A systematic scoping review of health-promoting interventions for contact centre employees examined through a behaviour change wheel lens.

PURPOSE: Social determinants of health and poor working conditions contribute to excessive sickness absence and attrition in contact centre advisors. With no recent review conducted, the current scoping review is needed to investigate the volume, effectiveness, acceptability, and feasibility of health-promoting interventions for contact centre advisors. This will inform the adoption and implementation of evidence-based practice, and future research. METHODS: Searches conducted across four databases (MEDLINE, PsycInfo, CINAHL, Web of Science) and reference checking in February 2023 identified health-promoting interventions for contact centre advisors. Extracted and coded data from eligible interventions were systematically synthesised using the nine intervention functions of the Behaviour Change Wheel and behaviour change technique taxonomy. RESULTS: This scoping review identified a low number of high quality and peer-reviewed health-promoting intervention studies for contact centre advisors (28 studies since 2002). Most interventions were conducted in high-income countries with office-based advisors, predominantly using environmental restructuring and training strategies to improve health. Most interventions reported positive effectiveness results for the primary intended outcomes, which were broadly organised into: i) health behaviours (sedentary behaviour, physical activity, smoking); ii) physical health outcomes (musculoskeletal health, visual health, vocal health, sick building syndrome); iii) mental health outcomes (stress, job control, job satisfaction, wellbeing). Few interventions evaluated acceptability and feasibility. CONCLUSION: There is little evidence on the effectiveness, acceptability, and feasibility of health-promoting interventions for contact centre advisors. Evidence is especially needed in low-to-middle income countries, and for remote/hybrid, nightshift, older and disabled advisors.

The Workwell trial: protocol for the process evaluation of a randomised controlled trial of job retention vocational rehabilitation for employed people with inflammatory arthritis.

BACKGROUND: The Workwell trial is a multi-centre randomised controlled trial with the aims of evaluating the effectiveness and cost-effectiveness of job retention vocational rehabilitation for employed people with inflammatory arthritis, who are experiencing work difficulties due to their arthritis. Vocational rehabilitation is delivered by health service occupational therapists, who have received additional training in providing this Workwell intervention. A process evaluation will be undertaken alongside the main trial to investigate implementation fidelity; understand key stakeholders' perspectives of the intervention and the social and structural context in which the intervention is provided; and explore issues related to future implementation in clinical practice. This protocol describes the aims, objectives, and methodology of the Workwell trial process evaluation. METHODS: This mixed methods process evaluation will follow the Medical Research Council's Guidance on process evaluations for complex interventions. It will be underpinned by the conceptual framework for implementation fidelity (CFIF) and normalisation process theory (NPT). We will analyse treatment records, work assessments, and treatment notes to ascertain implementation fidelity. Semi-structured interviews with trial participants, their employer/line managers, treating therapists, and their therapy service managers will be undertaken to explore perceptions of the intervention, contextual factors, and potential for future implementation in practice. Interview topic guides will be informed by NPT. Therapists' views about Workwell training will be explored via questionnaires following training, and interviews and focus groups following treatment delivery to inform future implementation. Quantitative data will be analysed descriptively. Qualitative data will be analysed using thematic analysis. NPT will guide data analysis and interpretation. Findings from the different elements of this embedded design process evaluation will be reported separately and then the elements integrated. The process evaluation data will be analysed independently of the Workwell trial outcome evaluation. The process evaluation data will then be reviewed in the light of the trial findings. DISCUSSION: Few trials of job retention vocational rehabilitation in arthritis have included process evaluations. This process evaluation will assist in understanding factors influencing trial outcomes and identifying potential contextual barriers and facilitators for the potential implementation of Workwell vocational rehabilitation into clinical services. TRIAL REGISTRATION: ClinicalTrials.gov NCT03942783 . Registered on 08 May 2019. ISRCTN Registry ISRCTN61762297 . Registered on 13 May 2019. Retrospectively registered.

