cognitive behavioural therapy - a type of counselling that focuses on the re-examination of attitudes and beliefs, has the potential of being successful.

A literature review of controlled trials¹⁰ found 27 trials that met methodological standards for inclusion in the review, and drew the conclusions that only one of nine randomized trials reported a positive effect from back schools.¹¹ As stated in this study, the assumption behind back schools and education is that people get LBP because of a lack of knowledge about body mechanics, lifting techniques, stress, and other factors that might lead to low back pain. As the findings state in this report, this is not always the case.

Further studies support this conclusion on the inefficacy of back schools. Shaw, Linton and Pransky found that back education had no effect on the prevention on low back pain.¹² Similarly, after reviewing 27 controlled trials on interventions, Linton and van Tulder found that back schools have no effect in preventing the onset of LBP. Only one of nine randomized trials reported a positive effect on LBP.¹³

In a literature review of randomized control trials and cohort studies looking at the efficacy of interventions for manual material handling workers, Martino et al. sought to find out what worked and what did not work. Four studies found moderate evidence that advice and training in manual material handling (MMH) is no more effective than doing nothing, while three studies found the MMH advice and training was no more effective than exercise and the use of back belts. One study found that using MMH advice, plus the use of assisted devices, is no more effective than just giving the advice. Therefore, the review concluded that there is no evidence supporting the efficacy of MMH advice and training. ¹⁴

Burton likewise found seven studies on the effect of information, advice and instruction more broadly. Six of the seven studies found no effect of these types of interventions on preventing sick leave due to LBP, the frequency of LBP episodes, or the cost of LBP to organizations. One review stated that there were strong positive effects when workers understood the correct posture and movement and back school contents. However, this was coupled with low effects on clinical outcomes. Burton concludes that traditional training on biomechanics, lifting techniques, optimal postures, etc. are not recommended for the prevention of low back pain, but promoting and improving training in coping with the condition could have positive benefits, i.e. employed as a secondary intervention.¹⁵

Maher, while conducting a literature review on preventative interventions for low back pain, found that education initiatives did not have sufficient quality research to draw conclusions on their efficacy.¹⁶ It is unclear whether this finding may help explain the overall trend in research on training and education in the prevention of low back pain.

Contrary to the training initiatives, cognitive behavioural therapy sessions have shown value in preventing low back pain. In a literature review of 17 studies published between 2000 and 2005, cognitive restructuring of pain beliefs was found to be an effective primary intervention. This underscores the premise that a worker’s beliefs and attitudes play a significant role in low back pain prevention.¹⁷

Werner et al.¹⁸ reviewed preventative measures taken in six different workplaces that included 3,500 workers, but no control group. These interventions included training and supervising one or several employees (non-medical) as peer advisors for back pain at each workplace, educational meetings with all employees, the provision of written material such as pamphlets and posters, and messages of intervention. These messages sought to reassure employees, for example, that low back pain is not necessarily a sign of injury but can be caused by natural changes in the spine. Another reassurance, offered by the non-medical co-worker, told workers that back pain is not dangerous and to maintain normal social and occupational life as much as possible.¹⁹ This last measure was found to have a positive effect. The study found that negative beliefs can serve as a strong predictor of LBP disability.²⁰

These preliminary findings on cognitive behavioural therapies require further research employing more rigorous methodology, including control groups.

Physical Environment - Lumbar Supports and Handling Equipment

Almost every study reviewed on the efficacy of lumbar supports indicates no preventative effect from their use. Lumbar supports have been promoted for the following assumptions: that people who wear them get support of the trunk, that they prevent pain-producing events due to over-flexion and remind the wearer to lift properly and increase abdominal pressure while decreasing pressure on the back. They have, however, shown no effect on the prevention of low back pain.²¹

Three studies in a literature review conducted by Burton, found strong evidence to suggest that back belts and lumbar supports are ineffective for the prevention of LBP. ²² In a further review of 27 controlled trials on interventions, Linton and van Tulder found that lumbar supports have no effect in preventing LBP.²³ Only one study in all of the literature reviews included in this report found that back belts were associated with a decrease in incidence risk among female home attendants. ²⁴

Another study reviewed material handler studies vetted based on methodology; in all, this review found 10 studies that demonstrated methodological rigour. Of these, three studies showed no effects after using a back belt, two studies had mixed results and could not conclude one way or the other, and one study did show positive results of back belt use. The literature review’s final recommendation was that there is inconclusive evidence to support the use of back belts to prevent occupational low back pain.²⁵

As a sign that LBP has become a public health concern, governments are also working to prevent low back pain. The Workers’ Compensation Board of Alberta recommends employing materials-handling equipment to do heavy lifting work in their publication Back to Basics. However, after having made this recommendation, the publication also states that low back pain is not always the result of lifting heavy materials; rather, even lifting a pencil while twisting the wrong way can lead to back pain.²⁶

Physical Environment - Ergonomics

Burton reviewed interventions designed to prevent the onset of low back pain. She found mixed results for the efficacy of using ergonomics as a primary intervention. Two reviews concluded there were no effects, while three concluded that the ergonomics result in reduced prevalence and severity. Therefore, there was inconsistent evidence to support this intervention for the prevention or reduction of the prevalence of LBP.²⁷ Burton additionally found three reviews that found moderate positive effects for temporary changes, like ergonomic workplace adaptations.²⁸

Secondary Interventions

The next area of review in this scan is secondary interventions, which serve to assist people already diagnosed with, or suffering from, low back pain. While it may be comforting to believe that low back pain can be prevented entirely, one evaluation posited that in light of growing evidence, the preventing of low back pain is pointless since such pain is an inescapable aspect of life. ²⁹ Therefore, according to Snook, secondary interventions are the only way to manage low back pain and prevent a potential disability.³⁰.

Health Practices - Exercise

In a meta study by Tveito, Hysing and Eriksen, 31 publications that resulted from 28 studies of interventions were reviewed and met the methodological criteria. These researchers found that, in addition to physical exercise and activity being a positive primary intervention, it also serves as a secondary intervention for workers already suffering from LBP. Tveito et al. found exercise effective in reducing sick leave, costs associated to low back pain, and new episodes of low back pain. It did not have an effect on the pain level itself.³¹

Personal Resources - Training and Cognitive Behavioural Therapy

The results for training and cognitive behavioural therapy as secondary interventions mirror the findings of the primary intervention category.

In a meta-analysis of randomized controlled trials on interventions, both cognitive behavioural and behavioural interventions indicated a positive effect on the treatment of chronic low back pain.³² This was not taken to mean that the pain is not real or physical, but that tension, stress and anxiety all exacerbate physical symptoms and can serve to prolong LBP. The cognitive behavioural approach assumed that individuals are active processors of information and that thoughts can have an impact on physiology or can drive behaviour. With that in mind, the researcher recommended that patients can learn coping skills, and should be active participants in treatment. Additionally, the authors of the study advocate for the increased prominence of psychological treatment in low back pain.³³

Regrettably, educational interventions were not as successful. Tveito et al. reviewed 31 publications that resulted from 28 studies of low back pain interventions. They found that educational interventions had no effect on sick leave, cost of LBP, or level of pain. ³⁴

Physical Environment - Lumbar Supports

Mirroring the results of the primary intervention section, back belts were shown ineffective in preventing new episodes of low back pain, reducing sick leave and costs, or having an effect on levels of pain.³⁵

Physical Environment - Work Station Redesign and Ergonomics 

One recommendation stemming from the literature is the use of workplace redesign and the employment of ergonomics. For example, one randomized clinical trial of 130 workers who had been absent for six weeks due to LBP had an increased chance of staying at work if given an ergonomic redesign. Ultimately, total days lost dropped to 67 days from 131 days. ³⁶

Combination Interventions

Snook conducted a literature review on secondary interventions for low back pain. Results were that changes to worker rotation schedules, reduced lifting loads and ergonomic redesign reduced the total days lost due to low back pain from 60.9 to 1.1 days. ³⁷

Shaw, Linton and Pransky found that exercise and training for workers with LBP, influenced both the short- and long-term effects of low back pain.³⁸ ‘Short’ was defined as six months and one year, while long-term was 10 years. Of two groups studied, one group was sent to back school, while the second group had both physical training and back school. Both groups were given pre- and post-intervention questionnaires, whose answers were evaluated. Group two, with a combination of interventions, fared better in both time-frames: at the one-year mark, it had decreased both self-reported pain and disability. At 10 years, upon self-assessment, group two had significantly better results.

Tertiary Interventions

Tertiary interventions are, by their nature, the last-resort measures that are taken. Given that there are numerous workers suffering from chronic low back pain, many of whom might still be able to return to the workplace or who need assistance in their return to work, this is a valid and important area of study.
 
Evidence suggests that different strategies be employed for the varying phases of low back disability. There are three phases: the sub-acute phase, the acute phase and the chronic phase. The sub-acute phase of LBP is the “golden hour for preventing low back pain disability”.³⁹ The sub-acute phase of LBP is defined as being off work for more than one month due to LBP. A precise management strategy to optimize the “golden hour” is unclear from the literature reviewed. This may be an area for further research.

In the acute phase of LBP, if there is no specific diagnosis by a physician, then employees are encouraged to employ reassurance and to return to activities that are possible, including work.

Shaw, Linton and Pransky argue that the chronic phase is seen as the most challenging, and would probably not occur if properly managed at the sub-acute phase. ⁴⁰ The seriousness of the chronic phase is illustrated by some staggering back-to-work statistics. If it takes four to 12 weeks to return to work, there is a 10-40% risk of still being off work in one year; if treatment takes one to two years; it is unlikely the worker will ever return to work. ⁴¹ There is plenty of evidence to suggest that the longer workers are away from work, the lower their chances of ever returning to work.

Health Habits - Exercise

In the series Back to Basics, the Workers’ Compensation Board of Alberta provided information for employees about LBP. The publication stated that most back problems are not due to an injury or disease, but that soft tissue back pain is most easily and successfully treated with physical activity.⁴²

Physical Environment - Work Station Redesign and Ergonomics

In one study on the effectiveness of ergonomic interventions, for when a worker goes back to work after low back pain,⁴³ the researchers found that ergonomic interventions were often late in arriving and followed a great deal of sick leave. The two-year study, conducted in 2004, considered 1,631 workers who had been away for three to four months on sick leave, although there was no control group. The workers were from Denmark, Germany, Israel, Sweden, the Netherlands, and the United States. Overall, the study determined that adapting the workplace was effective in helping workers upon their return to work, and that the adaptation of job tasks and working hours were effective after a period of more than 200 days of sick leave.

A population-based randomized clinical trial⁴⁴ showed that sub-acute back pain management, including rehabilitation and job modifications, sped up back-to-work by a factor of 2.4. Also, functional status improved and pain levels were reduced. In this same study, early identification was set at the equivalent of four weeks’ absence from regular work. With regard to the methodology used for the job modifications, a multidisciplinary team including an occupational medicine physician, ergonomist, supervisor, and union representative, made recommendations to the employer.

Personal Resources - Communication

One study showed moderate evidence that improved communication has positive effects on disability claims, despite the findings of one uncontrolled study in British Columbia. There, hospitals had reduced long-term disability due to LBP from 7.1 to 1.7% by increasing communication between worker, the occupational health team, the supervisor and the primary health care professional. ⁴⁵

Citing an Australian public health intervention that used media such as television and radio, as well as billboards, to communicate and improve awareness of low back pain, the result was a decline in the number of claims for back pain, days lost due to back pain, and medical payments for back pain claims.⁴⁶

Personal Resources - Training

Another tertiary intervention recommended in the literature was the training of supervisors. In an uncontrolled study, the training of management and supervisors on the nature of back pain resulted in a positive acceptance when it occurred; more pointedly, this intervention demonstrated that after three years, lost time due to low back pain was reduced by 32% and the cost of compensation claims was reduced by 90%.⁴⁷

In terms of whether extra time spent teaching victims of low back pain about their condition helps, one study⁴⁸ reviewed 24 different types of patient education programs designed to teach people about low back pain. The outcome measures included pain, function, and return to work. The study found that people who received an in-person patient education session lasting two hours, in addition to regular care, had better outcomes than people who received just regular care. However, those suffering from long-term LBP (chronic phase discussed above) were less likely to benefit from individual education sessions. The study concluded that it was unclear which type of ‘education treatment’ is most effective and recommended further research to validate results.

Personal Resources - Work-facilitated Treatment

A study of therapeutic interventions used when a worker already has LBP took place in 2001.⁴⁹ A randomized trial showed that the recommendation of continuing usual activities, where possible, was more effective in resolving the back pain and facilitating the return to work, than two days of bed rest or formal exercises.⁵⁰ Further, there was little evidence on the efficacy of rehabilitation interventions in the chronic phase of LBP. The most success in the literature was found in sub-acute phase of low back pain. Randomized clinical trials showed that workers in the sub-acute phase of LBP who submitted to graded exercises, which were closely linked to the worker’s job, took less sick leave, and had less reoccurrences than those submitted to usual healthcare. Perhaps tellingly, a randomized clinical trial showed that giving reassuring explanations about their back pain reduced the duration of workers’ absences by half.
 
Finally, an evaluation of chiropractors using spinal manipulation therapy for low back pain
set the objective of testing if clinical care administered by chiropractors improved patient outcomes versus family physician directed care.⁵¹ In this randomized and controlled study, however, the time to return to work could not be accurately determined due to the small number studies. However, it was found that clinical practice did improve patient outcomes.

Musculoskeletal Disorder

In the case of Musculoskeletal Disorders (MSD), the research was very industry-specific; that is, it targeted specific professions with specific tasks, and made recommendations preventing musculoskeletal disorders in that specific profession.

Musculoskeletal Disorder interventions will be categorized by primary, secondary and tertiary, as was the case for low back pain. Most of the research we found was weighted toward what to do only after the problem had occurred , and nothing was found on tertiary interventions that are evaluated.

A Comprehensive Approach: Engineering versus Administrative Control

Prior to considering the evaluated interventions for specific professions, it is instructive to first look at one study on prevention interventions against musculoskeletal disorder that endeavoured to utilize an ‘umbrella’ overview of prevention measures. This article explained the two main controls that exist for MSD hazards.⁵² These are engineering and administrative controls, which can be used separately or be combined.

Engineering controls include the modification of workstations, provision of new tools or equipment to reduce demands, change in the tools or equipment used to do the work, or modification of the production process. For example, this can include the use of lifting and carrying devices, providing for height-adjusted bins, tables, etc.

Administrative controls are designed to reduce the exposure of workers to MSD hazards, such as the development of policies, procedures, work schedules, staffing levels, training, etc. Examples include policies and procedures for tool and equipment use, inspection and maintenance, the rotation of physical demands, varying job content, training, scheduling breaks, reducing shift length, or redesigning workload such as making a one-person lifting job a two-person job.

Ultimately, administrative controls change the way work is done and not the physical work environment; therefore, they don’t eliminate hazards but they can reduce musculoskeletal disorders. In this manner, administrative controls are similar to secondary interventions since they help modify the response of the employee to the stressors present in the workplace. Engineering controls are similar to primary interventions in that they seek to address the source of the risk in the physical environment.

This is, however, not exclusive, since secondary interventions may also include modifications to the physical environment once a problem has been detected, i.e. as a reactionary measure. Additionally, administrative controls can be established to prevent further occurrences from happening; for instance, by developing a health and safety policy. Interestingly, in our report we did not come across any administrative controls that have been proven to prevent musculoskeletal disorders.

According to the Occupational Health and Safety Council of Ontario, engineering controls are preferred over administrative measures because they address musculoskeletal disorders at the source and rely less on workers to choose safe practices. ⁵³ These are viewed as often being the most cost-effective route to take over the long run because they do not require continuing administrative costs. However, a combination of both administrative and engineering controls is often preferred, such as a dual approach of training plus workstation adjustments. ⁵⁴

Primary Interventions

Physical Environment - Handling Equipment

As stated, some of the primary interventions were industry- and task-specific. For example, one study⁵⁵ sought to determine the risk of musculoskeletal disorders and fall-related injuries to drywall finishing workers when they were using a mechanical drywall finishing system. The study was of the drywall plastering task using mechanical tools and traditional hawk and trowel methods. In this study, the drywall mechanical tool was found to be a superior tool for applying drywall joint compound.⁵⁶ On average, there was a three-fold increase in productivity found when employing the mechanical tool. The large difference in productivity was consistent with the findings of a previous study. The increase in productivity when using the mechanical tool was determined to be positive because it allowed for greater rest periods between work tasks, which in turn could decrease fatigue and the risk of musculoskeletal disorders.

The British Columbia Institute of Technology (BCIT) developed a device to provide support while using a jackhammer, with the express purpose of reducing MSI.⁵⁷ Evaluators found three benefits of using the device: 1) more productivity between rest periods; 2) increased ratio of work to rest; and 3) the ability to apply greater force to the work surface. In the end, MSD strain was reduced when using the device because less weight was needed to be supported by workers, tools could be gripped less tightly, and workers were able to maintain balance in high-risk work environments. It was recommended to use the tool when the jackhammer was used for more than one hour, or when using it in overhead positions.

Another study found that the use of rebar tying machines⁵⁸ reduced awkward positioning in the back, wrist and arms when rod workers worked with the machine. Yet another⁵⁹ found that the impact on drywall workers’ musculoskeletal disorders was reduced when they used a pneumatic drywall finishing system. A third study on the use of power-line maintainers’ gloves found that, as glove class increased, performance decreased at the same time that effort increased and self-rated comfort and fit decreased. It recommended the use of class 1 or 0 gloves instead of class 2, safety permitting.⁶⁰

Physical Environment - Work Station Redesign and Ergonomics

Meanwhile, the Institute for Work and Health undertook several studies of primary interventions, including a meta-study⁶² of participatory ergonomic interventions. In this study, nine of 10 studies reported that participatory ergonomic interventions were positive on health outcomes, while one study reported no change. For the purposes of this study, participatory ergonomics is defined as “the involvement of people in planning and controlling a significant amount of their work activities, with sufficient knowledge and power to influence both processes and outcomes in order to achieve desirable goals.”⁶³ This often involves an intervention team consisting of employers and employees, and combining internal and external knowledge of ergonomics and training. Finally, health outcomes in this study were defined as MSD symptoms. This approach was also found to have a positive impact on the reduction of injuries and the number of worker compensation claims.

