Return on investment of workplace-based prevention interventions: a systematic review.

BACKGROUND: Occupational Safety and Health is an important public health topic. Many employers may regard health promotion or prevention initiatives as an additional cost with few benefits. The aim of this systematic review is to identify the studies conducted on the return on investment (ROI) of preventive health interventions conducted within workplaces, and to describe their designs, topics and calculation methods. METHODS: We searched PubMed, Web of Science, Science Direct, National Institute for Occupational Safety and Health, International Labour Organization and Occupational Safety and Health Administration from 2013 to 2021. We included studies that evaluated prevention interventions in the workplace setting and reported an economic outcome or company-related benefits. We report the findings according to PRISMA reporting guidelines. RESULTS: We included 141 articles reporting 138 interventions. Of them, 62 (44.9%) had an experimental design, 29 (21.0%) had a quasi-experimental design, 37 (26.8%) were observational studies and 10 (7.2%) were modelling studies. The interventions' objectives were mostly related to psychosocial risks (N = 42; 30.4%), absenteeism (N = 40; 29.0%), general health (N = 35; 25.4%), specific diseases (N = 31; 22.5%), nutrition (N = 24; 17.4%), sedentarism (N = 21; 15.2%) musculoskeletal disorders (N = 17; 12.3%) and accidents (N = 14; 10.1%). The ROI calculation was positive for 78 interventions (56.5%), negative for 12 (8.7%), neutral for 13 (9.4%) and undetermined for 35 (25.4%). CONCLUSION: There were many different ROI calculations. Most studies have a positive result but randomized controlled trials have fewer positive results than other designs. It is important to conduct more high-quality studies so that results can inform employers and policy-makers.

Sick leave due to COVID-19 during the first pandemic wave in France, 2020.

OBJECTIVES: To quantify the burden of COVID-19-related sick leave during the first pandemic wave in France, accounting for sick leaves due to symptomatic COVID-19 ('symptomatic sick leaves') and those due to close contact with COVID-19 cases ('contact sick leaves'). METHODS: We combined data from a national demographic database, an occupational health survey, a social behaviour survey and a dynamic SARS-CoV-2 transmission model. Sick leave incidence from 1 March 2020 to 31 May 2020 was estimated by summing daily probabilities of symptomatic and contact sick leaves, stratified by age and administrative region. RESULTS: There were an estimated 1.70M COVID-19-related sick leaves among France's 40M working-age adults during the first pandemic wave, including 0.42M due to COVID-19 symptoms and 1.28M due to COVID-19 contacts. There was great geographical variation, with peak daily sick leave incidence ranging from 230 in Corse (Corsica) to 33 000 in Île-de-France (the greater Paris region), and greatest overall burden in regions of north-eastern France. Regional sick leave burden was generally proportional to local COVID-19 prevalence, but age-adjusted employment rates and contact behaviours also contributed. For instance, 37% of symptomatic infections occurred in Île-de-France, but 45% of sick leaves. Middle-aged workers bore disproportionately high sick leave burden, owing predominantly to greater incidence of contact sick leaves. CONCLUSIONS: France was heavily impacted by sick leave during the first pandemic wave, with COVID-19 contacts accounting for approximately three-quarters of COVID-19-related sick leaves. In the absence of representative sick leave registry data, local demography, employment patterns, epidemiological trends and contact behaviours can be synthesised to quantify sick leave burden and, in turn, predict economic consequences of infectious disease epidemics.

Can we distinguish the roles of demographic and temporal changes in the incidence and prevalence of musculoskeletal disorders? A systematic review.