The effect on work presenteeism of job retention vocational rehabilitation compared to a written self-help work advice pack for employed people with inflammatory arthritis: protocol for a multi-centre randomised controlled trial (the WORKWELL trial).

BACKGROUND: Work problems are common in people with inflammatory arthritis. Up to 50% stop work within 10 years due to their condition and up to 67% report presenteeism (i.e. reduced work productivity), even amongst those with low disease activity. Job retention vocational rehabilitation (JRVR) may help prevent or postpone job loss and reduce presenteeism through work assessment, work-related rehabilitation and enabling job accommodations. This aims to create a better match between the person's abilities and their job demands. The objectives of the Workwell trial are to test the overall effectiveness and cost-effectiveness of JRVR (WORKWELL) provided by additionally trained National Health Service (NHS) occupational therapists compared to a control group who receive self-help information both in addition to usual care. METHODS: Based on the learning from a feasibility trial (the WORK-IA trial: ISRCTN76777720 ), the WORKWELL trial is a multi-centre, pragmatic, individually-randomised parallel group superiority trial, including economic evaluation, contextual factors analysis and process evaluation. Two hundred forty employed adults with rheumatoid arthritis, undifferentiated inflammatory arthritis or psoriatic arthritis (in secondary care), aged 18 years or older with work instability will be randomised to one of two groups: a self-help written work advice pack plus usual care (control intervention); or WORKWELL JRVR plus a self-help written work advice pack and usual care. WORKWELL will be delivered by occupational therapists provided with additional JRVR training from the research team. The primary outcome is presenteeism as measured using the Work Limitations Questionnaire-25. A comprehensive range of secondary outcomes of work, health, contextual factors and health resource use are included. Outcomes are measured at 6- and 12- months (with 12-months as the primary end-point). A multi-perspective within-trial cost-effectiveness analyses will also be conducted. DISCUSSION: This trial will contribute to the evidence base for provision of JRVR to people with inflammatory arthritis. If JRVR is found to be effective in enabling people to keep working, the findings will support decision-making about provision of JRVR by rheumatology teams, therapy services and healthcare commissioners, and providing evidence of the effectiveness of JRVR and the economic impact of its implementation. TRIAL REGISTRATION: Clinical Trials.Gov: NCT03942783 . Registered 08/05/2019 ( https://clinicaltrials.gov/ct2/show/NCT03942783 ); ISRCTN Registry: ISRCTN61762297 . Registered:13/05/2019 ( http://www.isrctn.com/ISRCTN61762297 ). Retrospectively registered.

Navigating employment retention with a chronic health condition: a meta-ethnography of the employment experiences of people with musculoskeletal disorders in the UK.

Purpose: Musculoskeletal disorders (MSDs) are associated with high rates of work disability in the UK. This review synthesized qualitative evidence concerning the employment experiences of people with MSDs to explore the factors shaping their employment trajectories post-onset and the resources they draw on to remain in work.Material and methods: Systematic database searches identified 16 qualitative studies of the employment consequences of having a chronic MSD in the UK. Meta-ethnographic methods were utilized to synthesize this body of evidence. This included a translation of concepts across studies to produce a line of argument synthesis.Results: The lack of certainty associated with often fluctuating and invisible MSD symptoms leads to employees struggling to maintain a stable work identity. Work retention is aided by having: a clear diagnosis, occupational tasks commensurate with altered abilities, and employers and colleagues who understand the nature of the condition. The ability to negotiate and implement workplace adjustments aids work retention but is dependent upon having good quality employee-employer relationships and the degree of autonomy available to the employee.Conclusion: Individuals with MSDs must draw on a range of personal, social, organizational and institutional resources to remain in or return to work post-onset.Implications for rehabilitationThe fluctuating and invisible nature of chronic musculoskeletal disorders (MSDs) creates uncertainty for individuals about their ability to remain working or return-to-work.Individuals with MSDs must draw on a range of personal, social, organizational, and institutional resources to remain in work following onset.Work retention is aided by having a clear diagnosis; occupational tasks commensurate with altered abilities; and understanding employers and coworkers.Organizational flexibility and the ability to act autonomously by changing occupations or self-implementing or requesting work adjustments are particularly important for work retention.