The Institute for Work and Health study on upper extremity MSD health argues that there is strong evidence that using only workstation adjustments has no effect on upper-extremity musculoskeletal health. The adjustments included changes to computer work-stations in office environments. ⁶⁴ The study also found moderate evidence to suggest positive effect of arm supports in reducing muscle loading in the upper extremity. Alternate keyboards, new chair, rest breaks had limited evidence on a positive effect.

The Occupational Health and Safety Council of Ontario is firm in pointing out that personal protective equipment is ineffective for most MSD hazards. Back belts, wrist supports and splints are not recommended or effective for preventing MSD, according to the study.⁶⁵

Social Environment - Work Processes

Another specific occupation targeted to prevent musculoskeletal problems is that of sign language interpreters.⁶¹ The author of an occupational health and safety guide specifically directed at practitioners in this profession recognizes that many professions have their specific ‘occupational health syndromes’. In the case of interpreters, musculoskeletal disorders in the hands, arms, neck, shoulders and overall upper body are common. The new guide, Occupational Health and Safety for Sign Language Interpreters, updates and expands upon the Resource Guide RSI for Sign Language Interpreters (Association for Visual Language Interpreters of Canada (AVLIC), 1995). Mentioning current musculoskeletal injury prevention guidelines for interpreters, which recommend a total weekly and daily proportions not exceeding 50% active signing ‘hands in the air’ time, with bouts of continuous signing limited to 90 minutes, the author makes further recommendations such as a team approach and shorter work bouts interspersed with rest. Ultimately, further research is recommended to determine the best preventative options for people in this profession.  

Secondary Interventions

Health Practices - Exercise

While exercise was not identified in the primary literature, as was the case for low back pain, it has been identified as an effective intervention to mitigate the effects of MSD symptoms. The Institute for Health and Work found that exercise has a positive effect on the intensity of neck symptoms and shoulder pain. ⁶⁶

Another systematic review of injury/illness prevention and loss control programs, summarizing literature review findings on the efficacy of interventions, by the Institute for Health and Work⁶⁷ found that exercise has a positive effect on MSD symptoms. ⁶⁸

Personal Resources - Training

Most training interventions had no effect on MSD symptoms, except exercise training. The majority of studies found that job stress training, biofeedback training, or cognitive behavioural training has little effect as a secondary intervention. Biofeedback training has no effect on the subjective discomfort scores in forearms, hands or the shoulder and neck. Job stress management likewise had no effect on the level of pain in the neck and upper extremity, or on symptom severity. However, four studies on exercise training had a positive effect for musculoskeletal symptoms.⁶⁹

These findings mirror the results for low back pain, with the exception of cognitive behavioural therapy that was successful as a secondary intervention for low back pain. This inconsistency would benefit from further research. 

Social Environment - Work Schedule

The Institute for Work and Health, in their review of interventions to protect the upper extremity from MSD, found that rest breaks had a positive effect on MSD symptoms. Of the four studies included that met methodological standards, three concluded with positive results. Rest breaks had a positive effect on symptoms in the neck, right shoulder, upper arm, wrist, forearm and left shoulder/upper arm, but there was no effect on discomfort in the neck or shoulder or incidences of sick leave for neck/shoulder and upper arm/forearm, wrist, hand, or fingers. ⁷⁰

Physical Environment - Work Station Redesign and Ergonomics

Participatory ergonomics seem to have a positive effect on MSD. An objective systematic literature review of participatory ergonomic interventions (PE) considered 442 articles, of which 23 met relevancy requirements and methodological rigour standards. The findings were of moderate evidence that participatory ergonomic interventions have a positive impact on musculoskeletal symptoms, a reduction in injuries and WCB claims, and lost days from work and sickness absence. ⁷¹

Likewise, another literature review found that participatory ergonomics had a positive effect on lost-time injury rates and manual handling lost-time injuries. In terms of broad-based musculoskeletal injury prevention program (MIPP), there was a positive effect for combined spine and shoulder disorder, upper back disorder and lower back disorder scores, but no effect on neck disorder or shoulder disorder scores. ⁷²

In contrast to the above two reports, a literature review conducted by the Institute for Work and Health found no effect of participatory ergonomics on the pain severity of shoulder/upper arm and forearm/hand. ⁷³

In addition to participatory ergonomics, other studies have evaluated the effects of ergonomic programs established in workplaces. For instance, Cole et al. evaluated the efficacy of a workplace ergonomic program to reduce musculoskeletal disorder in newspaper employees.⁷⁴ Employing pre- and post-study surveys that included 433 participants, the ergonomic program included employee repetitive strain injury training, a pro-active assessment of workstations and modifications, and encouraging early treatment via on-site physiotherapy. Altogether, 69% had RSI training and 56% had workstation adjustments. The results saw a reduction in reports of moderate or worse pain to 16% from 20%. Tellingly, stable or increased supervisor awareness, and concern about repetitive stress injury (RSI) were associated with decreased pain. Increased time spent mousing was associated to an increase in disability. Contrary to the many findings mentioned above, there was evidence found to support the use of back belts to reduce low back pain, or to prevent time loss due to LBP.

Another workplace of interest for many studies on musculoskeletal disorders is offices, given the large number of people employed in white collar work that requires use of a computer, sitting, and constant looking at a computer screen. A 2006 IWH report⁷⁵ focused both on musculoskeletal disorders and visual symptoms and disorders related to office work. Of 7,000 studies, only 31 studies met methodological scrutiny.⁷⁶ In this particular report, moderate evidence of no effect was found for workstation adjustment on either MSD or visual outcomes. Moderate evidence was found that rest breaks and exercise during the breaks had no effect on MSD outcomes. There was moderate evidence found that alternative pointing devices had a positive effect on MSD outcomes.  It is to be noted that these are aggregate results representing a number of different devices, including the trackball and alternative mouse. There was mixed evidence that ergonomics training, arm supports, alternative keyboards and rest breaks had an effect on MSD outcomes. As well, there was mixed evidence that screen filters have an effect on visual outcomes. Finally, all moderate evidence suggests the need for more research with high-quality methodology, the authors concluded.⁷⁷

More specific workstation modifications have also been found to be successful in combating MSD symptoms. For example, new chairs had a positive effect on neck and shoulder pain severity. ⁷⁸ Another example is the use of alternate mouse devices and arm supports.

One study looked at 206 engineers over the period of one year, with a control group. The objective was to determine the effects of alternate mouse devices and forearm supports on upper body discomfort scores and the development of musculoskeletal issues and problems. The group with forearm support had a reduction in symptoms of discomfort, versus those who did not have the support. The group with the alternate mouse had a somewhat, but not significant, effect on the incidence rate and a non-significant effect on the reduction of discomfort. The recommendations for engineers who use a computer for more than 20 hours per week was that forearm support may reduce discomfort in the right upper extremity. ⁷⁹

A similar study confirms these findings. In an editorial review paper summarizing the growing knowledge about what works to prevent work injuries⁸⁰, Conlon et al. show the importance of forearm supports in reducing musculoskeletal symptoms. Other researchers had similar findings in a 12-month follow up study, and found no effect after six weeks. This indicated that a six-week follow-up may be too short for the intervention to take effect; only at seven months did the researchers see improvement. For alternative mouse devices, Conlon found no effect, while another study by reported positive effects. Amick⁸¹ calls for more research on alternative mouse devices.

In a further look at specific white-collar professions, a study of 182 call centre computer workers included control groups and spent one year studying the efficacy of trackball and armboard use on upper body pain severity and the incidence of MSD. The use of an arm board was found to have a protective effect for neck and should disorders, and the use of an arm board (vs. the control group) also resulted in a reduction in pain. ⁸²

Changes to workstations (visual display terminal) to reduce MSD discomfort were part of another study.⁸³ The improvements were specifically tailored to each employee; indeed, most were on-the-spot adjustments while some required new furniture. After one year, these actions led to a reduction in discomfort in the wrist/hand (57%), low back (43%), and neck/shoulder (41%).

Physical Environment - Handling Equipment

In terms of low back pain, the Institute for Work and Health also studied interventions in health care settings, given the amount of physical work and heavy lifting that health care professionals are required to do in a given day. ⁸⁴ It was found that, after a 36-month intervention, multi-component patient handling had a positive effect on handling injury incidence. In another two studies, after a 12-month period, it had no effect on self-reported low back pain and workers’ compensation claims injury rates. Multi-component handling included policy change, equipment purchase and training on equipment usage, and patient handling.

Combination Interventions

Three studies on the combination intervention of rest breaks and exercise had positive effects on the mitigation of MSD. Likewise exercise and ergonomics training was found to have a positive effect on the prevalence of neck pain in the previous seven days, but there was no effect found in shoulder pain in the previous week. ⁸⁵

Ergonomics training plus workstation adjustment produced limited evidence of a positive effect. An interesting finding was that there was no effect for adjustment used alone, but that it worked when combined with the training. ⁸⁶ In a similar study employing control groups, researchers evaluated the efficacy of ergonomics training and the use of adjustable chairs for office workers.⁸⁷ The one-year intervention found that adjustable chairs combined with training resulted in reduced symptoms after 12 months. No effect was found in the group that had only training. The study concluded by recommending implementation of both training and the chair together.

Tertiary Interventions

Finally, there were no evaluated interventions found for musculoskeletal disorder and disability management and/or return to work. This gap indicates a need for further research in this area, because it is highly likely that there are many cases out there who could not be helped by prevention interventions but who had to leave work due to MSD. A study of evaluated tertiary interventions would add greatly to this important field of study. Given that a number of universities have formed multi-disciplinary teams to study musculoskeletal disorders, it is likely that further studies about tertiary interventions will be forthcoming.

Limitations and Recommendations

Based on the methodology employed for this section, 34 resources were included. Of the 34, six were either authored by or sponsored by a provincial government or a worker compensation board. Two of these publications were literature review and four represented new intervention studies. The Workers’ Compensation Board of Alberta and WorksafeBC each published two reports included in this review. The remaining two were produced by Ontario organizations.

Twenty-one of the 28 non-governmental publications were academic literature reviews. Eighty-six percent of these literature reviews (18 / 21) used methodological rigour in choosing the studies that would form part of their analysis. They excluded studies that were not randomized and controlled. When compared to the two literature reviews sponsored by government organizations, the latter did not indicate their selection criteria.

Recommended research includes more studies on the value of exercise as a primary intervention for low back pain. Determining what organizations can do to facilitate physical activity in the workplace in a cost effective manner would be highly useful to Canadian organizations.

A useful research endeavour may consist of a manual for organizations and employees on what procedures to follow in each phase of low back pain. Providing managers with tools that they can employ in discussion with their employees at each stage of the injury may help prevent and reduce the number of disability claims and days off work due to low back pain.

In the musculoskeletal disorder literature, ergonomics and workstation redesign dominated secondary interventions. It is curious that while these interventions are conceptualized as engineering controls, they are more often employed after an employee has shown symptoms. Further research should focus on how engineering controls may be of added value as a primary intervention that prevents conditions from developing. Furthermore, the literature is lacking exploration on the transferability of successful interventions between industries.

Additionally at the primary level for both low back pain and musculoskeletal disorders, more research should explore the use of cognitive behavioural therapies. There is growing evidence that this type of intervention is successful. However, are the proper outcome measures being employed? For instance, measuring reduced self-reported incidents may not be the correct measurement if the therapy alters employees’ perceptions of their condition. Unintended effects may result in employees no longer recognizing a problem, even if they suffer from one. This may exacerbate the challenges of early detection and treatment, especially for low back pain which seeks to optimize the “golden hour” sub-acute back pain phase.

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The Social Environment Avenue of Influence on Workplace Health

We found the following six social environment sub-risk categories in our scan of the needs and risks facing Canadians. They include: 1) overworking, 2) non-standardized work schedules, 3) absenteeism and presenteeism, 4) job insecurity and precarious employment, 5) job strain, and 6) bullying. Each category has descriptive statistics describing the risk category itself. This is followed by risk indicators and relationships found in the literature, categorized by the avenues of influence on workplace health.

Please note that the sources referenced in brackets can be located in Annex 2.

Avenue of influence on workplace health : 2 - Social Environment

Sub-risk category	2.1 - Overworking
Descriptive Indicators	13.3% of Canadian workers are overworked, i.e. more than 2,400 hrs/year (9) 9.9% work long or very long, i.e. 2,300 to 2,700 hours/year (8) Highest work hours per year is in oil and gas industry (8)
Risk Indicators and Relationships	Physical Environment - injuries / diseases Bad health highest among hi-lo workers, (at least one year with more than 2,400 hours and at least another year with fewer than 1,750 hours): 19.7% compared to 15.6% of regular hour workers (9) Long hours linked to increase in injury for men (11) Personal Resources - psychological disorder and anxiety If under-worked, less than 30 hours, more susceptible to depression (7) (0.35) 23% of accommodations, for people with disabilities in the workforce, needed reduced work hours (20)
Sub-risk category	2.2 - Non-standardized work schedules (part time and shift work)
Descriptive Indicators	30% of Canadians do shift work (16)(0.108) Non-standardized work schedules (shift and weekend) are 55% protective agencies, 42% in food services, 47% in eating and drinking places, 37% in transportation, 36% in health services (0.100) 1/6th of the full time labour force and ½ of part time labour force in North America work shifts (0.100)
Risk Indicators and Relationships	Physical Environment - injuries / diseases Shift workers have increased risk of chronic conditions (15) Male workers with evening, rotating or irregular shifts increase chances of having at least one new chronic condition within a 5-year study gap (15) Most common health complaints: lack of sleep, cardiovascular disease, hypertension, gastrointestinal disorders (15) Risk of injuries increases (11) Increased frequency of shift work increases severity of fatigue (0.77) Social Environment - job strain Part-time workers more likely to report high job strain (0.78) 40% of men who work evening shift have job strain; 29% for rotating shifts and 17% for regular shifts (16) 40% of women who work evening shift have job strain; 45% for rotating shifts, and 29% for regular shifts (16) Personal Resources - stress Part time and casual jobs are factors causing stress in women, especially in the retail and trade sectors (0.89) Women working irregular shifts are more likely to have high personal stress than regular shifts (15) Weekend and non-fixed schedules increase levels of emotional exhaustion (0.40) Significant correlation between shift work and stress compared to regular schedule (0.78) Weekend work employees report higher levels of emotional exhaustion, job stress and health problems (0.100) Shift work employees report higher emotional exhaustion, job stress and health problems (0.100) Night shift workers in winter display greater distress than in the summer (0.108) Personal Resources - psychological disorder and anxiety Part-time workers more likely to report prevalence of psychiatric disorders and anxiety (0.83) After two years of working evening shifts, there is increased psychological distress (15) Rate of depression increases for evening and night workers compared to day schedule workers (0.35) Shift workers suffer from increased sleep disturbance in the summer, and depressive symptoms and mental health issues in the winter months (0.108) Personal Resources - burnout Shift-work employees reported higher levels of burnout (0.100)
Sub-risk category	2.3 - Absenteeism and Presenteeism
Descriptive Indicators	Increase rates from 1997 to 2003 (2) From 1997 to 2006, part-week absences have more than doubled; full week absences rose by 1/3rd (1) High-risk groups Workers aged 35+ have 1.5 times likelihood to be on leave; as workforce increases this will increase overall absenteeism rate (12) Workers with osteoarthritis twice as likely to have high absenteeism compared to non-arthritic workers (0.68) Most days off taken by health sector employees, with 13 days lost; nurses with 15.4 days (2)
Risk Indicators and Relationships	Personal Resources - psychological disorder and anxiety Major depression represents a significant risk factor for absenteeism among workers with chronic pain (0.62) Depressed workers three times more likely to be absent from work for chronic pain compared to non-depressed workers (0.62) Depression and anxiety more associated to presenteeism than absenteeism (0.71)
Sub-risk category	2.4 - Job insecurity and Precarious employment
Descriptive Indicators	n/a
Risk Indicators and Relationships	Physical Environment - injuries / diseases Job insecurity leads to a small increase in risk of neck pain (0.94) Personal Resources - psychological disorder and anxiety Low level of job security for men associated with an increased risk of major depressive episode (0.3) Men in high demand and low control, who report high stress due to job insecurity, are more likely to have had a major depressive episode (0.86) Female and male workers who report high stress in job insecurity and social support are positively associated to having an anxiety disorder (0.86) Personal Resources - stress Precarious employment associated to increased rates of stress due to insecurity and transformation of work content (0.75)
Sub-risk category	2.5 - Job strain *this sub-risk is also sometimes characteristic of personal resources
Descriptive Indicators	High risk groups: Job strain more prevalent among women (0.78) Workers between 18 and 24 more likely to report high levels of job strain compared with workers aged 40-54 (0.78) Processing, manufacturing, sales and services have highest rates of job strain (0.78)
Risk Indicators and Relationships	Physical Environment - injuries / diseases High levels of job strain increase the risk of neck pain (0.94) High job strain paired with low decision latitude increases neck and shoulder symptoms (0.52) Back pain associated with job strain (0.51) High psychological demands and low skill discretion independently associated to non-clinically diagnosed pain and discomfort (0.44) Modest but significant effect on increased blood pressure in men and women (0.38) Personal Resources - psychological disorder and anxiety Increase in job strain significantly associated to increase risk of major depressive episode among men (0.3) Job strain risk factors include high psychological demands and low decision latitude (0.38) Men with job strain 2.5 times more likely to have experienced depression and to report new cases of depression (0.78) Workers with arthritis and job strain report difficulty balancing multiple roles and psychologically accepting their disease (0.97) Personal Resources - job satisfaction Women with job strain are four times more likely to be dissatisfied with their jobs than women with low job strain (0.78) Personal Resources - stress Women with job strain are twice more likely to find work stressful compared to women with low job strain (0.78)
Sub-risk category	2.6 - Bullying
Descriptive Indicators	n/a
Risk Indicators and Relationships	Verbal abuse and work being undermined are related to reciprocal forms of bullying (0.49) Belittlement bullying associated to self-doubt and indirect or passive coping mechanisms (0.49) Verbal abuse related to problem-solving coping behaviour (0.49)

Social Environment Intervention Case Study

Sub-risk category: 2.2 Non-standardized work schedules (part-time and shift work)

Shift Work

There was an overwhelming bias in the results for strategies to address the health concerns of shift workers. The recommended interventions can be clustered into two groups: What can be done by 1) the organization, and 2) the employee.