OBJECTIVES: Musculoskeletal disorders (MSD) represent a major public health issue, affecting more then 40 million European workers in 2017. The overall aging of the working population is expected to increase the burden of disease, but temporal changes in exposures or diagnosis may also drive the global trends in MSD. We therefore conducted a systematic review to summarize the evidence on the role of demographic and temporal changes in the occurrence of MSD. METHODS: We conducted a systematic review of articles reporting temporal trends in MSD in the general working-age population. Only articles controlling for age in the analysis were included. The risk of bias was assessed. The main indicators extracted were age-controlled time trends in MSD incidence or prevalence. RESULTS: Among 966 articles, 16 fulfilled the inclusion criteria, representing 23 results according to the indicators extracted. No study was found with a high risk of bias. Results presenting time trends in prevalence were found in 12 studies and incidence in 11. After controlling for age, the reported temporal trends varied, mostly between non-monotonic changes (N=12/23) and increases (N=10/23). One article also highlighted an increase among women and non-monotonic changes among men (N=1/23). Several factors other than aging were suggested to explain temporal trends in MSD, mainly trends in obesity, changing occupational exposures, and cultural factors regarding pain tolerance. CONCLUSION: This review shows that different kind of factors in addition to aging may contribute to varying or increasing trends in MSD. This review also highlighted the scarcity of evidence regarding time trends in the burden of MSD and their underlying causes.

Monitoring sick leave data for early detection of influenza outbreaks.

BACKGROUND: Workplace absenteeism increases significantly during influenza epidemics. Sick leave records may facilitate more timely detection of influenza outbreaks, as trends in increased sick leave may precede alerts issued by sentinel surveillance systems by days or weeks. Sick leave data have not been comprehensively evaluated in comparison to traditional surveillance methods. The aim of this paper is to study the performance and the feasibility of using a detection system based on sick leave data to detect influenza outbreaks. METHODS: Sick leave records were extracted from private French health insurance data, covering on average 209,932 companies per year across a wide range of sizes and sectors. We used linear regression to estimate the weekly number of new sick leave spells between 2016 and 2017 in 12 French regions, adjusting for trend, seasonality and worker leaves on historical data from 2010 to 2015. Outbreaks were detected using a 95%-prediction interval. This method was compared to results from the French Sentinelles network, a gold-standard primary care surveillance system currently in place. RESULTS: Using sick leave data, we detected 92% of reported influenza outbreaks between 2016 and 2017, on average 5.88 weeks prior to outbreak peaks. Compared to the existing Sentinelles model, our method had high sensitivity (89%) and positive predictive value (86%), and detected outbreaks on average 2.5 weeks earlier. CONCLUSION: Sick leave surveillance could be a sensitive, specific and timely tool for detection of influenza outbreaks.

Hierarchizing Determinants of Sick Leave: Insights From a Survey on Health and Well-being at the Workplace.

OBJECTIVE: We hierarchized a range of individual and occupational factors impacting the occurrence of very short (1-3 days), short (4 days to 1 month), or long-term (more than a month) sick leave spells. METHODS: Data were collected from a repeated cross-sectional survey conducted in the French private sector over the period 2011 to 2017. Fifty one sick leave determinants were ranked using a conditional random forest approach. RESULTS: The main determinants of long-term sick leaves were mainly health-related characteristics, such as perceived health, but also work-related covariates such as supervisor acknowledgment. On the contrary, very short-term spells were mainly defined by sociodemographic covariates. CONCLUSION: These results could be useful for devising appropriate actions to prevent against sick leave at the workplace, particularly long-term spells. Random forest approach is a promising approach for ranking correlated covariates from large datasets.

Impact of a multicomponent hand hygiene-related intervention on the infectious risk in nursing homes: A cluster randomized trial.

BACKGROUND: The aim of this study was to assess the impact of a multifaceted hand hygiene (HH) program on the infectious risk in nursing homes (NHs). METHODS: This was a 2-arm cluster randomized trial; French NHs were allocated randomly to the intervention (13 NHs) or control (13 NHs) groups. The intervention consisted of implementing a bundle of HH-related measures over 1 year, including increased availability of alcohol-based handrub, HH promotion, staff education, and local work groups. The primary end point was the incidence rate of acute respiratory infections and gastroenteritis reported in the context of clustered cases episodes. Secondary end points were mortality, hospitalization, and antibiotic prescription rates. RESULTS: Baseline characteristics did not differ between groups. The overall handrub consumption was higher in the intervention group over the 1-year intervention period. Because of underreporting, data on the primary end points were of insufficient quality for analysis. Hospitalizations did not differ between the 2 groups. However, the intervention group showed significantly lower mortality (2.10 vs 2.65 per 100 residents per month, respectively; P = .003) and antibiotic prescriptions (5.0 vs 5.8 defined daily doses per 100 resident days, respectively; P < .001). These results were confirmed by the longitudinal multivariate analysis adjusted for NH and resident characteristics and for seasonality (mortality rate ratio, 0.76). CONCLUSIONS: A multifaceted HH intervention may have a short-term impact on mortality in NHs. Nevertheless, other strategies may remain necessary to reduce morbidity.

