Workplace Health and the Cauldron of Evidence

Scott Lloyd and Sarah Slater, Advanced Public Health Practitioners, Public Health South Tees 

Systematic reviews are brilliant. They take all the available evidence for a particular topic, do something special (stick the results into a big cauldron) and churn out a finding that informs us mere mortals in policy and practice where we should and shouldn’t be investing our money and capacity.

Double, double toil and trouble...

In these austere times, such evidence about what works and what doesn’t is so important – especially when combined with the how and why. This recent review by Jenna Panter and colleagues is an excellent example of what works and how.

However, there is one sphere of public health where we feel that systematic reviews may not paint a full and fair picture.

Let us explain.

Workplace Health

Most public health colleagues have a speciality or five. This might be a topic (e.g. nutrition or addiction) or part of the life-course (e.g. children and young people or older adults).

We are Workplace Health Specialists with 28 years of combined experience. We’ve supported employers of all descriptions, including businesses of different sizes and in different sectors. We’ve worked on national workplace health programmes, such as the Well@Work programme led by the British Heart Foundation between 2005 and 2007, and have been involved in the North East Better Health at Work Award since its launch in 2009 (arguably the biggest and most successful workplace health programme in England). We’ve a lot of experience of supporting NHS organisations who are trying to improve the health of staff – sometimes successfully, sometimes less so.

Working with such a variety of employers to improve staff health is a challenge of both knowledge and skill because they are looking to you, as the expert, to come up with evidence-based suggestions. Consider how you might support the below employers (real examples for us) to encourage physical activity in their workforce:

• A tea factory which operates 24 hours a day with mixed shifts and a predominantly female, part-time workforce
• A call centre for a bank employing 1,200 mostly young staff, in a mainly sedentary occupation
• A call centre for a public sector organisation employing workers typically aged 40 plus, in a mainly sedentary occupation
• A mining company at which the majority of the workforce arrive, take a lift down a shaft for 20 minutes, work a shift underground in 40 degree heat, resurface in the lift and get straight in the car to head home
• A category B prison. 

How would you support an employer to encourage physical activity in a call centre?

What you might suggest to each of the above five employers (and what might work) could be completely different (and probably would be). At least in each of those scenarios, the workforce is likely to be pretty homogenous. Consider working with a huge employer such as a Local Authority or NHS Trust which arguably have massive internal differences in staffing groups in terms of age, gender, hours, and roles (e.g. office staff vs refuse collectors).

We believe that these differences make workplace health a different kettle of fish compared to other settings, such as schools, colleges, universities, and prisons, which could be comparatively homogeneous. They aren’t of course – there are massive differences between schools for example, but our suggestion is that they have the potential to be very similar if all variable things (e.g. culture, policies etc.) were the same. 

What’s our point?

Firstly, that lumping trials of workplace health interventions and programmes into a systematic review masks these potentially huge differences. We’re not sure how we get around this issue but we are raising it as an issue.

Secondly, to suggest that there is a lot more research to be done. There are some workplaces that should be considered a priority. For example, the majority of the working population in the private sector (60%) are employed by small-to-medium sized enterprises (less than 250 employees) and this is an area that no-one has cracked in terms of health and wellbeing via the workplace. Another example is call centres: given the sedentary, pressured nature of the work. One feasibility trial has recently been completed (Morris et al. 2019)[1] and another is underway (involving Scott). We can’t do individual studies for every type of workplace but some should be considered a priority.

Thirdly, to highlight the skills possessed by our peers who lead on workplace health. Employers and employees can throw all sorts of issues at you from bread and [low fat] butter stuff like physical activity and mental wellbeing to stuff like menopause awareness and sleep. Not only does a workplace health specialist need to maintain a base knowledge of all these topics, but they also need to understand how it might be tackled in the various types of workplace highlighted above.

It would be remiss of us not to plug the North East Better Health at Work Award. It needs a stronger evaluation building on previous work (Braun et al. 2014)[2], but we’re talking about a programme that was launched in 2009 and has actively engaged hundreds of employers every single year since (456 currently engaged at January 2020), supporting them to promote the health and wellbeing of their staff (potential combined reach of 202,962 working adults as of January 2020) and the wider community. We’re always recruiting more businesses so if you would like to know more visit www.betterhealthatworkne.org.


References

1. Morris, A.S., Murphy, R.C., Shepherd, S.O., Healy, G.N., Edwardson, C.L. & Graves, L.E.F. (2019). A multi-component intervention to sit less and move more in a contact centre setting: a feasibility study. BMC Public Health, 19 (1), 292                                    https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-6615-6
2. Braun, T., Bambra, C., Booth, M., Adetayo, K. & Milne, E. (2014). Better health at work? An evaluation of the effects and cost–benefits of a structured workplace health improvement programme in reducing sickness absence. Journal of Public Health, 37 (1), 138 –142  https://academic.oup.com/jpubhealth/article/37/1/138/1559494

Image 2: Photo by Arlington Research on Unsplash

Uniting planning and health to tackle obesity

Public Heath England (PHE) has just published practical guidance, informed by Fuse research, for local authorities wanting to use the planning system to improve public health. In this blog post Andy Netherton and Michael Chang, from PHE's Healthy Places Team, tell us how they hope the guidance will be used to tackle obesity.