1) Organizational Interventions:

At the organizational level, the employer can offset the health effects caused by shift work by altering the design of shift schedules, ensuring the physical workspace is appropriate, providing facilities for healthy lifestyle choices, and offering training and orientation.

Environment - Schedule Design

Schedule design is described by the Canadian Centre for Occupational Health and Safety as the most effective way of reducing the health and safety risks to shift workers.⁸⁸ The employer can alleviate health risks by way of schedule design, by considering the length of shift rotation, the direction of rotation changes, time between shift rotations, duration and frequency of rest breaks, and providing flexibility to employees.

Recommended speed of shift rotation should either be very short (every 2 to 3 days) or long (every 1 to 2 months). In the very short scenario, the body does not have time to adapt to the new sleep cycle and there is less accumulated sleep loss. In the long shift rotation, employees also have time to adapt to the new circadian cycle; however, there may be more sleep loss felt by the employee. Employers should avoid weekly rotations. This is because the body cannot adapt to the new schedule and there is time for a significant amount of accumulated fatigue to be felt.⁸⁹

In relation to the direction of rotation changes, adjustments should be forward-moving (day to afternoon to evening to night). This facilitates the body’s adaptation to a new sleep cycle. Since the human circadian clock is longer than 24 hours, workers appear to adjust faster to phase delays than to phase advances in the cycle.⁹⁰ As such, employers should avoid backward moving alterations to shift schedules.⁹¹

The recommended time between shift rotations is a 24-hour rest period. ⁹² However, the more consecutive night shifts there are in the previous shift, the more time should be allocated to rest before the next rotation. Studies show that recovery from night shifts is two days, since the worst sleep is experienced on the first day off after a night shift. ⁹³ Providing for some free weekends each month is also recommended not only for adequate rest, but also to maintain social relationships and the social support of shift workers. ⁹⁴

David et al. studied the effects of shift work on older workers and recommend a rest period between 12 to 16 hours between successive shifts for this demographic of the workforce. They additionally concluded that a one- or two-day rest period between shift rotations be factored into the shift design of older workers. ⁹⁵ This is due to the internal circadian synchronization that is not as resilient in older workers.⁹⁶

Shift flexibility was found to help role overload and the ability of employees to engage in physical activity. Role overload is defined as being overwhelmed by the multiple roles individuals take on in their lives, e.g. as a worker and as a parent. Shift workers given schedule flexibility were 30% less likely to suffer from role overload. ⁹⁷ Christina Loitz studied the impact of shift work on physical activity and found that active shift workers had greater scheduling flexibility. These workers were more able to find time to exercise regularly and used the flexibility in their schedule to participate in physical activities.⁹⁸

Environment - The Physical Work Space

The physical design of the workstation is also cited as a strategy for mitigating the effects caused by shift work. Appropriate lighting and ventilation are cited as integral to night shift working.⁹⁹ Boivin and James recommend that employers provide a work environment that is as bright as possible.¹⁰⁰

Studies have also been conducted on the type of lighting best suited for shift workers. Boivin and James studied the effects of phototherapy on full-time night shift workers and concluded that the use of phototherapeutic lamps can help mitigate the health effects of circadian disruption.¹⁰¹ Goh et al. found that the colour of light in the workplace is a factor affecting the body’s production of melatonin. According to their study, dim green light is preferable since it is better able to suppress melatonin than red light.¹⁰²

Employees can also benefit from positioning work stations closely, for social interaction.¹⁰³ Employers should avoid isolating shift workers from one another in the workplace.¹⁰⁴

Environment - Alertness and Injuries
There have been several studies to suggest that napping during night shifts, also referred to as “night-time napping”, increases performance and employee alertness. There is, however, some discrepancy in the literature on the recommended optimal duration of a night-time nap.
Purnell et al. studied the effects of a 20-minute nap on night shift aircraft maintenance engineers’ performance and alertness. Their results showed an increased speed of response on a vigilance task at the end of the shift compared with not taking the nap. ¹⁰⁵

Goh et al also found that naps between 30 and 50 minutes, when taken in the early hours of the morning during a night shift, improved employee alertness.¹⁰⁶ Similarly, a NASA study found that long-hour workers had increased performance by 34% and alertness by 54% after having taken a 40-minute nap during their shift.¹⁰⁷

Takeyama et al. found that introducing naps between 60- to 90- minutes in paramedic night shifts improved performance.¹⁰⁸ Additionally, studies show that night shift employees working long shifts benefitted from a 2- to 4-hour nap. It not only improved their mood, but also their performance on the job.¹⁰⁹

Takeyama et al. elaborate on the variables that may account for the differences in optimal length. They explain that individual differences can account for variance in the benefits of night-time napping. For instance, this may include the ease at which a worker can fall to sleep, their age, etc.¹¹⁰ Swenson et al., while studying correctional officers, found that this type of work requires a great deal of alertness and imposes considerable risk. As such, the workers’ in this industry tend to fatigue faster than other occupations and require more rest interventions.¹¹¹

Health Practices - Facilities for Health Promotion and Daycare

Organizations can also ensure facilities for healthy lifestyle choices are available to their employees. This includes cafeterias with nutritious food options and areas in the workplace for rests/breaks.¹¹²

Other sources also advocate that organizations provide quality day care services for shift workers, especially those working nights.¹¹³ The Canadian Women’s Health Network explains that less than 6% of daycare centers in Canada close after 18h00, which makes access to quality child care difficult for parents working irregular work schedules.¹¹⁴

Personal Resources - Education and Training

Employers who provide education and training on the health and safety of shift work to their employees can offset many health risks caused by shift work.¹¹⁵ Swenson et al. found that training on effective sleep, health and safety, and family challenges, reduced turnover by 10%.¹¹⁶ The Middlesex London Health Unit advocates that attendance at education sessions on shift work be mandatory for all employees.¹¹⁷

Wilson et al. examined if training in work-life balance helped to reduce the work-to-family and family-to-work conflicts of shift workers. These conflicts occur when the demands and stress in one sphere of life spill over into another. Results showed that family involvement in the training process was pivotal for success. Few training programs reviewed were successful without family support¹¹⁸

Personal Resources - Work-life Balance initiatives

Lochhead and Stephens from the Canadian Labour and Business Centre conducted a literature review of best practices using case studies from the plastics sector. In relation to shift work, they found that effective policies for helping work-life balance include: limiting split shifts, providing notice of shift changes, permitting employees to trade shifts with one another, and consulting with employees when preparing the schedule.¹¹⁹

Wilson et al. examined if training in work-life balance helped to reduce the work-to-family and family-to-work conflicts of shift workers. The researchers found that family involvement in the training was the key to success. Few training programs reviewed were successful without family support.¹²⁰

Williams, Statistics Canada, found that full-time shift workers were more satisfied with their work-life balance when their spouse worked full-time, compared with part-time or not in the labour force. Shift workers given schedule flexibility were 30% less likely to suffer role overload.¹²¹

Personal Resources - Job Strain: Job Demand and Control

Employers can mitigate the job strain of shift workers by increasing the task variation of employees, by providing decision-making autonomy and ensuring that direct supervisors are supportive.¹²²

A concrete strategy to enhance decision-making autonomy, recommended in the literature, is to include staff in the scheduling process. Employers that commit to a strong two-way communication on shift design elements can mitigate health risks and work-family conflicts. This includes providing advance notice of shift schedules and engaging staff prior to proposed schedule changes.¹²³

It was additionally found that within the nursing occupation, nurses who self-reported strong perceptions of career development suffered less from the adverse effects of shift work.¹²⁴

2) Individual level Interventions:

At the individual level, the literature suggests that employees can make healthy lifestyle choices that can help mitigate some of the adverse health effects of shift work. This includes optimizing sleeping conditions, establishing patterns for sleep, proper diet and physical activity. 

Environment - Sleep Conditions

Most resources advocate that employees ensure restful sleep conditions at their home. Strategies include “shift-proofing” their homes and sleep area. Shift workers can modify their bedrooms to ensure there is as little light as possible, that it is well-ventilated and that there are no potential disruptions in sleep.¹²⁵ This last condition can be accomplished by unplugging the phone, using ear-plugs, and discussing sleep schedules with others that share the home. Finally, Swenson et al. explain that people sleep best at temperatures between 68 and 72 degrees Fahrenheit (20.5 to 22 degrees Celsius). ¹²⁶

Health Practices - Diet, Exercise and Routine Resting

Diet is very important to the health of shift workers and their ability to maintain regular sleep patterns. The Canadian Centre for Occupational Health and Safety recommends that night shift workers eat lightly during their shift and have a moderately sized breakfast before their sleep period. This will limit digestive problems and avoid workers being too hungry while sleeping during the day. In contrast, it is optimal for afternoon shift workers to eat their primary meal in the middle of the day, instead of during their shift. ¹²⁷ Swenson et al. state that shift workers often have poor diets due to their irregular shifts. As such, they emphasize lighter meals and healthier foods be consumed, particularly before rest periods. ¹²⁸

Shift workers engaging in frequent physical activity were found better able to cope with shift work. Regular exercise improves the body’s stamina to fatigue and improves the quality of sleep during the primary rest periods of shift workers. It was not found to help mitigate the immediate effects of fatigue. ¹²⁹

In addition to exercise and diet, it is recommended that employees establish wake and rest routines.¹³⁰ This involves setting up a pattern for the primary sleep period and pre-shift naps. Taking a nap before a night shift is called a “prophylactic nap.” ¹³¹ These types of naps have been proven to help offset fatigue associated with shift work.¹³²

Pregnant Shift Workers

Lambton County Community Health Services Department specifically targets healthy pregnancies in shift workers. They recommend strategies for the employees, including reducing all other risk factors, taking rests during breaks, considering reduced hours, and making use of less stressful ways of commuting. ¹³³

Part-time Strategies

There was very little in the irregular schedule literature that proposed strategies aimed at part-time workers. Only one article emerged that addressed some of the concerns facing the majority of part-time workers. The three remaining articles reflected the use of part-time work as a strategy to mitigate work-life conflict.

McComb et al. recommend four strategies for managers of part-time workers in the service sector: 1) recognize that part-time workers are not a homogeneous group, 2) improve task variation and significance; increase control and feedback, 3) invest in training opportunities, and 4) include part-timers in the organizational culture and events.¹³⁴

On the other hand, Corwin et al. describe strategies for professional part time workers who have chosen part-time employment to mitigate work and family overload. Self-reported successful part-timers communicated their work-life priorities to management and made arrangements to protect time at work and at home. They additionally sought out champions within the organization to protect them, communicated the reason for their work arrangement with colleagues, and made efforts to maintain networks.¹³⁵

Following the work-life balance theme, Hill et al. explored how “new-concept” part time (NPT) employment impacts the work-life fulfillment of women professionals with small children. Their study showed that NPT mitigated work-to-family conflict but did not change the family-to-work strain.¹³⁶ On the other hand, Tremblay found that what employers offer as flexible work arrangements to their employees to balance work and family life are often another source of strain. Tremblay hypothesizes that this paradox may result from a difference in the perception of flexibility between employers and employees.¹³⁷

Limitations and Recommendations

Based on the methodology employed for this section, 25 resources were included. Twenty-five is smaller than we expected, given the needs identified in section III of the scan. This is especially true given that we extended our cut-off date to 2000 and included literature reviews and promotional materials produced by the government that did not explicitly state they were reflecting evaluated material.

Of the 25 sources, 10 were publications produced by government and regional health authorities, or funded by government sources. Eight of those 10 publications addressed interventions in a section of a larger report. These larger reports focused on work-life balance, the health of nurses, new workers and changing working conditions, as well as more generic workplace health promotion reports.

Of the remaining 15 publications from academia, only two had included the topic as part of a larger report. Six of the 13 academic studies, based solely on shift work or part-time work, were reviews of previous research and thus did not include an original intervention evaluation. Four of the seven academic studies that evaluated an intervention had used a control group in their study design. All but one had used statistical analyses before making their conclusions.

These findings may be indicative of two scenarios. First, the methodology employed for this section may not be optimal for finding strategies that addressed the workplace health risks caused by non-standardized work schedules. Secondly, there may be a lack of research on interventions addressing the health needs of non-standardized schedule workers.

In the first scenario, recall that we began with a search employing “strategies”, “initiatives”, “interventions” AND “non-standardized work schedules”, “part time”, and “shift work” as keywords in seven databases, including: Medline, Current Contents, Global Health, PsychINFO, SCOPUS, EMBASE, Canadian Research Index. We then complemented these results with a search through the 360 Canadian academic researchers found in section I of the scan. We searched through federal, provincial and territorial websites, health promotion resources on the Canadian Centre for Occupational Health and Safety website, and reviewed publications found in part I of the scan produced by workers’ compensation boards, unions and the voluntary sector. We finished with a Google search employing the same key words used for the database search. We reviewed the top 100 hits, representing the first 10 pages of 10 sources per page.

We welcome other researchers or organizations to build on this work in an attempt to find a comprehensive list of interventions that address non-standardized work schedules. We are also receptive to dialogue on how to improve our search methodologies to provide Canadians with the most comprehensive reviews.

If the second scenario is correct and our methodology is not at fault, then another possible conclusion for the lack of resources found is the absence of research on interventions for the shift-work and part-time workplace health needs and risks. Since just under half of our sources addressed the topic as part of a larger report, perhaps this is indicative that it is not getting enough attention in the research community. Additionally, based on our findings in the academic sector, more emphasis should be placed on developing a sound methodology for analysis of interventions, such as including a control group.

Based on our findings related to the general interventions, we encourage the further collection of information in each sub-area identified. For instance, at the organizational level, we suggest an exploration of the optimal nap length for shift length and an exploration of how organizational interventions differ across occupations. Recommended research for the individual level interventions include, among others, the determination of what types of food are best to consume before primary rest periods and how long before the rest period they should be eaten.

Bibliography

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21. Swenson, D. X., D. Waseleski, and R. Hartl, (2008). Shift work and correctional officers: Effects and strategies for adjustment. Journal of Correctional Health Care, 14(4), 299-310.
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The Personal Resources Avenue of Influence on Workplace Health

Five sub-risk categories were identified in the personal resources section of the scan. They include: 1) co-worker and supervisor support, 2) decision latitude, 3) stress, 4) psychological disorder and anxiety, and 5) burnout. Each category has descriptive statistics describing the risk category itself. This is followed by risk indicators and relationships found in the literature, categorized by the avenues of influence on workplace health.

Please note that the numbers in brackets located at the end of each statistic indicate its source, as numbered in Annex 2.