Association Between Maternal Education and Childhood Mortalities in Myanmar.

Maternal education is widely regarded as a core social determinant of child mortality in low-income countries. In Myanmar, the evidence related to context-specific social determinants of health including maternal education is scarce, limiting grounds to advocate for a comprehensive health policy. Employing multivariate methods, the study analyzed the 2015-2016 Demographic Health Survey data exploring independent effect of maternal education on neonatal, infant, and under-5 mortality. The study found that maternal education was not significantly associated with neonatal mortality as its effect was confounded by household wealth and geographic residence; however, it had independent effect on infant and under-5 mortality. Mothers with primary education had 23% reduction in the odds of under-5 mortality (P < .001); those with secondary level had 40% reduction (P < .001); and those at higher level had 62% reduction (P < .001). The study concluded that maternal education is a critical social determinant of childhood mortalities in Myanmar.

HIV risk behaviours among women who inject drugs in coastal Kenya: findings from secondary analysis of qualitative data.

BACKGROUND: Injecting drug users are at high risk of HIV infection globally. Research related to female drug users is rare in Kenya, yet it is required to inform the development of gender-sensitive HIV prevention and harm reduction services in East Africa, where injecting drug use is on the rise. METHODS: This study aimed to document the nature of HIV risks encountered by women who inject drugs in the Mombasa and Kilifi, Kenya. Secondary data analysis was conducted on an existing dataset from a 2015 primary qualitative study involving 24 interviews and 3 focus group discussions with 45 women who inject drugs. These were complemented with five interviews with key stakeholders involved in the provision of services to women who inject drugs. Guided by the social ecology theory, a thematic analysis was conducted to identify the nature of HIV risks and their underlying determinants. RESULTS: HIV risk behaviours fell into two broad categories: unsafe injecting and unprotected sex. These risks occurred in the form of sharing of needles, unprotected oral, anal, and vaginal sex, sexual assaults, injecting drug use during sex, sex work, and other types of transactional sex. The primary determinants underlying these risks were a low-risk perception, inequitable gender power, economic pressures, and poor availability of needles and condoms. These social-ecological determinants did not exist in isolation, but intersected with each other to create powerful influences which exposed women to HIV. Social-ecological determinants exerted constant influence and created a persistent 'HIV risk environment' that was involuntarily experienced by women. CONCLUSION: Individual, interpersonal, and societal-structural factors intersect to produce HIV risk behaviours. As a minimum, these risks will require a combination of multifaceted micro-level interventions including self-efficacy training, risk assessment skills, couple counselling, and universal access to the recommended harm reduction package. In addition, the current focus on micro-level interventions in Kenya needs to shift to incorporate macro-level interventions, including livelihood, employability, and gender norms-transforming interventions, to mitigate economic and gender-related drivers of HIV risks. In the Kenyan context, injecting drug use during sex work is emerging as an increasingly important HIV risk behaviour needing to be addressed.

Role of boyfriends and intimate sexual partners in the initiation and maintenance of injecting drug use among women in coastal Kenya.