PRIORITIES FOR HEALTH ECONOMIC METHODOLOGICAL RESEARCH: RESULTS OF AN EXPERT CONSULTATION.

BACKGROUND: The importance of economic evaluation in decision making is growing with increasing budgetary pressures on health systems. Diverse economic evidence is available for a range of interventions across national contexts within Europe, but little attention has been given to identifying evidence gaps that, if filled, could contribute to more efficient allocation of resources. One objective of the Research Agenda for Health Economic Evaluation project is to determine the most important methodological evidence gaps for the ten highest burden conditions in the European Union (EU), and to suggest ways of filling these gaps. METHODS: The highest burden conditions in the EU by Disability Adjusted Life Years were determined using the Global Burden of Disease study. Clinical interventions were identified for each condition based on published guidelines, and economic evaluations indexed in MEDLINE were mapped to each intervention. A panel of public health and health economics experts discussed the evidence during a workshop and identified evidence gaps. RESULTS: The literature analysis contributed to identifying cross-cutting methodological and technical issues, which were considered by the expert panel to derive methodological research priorities. CONCLUSIONS: The panel suggests a research agenda for health economics which incorporates the use of real-world evidence in the assessment of new and existing interventions; increased understanding of cost-effectiveness according to patient characteristics beyond the "-omics" approach to inform both investment and disinvestment decisions; methods for assessment of complex interventions; improved cross-talk between economic evaluations from health and other sectors; early health technology assessment; and standardized, transferable approaches to economic modeling.

Public health and chronic low chlordecone exposure in Guadeloupe, Part 1: hazards, exposure-response functions, and exposures.

BACKGROUND: Inhabitants of Guadeloupe are chronically exposed to low dose of chlordecone via local food. The corresponding health impacts have not been quantified. Nevertheless the public authority implemented an exposure reduction program in 2003. We develop methods for quantifying the health impacts of chlordecone and present the results in 2 articles: 1. hazard identification, exposure-response functions (ERF) and exposure in Guadeloupe, 2. Health impacts and benefits of exposure reduction. Here is the first article. METHODS: Relevant data are extracted from publications searched in Medline and Toxline. Available knowledges on mode of action and key-event hazards of chlordecone are used to identify effects of chlordecone that could occur at low dose. Then a linear ERF is derived for each possible effect. From epidemiological data, ERF is the delta relative risk (RR-1) divided by the corresponding delta exposure. From animal studies, ERF is the benchmark response (10 %) divided by the best benchmark dose modeled with BMDS2.4.0. Our goal is to obtain central values for the ERF slopes, applicable to typical human populations, rather than lower or upper bounds in the most sensitive species or sex. RESULTS: We derive ERFs for 3 possible effects at chronic low chlordecone dose: cancers, developmental impairment, and hepatotoxicity. Neurotoxicity in adults is also a possible effect at low dose but we lack quantitative data for the ERF derivation. A renal toxicity ERF is derived for comparison purpose. Two ERFs are based on epidemiological studies: prostate cancer in men aged >44y (0.0019 per µg/Lblood) and altered neurodevelopment in boys (-0.32 QIpoint per µg/Lcord-blood). Two are based on animal studies: liver cancer (2.69 per mg/kg/d), and renal dysfunction in women (0.0022 per mg/kg/d). CONCLUSION: The methodological framework developed here yields ERFs for central risk estimates for non-genotoxic effects of chemicals; it is robust with regard to models used. This framework can be used generally to derive ERFs suitable for risk assessment and for cost-benefit analysis of public health decisions.