Avenue of influence on workplace health : 3 - Personal Resources

Sub-risk category	3.1 - Co-worker and Supervisor support *this sub-risk is also sometimes characteristic of the social environment
Descriptive Indicators	32% of workers in Canada report low co-worker support (0.78) One in six workers in Canada report low supervisor support (0.78)
Risk Indicators and Relationships	Physical Environment - injuries / diseases Low support increases risk of higher blood pressure (0.38) Good relationships with co-workers increases the return to work following an injury (0.112) Workers with arthritis with high levels of co-worker support have better mental health (0.53) Social Environment - job strain Supervisor support serves to deter stress and job strain (0.21) Social Environment - work to home conflicts Support from family and supervisor avoid work-family conflict (0.45) Personal Resources - job satisfaction Access to support is the most significant empowerment factor related to job satisfaction (0.27) Personal Resources - psychological disorder and anxiety Lack of support at work significantly related to depression (0.3) Low social support and conflicts at work associated with high psychological demands in correctional officers (0.5) Workers who suffer from depression were more likely to report low co-worker support (0.35) Co-worker support positively associated to mental disorders in men and women (0.86) Women who perceived high stress in social support more likely to report a major depressive episode (0.86) Low co-worker support increased likelihood of being absent from work if suffer from depression (0.35)
Sub-risk category	3.2 - Decision latitude *this sub-risk is also sometimes characteristic of the social environment
Descriptive Indicators	High risk groups: Women feel have less decision latitude than men, with 47.9% (6) Women have higher psychological demands and low decision latitude compared to men (0.78) Youth highest demographic group to feel low decision latitude, with 62.5% (6)
Risk Indicators and Relationships	Physical Environment - injuries / diseases Low decision latitude combined with high job demands associated with neck pain in women (0.51) Higher job control associated with higher levels of physical activity and increased self rated health status (0.79) Personal Resources - psychological disorder and anxiety High psychological demands combined with low or high decision latitude were associated with psychological distress (0.5) Workers who report high demand and low control more likely to have mental disorders (0.86) Higher job control associated with lower levels of psychological distress (0.79)
Sub-risk category	3.3 - Stress
Descriptive Indicators	25% of Canadians say work day quite a bit stressful (6) 5.4% Canadians say work day extremely stressful (6)
Risk Indicators and Relationships	Physical Environment - injuries / diseases Risk factor for developing chronic pain or discomfort (0.44) If job stressful, female workers twice at risk of injury (11) Women who reported their work was extremely stressful were three times more likely to be injured on the job (0.87) High stress predisposes an injured worker to chronic disability from low back pain (0.112) If stressed, workers are 2.4 times more likely to have absenteeism (9) Social Environment - overworking Overworked Canadians report most stress -more than 2,400 hours/year (9) Hi-lo workers have 50.5% rate of stress compared to 37.6% of standard hour workers - hi-lo is one year with 2,400 hours and one year with fewer than 1,750 hours (9) Social Environment - non-standardized work schedules Irregular shifts are determinants of stress (0.55) Social Environment - work-to-home conflicts 55% of people managing care-giving and work felt stressed and had positive association to increase of hours (13) Social Environment - job strain Increased risk of stress when imbalance of effort and reward (0.6) Personal Resources - psychological disorder and anxiety High work stress significant risk factor for major depressive episode (0.83) High stress associated with mental disorders in both men and women (0.86) Workers reporting that most work days stressful more likely to have had a depressive episode in the last year (0.35) Psychological demands of work and workplace harassment are determinants of stress (0.55) Personal Resources - burnout stress is related to burnout and job satisfaction (0.101)
Sub-risk category	3.4 - Psychological Disorder and Anxiety
Descriptive Indicators	3.7% of workers aged 25-64 had depression episode in previous year: 79% of these said it interfered with work (7) 15-20% of the Quebec workforce experiences psychological distress and depression (0.107) From 1987 to 1998 in Quebec all occupations, except upper managers, show increase in psychological distress (0.107) High-risk groups: Twice as likely for women than men (7) White collar and sales/service jobs more likely than blue collar (7) Semi-qualified blue collar workers have a 43% greater risk of suffering from psychological distress compared to upper managers in Quebec (0.107)
Risk Indicators and Relationships	Physical Environment - injuries / diseases Positive correlation between chronic pain and depression (0.61) Workers with rheumatoid arthritis are more likely to be depressed compared to the general population (0.53) Social Environment - job insecurity Increased risk for major depressive episode if elevated levels of job insecurity (0.82) Predictor of psychological distress includes job insecurity (0.56) Social Environment - schedule of work More likely to be depressed if work less than 30 hours, than if work more than 40 hours (7) 13% of workers who had depressive episode in previous year, took at least one day off in past two weeks (7) Social Environment - work to home conflicts Work-to-family conflict independently associated to mood and anxiety disorders (0.85) Personal Resources - decision latitude Increased risk for major depressive episode if elevated decision authority (0.82) Predictors of psychological distress include greater decision authority (0.56) Low decision authority and high psychological demands risk factors for depression (0.61) Personal Resources - co-worker and supervisor support Increased risk for major depressive episode if lack of support at work (0.82) Predictor of psychological distress includes support at work (0.56) Personal Resources - stress Work stress is a risk factor for depression (0.61) High work stress is a significant risk factor for major depressive episode (0.83) Work stress independently associated to mood and anxiety disorders (0.84) High psychological demands are the strongest predictor of major depression (0.61)
Sub-risk category	3.5 - Burnout
Descriptive Indicators	15-20% of the Quebec workforce experiences burnout (0.107) High risk groups: Self-employed workers more likely to report burnout and emotional exhaustion than workers employed by organizations (0.41)
Risk Indicators and Relationships	Social Environment - workload and perceived fairness Workload and perceived fairness strongly correlated to level of burnout (0.36) Demanding work, time constraints and work overload associated to burnout (0.36) Personal Resources - co-worker and supervisor support Professionals with high social support experience lower burnout than those with low support, regardless of stress level (0.109) Low support associated to burnout (0.36) Burnout associated to support at work (0.64) Personal Resources - decision latitude Significant relationship between lack of empowerment and burnout and emotional exhaustion (0.72) Control strongly correlated to level of burnout (0.36) Personal Resources - stress Burnout associated to work stress (0.64) Burnout and stress in professionals significantly related to absenteeism, low job satisfaction, intention to quit and maladaptive coping (0.109)

Personal Resources Intervention Case Study

Sub-risk category: 3.4 Psychological Disorder and Anxiety

Interventions that address the needs and risks associated to Psychological Disorders and Anxiety in the workplace are categorized by target group and intended objective. 

Interventions for different target groups are classified as universal (intended for the entire working population), selective (targeted at high-risk groups), and indicated (for workers who already display symptoms).¹³⁸ Although the interventions are separated in this manner, the universal or organization-wide initiatives are also of significant benefit to workers already suffering from a mental illness. Employees with mental illness will thus be beneficiaries of all three approaches, while employees without mental illness will profit from a healthy workplace and a reduced chance of developing a psychological problem in the future. The fact that work-related stress is one of the primary risk factors for depression is a clear illustration of this point.

In addition to the target, interventions are also categorized by objective. There are three categories of intended objectives: primary, secondary and tertiary. Primary interventions are proactive measures that attempt to prevent the causes of psychological distress in the workplace. These strategies address the sources of psychological distress in an organization. Secondary interventions seek to provide employees with tools that enable them to adjust their responses to stressors in the workplace. Finally, tertiary interventions are reactionary, often involving rehabilitation and return to work initiatives.¹³⁹ Ideally these three strategies should operate collaboratively. Issues identified from secondary and tertiary interventions should feed into the primary prevention strategies.

Universal strategies are primary because they target the root of psychological distress in the workplace. Selective and indicated interventions are secondary and tertiary since they provide employees at high risk or with pre-existing conditions with tools to help offset the stressors at their work.

For the purpose of this review, interventions will be categorized by:

1. Universal interventions targeting the sources of psychological distress in the workplace, and
2. Selective and indicated interventions seeking to arm employees with tools to modify their responses to stressors in the workplace.

A Comprehensive Approach: Individual versus Organizational Interventions:

There is some debate in the literature if the best approach to workplace interventions is individually or organizationally focused. Universal, primary interventions are organizationally focused, while selective and indicated strategies aimed at modifying responses to stressors are individually focused.  

Seymour and Grove, for instance, argue that individually focused strategies like skill development have more robust evidence supporting their efficacy compared to organizational or social environment interventions.¹⁴⁰ They further state that individually based strategies are more effective than combined or “multi-modal approaches”.¹⁴¹ Multi-modal approaches are those that combine personal resource development and changes to structures in the social environment.

Richardson and Rothstein also found that “single-modal” skills development initiatives were more effective than “multi-modal” approaches in their literature review. They propose that this could be due to the difficulty organizations have to implement multiple interventions at the same time in an effective manner. They support this hypothesis based on their observation that multi-modal interventions employing simple interventions are more effective than complicated ones.¹⁴²

Terri Krupa reviewed mental health and disability literature between 1990 and 2005. She describes the organizational interventions or changes in the social environment as “far less developed and researched than individual interventions”.¹⁴³ Lamontagne et al. observe similar findings but for organizational outcomes. They argue that the indicators used to evaluate individually-focused interventions like skills training are most often individual health reports, not organizational indicators such as absenteeism rates. When they did encounter skill training interventions that used organizational indicators, there were no effects found. Similarly, the results from skill based training on self-health reports were often short-term gains disappearing over time. ¹⁴⁴ This suggests that used alone, individually targeted approaches may not address the underlying issues causing the psychological strain.

Some researchers support this hypothesis, that simply focusing on the development of coping skills, i.e. personal resources, will not act as a long-term solution without also addressing organizational measures for reducing or preventing environmental stressors.¹⁴⁵ Focusing solely on the individual employee removes the responsibility of the employer and may result in faulting the employee rather than looking to environmental factors that may cause or exacerbate pre-existing conditions. 

It is thus encouraging to observe that many combined strategies have been successful. Lamontagne et al characterize these as “systems approaches” and after reviewing 90 interventions have found that they are the most effective due to their targeting the sources of stress in the workplace.¹⁴⁶ Similarly Jordan et al, in their article reviewing 74 interventions, state “it is no longer viable for employers to consider the management and prevention of work-related stress as a matter that should be resolved at the individual level alone”.¹⁴⁷ Jordan et al advocate a combination of work-related and worker-related interventions. 

The Australian Government, in their article on preventing psychological injury, likewise argues that individual-level interventions do little to address the sources of work-related strain present in the workplace. They argue that a combined approach, employing both organizational and individual level interventions, is the most effective and sustainable way to address psychological strain and improve organizational performance.¹⁴⁸

While the selective/indicated strategies develop individual level coping skills, and the universal approaches target the root causes at an organizational level, a comprehensive approach implementing both will garner the best health outcomes for employees and organizations.

Universal Primary Interventions: Promoting Mental Health

Mental health is defined as a “positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnections and personal dignity”.¹⁴⁹ The intervention literature that emerged from our scan includes studies on the improvement of mental and psychological health, and the management of work-related stress.

Social Environment - Work Schedule and Job Design

Features of the work environment, including work schedules and the way work processes are designed, play a large role in the psychological well-being of employees. Many studies have shown that modifications to these factors have a positive result on mental health.

For instance, Hurrell conducted a literature review of the impact of these organizational features on work-related stress. He found that changes to workload, schedules, work processes and procedures, were consistently an effective choice for employers. What he describes as “socio-technical changes” have the ability to target and eliminate the cause of stressors on the employee.¹⁵⁰

Likewise, in a comprehensive literature review, Harvey et al. found numerous studies to suggest that changes to the work environment can produce tangible improvements in the performance and well-being of employees.¹⁵¹ Cited in multiple sources of their review, changes to work schedules and work demands were effective at reducing psychological strain and often had an immediate impact on employees.¹⁵²

While the details of these changes are not always forthcoming and often unique to each workplace, Giga, Cooper and Faragher do provide tangible examples in their study on interventions targeting organizational policies and practices. Included were interventions of selection, placement and job re-design.¹⁵³ Selection and placement interventions are changes to the process with which the employer selects individuals to ensure that they are a good fit for the job description, based on stress and job demand indicators. This likewise applies to potential employees who should be alerted to the expectations of the job and determine if it is reasonable for them. Ensuring that both the employee and employer are finding a “good fit” may alleviate psychological strain in the future.¹⁵⁴ Job re-design interventions are promoted for reducing job strain in the workplace. They include designing positions to have some significance for employees, providing education and training opportunities, and setting realistic goals and deadlines.¹⁵⁵

Personal Resources - Job Strain: Job Demand and Control

Opportunities for control, decision latitude and task discretion can also address the psychological strain on employees in the workplace.¹⁵⁶ Bourbonnais and Gauthier found that an organizational intervention, combining strategies to address psychological demand, recognition, social support and decision latitude, had a positive influence on mental health.¹⁵⁷ Concretely, the interventions included stabilizing working teams, clarifying roles and responsibilities, reinforcing team work, and delegating tasks to members of work teams according to their competencies.¹⁵⁸

Another study found that improving job control, by reorganizing work conditions, favoured employee discretion and choice. This one-year intervention resulted in better mental health outcomes as well as reduced sickness-related absences.¹⁵⁹ In addition to individual health benefits, increasing employee job control can also result in favourable organizational outcomes including a reduction in absenteeism and turnover rate, and improved productivity and team performance.¹⁶⁰

Personal Resources - Supervisor and Social Support

Interventions employing social and supervisor support in the workplace have been proven to reduce strains to psychological health. Rousseau et al. observed that high quality leader-member exchange and work group integration increases the self-reported well-being and psychological health of correctional officers.¹⁶¹ Leader-member exchange is defined as mutual respect and trust between the immediate supervisor and the employee. Supervisors provide resources and remove constraints to ease work-related stress. Work group integration is the perceived quality of the relationships an employee has with co-workers.¹⁶²

Bourbonnais and Gauthier also found social support interventions to be effective in improving mental health outcomes at work. By organizing regular team meetings, improving communication and strengthening team work, workers of two participating hospitals had self-reported improvements.¹⁶³

Personal Resources: Training

Many authors agree that an effective intervention relating to psychological and mental health is providing training. These include mental health and illness literacy programs, and group-based skills training sessions. Arguably, these interventions may be perceived as secondary due to their objective of providing employees with tools to adapt their responses to stressors in the workplace. For instance, Brun et al. observed that after 15 years of education initiatives by way of training and conferences in four different organizations, absenteeism rates for psychological health had not decreased. They suggest that while training is an important intervention, it does not focus on the organizational sources of mental health problems in the workplace.¹⁶⁴

While this may be the case, training intended for the entire organization is arguably proactive and can have positive results for employees who have yet to display any mental illness symptoms. For instance, group-based education programs, including conflict management, communication and relaxation, were found to reduce the frequency of employees reporting depressive symptoms in emergency personnel following a three-year intervention.¹⁶⁵

Training can also be employed as an effective means of implementing and engaging employees on recommended changes in other avenues of workplace health that do address the root causes of psychological strain. 

An illustration of this point is described by Michie et al. in their review of six studies employing a training intervention. They found that successful training programs focused on increasing participation in decision-making and problem-solving, thereby increasing social support, and strengthening feedback and communication mechanisms in the organization.¹⁶⁶ Not only did they observe an increase in psychological health, but also a reduction in absenteeism due to sickness.

Another example was observed by Giga et al. They found instances of training focussed on new work methods and concrete ways of reducing stress in work operations. These initiatives included training on managing schedules and conflicting priorities, which results in reducing the strain felt by employees in the workplace.¹⁶⁷

Health Practices - Exercise

Seymour and Grove found little evidence to support the claim that physical activity prevented mental health problems in the workplace. They did, however, cite a study where positive effects were observed for the prevention and management of stress.¹⁶⁸

Combination Interventions

There are several studies that evaluated combination interventions. Most included two if not all three avenues of influence on workplace health, including: Personal Resources, the Environment, and Health Practices.

Brun, Biron and Ivers studied the efficacy of seven interventions over a period of 12 to 18 months. Interventions were determined by risk factors in each unit participating in the study. Successful interventions included combined approaches, including personal resources training in mental health, communication and teamwork, social environment factors including reorganization of work hours and processes, as well as health promotional activities such as the establishment of a physical activity club.¹⁶⁹

Kompier et al. reviewed 13 case studies of workplace interventions among urban transit drivers. They found that a combination of strategies had positive effects on employee health, well-being and job satisfaction. Successful strategies included a range of interventions: team based work, improved communication, training on stress management and conflict resolution, and the promotion of healthy lifestyle choices.¹⁷⁰

There were more studies that observed combinations of personal resources and social environment initiatives without including the promotion of healthy practices. This mirrors the lack of research we found in the health practices avenue of influence on workplace health.

Bourbonnais et al. reviewed an organizational intervention employing training sessions, team support, and regular team meetings, increasing decision latitude and improving communication systems. The results after a one-year intervention strategy resulted in decreased work-related burnout, but did not affect the frequency of sleeping problems.¹⁷¹

Larocque et al. also reviewed an intervention using combined personal resources and social environment practices. After an 18-month intervention period establishing recognition and evaluation procedures, enhanced communication, making worker positions permanent, and offering training conferences, workers’ self-reported psychological distress decreased.¹⁷²

Legault observed similar strategies targeting workload, role clarification and recognition in an intervention for employees of a youth centre. Legault found that after two rounds of initiatives spanning four years, there were improvements in psychological health at work.¹⁷³

We also found one study that did not find improvements in psychological health following an intervention of improved communication, role clarification, management training and reduction in work load. While changes to self-reported psychological health were not significant, Brun did observe noteworthy improvements in general well-being indicators including harassment at work, decision latitude, job security, and stress related to workplace decisions.¹⁷⁴ It is interesting that improvements in the well-being indicators that were previously shown to have a positive effect on mental health, did not impact the psychological health of employees in Brun’s study. One explanation may be that the change in well-being indicators was an illustration of short-term effects.

Indicated and Selective Interventions: Coping with Mental Illness

Mental illness is “characterized by alterations in thinking, mood, or behaviour - or some combination thereof - associated with significant distress and impaired functioning.”¹⁷⁵

Before implementing secondary and tertiary interventions, employers first need to identify workers with pre-existing conditions or who are at risk of developing a mental illness. One method is to establish routine screening strategies. While screening is described as a valuable tool for the early identification and diagnosis of employees,¹⁷⁶ there is little guidance in the studies we reviewed on how this should be implemented in a safe and respectful way. Gregory Couser likewise observes that “general screening endorsements leave employers with much latitude and difficult decisions to make.”¹⁷⁷ Many factors remain unanswered, including the recommended scope, tools and techniques for implementing a respectful and cost-effective screening process.

One process followed by the National Institute of Mental Health Harvard Work Outcomes Research and Cost-Effectiveness Study is to include depression screening questions in a pre-existing workplace health survey. Workers who screened positively in the survey were subsequently contacted for a second phase telephone interview specifically on depression, using the Quick Inventory of Depression Symptoms Self-Report telephone interview. ¹⁷⁸

Personal Resources - Training

Workplace training has been proven to help mitigate the impacts of depression at the workplace. In employees with pre-existing conditions or signalling early warning symptoms, individually focused training programs have been effective. 

Psycho-education is one type of training program offered in the workplace for individuals. It includes building resiliency and skill development for workers screened as high risk or having a pre-existing condition. Examples include effective problem-solving, improving communication and social skills, coping skills, and building support systems.¹⁷⁹ There were also numerous studies showing the effectiveness of stress management training on depressive symptom outcomes.¹⁸⁰

Self-awareness training provides opportunities to employees with, or at risk of developing, a mental illness to learn more about their health condition. Employers who offer information sessions on illness and disability increase the employee’s awareness of themselves and the changes they may be observing in their lives. Greater understanding also enables employees to increase their level of control over their work situation.¹⁸¹ As mentioned in a prior section, increasing control has been shown to alleviate psychological strain.

