Ever since Aristotle’s time, the main determinants of health and sickness have been considered to be socioeconomic factors such as lifestyle, healthy behaviours, and a person’s social and physical environment, rather than biological status, or access to healthcare. A public health researcher perspective suggests that this is also true today1,2. Evidence supports the biopsychosocial model (BSP) as an interactive and person-centred approach that considers the individual, their health condition, and their social/work-related context. The factors that influence a person’s inability to work and their return to work, as well as the changing importance of each factor, vary over time. Self-perceptions can also change, and individuals may change between periods of disability and ability, work and non-working capacity3. Therefore, a multi-dimensional approach that spans several levels may be required, which is the characteristic of many health and social policy interventions.
Biopsychosocial model in practice
The BSP approach demands a personalised, patient-centred, and above all, egalitarian relationship between patient and provider. This is not an impossible goal: it is a major part of therapist and medical training4. The ultimate goal is to consider the patient and their health condition and then strike the balance between providing care and achieving the best social and occupational outcomes. Within the occupational health environment, clinicians and researchers are interested in preventing ill health, with a reciprocal relationship between health and work. Early intervention is essential, since the longer an individual is off work, the greater the obstacles to return to work (RTW), and the more difficult it is to implement work-related strategies. It is simpler, more effective, and less expensive for all stakeholders to reduce the levels of long-term sickness absence.
Each obstacle requires a different set of expectations, behaviours, and social interactions. The outcome of any intervention (eg, healthcare, activity levels, behaviour changes, employer etc) may differ, and timing is critical. All successful rehabilitation programmes include some form of exercise, or graded exposure activity. The key element is in the activity and the task, with the immediate goal of exposure to functional limitations and improving capability. Activity also leads to increases in group participation, as well as recovering social and physical function. These core principles are common for a mixed mental- and physical-health condition, where increased physical activity has been shown to improve mental health and reduce depression5.
Small steps to long-term health
Evidence supports the notion that large changes in acute loads are tolerated when they are preceded by a consistent and slow progression of workload or stressors. Incremental changes are fundamental to elicit a positive response to stress, rather than a breakdown in the person’s capacity to cope. Proper implementation of increasing levels of activity or workload will increase a sense of well-being, confidence, self-efficacy, and recovery. Building up to these slowly will promote adherence to a more stable state of being. However, a person’s adaptability is finite, and the speed of that adaptability is limited, so careful consideration of safe exposure activity to develop strength and confidence is needed.
Managing sickness absence, assisting return to work, and promoting rehabilitation are matters of good healthcare practice, sound occupational health principles, and good business sense. Interestingly, the adaptability model does not just consider biomechanics, medical conditions, or physical workload in isolation. Our adaptability and response to the physical workload, or our ‘preparedness’ for this, is influenced by a range of psychosocial stressors, especially in an occupational setting. The Oxford Dictionary defines rehabilitation as the ‘The action of restoring someone to health or normal life through training and therapy after illness’ 6. The ‘World Report on Disability’, defines rehabilitation as ‘enabling people with disabilities whose functions are limited to remain in or return to their home or community, live independently, and participate in education, the labour market, and civic life’6.
Prolonged absence from normal activities, including one’s work, is often detrimental to a person’s mental, physical, and social wellbeing. It also has significant impact on communities and society, in terms of healthcare costs, efficiency, and burden of ill-health. Conversely, appropriate and supported RTW can benefit the employee and their communities by enhancing recovery, thus reducing disability.
Mental and musculoskeletal conditions remain the most common issues, contributing to work-related ill health. An approach to rehabilitation based upon the BSP model is necessary to identity and address the obstacles to recovery and barriers to RTW. It should also meet the needs of those employees with common health problems who do not recover within a suitable timeframe. An employee’s prompt RTW after injury or illness should be encouraged and supported by employers, health professionals, fellow employees, occupational health, and rehabilitation services, with the use of targeted work-related adjustments. Lastly, a safe and expedited RTW preserves a skilled and stable workforce and reduced demands on health services. This is particularly vital at a time of international workforce pressures, where access to healthcare may be more difficult.
References1. Aylward, M, (2006). Beliefs: Clinical and vocational interventions; tackling psychological and social determinants of illness and disability.
2. Marmot M, Bell R, (2010). Challenging health inequalities—implications for the workplace. Occupational medicine. 2010 May 1;60(3):162-4.
3. Burchardt, T, (2000). The dynamics of being disabled. Journal of Social Policy, 29(4), pp.645-668.
4. Waddell, G, Burton, AK, (2004). Concepts of rehabilitation for the management of common health problems. The Stationery Office.
5. Waddell, G, Aylward, M, (2009). Models of sickness and disability: applied to common health problems. Royal Society of Medicine Press.
6. Rehabilitation. In: Oxford Dictionary of English, 3rd edn. (2017). Available at: oxforddictionaires/com/definition/rehabilitation
7. World Health Organization, 2011. Summary: World report on disability 2011 (No. WHO/NMH/VIP/11.01). World Health Organization.