INTRODUCTION: Gender dynamics and interpersonal relations within intimate partnerships are known to determine health behaviors, including substance use, within couples. In addition, influence from intimate partners may occur in the context of wider social ecological determinants of health behavior. The aim of this study was to document the role of intimate partners in influencing injecting drug use among women in Kenya, where injecting drug use is on the rise. METHODS: We performed secondary data analysis of an existing dataset from a 2015 qualitative study involving 45 women who inject drugs and 5 key stakeholders in coastal Kenya. Primary data had been collected via a combination of in-depth interviews and focus group discussions exploring sexual, reproductive, drug use, and other social contexts of women who inject drugs. The process by which intimate partners influenced women's initiation of drug use, transition to injecting practices, and maintenance of injecting drug use were identified using thematic analysis. RESULTS: Boyfriends and intimate either facilitated or restrained women's drug-injecting. On the one hand, young women's entry into drug use was prompted by relationship problems, or a need to acquiesce with their drug-using boyfriends. Once women started injecting, intimate partners facilitated ongoing drug-injecting by financing the acquisition of drugs, peddling drugs to their women, or sharing their drugs with their women. The social capital that peddlers held insulated women from police arrests, and encouraged women to seek and sustain intimate relations with well-connected peddlers. Men's influences over women were driven by an underlying patriarchal drug acquisition and economic power. On the other hand, boyfriends and intimate partners who were non-injectors or non-drug users sought to moderate women's injecting drug use by encouraging them to inject less, to smoke or snort instead of injecting, or to enroll into rehabilitation. These moderating influences were most prominent when couples were pregnant. Despite men being a source of practical and emotional support, women were frequently unable limit or alter their injecting drug use, due to its addictive nature. Men's disagreement with women's ongoing injecting strained relationships, and occasionally led to separation. CONCLUSIONS: Some boyfriends facilitated women's injecting drug use, while others moderated it, supporting assertions that intimate relationships can both be a site of injecting risks or protection. At the micro-level, these findings highlight an opportunity for couple-based interventions, leveraging on non-drug injecting males as a resource to support women adopt safer injecting practices. At a macro level, incorporating livelihood interventions into harm reduction programs is required in order to mitigate economic-based influence of male intimate partners on women's injecting drug use. At both levels, gender transformative approaches are essential. To gain a comprehensive understanding of women's injecting drug use, future studies drug use should explore women's contexts beyond micro influences and consider their wider macro-structural determinants.

"Whenever I can I push myself to go to work": a qualitative study of experiences of sickness presenteeism among workers with rheumatoid arthritis.

PURPOSE: UK government policy emphasizes the importance of continuing to work for recovery from poor health, yet sickness presenteeism (going to work whilst ill) is commonly regarded as having negative consequences for organizations and individuals. Our study explores experiences of working after onset of rheumatoid arthritis (RA), a chronic musculoskeletal disorder characterized by high rates of work disability. MATERIALS AND METHODS: An exploratory qualitative study consisting of in-depth interviews and six-month follow-up with 11 men and women with RA employed at disease onset. RESULTS: We expand upon previous models of sickness presenteeism by distinguishing between presenteeism that occurs voluntarily (wanting to work despite illness) and involuntarily (feeling pressured to work when ill). RA onset affected participants' ability to work, yet motivation to remain working remained high. The implementation of workplace adjustments enabled participants to stay working and restore their work capacity. Conversely, managers' misinterpretation of organizational sickness absence policies could lead to involuntary presenteeism or delayed return to work, conflicting with the notion of work as an aid to recovery. CONCLUSION: Workplace adjustments can facilitate voluntary sickness presenteeism. To reduce work disability and sickness absence, organizational policies should be sufficiently flexible to accommodate the needs of workers with fluctuating conditions. Implications for rehabilitation Individuals with rheumatoid arthritis (RA) are at high risk of work disability. Individuals' motivation to remain in work following onset of RA remains high, yet sickness presenteeism (working while ill) has received largely negative attention. It is important to distinguish between voluntary and involuntary forms of sickness presenteeism. Workplace adjustments facilitate voluntary sickness presenteeism (wanting to work despite illness) and improve job retention and productivity among workers with RA. Involuntary presenteeism (feeling pressured to work while ill) may occur if organizational policies are not sufficiently flexible to accommodate the needs of workers with RA.

Awareness and willingness to use HIV pre-exposure prophylaxis among men who have sex with men in low- and middle-income countries: a systematic review and meta-analysis.