Benefits and disclosure training are two additional types of education programs relevant to employees with pre-existing conditions. Krupa explains that benefits training enable employees to navigate the often complex process of accessing health and disability benefits. Disclosure training is also useful to employees with pre-existing conditions. Within the context of personal rights and the use of workplace accommodations, this training arms employees with the necessary tools to reveal aspects of their illness to managers and co-workers.¹⁸²

Finally, training can also facilitate the return to work process. “Workplace-hardening” training is offered by some organizations to simulate work related tasks in increasingly difficult scenarios. These exercises fortify the cognitive, psychological and emotional functions of an employee off work due to depression. It can additionally act as a gauge of a worker’s readiness to return to work.¹⁸³

Personal Resources - Stress Management

Stress management interventions are cited as the most significant workplace strategy for depression.¹⁸⁴ This is most likely due to the significant impact that stress has on the onset and continuation of depression. These types of interventions span across several avenues of influence on workplace health. The two most prominent in the stress management toolbox are personal resource skill development and social support, as well as job design in the social environment. 

In this sense, a lot of stress management approaches seek to be both primary and secondary interventions. For example, in one study the organization performed a stress needs analysis to identify the causes of stress in the workplace and subsequently implemented a management program unique to the needs of factory workers. The result was a reduction in depressive disorders and absenteeism related to illness.¹⁸⁵

Other stress management approaches targeting depression include areas previously mentioned in this review: training, social support, job redesign and treatment options like cognitive behavioural therapy (discussed in the next section).

Bilsker et al. reviewed targeted actions to reduce stress in the workplace, thus impacting the frequency of depression symptoms. They observed interventions ranging from stress reduction training, conflict management sessions and job redesign.¹⁸⁶ Another intervention study employing six training sessions on social support and conflict resolution produced a decline in depressive symptoms in 1200 caregiver workers in a residential facility.¹⁸⁷ Finally, an intervention including job redesign and coping training resulted in lower absenteeism rates and reduced depression symptoms.¹⁸⁸

Gregory Couser reviewed a controlled study employing a psychological and physiological treatment in the workplace. The combined two-hour stress management workshop and two-hour muscle relaxation session resulted in improved depression symptoms.¹⁸⁹ A similar study conducted on nursing students found that the combination of relaxation and coping training resulted in a reduction of depression symptoms compared with a control group that did not receive the intervention.¹⁹⁰

Personal Resources - Social Support

Building social support within the organization is one way an employer can help employees who are at risk of developing, or are currently living with, a pre-existing mental illness. While the details of these strategies are not well-developed in the articles reviewed for this scan, providing a safe and well-informed workforce will make illness disclosure easier. Managers can additionally help identify co-workers who are willing to provide support.

Mental health and illness literacy programs for work teams can be one practical way of building social support. Often when co-workers do not fully understand mental illness and the reasons for accommodation, it can result in opposition or social exclusion.¹⁹¹ These training sessions can also result in positive outcomes for co-workers who do not already exhibit symptoms. (Refer to “training” in the mental health promotion section)

Personal Resources - Work-facilitated Treatment

Work-facilitated treatment options identified by our sources include counselling as part of employee assistance programs, and work-facilitated cognitive behavioural therapy.

Preece et al. studied the efficacy of an employee assistance program (EAP) in the treatment of workplace depression. They found that while employees showed improvements after having used EAP services, they nonetheless remained impaired according to depression indicators. The authors conclude that treatment beyond an EAP is required for employees suffering from depression. ¹⁹²

Wang et al. further this argument by advocating for an enhanced depressive care model. They implemented a controlled intervention consisting of systematic screening, the use of mental health care professionals as care managers with scheduled routine supervision, and the use of structured cognitive behavioural therapy provided in person and over the telephone. The result of their study was improved clinical outcomes for employees with depression, including those with less severe cases, and increased productivity equivalent to 2.6 hours per week.¹⁹³

Cognitive Behavioural Therapy (CBT) mediated by a trained professional is a form of psycho-education that instructs workers on how to substitute negative thoughts and beliefs into positive and realistic ones. Although initial interventions include hired therapists to deliver CBT to employees, as in the Wang et al study, researchers have found that employees are able to implement the skills on their own following the sessions.¹⁹⁴

Van Der Klink et al. conducted a meta-analysis review of 48 studies between 1977 and 1996. Their study found that CBT intervention was the most successful at reducing employees’ stress-related complaints at work.¹⁹⁵ Richardson and Rothstein conducted a similar meta-analysis covering 55 interventions including only controlled studies with random assignment and control groups. They also found that the most effective interventions were cognitive-behavioural. In fact, combining this type of intervention with others, such as relaxation training, actually reduced the positive effect.¹⁹⁶

Seymour and Grove’s findings mirror those of Richardson and Rothstein. They assert that CBT is the most effective intervention for employees with common mental health problems. In fact, according to their literature review, shorter CBT sessions, defined as eight weeks or less, yield the best results.¹⁹⁷

There have additionally been successful interventions using technology to administer CBT. Computer-based programs were found to improve participation due to decreased potential for stigma and limited resources in organizations to provide hired therapists.¹⁹⁸

Environment - Job Accommodations

Krupa, in her investigation of interventions to improve employment outcomes for workers with mental illness, observed that changes to work tasks and environmental factors played a useful role in mitigating symptoms at work for employees with a pre-existing condition. While accommodations are measures unique to each individual, Krupa described some practical strategies employers can implement, including adjusting lighting, providing uninterrupted work time, providing opportunities to work from home, and dividing tasks into smaller segments to avoid overwhelming employees.¹⁹⁹

Limitations and Recommendations

The methodology employed in this section brought forward 32 articles. Again, for this section we extended our cut-off date to 2000, in order to include relevant articles. Of the 32 sources, only three were government reports. The three government reports were authored by the Australian, United Kingdom and Canadian governments on the topic of mental health and stress in the workplace. There were no sources included that addressed psychological health or illness as a section of a larger report.

The remaining 29 articles and presentations were authored by academic researchers. Sixteen of these 29 sources were literature reviews and thirteen reflected original work on evaluations of interventions. Only 30% of the original studies used a control group in their research model (four of thirteen).

There was a great deal of inconsistency found in the literature. This was true for the identification of the intervention subject and the outcome measures. Study subjects ranged from psychological health, injury, distress, mental health, mental health problems, depression, stress and workplace health. Rarely were these terms defined at the outset by the author.

Outcome measures were also inconsistently applied in the sources used for this review. Some articles addressed this question directly, and explained why they employed individually focused measures such as self-reported psychological health outcomes or organizationally focussed indicators such as absenteeism rates, disability, and compensation costs. Many studies, however, did not explain their choice of indicators or study method. 

Three articles surfaced that looked specifically at the process for implementing interventions. Cox et al. argues that we should not be simply looking at the outcome of interventions, but also the process with which it was administered. The researchers appeal to their colleagues in evaluation research to include the implementation process, since the outcome may be a combination of initiative and the way it was administered in an organization.²⁰⁰For example, Cox et al. explain the importance management support can have on the success of a workplace intervention.²⁰¹

Along similar lines, Simard, Trudel and Vézina studied the efficacy of intervention support groups. They found that these working groups contributed to the mobilization and participatory process.²⁰² In another study looking at the role of intervention groups in the intervention process, Gignac et al. conclude that while they are important to the participatory nature of the exercise, workers’ groups should be facilitated by trained professionals to improve and validate solutions to workplace risks.²⁰³

Karasek builds on these recommendations by reviewing the processes of 19 intervention studies. He found that different kinds of interventions were more successful with worker participation and others excelled when led by experts. When interventions involved task and work restructuring, the most effective were implemented by a worker participation process. On the other hand, when engaging in large-scale work reorganizations, expert-led initiatives resulted in the best outcome.²⁰⁴

We recommend more process-oriented research on both the evaluation of and the intervention itself. This includes improved consistency and validation of subject definitions and outcome variables, as well as investigation into the recommended length for an intervention before claims of success or failure can be drawn. Finally, do different interventions succeed for some occupations and not others? Does the nature of the work impact the success of a workplace intervention, or can these interventions be applied universally across labour sectors? These questions remain unanswered.

In addition to process, we also recommend that more interventions be evaluated. This is particularly the case for screening techniques and organizational-level interventions. Explaining what social support and job redesign practically mean for managers is another area that requires further exploration. Lastly, more research is required on secondary and tertiary social support measures, as well as the health practices avenue of influence on psychological health.

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Needs and Risk of Canadians Relative to Workplace Health

Please note that the numbers in brackets located at the end of each statistic indicate its source, as numbered in Annex 2.

Labour Sectors

Canadian labour sector 1 - Sales and Services
Sector profile	15.9% of the labour force
Physical Environment	Injuries: 27% of injuries are serious resulting in hospitalization (11) Most commonly injured body part is the hand (11) 15% of injuries are burns and scalds compared with only 6% in other sectors (11) Chefs’ and cooks’ rate of injury twice that of industry-wide average (0.87) Musculoskeletal injuries the most common among food service workers and cooks (0.8)
Social Environment	Absenteeism Second-highest absenteeism rate with 12.2 days lost (11) Canada-wide, sales and services is the third-highest time-loss injury sector (4) In Ontario, 25% of time-loss claims from 1997 to 2006 are in the sales and service sector (21) Non-standardized work schedules Highest amount of shift workers are in service sector (16) 40% of male and 41% of female shift workers in service sector (16) Work on average 1,650 hours per year - below-average work hours (8)
Personal Resources	Psychological disorder and anxiety Sales and services represent the second-highest industry prevalence for mental health issues; most significant in chefs/cooks, cashiers and cleaners (0.57)
Canadian labour sector 2 - Manufacturing
Sector profile	12.1 % of the labour force
Physical Environment	Injuries Machinists, metal formers, shapers and erectors have the highest rates of injuries in the industry (0.86) Canada -wide second highest fatality rate; most in Ontario and Quebec (5) In British Columbia, between 2002 and 2006 14.8% of claims (22) In Manitoba, top sector for claims in 2006 (20)
Social Environment	Absenteeism Canada-wide most time-loss injuries; majority in Quebec, then Ontario (4) The most time-loss injury claims in Ontario, Quebec, British Columbia, Alberta, Manitoba, New Brunswick, and Prince Edward Island are in the manufacturing sector (4) In Ontario, second-highest time loss claim sector with 15.4% (21)
Personal resources	Psychological disorder and anxiety Highest risk occupations in manufacturing for mental health include textile workers, fur and leather producers, and assembly workers
Canadian labour sector 3 - Health Care and Social Services
Sector profile	10.9 % of the labour force
Most at risk groups	Care aides, nursing aides and acute care workers Care aides have the highest injury rate in every health care setting (0.9) Care aides have highest musculoskeletal injuries due to transfer and repositioning of patients (0.9) Acute care has the highest needle-stick, sharps (any sharp instrument used in the workplace), and splash events with blood or body fluid exposure rate at 2 to 3 times higher than in nursing homes or community care setting (0.10) Nursing aides in rural nursing homes with special care units reported lower psychological demands and less job strain than nurses without special care units (0.60)
Physical Environment	Injuries:  Largest proportion of injuries across sectors, highest for care aides (2)  In Nova Scotia, Saskatchewan, and Newfoundland the most time-loss injuries are in the health and social services sector (4)  25% of nurses say they work with musculoskeletal pain most or all of the time (12)  Sector with highest proportion of neck pain claims in Ontario (0.23)  Health care workers rate of injury higher than average of all white collar workers combined (0.86) Back pain 25% of nurses suffer chronic back problems (10) 62% of lost-time claim injuries are work-related low back injury (13) 40% of nurses report back, neck, buttock pain some to all the time (12) Psychological distress predicts long-term severe functional limitations in back (0.28) 74% of work related lower back injuries due to overexertion (13) Needle-stick, sharps (any sharp instrument used in the workplace), splash injuries 48% of nurses suffer from a needle-stick accident (10) 48% of nurses involved in direct care had injuries due to contaminated needle-sticks (15) Most common injury for registered nurses are puncture and irritation injuries with 32.4% (2) 35% of nurses get infections from a hospital environment (15) Registered nurses have the highest number of needle-stick, sharps and splash events (0.10) Highest exposure rate from needle-stick and splash for laboratory assistants (0.10) Work design 70% of nurse injuries due to lifting patients (13) 80% of nurses require a lot of physical effort (6) 62.4% of nurses report high physical demands (15) Licensed practical nurses required to lift patients 84% of the time, registered nurses 76% of the time (15) 36% of nurses required to lift patients did not have access to mechanical lifts (15)
Social Environment	Absenteeism:  Majority of time loss claims across all provinces (23)  Highest rate of absenteeism across sectors (6)  Most days off, compared to other sectors with 13 days off (1)  Highest amount of days off for illness and disability (1)  Nurses take 15.4 days off and support staff with 15.3 days off (1)  61% took time off for health reasons in last year (4)  44% of nurses report missing one of more shift in past three months due to illness (12)  Nurses with job strain and work overload more likely to be absent more than 20 days (4) Harassment and bullying 40.2% of nurses assaulted by a patient (6) 29% of nurses report physical assault by patient in 2005 (13) 44% of nurses report emotional abuse (13) Job strain and high job demands associated with increased risk of assault (0.60) Higher level of training associated with lower frequency of assault (0.60) 47.2% of nurses experienced negative behaviour at least once per week, but only 18.6% labelled it bullying (0.65) Overworking Registered nurses risk of time loss claims increases by 70% if working overtime (0.63)
Personal Resources	Co-worker and supervisor support Perceived increase in social support at work reduced job stress and improved job performance (0.7) Supervisor support determinant of job satisfaction and reduced job stress (0.58) Registered nurses’ musculoskeletal claims reduced when reporting a positive relationship with physicians (0.63) Stress 67% of head nurses report extreme stress (18) Higher-than-average say ‘quite’ or ‘extremely’ stressed, 45% vs 31% (18) 36.3% of nurses report highest level of emotional exhaustion; over two-thirds report moderate to high levels (12) Psychological disorders and anxiety 1/5 of nurses report mental health reasons made workload hard to handle (15) 9% of nurses suffer from depression (10) Industry with the highest prevalence of mental health issues; largest in health support services (0.57) Burnout 45% of variation in physical and mental health in nurse managers explained by empowerment and burnout (0.46) Jobs characterized by exhaustion, cynicism, and low professional efficacy were all affected by empowerment and person-job fit (0.47) Burnout among family physicians defined as emotional exhaustion, depersonalization; perceived lack of personal accomplishment reduced with nutritious meals and spending time with family and friends (0.48) Staffing, shortfall in resources, and equipment and supplies access all predictors of burnout and emotional exhaustion in nurses (0.50) Structural empowerment for nurse managers was the strongest predictor of job satisfaction (0.46)
Canadian labour sector 4 - Construction
Sector Profile	6.7 % of the labour force
Physical Environment	Injuries, diseases and fatalities Canada-wide fourth highest in time loss injury sector (4) In British Columbia between 2002 and 2006, 12.7% of claims; general construction is the most with 11.5% of construction sector (22) In Manitoba, 21% of acute hazards in this sector were in youth (20) Canada -wide top fatalities; most in Ontario, Alberta and British Columbia (5) In British Columbia, second-highest in fatality rate, predominantly asbestos-related (22) In Alberta, top sector for fatalities between 2002 and 2006 with 34% (3) In Manitoba, 44% of occupational disease fatalities from asbestos (20) Heavy equipment operators at an increased risk to diesel exhaust particulate, resulting in increased pulmonary inflammation (0.31) Traumatic brain injury Most common for traumatic brain injury in Ontario (9) Third-highest for traumatic brain injury fatality in Ontario from 1996-2000 with 20% (17) In Ontario, most common work environment for a traumatic brain injury to occur is construction site (17)
Social Environment	Absenteeism Third-highest absenteeism rate across sectors with 11.1 days lost (1)
Canadian labour sector 5 - Transportation and Warehousing
Sector Profile	4.9 % of the labour force
Physical Environment	Injuries, diseases and fatalities In British Columbia, between 2002 and 2006, 9.4% of claims (22) Second most-likely sector to have traumatic brain injury (9) Canada -wide, third-highest fatality rate; most in Ontario and Quebec (5) 21% of occupational disease fatalities (20) In British Columbia, third-highest fatality rate; majority vehicle-related (22) In Alberta, second-highest fatality sector with 18% (3) In Manitoba, 25% of acute hazard fatalities (20) Acute hazard fatalities rose between 1995 and 2005 in Manitoba (20)
Social Environment	Second-highest absenteeism rate with 11.4 days lost (1) Indirect effect of organizational support on truck accidents because it enables better planning for routes (0.93)
Personal Resources	Psychological disorders and anxiety Highest risk sub-group in this industry for mental health include longshore workers, material handlers, and motor vehicle mechanics (0.57)
Canadian labour sector 6 - Primary Resources
Sector Profile	2.0 % of the labour force
Physical Environment	Injuries, diseases and fatalities Highest fatality rate in British Columbia between 1997 and 2006 (22) In British Columbia, most fatalities include vehicles (22) In Alberta, third-highest fatality sector with 13% (3) In Ontario between 1996 and 2000, highest rate of traumatic brain injury fatalities in mining and logging with 59.1% (17) Sector specific - sawmills and plywood manufacturing: Sawmill workers chronically exposed to noise are at an increased risk of acute myocardial infarction mortality (0.26) Most common injury is musculoskeletal and affecting the upper body (0.42)(0.43) Most claim injuries are made within one to six months on the job (0.42) Majority of claims in Alberta from workers aged between 24-35(0.42) Western red cedar saw mills at very high risk for occupational asthma (0.105) Sector specific - mining: Non-powered hand tools most involved in non-fatal injuries (0.37) Off-road and underground ore haulage most common source of fatalities (0.37) Younger workers at higher risk of injury (0.37)
Social Environment	Sector specific - sawmills and plywood manufacturing: Control and psychological demand were significantly associated to attempted and completed suicide (0.110) Risk factor for attempted suicide is lack of social support for men in sawmills (0.110) Periodic lay-offs associated to completed suicide (0.110)
Canadian labour sector 7 - Agriculture
Sector Profile	1.9 % of the labour force
Physical Environment	Injuries Falls most common injury for women farmers (17) Women more likely to have animal injury than men (0.59) Most common non-machine injury is animal-related or being caught between objects (17) 70% of farm injuries in Manitoba are in older workers (20) Younger farmers in B.C., between 20 and 49, have higher rates of hospitalization due to work (0.70) Diseases Links between pesticides and retinal degeneration (0.90) Farmers have increased risk of cancers: brain, breast, leukemia, lip cancer, lymphomas, prostate, skin, soft tissue sarcoma, cancer of the stomach (0.95) Machine injuries 80% of hospitalization rates involved men and machines (14) Most common male injury is roll over (7) Most common female injury is run over (7) 51.2% of fatalities were tractor-related in British Columbia (14) 32% of male occupational injuries are roll over with machinery; 65% with tractors (0.59) 45% of female occupational injuries are caused by being run over by machinery, 69% with tractors (0.60) Age is a significant factor in machine-related farm injuries (0.99) Tractors and harvest equipment injuries are more dominant in older farmers (0.99) Traumatic brain injury In Ontario, between 1996 and 2000, second-highest rate of traumatic brain injuries with 24.5% (17) Sector specific - swine farming Long-term swine farmers have gradual reduction in lung health (0.23) Farmers who continue in industry have superior lung function and ability to withstand exposure (0.23) Male and female swine farmers more likely to have chronic and unusual cough and phlegm compared to non-farmers, after controlling for smoking and age (0.76) Respiratory diseases Women are at greater risk for respiratory symptoms than men (0.76) Grain elevator workers had increased chronic respiratory symptoms positively correlated to the number of years in the industry (0.66) Most frequent cause of respiratory disease is confined animals inside animal housing buildings
Social Environment	Schedule of work Farmers who work less than 40 hours a week are more likely to get an injury (0.54) Farmers who work more than 50 hours have a higher risk of injury (0.90) Increased frequency of days worked a protective factor against high-risk behaviour with animals (0.80) Risk of injury decreases with age and amount of hours spent on the farm, suggesting that experience is a good prevention of injury (0.54)
Personal Resources	Psychological disorder and anxiety Industry with the highest rate of suicide (0.32) Mental health in farmers associated to physical demands of the job, structure of farming families, economic difficulties and uncertainty (0.32) Farmers with depression are less likely to employ safety behaviours on the farm (0.80) Stress Risk of injury increases with higher level of stress in both men and women (0.73) Most common source of stress is financial concerns (0.73) Women who do not supplement income off the farm are more likely to be stressed than those who work off the farm (0.73) Most stressful situations for women on farms in Saskatchewan were 45% financial problems, harvest and seeding (17%), too much work (9.5%), weather (5.2%), uncertainty (4.9%) (0.103)
Health Habits	Male farmers who used pain medication, especially narcotics, were more likely to have a subsequent injury (0.81)