Public health and chronic low chlordecone exposures in Guadeloupe; Part 2: Health impacts, and benefits of prevention.

BACKGROUND: Inhabitants of Guadeloupe are chronically exposed to low doses of chlordecone via local food due to its past use in banana plantations. The corresponding health impacts have not been quantified. We develop a quantitative method and present the results in two articles: 1. Hazard identification, exposure-response functions, and exposure, 2. Health impacts, and benefits of a program to reduce the exposure of the population. Here is the second article. METHODS: The exposure-response functions derived in Part 1 (for liver and prostate cancer, renal dysfunction and cognitive development) are combined with the exposure data to calculate the impacts. The corresponding costs are calculated via DALY's and VOLY. A no-effect threshold is included via the marginal fraction of the collective exposure above the reference dose. The health benefits are the impacts in 2002 (before the exposure reduction program) minus the impacts in 2006 (since the program). They are compared to the costs, namely the public annual expenditures for reducing the population exposure. RESULTS: Without threshold, estimated annual cases of liver cancer, prostate cancer and renal dysfunction are respectively 5.4, 2.8, 0.10 in 2002; and 2.0, 1.0, 0.04 in 2006. Annual IQ points lost (cognitive development) are respectively: 1 173 and 1 003. The annual cost of total impacts is 38.3 Million Euros (M€) in 2002 and 23.7 M€ in 2006. Comparing the benefit of 14.6 M€ with the 3.25 M€ spent for prevention, the program appears well justified. With threshold, the costs of the impacts are lower, respectively: 26.5 M€ in 2002 and 12.8 M€ in 2006, but the benefit is not very different: 13.7 M€. CONCLUSION: This is the first study that quantified chronic non genotoxic effects of chlordecone exposures in Guadeloupe. According to our results, preventive actions should be focused on pregnant women because of the high social cost of development impairment and also because their exposures decreased less rapidly than others. Prevention effort should be sustained as long as chlordecone remains in soils. Additional toxicological and epidemiological research would also be required for health endpoints that could not be taken into account (neurotoxicity of adults, autoimmune diseases and other developmental effects).

How to Identify and Prioritize Psychosocial Factors Impacting Stress Level.

We develop a methodological approach to identify and prioritize psychosocial factors (stressors) requiring priority action to reduce stress levels. Data analysis was carried out on a random sample of 10 000 French employees who completed, during a routine interview with the occupational physician, a 25-item questionnaire about stress levels, as well as a questionnaire about 58 stressors grouped into 5 latent variables: job control, job context, relationships at work, tasks performed and recognition. Our method combines Importance-Performance Analysis, a valuable approach for prioritizing improvements in the quality of services, with Partial Least Squares-Path modeling, a Structural Equation Modeling approach widely applied in psychosocial research. Findings on our data suggest two areas worthy of attention: one with five stressors on which decision makers should concentrate, and another with five stressors that managers should leave alone when acting to reduce stress levels. We show that IPA is robust when answers to questions are dichotomized, as opposed to the initial 6-point Likert scale. We believe that our approach will be a useful tool for experts and decision-makers in the field of stress management and prevention.

Demographic and occupational predictors of stress and fatigue in French intensive-care registered nurses and nurses' aides: a cross-sectional study.