INTRODUCTION: To facilitate provision of pre-exposure prophylaxis (PrEP) in low- and middle-income countries (LMIC), a better understanding of potential demand and user preferences is required. This review assessed awareness and willingness to use oral PrEP among men who have sex with men (MSM) in LMIC. METHODS: Electronic literature search of Cochrane library, Embase, PubMed, PsychINFO, CINHAL, Web of Science, and Google Scholar was conducted between July and September 2016. Reference lists of relevant studies were searched, and three authors contacted for additional data. Non-peer reviewed publications were excluded. Studies were screened for inclusion, and relevant data abstracted, assessed for bias, and synthesized. RESULTS: In total, 2186 records were identified, of which 23 studies involving 14,040 MSM from LMIC were included. The proportion of MSM who were aware of PrEP was low at 29.7% (95% CI: 16.9-44.3). However, the proportion willing to use PrEP was higher, at 64.4% (95% CI: 53.3-74.8). Proportions of MSM aware of PrEP was <50% in 11 studies and 50-70% in 3 studies, while willingness to use PrEP was <50% in 6 studies, 50-70% in 9 studies, and over 80% in 5 studies. Several factors affected willingness to use PrEP. At the individual domain, poor knowledge of PrEP, doubts about its effectiveness, fear of side effects, low perception of HIV risk, and the need to adhere or take medicines frequently reduced willingness to use PrEP, while PrEP education and motivation to maintain good health were facilitators of potential use. Demographic factors (education, age, and migration) influenced both awareness and willingness to use PrEP, but their effects were not consistent across studies. At the social domain, anticipated stigma from peers, partners, and family members related to sexual orientation, PrEP, or HIV status were barriers to potential use of PrEP, while partner, peer, and family support were facilitators of potential use. At the structural domain, concerns regarding attitudes of healthcare providers, quality assurance, data protection, and cost were determinants of potential use. CONCLUSIONS: This review found that despite low levels of awareness of PrEP, MSM in LMIC are willing to use it if they are supported appropriately to deal with a range of individual, social, and structural barriers.

Detention of People Lost to Follow-Up on TB Treatment in Kenya: The Need for Human Rights-Based Alternatives.

Adherence to treatment is a key element for global TB control. Public health laws can be used to enforce isolation, adherence, and completion of TB treatment. However, the practical application of public health laws can potentially range from voluntary measures to involuntary detention approaches. This paper explores the potential risks and impacts of using detention approaches to enforce TB treatment adherence. In August 2015, we conducted a literature search regarding the application of public health laws to enforce adherence to TB treatment globally, and specifically in Kenya. Texts were analyzed using narrative synthesis. Results indicated that in Kenya, people lost to follow-up on TB treatment were frequently detained in prisons. However, incarceration and detention approaches curtail the rights to health, informed consent, privacy, freedom from non-consensual treatment, freedom from inhumane and degrading treatment, and freedom of movement of people lost to follow-up. Detention could also worsen social inequalities and lead to a paradoxical increase in TB incidence. We suggest the incorporation of less intrusive solutions in legislation and policies. These include strengthening health systems to reduce dependency on prisons as isolation spaces, decentralizing TB treatment to communities, enhancing treatment education, revising the public health laws, and addressing socioeconomic and structural determinants associated with TB incidence and loss to follow-up.

Intersectionality of HIV stigma and masculinity in eastern Uganda: implications for involving men in HIV programmes.

BACKGROUND: Stigma is a determinant of social and health inequalities. In addition, some notions of masculinity can disadvantage men in terms of health outcomes. However, few studies have explored the extent to which these two axes of social inequality intersect to influence men's health outcomes. This paper investigates the intersection of HIV stigma and masculinity, and its perceived impact on men's participation in and utilisation of HIV services in Uganda. METHODS: Interviews and focus group discussions were conducted in Mbale and Jinja districts of Uganda between June and October 2010. Participants were men and women living with HIV (n = 40), their family members (n = 10) and health providers (n = 15). Inductive analysis was used to identify mechanisms through which stigma and masculinity were linked. RESULTS: Our findings showed that HIV stigma and masculinity did not exist as isolated variables, but as intersecting phenomena that influenced men's participation in HIV services. Specifically, HIV stigma threatened masculine notions of respectability, independence and emotional control, while it amplified men's risk-taking. As a result, the intersection of masculinity and HIV stigma prevented some men from i) seeking health care and accepting a 'sick role'; ii) fulfilling their economic family responsibilities; iii) safeguarding their reputation and respectability; iv) disclosing their HIV status; and v) participating in peer support groups. Participation in some peer support activities was considered a female trait and it also exacerbated HIV stigma as it implicitly singled out those with HIV. In contrast, inclusion of income-generating activities in peer support groups encouraged men's involvement as it enabled them to provide for their families, cushioned them from HIV stigma, and in the process, provided them with an opportunity to redeem their reputation and respectability. CONCLUSION: To improve men's involvement in HIV services, the intersection between HIV stigma and masculinity should be considered. In particular, better integration of and linkage between gender transformative interventions that support men to reconstruct their male identities and reject signifiers of masculinity that prevent their access to HIV services, and stigma-reduction interventions that target social and structural drivers of stigma is required within HIV programmes.