Demographic

Canadian sub-group 1 - Youth
Profile	Labour sectors More likely to be in sales and service jobs (0.11) Retail trade and food services employ 80% of young workers; the other 20% employed in manufacturing and construction (0.103) Young workers over-represented in smaller firms (0.11) Schedule of work More likely to work part-time and have less than 6 months tenure (0.11)
Physical Environment	Injuries / diseases Twice as likely to suffer from burns, scalds, chemical burns, cuts, punctures, bites, scrapes, bruises and blisters (0.11) Youth suffer from upper extremity injuries, open wounds; one-eighth had head injuries (0.104) Work design and injury Adolescents report more physical exertion at work than adults (0.11) Majority of youth fatalities in Manitoba are caused by motor vehicles and contact with machinery (0.91) Youth in manual labour jobs twice as likely to have one week work disability (0.13) Majority of claims in Manitoba in manufacturing, trade, service and construction (0.91) Saskatchewan youth twice as likely to be injured compared to Ontario due to type of jobs (0.15) Work pace, overload, job tenure, work setting and supervisor attributes positively associated to increased injury rate (0.18)
Social Environment	Job strain: Workers between 18 and 24 more likely to report high levels of job strain compared with workers aged 40-54 (0.78) Schedule of work: Work hours positively correlated to frequency of heavy drinking (0.12) Youth who had high work hours and high recreational activity hours were twice as likely to sustain a medical injury (0.17) Most injuries were during the summer, weeknights and weekends, suggesting that part-time workers are more likely to be injured (0.104)
Personal Resources	Training, education and tenure 50% report no training (0.11) In mining, group most at risk for injury and those with less than five years’ experience (0.37) If less than a high school education, three times more likely to have a disability absence (0.13) Youth not in school had 43% increase of injury compared to full-time students (0.17) Decision latitude Youth largest demographic group to feel low decision latitude with 62.5% (6)
Canadian sub-group 2 - Women
Physical Environment	Physical injuries /diseases More women have repetitive strain injuries than men (5) Neck symptoms most prevalent in women (0.51) (0.52) Higher prevalence of chronic pain than men (0.61) Cancer and agriculture Farming is strongly and positively associated with breast cancer (0.95) Women farmers have an elevated risk of many different cancers, non-Hodgkins lymphoma, leukemia, breast, ovary, lung, bladder, cervix (0.95) Women who have worked in agricultural industry are three times more likely to have breast cancer (0.20) Women who have worked in agriculture and then in the automotive sector have four times the increased risk of breast cancer (0.20)
Social Environment	Schedule of work and stress Part-time and casual jobs are factors causing stress in women, especially in the retail and trade sector (0.89) Women working irregular shifts are more likely to have high personal stress than regular shifts (15) Shift work is associated with increased menstrual-cycle abnormalities (0.114) Job strain Job strain is more prevalent among women (0.78) Women with job strain are twice more likely to find work stressful compared to women with low job strain (0.78)
Personal Resources	Co-worker and supervisor support Women who perceived their social support relationships as highly stressful, were more likely to report a major depressive episode (0.86) For female professionals, high supervisor and colleague support lowers the level of emotional exhaustion, and higher feelings of personal accomplishment (0.109) Decision latitude Women feel have less decision latitude than men, with 47.9% (6) Women have lower decision latitude compared to men (0.78) Low decision latitude combined with high job demands associated with neck pain in women (0.51) Stress and injury If job stressful, female workers have twice the risk of injury (11) Women who reported that their work was extremely stressful were three times more likely to be injured on the job (0.87) Psychological disorders and anxiety Depression twice as likely for women than men (7) Twice the rate of depression in women workers compared to men (0.35) Women have higher psychological demands compared to men (0.78)
Pregnancy	Physical work demands Higher risk of preeclampsia (leading cause of maternal and perinatal morbidity) if standing at least 1 hour consecutively without walking, climbing stairs frequently, working more than 5 consecutive days without a day off (0.98) Physically demanding occupations increase the risk of preeclampsia (0.98) Demanding posture for at least three hours per day and whole body vibrations during pregnancy increase risk of pre-term delivery (0.25) Schedule of work Low support coupled with irregular hours or shift work and high psychological demands during pregnancy increase the risk of having small-for-gestational-age infants (0.24) Risk of having small-for-gestational-age infant increased with irregular (night hours) and shift work (0.24) Shift work is associated with an increase in first-trimester miscarriages, preterm deliveries, and decreased birth weight for gestational age (0.113) Night work and varying shifts associated with increased risk for miscarriage (0.113) Working longer than 40 hours/week and more than 8 hours/day increases risk of preterm births, low birth weight, small-for-gestational-age and miscarriage (0.113) Job strain Job strain combined with low or moderate social support during pregnancy increase risk of pre-term delivery (0.25) Decision latitude Preeclampsia also correlated to lack of control at the workplace and high job demand and low latitude at the onset of the pregnancy (0.98) Stress Stressful occupations increase the risk of preeclampsia (0.98)

Annex 1:

Needs of the Canadian population relative to workplace health: Search Strategy

Medline & Current Contents

1 (((new brunswic*) or (quebec*) or (ontari*) or (manitob*) or (yukon*) or (north west territor*) or (nunavu*) or (saskatchewan*) or (alberta?) or (british columbi*) or (canad*) or (prince edward island*) or (newfoundland*) or (nova scoti*) ) in ti,ab,mesh,su,de,kw) or (explode "Canada-" / all SUBHEADINGS in MIME,MJME,PT)

2 (((office* or employee* or industrial* or work* or occupation*) near2 (hygiene or health* or safe* or expos* or burnout or accident* or injur* or violence or trauma* or stress* or wellbeing or (well being) or mortalit* or death?)) in ti,ab,mesh,kw) or (("Air-Pollutants-Occupational" / all SUBHEADINGS in MIME,MJME,PT) or ("Noise-Occupational" / all SUBHEADINGS in MIME,MJME,PT) or (explode "Occupational-Exposure" / all SUBHEADINGS in MIME,MJME,PT) or (explode "Occupational-Diseases" / all SUBHEADINGS in MIME,MJME,PT) or (explode "Accidents-Occupational" / all SUBHEADINGS in MIME,MJME,PT) or ("Occupational-Health" / all SUBHEADINGS in MIME,MJME,PT) or (explode "Employment-" / all SUBHEADINGS in MIME,MJME,PT) or (explode "Work-" / all SUBHEADINGS in MIME,MJME,PT) or (explode "Job-Satisfaction" / WITHOUT SUBHEADINGS in MIME,MJME,PT) or ("Burnout-Professional" / all SUBHEADINGS in MIME,MJME,PT))

3 (explode "Health-Promotion" / all SUBHEADINGS in MIME,MJME,PT) or (explode "Stress-Psychological" / all SUBHEADINGS in MIME,MJME,PT) or ((explode "Risk-" / all SUBHEADINGS in MIME,MJME,PT) or (explode "Risk-Management" / all SUBHEADINGS in MIME,MJME,PT)) or ((risk* or hazard* or psycho* or (health promotion) or determinant* ) in ti,ab,mesh,kw)

4 ((((sex or social) adj worker?) or workshop? or ((health or safety) near2 patient?)) in ti,ab,mesh,kw) or ((rat or rats or mice or mouse or immunohisto* or patholog*) in ti,ab,mesh,kw)

((1 and 2 and 3) not 4) and py>=2004

UD Code Medline :20080321

UD Code Current Contents : 200813

Global Health (CAB Health)

1 (explode "Canada-" in BT,DE,GE,OD) or (((new brunswic*) or (quebec*) or (ontari*) or (manitob*) or (yukon*) or (north west territor*) or (nunavu*) or (saskatchewan*) or (alberta?) or (british columbi*) or (canad*) or (prince edward island*) or (newfoundland*) or (nova scoti*) ) in ti,ab,su,de)

2 (((office* or employee* or industrial* or work* or occupation*) near2 (hygiene or health* or safe* or expos* or burnout or accident* or injur* or violence or trauma* or stress* or wellbeing or (well being))) in ti,ab,su,de) or ((explode "occupations-" in BT,DE,GE,OD) or (("organization-of-work" in BT,DE,GE,OD) or ("safety-at-work" in BT,DE,GE,OD) or ("work-" in BT,DE,GE,OD) or ("work-places" in BT,DE,GE,OD) or ("work-satisfaction" in BT,DE,GE,OD) or ("work-stress" in BT,DE,GE,OD) or ("workers-" in BT,DE,GE,OD) or ("working-conditions" in BT,DE,GE,OD)) or (explode "employment-" in BT,DE,GE,OD) or ((explode "occupational-hazards" in BT,DE,GE,OD) or (explode "occupational-health" in BT,DE,GE,OD) or (explode "occupational-transmission" in BT,DE,GE,OD) or (explode "safety-at-work" in BT,DE,GE,OD)) or ("operator-comfort" in BT,DE,GE,OD))

3 ((risk* or hazard* or psycho* or (health promotion) or determinant* ) in ti,ab,su,de) or ((("health-promotion" in BT,DE,GE,OD) or ("health-protection" in BT,DE,GE,OD) or ("hygiene-" in BT,DE,GE,OD) or ("safety-" in BT,DE,GE,OD) or ("stress-management" in BT,DE,GE,OD)) or ("risk-" in BT,DE,GE,OD) or (("risk-behaviour" in BT,DE,GE,OD) or ("risk-factors" in BT,DE,GE,OD)) or (("hazards-" in BT,DE,GE,OD) or ("risk-" in BT,DE,GE,OD) or ("risk-analysis" in BT,DE,GE,OD) or ("risk-assessment" in BT,DE,GE,OD)) or ("work-stress" in BT,DE,GE,OD))
4 ((((sex or social) adj worker?) or workshop? or ((health or safety) near2 patient?)) in ti,ab,su,de) or ((rat or rats or mice or mouse or immunohisto* or patholog*) in ti,ab,su,de)

((1 and 2 and 3) not 4) and py>=2004

UD Code : 200802

PsychINFO

1 ((new brunswic*) or (quebec*) or (ontari*) or (manitob*) or (yukon*) or (north west territor*) or (nunavu*) or (saskatchewan*) or (alberta?) or (british columbi*) or (canad*) or (prince edward island*) or (newfoundland*) or (nova scoti*) ) in ti,ab,su,

2 ("Safety-" in MJ,MN) or ("Hygiene-" in MJ,MN) or ("Health-Promotion" in MJ,MN) or (explode "Occupational-Stress" in MJ,MN) or (("Risk-Assessment" in MJ,MN) or ("Risk-Factors" in MJ,MN) or ("Risk-Management" in MJ,MN)) or ((risk* or hazard* or (health promotion) or determinant* ) in ti,ab,su)

3 ("Occupational-Safety" in MJ,MN) or ((explode "Job-Characteristics" in MJ,MN) or ((explode "Occupational-Exposure" in MJ,MN) or (explode "Working-Conditions-+" in MJ,MN)) or ((explode "Occupational-Stress" in MJ,MN) or (explode "Occupations-+" in MJ,MN) or (explode "Quality-of-Work-Life" in MJ,MN) or (explode "Work-Related-Illnesses" in MJ,MN)) or (((office* or employee* or industrial* or work* or occupation*) near2 (hygiene or health* or safe* or expos* or burnout or accident* or injur* or violence or trauma* or stress* or wellbeing or (well being) or mortalit* or death?)) in ti,ab,su))

4 ((((sex or social) adj worker?) or workshop? or ((health or safety) near2 patient?)) in ti,ab,su) or ((rat or rats or mice or mouse or immunohisto* or patholog*) in ti,ab,su)