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Obesity is a modern day public health challenge that cannot be met by a traditional scientific approach alone. Tackling obesity levels in England requires action by national and local government, health and social care, non-governmental agencies, communities and individuals – a whole system approach.

Traditionally the vast majority of public discussion and state campaigns target individual level behaviour change and treatment. This does not address the environment in which we live, that influences the decisions and actions that we make; things such as what we eat, whether we exercise, how we travel to work, how we interact within the community and if we have access to and use open spaces.

These physical environmental factors can be influenced by national and local policy and action. State led interventions are difficult to put into place due to the need for evidence within complex social and environmental determinants. The difficulty to isolate evidence related to these interventions and local government capacity to balance competing demands results in an inconsistent approach to policy adoption.

The use of planning policy and development management is a clear example of an intervention to tackle obesity which is not yet consistently applied across the country. Practice across the country has shown a diverse range of approaches in local plans and planning appeal decisions which has taken over 10 years to develop, but is now accelerating.

Figure 1 – Charting the use of planning for healthy weight environments

This policy to implementation lag has to be seen in the context of an increasing obesity challenge, both in terms of prevalence and health inequalities.

Figure 2 – key obesity data and trends

Statistics on Obesity, Physical Activity and Diet, England, May 2019 - NHS Digital, Government Statistical Service

Is the reason down to the nature of local evidence provided or the knowledge of the individual local authority teams, planning inspectors or the wider planning regime?

This was recognised within the Childhood Obesity: a plan for action, Chapter 2. The challenges it identified, included the proliferation of fast food outlets, less active travel, limited access to green spaces and physical activity; and these factors create an environment that makes it harder for children and their families to make healthy choices, particularly in some of our most deprived areas.

The Childhood Obesity plan confirmed that local authorities have a key role in tackling this challenge and pledged support:

• to make sure that all local authorities are empowered and confident in finding what works for them, and;
• to develop resources that support local authorities who want to use their powers and provide up to date guidance and training for planning inspectors. 

In response Public Health England (PHE) has released guidance on using the planning system to promote healthy weight environments.

Previous research by PHE (Spatial Planning and Health: Getting Research into Practice (GRIP) study report) identified that local authorities would benefit from support that reduced the need for resource input, for example reduced duplication to create policy and practice. This publication is aimed at getting knowledge into action by providing guidance and a template supplementary planning document (SPD), one of many planning levers available to local authorities, that can be used by local authority planning and public health teams. It answers the following questions:

• What is the current evidence base linking the built and natural environment and healthy weight? Specifically, can the local food environment influence diet and obesity?
• How can the planning regime be used to promote healthy weight environments?

The publication identifies the background work necessary in order to comply with planning policy development, where the key is the use of local evidence and consultation. It specifically provides guidance on the use of the 400m exclusion zone for hot food takeaways, features of the built environment and building design that promotes physical activity, use of green space, allotments and neighbourhood design.

The provided supplementary planning document (SPD) is a starting point that requires local content and policy to be added. It can be used as a whole or parts selected on local need or to dovetail to existing local policies. Clearly this intervention is one intervention that must be used within a wider national and local obesity strategy.

There remain challenges to promoting a healthy food environment, for example the impact from the rise of industrial kitchens for food delivery must be monitored. Work must continue to influence the energy and compositional content of other food options and build our homes and neighbourhood to allow people to more active.

This publication provides guidance on a practical evidence based intervention that draws together several professional groups within a local authority. Gateshead Council have successfully adopted and defended on appeal, controls on hot food takeaways as part of a wider approach to tackling obesity and promoting healthy weight environments. It is hoped that for many areas working together to tackle obesity will provide confidence to further unite planning and health. It moves the debate from a deficit model of obesity to an asset based (salutatogenic*) approach to promoting healthy weight.


*Israeli-American sociologist Aaron Antonovsky coined the term "salutogenesis" to describe an approach which focuses on a positive view of wellbeing rather than a negative view of disease.

Coronavirus: expect the unexpected in an unfolding emergency

Posted by John Mooney, FFPH (Fellow, Faculty of Public Health), Fuse Associate & Senior Lecturer in Public Health at University of Sunderland @StandupforPHlth 

In an age when public health and health improvement efforts in much of the world are justifiably focused on chronic disease, lifestyle factors and the ever increasing health and social care needs of an ageing population, we would do well to remember that humankinds’ most determined and persistent adversaries are always “waiting in the wings” ready to step on the stage for a lead role once again.

Step forward new variant Coronavirus (2019-nCoV), which the World Health Organisation has declared a Global public health emergency[1] reminding us all of the enduring critical importance of basic public health principles and practice and internationally co-ordinated vigilance for new microbial challenges. ‘International’ of course being a critical component of any response plans, since infectious diseases do not respect national borders and less so, referendum results. The first confirmed UK cases on Friday[2], currently being treated in this region, only serves to remind us of the ‘global village’ we all inhabit from the perspective of infectious diseases.