How do macro-level contexts and policies affect the employment chances of chronically ill and disabled people? Part I: The impact of recession and deindustrialization.

Low employment rates of chronically ill and disabled people are of serious concern. Being out of work increases the risk of poverty and social exclusion, which may further damage the health of these groups, exacerbating health inequalities. Macro-level policies have a potentially tremendous impact on their employment chances, and these influences urgently need to be understood as the current economic crisis intensifies. In Part I of this two-part study, the authors examine employment trends for people who report a chronic illness or disability, by gender and educational level, in Canada, Denmark, Norway, Sweden, and the United Kingdom in the context of economic booms and busts and deindustrialization. People with the double burden of chronic illness and low education have become increasingly marginalized from the labor market. Deindustrialization may have played a part in this process. In addition, periods of high unemployment have sparked a downward trend in employment for already marginalized groups who did not feel the benefits when the economy improved. Norway and Sweden have been better able to protect the employment of these groups than the United Kingdom and Canada. These contextual differences suggest that other macro-level factors, such as active and passive labor market polices, may be important, as examined in part II.

How do macro-level contexts and policies affect the employment chances of chronically ill and disabled people? Part II: The impact of active and passive labor market policies.

The authors investigate three hypotheses on the influence of labor market deregulation, decommodification, and investment in active labor market policies on the employment of chronically ill and disabled people. The study explores the interaction between employment, chronic illness, and educational level for men and women in Canada, Denmark, Norway, Sweden, and the United Kingdom, countries with advanced social welfare systems and universal health care but with varying types of active and passive labor market policies. People with chronic illness were found to fare better in employment terms in the Nordic countries than in Canada or the United Kingdom. Their employment chances also varied by educational level and country. The employment impact of having both chronic illness and low education was not just additive but synergistic. This amplification was strongest for British men and women, Norwegian men, and Danish women. Hypotheses on the disincentive effects of tighter employment regulation or more generous welfare benefits were not supported. The hypothesis that greater investments in active labor market policies may improve the employment of chronically ill people was partially supported. Attention must be paid to the differential impact of macro-level policies on the labor market participation of chronically ill and disabled people with low education, a group facing multiple barriers to gaining employment.

Socioeconomic inequalities in the employment impact of ischaemic heart disease: a longitudinal record linkage study in Sweden.

AIMS: Low socioeconomic status is associated with increased risk of ischaemic heart disease (IHD) in many European and North American countries. We hypothesize that the adverse impact of having IHD may also be heavier in lower socioeconomic groups and may constitute a mechanism for generating or reinforcing social inequalities in health. METHODS: Population registers of the 1.8 million residents of Stockholm County were used to assess the employment consequences over five years of having a diagnosis of IHD (600 cases) requiring hospital admission in 1996. We calculated annual age-standardized employment rates and age-adjusted odds of leaving employment during 1997-2001 by social class for in-patients and the general population. RESULTS: Men and women who had an in-patient episode for IHD had lower age-standardized employment rates than the general population. Following hospital admission, the likelihood of patients with IHD leaving employment increased annually, and by 2001 their adjusted odds were almost four times greater (odds ratio 3.95, 95% confidence interval 3.23-4.83) than for the general population. The impact of IHD on employment was more severe with decreasing social class and patients employed in low-skilled manual occupations were significantly more likely to lose employment than professional workers with the same diagnosis. Within each social class patients had significantly higher odds of leaving employment than the general population. CONCLUSIONS: In spite of its progressive employment and rehabilitation policies, our study revealed considerable and socially differentiated employment consequences of IHD in Sweden. More account needs to be taken of such differential impact in health and social policy development.