((1 and 2 and 3) not 4) and py>=2004

UD Code: 20080331

Scopus

((((((TITLE-ABS-KEY((new PRE/0 brunswic*) OR quebec* OR ontari* OR manitob* OR yukon* OR (north PRE/0 west PRE/0 territor*) OR nunavu* OR saskatchewan* OR alberta OR (british PRE/0 columbi*) OR canad* OR (prince PRE/0 edward PRE/0 island*) OR newfoundland*) OR TITLE-ABS-KEY((nova PRE/0 scoti*))) AND PUBYEAR AFT 2003) OR (TITLE-ABS-KEY(halifax OR charlottetown OR (st PRE/0 johns) OR frederickton OR montreal OR toronto OR ottawa OR winnipeg OR regina OR calgary OR vancouver OR victoria OR whitehorse OR yellowknife OR iqaluit) AND PUBYEAR AFT 2003)) AND ((TITLE-ABS-KEY((office* W/2 hygiene) OR (office* W/2 health*) OR (office* W/2 safe*) OR (office* W/2 expos*) OR (office* W/2 burnout) OR (office* W/2 accident*) OR (office* W/2 injur*) OR (office* W/2 violence) OR (office* W/2 trauma*) OR (office* W/2 stress*)) OR TITLE-ABS-KEY((office* W/2 wellbeing) OR (office* W/2 mortalit*) OR (office* W/2 death) OR (office* W/2 well W/2 being))) AND PUBYEAR AFT 2003)) AND (TITLE-ABS-KEY(risk* OR hazard* OR (health PRE/0 promotion) OR determinant*) AND PUBYEAR AFT 2003)) AND NOT ((TITLE-ABS-KEY((sex PRE/0 worker) OR (social PRE/0 worker) OR workshop OR (health W/2 patient) OR (safe* W/2 patient)) OR TITLE-ABS-KEY(rat OR mice OR mouse OR immunohisto* OR patholog*)) AND PUBYEAR AFT 2003)) OR ((((TITLE-ABS-KEY((new PRE/0 brunswic*) OR quebec* OR ontari* OR manitob* OR yukon* OR (north PRE/0 west PRE/0 territor*) OR nunavu* OR saskatchewan* OR alberta OR (british PRE/0 columbi*) OR canad* OR (prince PRE/0 edward PRE/0 island*) OR newfoundland*) OR TITLE-ABS-KEY((nova PRE/0 scoti*))) AND PUBYEAR AFT 2003) AND ((TITLE-ABS-KEY((employee* W/2 hygiene) OR (employee* W/2 health*) OR (employee* W/2 safe*) OR (employee* W/2 expos*) OR (employee* W/2 burnout) OR (employee* W/2 accident*) OR (employee* W/2 injur*) OR (employee* W/2 violence) OR (employee* W/2 trauma*) OR (employee* W/2 stress*)) OR TITLE-ABS-KEY((employee* W/2 wellbeing) OR (employee* W/2 mortalit*) OR (employee* W/2 death) OR (employee* W/2 well W/2 being))) AND PUBYEAR AFT 2003) AND (TITLE-ABS-KEY(risk* OR hazard* OR (health PRE/0 promotion) OR determinant*) AND PUBYEAR AFT 2003)) AND NOT ((TITLE-ABS-KEY((sex PRE/0 worker) OR (social PRE/0 worker) OR workshop OR (health W/2 patient) OR (safe* W/2 patient)) OR TITLE-ABS-KEY(rat OR mice OR mouse OR immunohisto* OR patholog*)) AND PUBYEAR AFT 2003)) OR ((((TITLE-ABS-KEY((new PRE/0 brunswic*) OR quebec* OR ontari* OR manitob* OR yukon* OR (north PRE/0 west PRE/0 territor*) OR nunavu* OR saskatchewan* OR alberta OR (british PRE/0 columbi*) OR canad* OR (prince PRE/0 edward PRE/0 island*) OR newfoundland*) OR TITLE-ABS-KEY((nova PRE/0 scoti*))) AND PUBYEAR AFT 2003) AND ((TITLE-ABS-KEY((industrial* W/2 hygiene) OR (industrial* W/2 health*) OR (industrial* W/2 safe*) OR (industrial* W/2 expos*) OR (industrial* W/2 burnout) OR (industrial* W/2 accident*) OR (industrial* W/2 injur*) OR (industrial* W/2 violence) OR (industrial* W/2 trauma*) OR (industrial* W/2 stress*)) OR TITLE-ABS-KEY((industrial* W/2 wellbeing) OR (industrial* W/2 mortalit*) OR (industrial* W/2 death) OR (industrial* W/2 well W/2 being))) AND PUBYEAR AFT 2003) AND (TITLE-ABS-KEY(risk* OR hazard* OR (health PRE/0 promotion) OR determinant*) AND PUBYEAR AFT 2003)) AND NOT ((TITLE-ABS-KEY((sex PRE/0 worker) OR (social PRE/0 worker) OR workshop OR (health W/2 patient) OR (safe* W/2 patient)) OR TITLE-ABS-KEY(rat OR mice OR mouse OR immunohisto* OR patholog*)) AND PUBYEAR AFT 2003)) OR ((((TITLE-ABS-KEY((new PRE/0 brunswic*) OR quebec* OR ontari* OR manitob* OR yukon* OR (north PRE/0 west PRE/0 territor*) OR nunavu* OR saskatchewan* OR alberta OR (british PRE/0 columbi*) OR canad* OR (prince PRE/0 edward PRE/0 island*) OR newfoundland*) OR TITLE-ABS-KEY((nova PRE/0 scoti*))) AND PUBYEAR AFT 2003) AND ((TITLE-ABS-KEY((work* W/2 hygiene) OR (work* W/2 health*) OR (work* W/2 safe*) OR (work* W/2 expos*) OR (work* W/2 burnout) OR (work* W/2 accident*) OR (work* W/2 injur*) OR (work* W/2 violence) OR (work* W/2 trauma*) OR (work* W/2 stress*)) OR TITLE-ABS-KEY((work* W/2 wellbeing) OR (work* W/2 mortalit*) OR (work* W/2 death) OR (work* W/2 well W/2 being))) AND PUBYEAR AFT 2003) AND (TITLE-ABS-KEY(risk* OR hazard* OR (health PRE/0 promotion) OR determinant*) AND PUBYEAR AFT 2003)) AND NOT ((TITLE-ABS-KEY((sex PRE/0 worker) OR (social PRE/0 worker) OR workshop OR (health W/2 patient) OR (safe* W/2 patient)) OR TITLE-ABS-KEY(rat OR mice OR mouse OR immunohisto* OR patholog*)) AND PUBYEAR AFT 2003)) OR ((((TITLE-ABS-KEY((new PRE/0 brunswic*) OR quebec* OR ontari* OR manitob* OR yukon* OR (north PRE/0 west PRE/0 territor*) OR nunavu* OR saskatchewan* OR alberta OR (british PRE/0 columbi*) OR canad* OR (prince PRE/0 edward PRE/0 island*) OR newfoundland*) OR TITLE-ABS-KEY((nova PRE/0 scoti*))) AND PUBYEAR AFT 2003) AND ((TITLE-ABS-KEY((occupation* W/2 hygiene) OR (occupation* W/2 health*) OR (occupation* W/2 safe*) OR (occupation* W/2 expos*) OR (occupation* W/2 burnout) OR (occupation* W/2 accident*) OR (occupation* W/2 injur*) OR (occupation* W/2 violence) OR (occupation* W/2 trauma*) OR (occupation* W/2 stress*)) OR TITLE-ABS-KEY((occupation* W/2 wellbeing) OR (occupation* W/2 mortalit*) OR (occupation* W/2 death) OR (occupation* W/2 well W/2 being))) AND PUBYEAR AFT 2003) AND (TITLE-ABS-KEY(risk* OR hazard* OR (health PRE/0 promotion) OR determinant*) AND PUBYEAR AFT 2003)) AND NOT ((TITLE-ABS-KEY((sex PRE/0 worker) OR (social PRE/0 worker) OR workshop OR (health W/2 patient) OR (safe* W/2 patient)) OR TITLE-ABS-KEY(rat OR mice OR mouse OR immunohisto* OR patholog*)) AND PUBYEAR AFT 2003))

EMBASE

1 (new brunswic* or quebec* or ontari* or manitob* or yukon* or north west territor* or nunavu* or saskatchewan* or alberta? or british columbi* or canad* or prince edward island* or newfoundland* or nova scoti*).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (49633)

2 exp CANADA/ (25182)

3 ((office* or employee* or industrial* or work* or occupation*) adj2 (hygiene or health* or safe* or expos* or burnout or accident* or injur* or violence or trauma* or stress* or wellbeing or well being or mortalit* or death?)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (70494)

4 exp Occupational Disease/ (25487)

5 exp "occupation and occupation related phenomena"/ (120424)

6 (risk* or hazard* or psycho* or health promotion or determinant*).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (923871)

7 exp "danger, risk, safety and related phenomena"/ (562990)

8 (((sex or social) adj worker?) or workshop? or ((health or safety) adj2 patient?)).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (29654)

9 (rat or rats or mice or mouse or immunohisto* or patholog*).mp. [mp=title, abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer name] (1017709)

10 1 or 2 (49633)

11 3 or 4 or 5 (151227)

12 6 or 7 (977957)

13 8 or 9 (1046240)

14 (10 and 11 and 12) not 13 (1539)

15 ..l/ 14 yr=2004-2008 (700)

Canadian Research Index

SU((office* or employee* or industrial* or work* or occupation*) w/2 (hygiene or health* or safe* )) AND (risk* or hazard* or psycho* or (health promotion) or determinant* ) AND PDN(>1/1/2004)
or
SU((office* or employee* or industrial* or work* or occupation*) w/2 (expos* or burnout or accident* or injur* or violence )) AND (risk* or hazard* or psycho* or (health promotion) or determinant* ) AND PDN(>1/1/2004)
or
SU((office* or employee* or industrial* or work* or occupation*) w/2 ( trauma* or stress* or wellbeing or (well being) or mortalit* or death* )) AND (risk* or hazard* or psycho* or (health promotion) or determinant* ) AND PDN(>1/1/2004)

Annex 2:

Needs of the Canadian population relative to workplace health: Sources Referenced

(1) Akyeampong, Ernest. (2007). Trends and seasonality in absenteeism.  Perspectives on Labour and Income, 8(6), Statistics Canada Catalogue no.75-001-XIE.
http://www.statcan.ca/bsolc/english/bsolc?catno=75-001-X20071069974

(2) Akyeampong, Ernest. (2005). Fact-sheet on work absences.  Perspectives on Labour and Income. 6(4), Statistics Canada Catalogue no.75-001-XIE.
http://www.statcan.gc.ca/pub/75-001-x/10304/5990-eng.pdf

(3) Alberta Employment, Immigration and Industry. (2007). Occupational Injuries and Diseases in Alberta: Lost-time claims, disabling injury claims and claim rates.
http://employment.alberta.ca/documents/WHS/WHS-PUB_oid_amta.pdf

(4) Breslin, F.C., and P. Smith. (2006). Trial by fire: a multivariate examination of relation between job tenure and work injuries. Occupational and Environmental Medicine, 63(1), pp. 27-32.

(5) Cole, D.C., S. Ibrahim, and H.S. Shannon. (2005). Predictors of work-related repetitive strain injuries in a population cohort. American Journal of Public Health, 95(7), pp. 1233-7.

(6) Eco-Santé Québec. (2007).  Proportion de travailleurs n’ayant pas une grande latitude de prise de décision au travail. - available in French only
http://www.ecosante.org/index2.php?base=QUEB&langh=FRA&langs=FRA&sessionid=

(7) Gilmour, Heather, and Scott B. Patten. (2007). Depression and work impairment.  Health Reports, 18(1), Statistics Canada Catalogue no.82-003.
http://www.statcan.ca/bsolc/english/bsolc?catno=82-003-X20060039566

(8) Heisz, Andrew, and Sébastien LaRochelle-Côté. (2007).  Understanding regional differences in work hours. Analytical Studies Branch Research Paper Series, 2007(293), Statistics Canada Catalogue no. 11F0019MIE.
http://www.statcan.ca/english/research/11F0019MIE/11F0019MIE2007293.htm

(9) Heisz, Andrew, and Sébastien LaRochelle-Côté. (2006).  Work hours instability in Canada. Analytical Studies Branch Research Paper Series, 2006(273), Statistics Canada Catalogue no. 11F0019MIE.
http://www.statcan.ca/cgi-bin/downpub/listpub.cgi?catno=11F0019MIE2006278

(10) Hwan, Kim, Angela Colantonio and Mary Chipman. (2006). Traumatic brain injury occurring at work. NeuroRehabilitation, 21(4), pp. 269-278.

(11) Mackenzie, Susan G., and Kathryn Wilkins. (2007).  Work Injuries. Health Reports, 18(3), Statistics Canada Catalogue no.82-003.
http://www.statcan.ca/bsolc/english/bsolc?catno=82-003-X200600910191

(12) Marshall, Katherine. (2006).  On sick leave. Perspectives on Labour and Income. 7(4), Statistics Canada Catalogue no.75-001-XIE.
http://www.statcan.ca/bsolc/english/bsolc?catno=75-001-X20061049185

(13) Pyper, Wendy. (2006).  Balancing career and care. Perspectives on Labour and Income, 7(11). Statistics Canada Catalogue no.75-001-XIE.
http://www.statcan.ca/bsolc/english/bsolc?catno=75-001-X20061119520

(14) Saskatchewan Workers’ Compensation Board. (2007).  Injury statistics.
http://www.wcbsask.com/book_statistics.page

(15) Shields, Margot. (2003).  The health of Canada’s shift workers. Canadian Social Trends, Summer 2003(69), Statistics Canada Catalogue no.11-008.
http://www.statcan.ca/bsolc/english/bsolc?catno=11-008-X20030016532

(16) Shields, Margot. (2002).  Shift work and health. Health Reports, 13(4), Statistics Canada Catalogue no.82-003.
http://www.statcan.ca/cgi-bin/downpub/listpub.cgi?catno=82-003-XIE2001004

(17) Smith, P.M., and C.A. Mustard. (2004). Examining the associations between physical work demands and work injury rates between men and women in Ontario, 1990-2000. Occupational Environmental Medicine, 61(9), 750-6.

(18) Tricco, Andrea, Angela Colantonio, Mary Chipman, Gary Liss, and Barry McLellan. (2006). Work-related deaths and traumatic brain injury. Brain Injury, 20(7), pp. 719-724.

(19) Village, Judy, David Rempel and Kay Teshcke. (2005). Musculoskeletal disorders of the upper extremity associated with computer work: a systematic review. Occupational Ergonomics, 5(4), pp. 205-218.

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0.2  P.R. Band, N.D. Le, A.C. MacArthur, R. Fang, R.P. Gallagher (2005). Identification of occupational cancer risks in British Columbia: a population-based case-control study of 1129 cases of bladder cancer. J Occup Environ Medicine, 47(8), pp. 854-8.

0.3 E.R. Blackmore, S.A. Stansfeld, I. Weller, S. Munce, B.M. Zagorski, D.E. Stewart. (2007). Major depressive episodes and work stress: Results from a national population survey. American Journal of Public Health, 97(11), pp. 2088-93.

0.4  M. Bouchard, D. Mergler, M. Baldwin, M. Panisset, H.A. Roels. (2007). Neuropsychiatric symptoms and past manganese exposure in a ferro-alloy plant. Neurotoxicology, 28(2), pp. 290-7.

0.5  R. Bourbonnais, R. Malenfant, M. Vezina, N. Jauvin, I. Brisson. (2005). Work characteristics and health of correctional officers. Revue D Epidemiologie et de Sante Publique, 53(2), pp. 127-42.

0.6  R. Bourbonnais, N. Jauvin, J. Dussault, M. Vezina. (2007). Psychosocial work environment, interpersonal violence at work and mental health among correctional officers. Int J Law Psychiatry, 30(4-5), pp. 355-68.

0.7  R.F. AbuAlRub. (2004). Job stress, job performance, and social support among hospital nurses. J Nurs Scholarsh, 236(1), pp. 73-8.

0.8  H. Alamgir, H. Swinkels, S. Yu, A. Yassi. (2007). Occupational injury among cooks and food service workers in the healthcare sector. Am J Ind Med, 50(7), pp. 528-35.

0.9  H. Alamgir, Y. Cvitkovich, S. Yu, A. Yassi. (2007). Work-related injury among direct care occupations in British Columbia, Canada. Occupational and Environmental Medicine, 64(11), pp. 769-75.

0.10  H. Alamgir, Y. Cvitkovich, G. Astrakianakis, S. Yu, A. Yassi. (2008). Needlestick and other potential blood and body fluid exposures among health care workers in British Columbia, Canada. American Journal of Infection Control, 36(1), pp. 12-21.

0.11  F.C. Breslin, P. Smith. (2005). Age-related differences in work injuries: A multivariate, population-based study. American Journal of Industrial Medicine, 48(1), pp. 50-6.

0.12  F.C. Breslin, E.M. Adlaf. (2005). Part-time work and adolescent heavy episodic drinking: The influence of family and community context. Journal of Studies on Alcohol, 66(6), 784-794.

0.13  F.C. Breslin, J.D. Pole, E. Tompa, B.C. Amick, P. Smith, S.H. Johnson. (2007). Antecedents of work disability absence among young people: a prospective study. Ann Epidemiol, 17(10), pp. 814-20.

0.14  F.C. Breslin, E. Tompa, R. Zhao et al. (2008). The relationship between job tenure and work disability absence among adults: a prospective study. Accid Anal Prev, 40(1), pp. 368-75.

0.15  F.C. Breslin, P. Smith, C. Mustard, R. Zhao. (2006). Young people and work injuries: an examination of jurisdictional variation within Canada. Injury Prevention, 12(2), pp. 105-10.

0.16  F.C. Breslin, P. Smith. (2006). Trial by fire: a multivariate examination of the relation between job tenure and work injuries. Occup Environ Med, 63(1), pp. 27-32.

0.17  F.C. Breslin, S.D. Karmakar, P. Smith, J. Etches, C. Mustard. (2007). Time allocation between work and recreation and the associated injury risks among young people. J Safety Res, 38(3), pp. 373-9.

0.18  F.C. Breslin, D. Day, E. Tompa et al. (2007). Non-agricultural work injuries among youth: a systematic review. Am J Prev Med, 32(2), pp. 151-62.

0.19  F.C. Breslin, E. Tompa, R. Zhao et al. (2008). The relationship between job tenure and work disability absence among adults: a prospective study. Accid Anal Prev, 40(1), pp. 368-75.

0.20  J.T. Brophy, M.M. Keith, K.M. Gorey et al. (2006). Occupation and breast cancer: A Canadian case-control study. Living in a Chemical World: Framing the Future in Light of the Past Annals of the New York Academy of Sciences, 1076()(pp 765-777), 2006 Date of Publication: Sep 2006 2006; pp. 765-77.

0.21  C.M. Brotheridge, R.T. Lee. (2005). Impact of Work-Family Interference on General Well-Being: A Replication and Extension. International Journal of Stress Management, 12(3), pp. 203-221.

0.22  L. Chenard, A. Senthilselvan, V.K. Grover et al. (2007). Lung function and farm size predict healthy worker effect in swine farmers. Chest, 131(1), 245-254.

0.23  P. Cote, V. Kristman, M. Vidmar et al. (2008). The prevalence and incidence of work absenteeism involving neck pain: a cohort of Ontario lost-time claimants. Spine, 15(33), S192-S198.

0.24  A. Croteau, S. Marcoux, C. Brisson. (2006). Work activity in pregnancy, preventive measures, and the risk of delivering a small-for-gestational-age infant. American Journal of Public Health, 96(5), pp. 846-55.

0.25  A. Croteau, S. Marcoux, C. Brisson. (2007). Work activity in pregnancy, preventive measures, and the risk of preterm delivery. American Journal of Epidemiology, 166(8), pp. 951-65.

0.26  H.W. Davies, K. Teschke, S.M. Kennedy, M.R. Hodgson, C. Hertzman, P.A. Demers. (2005). Occupational exposure to noise and mortality from acute myocardial infarction. Epidemiology, 16(1), pp. 25-32.

0.27  M.A. Davies, H.K. Spence Laschinger, M.A. Andrusyszyn. (2006). Clinical educators' empowerment, job tension, and job satisfaction: A test of Kanter's Theory. J Nurses Staff Dev, 22(2), pp. 78-86.

0.28  C.E. Dionne. (2005). Psychological distress confirmed as predictor of long-term back-related functional limitations in primary care settings. J Clin Epidemiol, 58(7), pp. 714-8.

0.29  M.M. Finkelstein, D.K. Verma. (2004). A cohort study of mortality among Ontario pipe trades workers. Occupational and Environmental Medicine, 61(9), pp. 736-42.

0.30  M.M. Finkelstein, D.K. Verma. (2005). Mortality among Ontario members of the International Union of Bricklayers and Allied Craftworkers. American Journal of Industrial Medicine, 47(1), pp. 4-9.