Coronaviruses are a large family of viruses, some causing (mostly mild) illnesses in people and others that circulate among animals, including camels, cats and bats. The recently emerged 2019-nCoV is not the same as the coronaviruses that caused Middle East Respiratory Syndrome (MERS) or Severe Acute Respiratory Syndrome (SARS) though genetic analyses so far suggests that the new variant is more closely related to SARS[3].

Ninety Nine percent (99%) of the 24,000+ cases and nearly all of the 490 confirmed deaths (with 2 exceptions, one in Hong Kong and one in the Philippines) so far have been in China.  Despite this, the WHO emergency declaration crucially allows for additional resources and support for lower and middle-income countries to strengthen their disease surveillance and prepare them for potential cases or outbreaks. At the present time, to the considerable credit of the Chinese response – partly arising of course from international condemnation of a less than transparent response to the SARS outbreak in 2003 – there are Herculean efforts and resources being devoted to containing the threat from the new pathogen.  This includes the drastic attempted quarantine of a whole region and the speed of construction of new facilities such as 1000 bed dedicated hospitals.

Capture from the BBC News website, 5 February 2020

While 2019-nCoV seems to be less lethal than SARS, there is no doubt that it is clearly more transmissible with The World Health Organization stating that the preliminary R0 (reproduction number) estimate is 1.4 to 2.5, meaning that every person infected can potentially infect between 1.4 and 2.5 people (R0 for SARS being 0.19–1.08, with a median of 0.49)[4]. With the spectrum of clinical presentations ranging from mild respiratory illness to life threatening viral pneumonia, the health impact of the ongoing outbreak is very difficult to predict and unanswered questions abound. How many people may have shrugged off mild / virtually asymptomatic infections for instance is not possible to know until follow-up sero-conversion studies[5] can be used to estimate the burden of ‘silent infections’.

Aside from higher transmissibility, the more worrying aspect of 2019-nCov however is the reports of an incubation period of up to 14 days during which an infected individual might both be asymptomatic (displaying no evident symptoms that could be screened for) and also crucially, at the same time during this period, infectious and capable of transmitting the virus to new hosts. The potential 14 day incubation period without symptoms effectively means that the cases which are being confirmed at the present time merely reflect the ‘true burden of infection’ from two weeks ago. As a result we will only have any real sense of the effectiveness of Chinese efforts to contain the virus a fortnight after the stringent travel restrictions imposed around Wuhan province and other parts of China.

As many seasoned experts in these matters have cautioned, schooled as they have been by experience of previous episodes, predicting the behaviour of a newly emergent pathogen is a hazardous business and a great deal of uncertainty surrounds its likely route to potential pandemic status. A virus adapting to a new species host (in this case humans!) is an unstable entity and its defining characteristics today in terms of those who are most vulnerable and their risk of serious or life threatening illness may be very different in the weeks and months ahead.

Eventually of course, a virus keen on longevity in a new host needs to curb its pathogenicity[6] and ideally result in only mild symptoms that will reduce the attention it attracts from a host immune response. Many of the hundreds of viruses, including coronavirus subtypes that cause the common cold, once jumped the species barrier and evolved into relatively benign pathogens. Even the deadly “Spanish flu” epidemic of 1918[7], which killed around 60 million people Worldwide in 1918-1920 and comprised of the influenza subunits H1N1, circulates today in the form of seasonal flu in a genetic variant with greatly reduced lethality.

How serious the current outbreak will be in terms of impact and mortality remains to be seen. SARS of course was eventually successfully contained by stringent infection control, contact tracing and quarantine procedures. While 2019-nCov is not currently as life-threatening an illness as SARS, its greater transmissibility, longer incubation period and potential for symptomless transmission (SARS was only transmissible when symptomatic), do not bode well for ease of containment so it is hardly surprising that the WHO have seen fit to play their strongest card and declare it an emergency.

We can only hope that the response may be timely enough.


John Mooney worked previously for NHS Health Protection where he specialised in the epidemiology of respiratory infectious diseases.


References:

1. Coronavirus declared global health emergency by WHO: https://www.bbc.co.uk/news/world-51318246
2. Coronavirus: UK patient is University of York student: https://www.bbc.co.uk/news/health-51337400 
3. 2019 Novel Coronavirus Basics: CDC FAQs: https://www.cdc.gov/coronavirus/2019-ncov/faq.html
4. Emerg Infect Dis. 2004 Jul; 10(7): 1258–1263 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3323341/
5. Seroconversion: The development of detectable antibodies in the blood that are directed against an infectious agent. Antibodies do not usually develop until some time after the initial exposure to the agent.
6. Pathogenicity is defined as the absolute ability of an infectious agent to cause disease/damage in a host - an infectious agent is either pathogenic or not. From: Fenner and White's Medical Virology (Fifth Edition), 2017
7. 1918 Pandemic (H1N1 virus): https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html

Image 2: Capture from the BBC News website, 5 February 2020. Coronavirus: Ten passengers on cruise ship test positive for virus. Source: European Centre for Disease Prevention and Control. Updated 5 Feb. https://www.bbc.co.uk/news/world-asia-51381594.