Labor market participation following onset of seizures and early epilepsy: Findings from a UK cohort.

PURPOSE: Previous studies have reported a considerable employment disadvantage among people with epilepsy. In a cohort of men and women who had experienced a single seizure or had early epilepsy at study entry we explored employment status and social mobility over 4 years and investigated whether employment outcomes were more disadvantageous for certain social groups. METHODS: Analyses were based on 350 individuals of working age identified via the UK Multicentre Study of Early Epilepsy and Single Seizures. Employment rates were calculated for the cohort and general population. Employment trajectories over 4 years were explored according to occupational social class. The relative risk of employment was calculated by clinical features of seizures and social class. RESULTS: Individuals with single seizures or early epilepsy had significantly lower employment rates than the general population at study entry, and 2- and 4-year follow-up. Employment rates of men and women in the cohort did not differ significantly. Although little social class mobility occurred during follow-up, there was evidence of some downward mobility between first seizure(s) and study entry. In the fully adjusted model, nonemployment was predicted at all time points by having fair/poor self-rated health and experiencing four or more seizures. We observed that some individuals continued to work in hazardous occupations or drive professionally within a year of experiencing seizure(s). DISCUSSION: People who have recently experienced a single seizure or who have early epilepsy are exposed to substantial employment disadvantage. Greater efforts are necessary to help these people return to work and stay employed.

Financial stress and strain associated with terminal cancer--a review of the evidence.

Financial circumstances are a significant influence on the quality of life for older people and may be important to health and wellbeing at the end of life. The aim of this study is to review the evidence for the existence and consequences of financial stress and strain at the end of life for people dying with cancer. We conducted a systematic search of four electronic databases for studies, providing data on illness-related financial burden (stress), or perception of financial hardship (strain), from patients with terminal cancer or their caregivers. Twenty-four papers were identified from 21 studies published in English between 1980 and 2006, the majority (14) of cross-sectional design. Financial stress was reported in all 13 studies from the USA (median 33%, range 10-66%), but only four sought measures of financial strain. In the USA, specific social consequences, such as moving house or change in employment to cope with caregiving, were reported in four of these studies; one of these also noted changes in treatment choices and avoidance of care for other family members. In studies from outside the USA, there is a dearth of data on financial stresses and the consequences of this for the household, despite widespread reporting of financial strain. To fill a gap in our understanding and improve holistic palliative care, researchers need to ask the questions about the consequences of financial stresses and strain for the health and wellbeing of the household.

Winners and losers in flexible labor markets: the fate of women with chronic illness in contrasting policy environments--Sweden and Britain.

This study compares employment rates among men and women with and without chronic illness in the contrasting policy environments of Britain and Sweden, through analysis of household surveys for 1979-1995. Professional and managerial groups were winners in both countries, including during recession. By the 1990s, employment rates for healthy Swedish women were uniformly high across the social groups and almost comparable with those of their male counterparts; rates for women and men with a chronic illness were also comparable, albeit at a lower overall rate. The greatest losers were male and female unskilled manual workers in Britain. British women with a chronic illness in the 1990s had less than half the employment rates of healthy women. Such social inequalities were much smaller and less consistent in Sweden, where the impact of illness was softened for all social groups. In Britain, workless men tended to be classed as unemployed or permanently sick, while workless women were more likely to be classed as looking after home/family. Lesser differences were seen in Sweden. No evidence was found to support the hypothesis that women in general, and the less skilled and sick in particular, would be the winners in a more flexible, less regulated labor market-quite the reverse.