0.31  M.M. Finkelstein. (2008). Diesel particulate exposure and diabetes mortality among workers in the Ontario construction trades. Occupational and Environmental Medicine, 65(3), pp. 215.

0.32  C.E. Fraser, Smith KB, Judd F, Humphreys JS, Fragar LJ, Henderson A. (2005). Farming and mental health problems and mental illness. Int J Soc Psychiatry, 51(4), pp. 340-9.

0.33  R.R. Gaertner, L. Trpeski, K.C. Johnson. (2004). A case-control study of occupational risk factors for bladder cancer in Canada. Cancer Causes Control, 15(10), pp. 1007-19.

0.34  G.W. Gibbs, M. Sevigny. (2007). Mortality and cancer experience of Quebec aluminum reduction plant workers, part 4: Cancer incidence. Journal of Occupational and Environmental Medicine, 49(12), pp. 1351-1366.

0.35  H. Gilmour, S.B. Patten. (2007). Depression and work impairment. Health Rep, 18(1), pp. 9-22.

0.36  P. Greco, H.K. Laschinger, C. Wong. (2006). Leader empowering behaviours, staff nurse empowerment and work engagement/burnout. Can J Nurs Leadersh, 19(4), pp. 41-56.

0.37  W.A. Groves, V.J. Kecojevic, D. Komljenovic. (2007). Analysis of fatalities and injuries involving mining equipment. J Safety Res, 38(4), pp. 461-70.

0.38  C. Guimont, C. Brisson, G.R. Dagenais et al. (2006). Effects of job strain on blood pressure: a prospective study of male and female white-collar workers. Am J Public Health, 96(8), pp. 1436-43.

0.39  A. Hossain, H.H. McDuffie, M.G. Bickis, P. Pahwa. (2007). Case-control study on occupational dusk factors for soft-tissue sarcoma. Journal of Occupational and Environmental Medicine, 49(12), pp. 1386-93.

0.40  M. Jamal. (2004). Burnout, stress and health of employees on non-standard work schedules: A study of Canadian workers. Stress and Health, 20(3), pp. 113-119.

0.41  M. Jamal. Short (2007). Communication: Burnout and self-employment: A cross-cultural empirical study. Stress and Health: Journal of the International Society for the Investigation of Stress, 23(4), pp. 249-256.

0.42  T. Jones, S. Kumar. (2004). Occupational injuries and illnesses in the sawmill industry of Alberta. International Journal of Industrial Ergonomics, 33(5), pp. 415-27.

0.43  T. Jones, S. Kumar. (2005). Occupational injuries and illnesses in the plywood manufacturing industry group 1997-2002: A descriptive study of workers compensation board claims. International Journal of Industrial Ergonomics,35(3), pp. 183-196.

0.44  J.A. Kopec, E.C. Sayre. (2004). Work-related psychosocial factors and chronic pain: A prospective cohort study in Canadian workers. Journal of Occupational and Environmental Medicine, 46(12), 1263-71.

0.45  L.M. Lapierre, T.D. Allen. (2006). Work-supportive family, family-supportive supervision, use of organizational benefits, and problem-focused coping: implications for work-family conflict and employee well-being. J Occup Health Psychol, 11(2), pp. 169-81.

0.46  H.K. Laschinger, J. Almost, N. Purdy, J. Kim. (2004). Predictors of nurse managers' health in Canadian restructured healthcare settings. Can J Nurs Leadersh, 17(4), pp. 88-105.

0.47  H.K. Laschinger, C.A. Wong, P. Greco. (2006). The impact of staff nurse empowerment on person-job fit and work engagement/burnout. Nurs Adm Q, 30(4), pp. 358-67.

0.48  F.J. Lee, M. Stewart, J.B. Brown. (2008). Stress, burnout, and strategies for reducing them: what's the situation among Canadian family physicians? Can Fam Physician, 54(2), pp. 234-5.

0.49  R.T. Lee, C.M. Brotheridge. (2006). When prey turns predatory: Workplace bullying as a predictor of counteraggression/bullying, coping, and well-being. European Journal of Work and Organizational Psychology, 15(3), pp. 330-355.

0.50  M.P. Leiter, H.K. Spence Laschinger. (2006). Relationships of work and practice environment to professional burnout: testing a causal model. Nurs Res, 55(2), pp. 137-46.

0.51  I. Leroux, C.E. Dionne, R. Bourbonnais, C. Brisson. (2005). Prevalence of musculoskeletal pain and associated factors in the Quebec working population. Int Arch Occup Environ Health, 78(5), pp. 379-86.

0.52  I. Leroux, C. Brisson, S. Montreuil. (2006). Job strain and neck-shoulder symptoms: a prevalence study of women and men white-collar workers. Occup Med (Lond), 56(2), pp. 102-9.

0.53  X. Li, M.A. Gignac, A.H. Anis. (2006). Workplace, psychosocial factors, and depressive symptoms among working people with arthritis: a longitudinal study. J Rheumatol, 33(9), pp. 849-55.

0.54  A.C. MacArthur, N.D. Le, Z.U. Abanto, R.P. Gallagher. (2007). Occupational female breast and reproductive cancer mortality in British Columbia, Canada, 1950-94. Occupational Medicine Oxford, 57(4), pp. 246-53.

0.55  A. Marchand, A. Demers, P. Durand. (2005). Does work really cause distress? The contribution of occupational structure and work organization to the experience of psychological distress. Soc Sci Med, 61(1), pp. 1-14.

0.56  A. Marchand, A. Demers, P. Durand. (2005). Do occupation and work conditions really matter? A longitudinal analysis of psychological distress experiences among Canadian workers. Sociol Health Illn, 27(5), pp. 602-27.

0.57  A. Marchand. (2007). Mental health in Canada: are there any risky occupations and industries? Int J Law Psychiatry, 30(4-5), pp. 272-83.

0.58  K.S. McGilton, L.M. Hall, W.P. Wodchis, U. Petroz. (2007). Supervisory support, job stress, and job satisfaction among long-term care nursing staff. J Nurs Adm, 37(7-8), pp. 366-72.

0.59  H. Mich-Ward, J.R. Guernsey, W. Pickett, D. Rennie, L. Hartling, R.J. Brison. (2004). Gender differences in the occurrence of farm related injuries. Occupational and Environmental Medicine, 61(1), pp. 52-6.

0.60  D.G. Morgan, N.J. Stewart, C. D'Arcy, D. Forbes, J. Lawson. (2005). Work stress and physical assault of nursing aides in rural nursing homes with and without dementia special care units. J Psychiatr Ment Health Nurs, 12(3), pp. 347-58.

0.61  S.E. Munce, I. Weller, E.K. Robertson Blackmore, M. Heinmaa, J. Katz, D.E. Stewart. (2006). The role of work stress as a moderating variable in the chronic pain and depression association. J Psychosom Res, 61(5), pp. 653-60.

0.62  S.E.P. Munce, S.A. Stansfeld, E.R. Blackmore, D.E. Stewart. (2007). The role of depression and chronic pain conditions in absenteeism: Results from a national epidemiologic survey. Journal of Occupational and Environmental Medicine, 49(11), pp. 1206-1211.

0.63  L. O'Brien Pallas, J. Shamian, D. Thomson et al. (2004). Work-related disability in Canadian nurses. J Nurs Scholarsh, 36(4), 352-7.

0.64  E.D. Ogus. (2008). Burnout among professionals: Work stress, coping and gender. Dissertation Abstracts International: Section B: The Sciences and Engineering, 68(7-B).

0.65  J.W. Out. (2008). Meanings of workplace bullying: Labelling versus experiencing and the belief in a just world. Dissertation Abstracts International: Section B: The Sciences and Engineering, 66(11-B).

0.66  P. Pahwa, H.H. McDuffie, J.A. Dosman. (2006). Longitudinal changes in prevalence of respiratory symptoms among Canadian grain elevator workers. Chest, 129(6), pp. 1605-13.

0.67  S.Y. Pan, A.M. Ugnat, Y. Mao. (2005). Occupational risk factors for brain cancer in Canada. Journal of Occupational and Environmental Medicine, 47(7), pp. 704-17.

0.68  M. Rossignol. (2004). Primary osteoarthritis and occupation in the Quebec National Health and Social Survey. Occupational and Environmental Medicine, 61(9), pp. 729-35.

0.69  M-C. Rousseau, M-E. Parent, L. Nadon, B. Latreille, J. Siemiatycki. (2007). Occupational exposure to lead compounds and risk of cancer among men: A population-based case-control study. American Journal of Epidemiology, 166(9), pp. 1005-1014.

0.70  P.E. Saar, H. Mich Ward, K.D. Kelly, D.C. Voaklander. (2006). Farm injuries and fatalities in British Columbia, 1990-2000. Can J Public Health, 97(2), pp. 100-104.

0.71  K. Sanderson, G. Andrews. (2006). Common mental disorders in the workforce: recent findings from descriptive and social epidemiology. Can J Psychiatry, 51(2), pp. 63-75.

0.72  T.P. Sarmiento, H.K. Laschinger, C. Iwasiw. (2004). Nurse educators' workplace empowerment, burnout, and job satisfaction: testing Kanter's theory. J Adv Nurs, 46(2), pp. 134-43.

0.73  K. Simpson, R. Sebastian, T.E. Arbuckle, C. Bancej, W. Pickett. (2004). Stress on the farm and its association with injury. J Agric Saf Health, 10(3), pp. 141-53.

0.74  S. Schieman, Y.K. Whitestone, K. Van Gundy. (2006). The nature of work and the stress of higher status. J Health Soc Behav, 47(3), pp. 242-57.

0.75  A.M. Seifert, K. Messing, J. Riel, C. Chatigny. (2007). Precarious employment conditions affect work content in education and social work: results of work analyses. Int J Law Psychiatr. 30(4-5), pp. 299-310.

0.76  A. Senthilselvan, L. Chenard, K. Ulmer, N. Gibson Burlinguette, C. Leuschen, J.A. Dosman. (2007). Excess respiratory symptoms in full-time male and female workers in large-scale swine operations. Chest, 131(4), pp. 197-204.

0.77  J. Shen, L.C.P. Botly, S.A. Chung, A.L. Gibbs, S. Sabanadzovic, C.M. Shapiro. (2006). Fatigue and shift work. Journal of Sleep Research, 15(1), pp. 1-5.

0.78  M. Shields. (2006). Stress and depression in the employed population. Health Rep, 17(4), pp. 11-29.

0.79  P. Smith, J. Frank, S. Bondy, C. Mustard. (2008). Do changes in job control predict differences in health status? Results from a longitudinal national survey of Canadians. Psychosomatic Medicine, 70(1), pp. 85-91.

0.80  L. Jones, C. Beseler. (2004). Safety practices and depression among farm residents. Annals of Epidemiology, 14(8), pp. 571-8.

0.81  D.C. Voaklander, K.D. Kelly, B.H. Rowe et al. (2006). Pain, medication, and injury in older farmers. American Journal of Industrial Medicine, 49(5), pp. 374-82.

0.82  J. Wang. (2004). Perceived work stress and major depressive episodes in a population of employed Canadians over 18 years old. J Nerv Ment Dis, 192(2), pp. 160-3.

0.83  J. Wang. (2005). Work stress as a risk factor for major depressive episode(s). Psychol Med, 35(6), pp. 865-71.

0.84  J.L. Wang, C.E. Adair, S.B. Patten. (2006). Mental health and related disability among workers: A population-based study. American Journal of Industrial Medicine, 49(7), pp. 514-22.

0.85  J.L. Wang. (2006). Perceived work stress, imbalance between work and family/personal lives, and mental disorders. Soc Psychiatry Psychiatr Epidemiol, 41(7), pp. 541-8.

0.86  J.L. Wang, A. Lesage, N. Schmitz, A. Drapeau. (2008). The relationship between work stress and mental disorders in men and women: findings from a population-based study. Journal of Epidemiology and Community Health, 62(1), pp. 42-7.

0.87  K. Wilkins, S.G. Mackenzie. (2007). Work injuries. Health Rep, 18(3), pp. 25-42.

0.88  S. Youakim.(2006). Risk of cancer among firefighters a quantitative review of selected malignancies. Archives of Environmental and Occupational Health, 61(5), pp. 223-231.

0.89  I.U. Zeytinogla, M.B. Seaton, W. Lillevik, J. Moruz. (2005). Working in the margins women's experiences of stress and occupational health problems in part-time and casual retail jobs. Women Health, 41(1), pp. 87-107.

0.90 Blair, A. D. Sandler, K. Thomas, J.A. Hoppin, F. Kamel, J. Coble, W.J. Lee, J. Rusiecki, C. Knott, M. Dosemeci, C.F. Lynch, J. Lubin, and M. Alavanja. (2005). Disease and Injury among participants in the agricultural health study. Journal of Agricultural Safety and Health, 11(2), pp. 141-151.

0.91 Manitoba workplace injury and illness statistics report. Canadian Research Index 2005.

0.92  J. Barrette, L. Lemyre, W. Corneil, N. Beauregard. (2007). Organizational learning among senior public-service executives: An empirical investigation of culture, decisional latitude and supportive communication. Canadian Public Administration, 50(3), pp. 333-53.

0.93  J.K. Caird, T.J. Kline. (2004). The relationships between organizational and individual variables to on-the-job driver accidents and accident-free kilometres. Ergonomics, 47(15), pp. 1598-613.

0.94  P. Cote, G. van der Velde, J.D. Cassidy et al. (2008). The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 15(33), S60-S74.

0.95  J.T. Brophy. (2002). Occupational histories of cancer patients in a Canadian Treatment Center and the generated hypothesis regarding breast cancer and farming International Journal of Occupational and Environmental Health, 8(4), pp. 346-353.

0.96  K. Garabedian. (2007). A study on the drinking patterns of male and female employees in Alberta: The impact of work environment and job stress. Dissertation Abstracts International Section A: Humanities and Social Sciences, 68(2-A).

0.97  M.A. Gignac, D. Sutton, E.M. Badley. (2007). Arthritis symptoms, the work environment, and the future: measuring perceived job strain among employed persons with arthritis. Arthritis Rheum, 57(5), 738-47.

0.98  E. Haelterman, S. Marcoux, A. Croteau, M. Dramaix. (2007). Population-based study on occupational risk factors for preeclampsia and gestational hypertension. Scandinavian Journal of Work Environment and Health, 33(4), pp. 304-17.

0.99  L.M. Hagel, J.A. Dosman, D.C. Rennie, M.W. Ingram, A. Senthilselvan. (2004). Effect of age on hospitalized machine-related farm injuries among the Saskatchewan farm population. Journal of Agricultural Safety and Health, 10(3), pp. 155-62.

0.100  M. Jamal. (2004). Burnout, stress and health of employees on non-standard work schedules: A study of Canadian workers. Stress and Health, 20(3), pp. 113-119.

0.101  M. Jamal. (2005). Short communication: Personal and organizational outcomes related to job stress and Type-A behaviour: A study of Canadian and Chinese employees. Stress and Health: Journal of the International Society for the Investigation of Stress, 21(2), pp. 129-137.

0.102  M. Koehoorn, P.A. Demers, C. Hertzman, J. Village, S.M. Kennedy. (2006). Work organization and musculoskeletal injuries among a cohort of health care workers. Scandinavian Journal of Work Environment and Health, 32(4), pp. 285-93.

0.103  W. Kubik, R.J. Moore. (2005). Health and well-being of farm women: contradictory roles in the contemporary economy. J Agric Saf Health, 11(2), pp. 249-56.

0.104  T. Lipskie, F.C. Breslin. (2005). A descriptive analysis of Canadian youth treated in emergency departments for work-related injuries. Chronic Dis Can, 26(4), pp. 107-13.

0.105  J-L. Malo, M. Chan-Yeung. (2007). Asthma in the workplace: A Canadian contribution and perspective. Canadian Respiratory Journal, 14(7), pp. 407-413.

0.106  R.T. Manktelow, P. Binhammer, L.R. Tomat, V. Bril, J.P. Szalai. (2004). Carpal tunnel syndrome: Cross-sectional and outcome study in Ontario workers. Journal of Hand Surgery American, 29A(2), pp. 307-17.

0.107  A. Marchand, P. Durand, A. Demers. (2005). Work and mental health: the experience of the Quebec workforce between 1987 and 1998. Work, 25(2), pp. 135-42.

0.108  C. Mclaughlin. (2005). Seasonal variation in adaptation to shiftwork. Dissertation Abstracts International: Section B: The Sciences and Engineering, 66(6-B).

0.109  E.D. Ogus. (2008). Burnout among professionals: Work stress, coping and gender. Dissertation Abstracts International: Section B: The Sciences and Engineering, 68(7-B).

0.110  A. Ostry, S. Maggi, J. Tansey et al. (2007). The impact of psychosocial work conditions on attempted and completed suicide among western Canadian sawmill workers. Scandinavian Journal of Public Health, 35(3), pp. 265-71.

0.111  K. Richardson, P.R. Band, G. Astrakianakis, N.D. Le. (2007). Male bladder cancer risk and occupational exposure according to a jobexposure matrix - a case-control study in British Columbia, Canada. Scandinavian Journal of Work Environment and Health, 33(6), pp. 454-64.

0.112  I. Soucy, M. Truchon, D Cote. (2006). Work-related factors contributing to chronic disability in low back pain. Work, 26(3), pp. 313-26.

0.113 Best Start: Ontario’s Maternal, Newborn and Early Child Development Resource Centre. (2001). Workplace Reproductive Health: Research and Strategies. Ontario Ministry of Health and Long-term Care. Accessed on April 09 2009, http://www.beststart.org/resources/wrkplc_health/pdf/WorkplaceDocum.pdf

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¹⁰¹ Boivin, B. Diane, & Francine O. James. (2003), p.19

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¹⁰⁴ Canadian Centre for Occupational Health and Safety. (2007), no pag.

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