BACKGROUND: Healthcare workers (HCWs) working in intensive-care units (ICUs) are exposed to high physical and mental demands potentially affecting their health or having repercussions on patient care. Although several studies have explored the links between some aspects of working conditions in hospitals and HCW health, the complex dynamics at play are not fully understood. OBJECTIVES: This study aimed to explore the impact of a wide array of demographic, employment and organizational factors related to fatigue and stress of French ICU HCWs. DESIGN AND SETTING: A cross-sectional study was conducted in ICUs of Paris-area hospitals between January 18, 2013 and April 2, 2013. All types of adult ICUs were included (medical, surgical and polyvalent). PARTICIPANTS: Included in the study were HCWs with patient contact (doctors, residents, registered nurses, nurse's aides and physical therapists). Participation was proposed to all eligible HCWs present during on-site visits. Temporary staff not typically assigned to the given ICU was excluded. METHODS: Data were collected using an individual questionnaire administered in interviews during day and night shifts (N=682). Stress and fatigue outcomes included the 10-item Perceived Stress Scale (PSS10), the Nottingham Health Profile sleep and energy level rubrics and the current fatigue state at the interview. Multivariate analysis was restricted to nurse and nurse's aide data (n=536). RESULTS: Doctors and residents reported fewer sleep difficulties but were more likely to report a tired current state. Female gender was associated with higher stress levels and greater fatigue for all outcomes, while greater social support of supervisor or colleagues decreased stress and fatigue. At the organizational level, longer shifts (12 h vs. 8 h) were associated with tired current state and greater sleep difficulties. Personnel on rotating shifts had lower stress and a better current state, while those on night shifts had greater sleep and energy level difficulties. CONCLUSIONS: Even when controlling for demographic factors, employment and organizational elements remained significantly associated with stress and fatigue outcomes. To improve HCW health it is important to consider simultaneously factors at the individual and organizational level.

Cost-effectiveness of magnetic resonance imaging with a new contrast agent for the early diagnosis of Alzheimer's disease.

BACKGROUND: Used as contrast agents for brain magnetic resonance imaging (MRI), markers for beta-amyloid deposits might allow early diagnosis of Alzheimer's disease (AD). We evaluated the cost-effectiveness of such a diagnostic test, MRI+CLP (contrastophore-linker-pharmacophore), should it become clinically available. METHODOLOGY/PRINCIPAL FINDINGS: We compared the cost-effectiveness of MRI+CLP to that of standard diagnosis using currently available cognition tests and of standard MRI, and investigated the impact of a hypothetical treatment efficient in early AD. The primary analysis was based on the current French context for 70-year-old patients with Mild Cognitive Impairment (MCI). In alternative "screen and treat" scenarios, we analyzed the consequences of systematic screenings of over-60 individuals (either population-wide or restricted to the ApoE4 genotype population). We used a Markov model of AD progression; model parameters, as well as incurred costs and quality-of-life weights in France were taken from the literature. We performed univariate and probabilistic multivariate sensitivity analyses. The base-case preferred strategy was the standard MRI diagnosis strategy. In the primary analysis however, MRI+CLP could become the preferred strategy under a wide array of scenarios involving lower cost and/or higher sensitivity or specificity. By contrast, in the "screen and treat" analyses, the probability of MRI+CLP becoming the preferred strategy remained lower than 5%. CONCLUSIONS/SIGNIFICANCE: It is thought that anti-beta-amyloid compounds might halt the development of dementia in early stage patients. This study suggests that, even should such treatments become available, systematically screening the over-60 population for AD would only become cost-effective with highly specific tests able to diagnose early stages of the disease. However, offering a new diagnostic test based on beta-amyloid markers to elderly patients with MCI might prove cost-effective.

Cancer mortality study among French cement production workers.

PURPOSE: To analyse the mortality and its causes, especially cancer, among French cement production workers. METHODS: A cohort of all workers employed at least 1 year in one of the main four cement companies in France was assembled (9,118 workers, 122,124 person-years of follow-up between 1990 and 2005). A common job titles classification was used to analyse occupational risk factors. We conducted a standardized mortality ratio analysis based on age, gender and calendar-period-specific national mortality rates and explored the combined effect of job titles and duration through an internal Cox regression analysis. RESULTS: The number of deaths during the follow-up period was 430 (4.7%). Malignant neoplasm was the cause of 48.1% of deaths. Overall, a deficit in all-causes mortality (standardized mortality ratio (SMR): 0.68, 95% confidence interval (CI) 0.61-0.74) and in cancer mortality (SMR: 0.80, CI 0.69-0.92) was observed. Working in the quarry, yard and shipping sectors was associated with a 50% higher all-causes mortality risk in comparison with the administrative sector. CONCLUSIONS: This cohort study does not support previous observations that cement workers are at higher risk of cancer mortality than the general population. The length of follow-up should be increased, and specific exposures deserve analysis.