Review article 107

The Work Activity and Participation Outcomes Framework: a new look at work disability outcomes through the lens of the ICF Rawan A. AlHeresha and Julie J. Keysorb Work disability is common among people with chronic conditions. The terminology in the field is variable and often used interchangeably and there is a lack of comprehensive frameworks to describe work as an outcome. Varied operationalization of work disability makes it difficult to establish precise estimates of the impact of chronic musculoskeletal conditions on work. A new conceptual framework was developed using the International Classification of Functioning, Disability and Health and was named ‘Work Activity and Participation Outcome (Work APO) Framework’ which clarified definitions in the field. Applying the framework to people at risk of work disability and evaluating their outcomes could advance the literature. International Journal of Rehabilitation Research

Introduction Work disability is common among people with chronic musculoskeletal conditions. Back pain, arthritis, and rheumatological conditions are the leading cause of workrelated disability (Woolf and Pfleger, 2003; Wolfe et al., 2007). In all, 10–40% of people with chronic musculoskeletal conditions are unemployed within 10 years (Allaire, 2001; Sullivan et al., 2010; Tillett et al., 2012). The societal costs of work disability in the USA are tremendous, with estimates showing 234 billion dollars spent annually on work losses (Allaire et al., 2005; Burton et al., 2006). Although there is a robust literature on work among individuals with chronic musculoskeletal conditions, terminology in the field is highly variable and often used interchangeably; making it difficult to establish precise estimates of the impact of these conditions on work. Inconsistent terminology could reflect a lack of conceptual frameworks guiding the field. Indeed, there is a dearth of work disability outcome conceptual frameworks. In the arthritis literature, one model is predominate; however, it focuses on work productivity – a narrow construct in the broader ‘work role’ or the ‘life situation of work’ (Tang et al., 2011). The International Classification of Functioning, Disability and Health (ICF), a conceptual framework in disability research, is the basis for many recent health and functioning outcome assessments (WHO, 2001). The ICF was used to guide work capacity evaluations for social security benefits and wage supplementation 0342-5282 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

38:107–112 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. International Journal of Rehabilitation Research 2015, 38:107–112 Keywords: conceptual framework, International Classification of Functioning, Disability and Health, work a

Boston University Sargent College of Health and Rehabilitation Sciences and Department of Physical Therapy and Athletic Training, Boston University Sargent College of Health and Rehabilitation Sciences, Boston, Massachusetts, USA b

Correspondence to Rawan A. AlHeresh, MS OT, Boston University Sargent College of Health and Rehabilitation Sciences, Boston, 02151 MA, USA Tel: + 1 617 353 2384; fax: + 1 617 358 6891; e-mail: [email protected] Received 24 November 2014 Accepted 16 January 2015

(Anner et al., 2012; Oberhauser et al., 2013); but not to examine work outcomes while people are in the workforce. Given the lack of frameworks for work, we aim to develop a new conceptual framework for work outcomes among individuals with chronic musculoskeletal conditions. To accomplish this aim, we (a) critically review existing terminology and frameworks, and (b) discuss a new framework to conceptualize work for musculoskeletal conditions.

Current work outcomes: terminology and conceptual frameworks Databases including PubMed and Web of Science were searched for frameworks of work outcomes. Search terms included ‘conceptual framework, theoretical framework and framework’, ‘work and employment’, and ‘musculoskeletal conditions, arthritis, and low back pain’. Papers that described relationships between these constructs by including a framework were included. This, however, yielded very limited results. Because of the restricted number of articles from the search, a convenient selection of scientific articles was reviewed. The term work disability has a wide usage in the literature. Work disability refers to employment status (Allaire, 2008), work limitations (Dhanhani et al., 2009), productivity restrictions (Escorpizo et al., 2007), or presenteeism restrictions (Goetzel et al., 2004). Others use it to indicate employment-related situations (Burton et al., 2006; Escorpizo et al., 2007; Gaudreault et al., 2014). DOI: 10.1097/MRR.0000000000000112

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108 International Journal of Rehabilitation Research 2015, Vol 38 No 2

Employment status generally refers to whether someone is employed full-time or part-time, on disability leave, or unemployed/retired. Work limitations are limitations in performing work demands to the fullest capacity (Lerner et al., 2001), or not being able to perform certain tasks in the workplace (Macedo et al., 2009). Work productivity is a major focus of the literature. It is defined as work input divided by work output (Escorpizo et al., 2007) and is viewed as a combination of absenteeism and presenteeism. Presenteeism is widely studied; yet, usage of the term is inconsistent. Presenteeism is productivity loss associated with reduced work efficiency, or the degree of workplace activity limitations (Gignac et al., 2012), or at-work disability (Beaton et al., 2010). Others define presenteeism as the time of impaired performance while at work generally or due to health reasons resulting in productivity loss (Beaton et al., 2009); or more generally as a loss of productivity regardless of time (Escorpizo et al., 2007). The review by Johns (2010), shows the wide and varied usage of ‘presenteeism’ with the term meaning attendance (not being absent), going to work despite feeling unhealthy (Smithy, 1970), or reduced productivity at work due to health. Absenteeism is defined as the extent of time/frequency of being off work due to health (Escorpizo et al., 2007). The only framework for arthritis work outcomes is focused on work productivity. In this framework, Beaton and colleagues’ view work productivity as a combination of absenteeism and presenteeism. Work productivity has two states: outcomes and costs. Outcome states pertain to the number of days/hours off from work (absenteeism) and difficulties at work (at work-productivity loss or presenteeism). Cost indicator states pertain to the costs of time away from work (absenteeism) and worker productivity loss expressed in hours and translated to dollars (at work-productivity loss or presenteeism). Thus, the authors suggest work productivity measurement along four domains: time away from work, costs of time away from work, difficulties at work, and worker productivity loss in hours and translated to dollars (Beaton et al., 2009). Another element of the Beaton and colleagues’ framework is that work outcomes vary over time. People cycle through periods of being absent from work due to health problems to being present but with decreased work productivity to being fully functional at work and meeting all productivity expectations; thus, bringing forward the dynamic nature of chronic health conditions and work activities and expectations. External work factors as well as person-level factors are also proposed to influence work. Moreover, this framework highlights linking worker and societal costs together and the dynamic nature of work productivity outcomes over time; however, their focus is on work productivity and not employment status.

The broader notion of employment is addressed by Koopmans and colleagues. Their perspective is based on 32 articles examining work frameworks from management, occupational health, and psychology. The authors identify four critical areas of work performance: task performance (e.g. work quality, work quantity, and decision-making), contextual performance (e.g. enthusiasm, proactivity, interpersonal relations, and organizational commitment), adaptive performance (e.g. adjusting goals and plans to situation and acting appropriately), and counterproductive work behavior (e.g. tiredness or doing tasks incorrectly) (Koopmans et al., 2011). Koopmans and colleagues’ framework conceptualizes the experiences of an individual at work role more broadly than productivity, yet many of the dimensions of work outcomes do not readily fit into general frameworks of rehabilitation health sciences that focus more on health and disability outcomes. Many rehabilitation fields have adopted the ICF as a guiding framework to development of health and disability outcomes for individuals with chronic conditions (WHO, 2001) and has been used quite extensively in rehabilitation outcomes measurement over the past decade. In the ICF, ‘health’ and ‘disability’ are viewed as umbrella terms that reflect the positive and negative aspects of functioning from a biological, individual, and societal level (WHO, 2001). The ICF is organized into two parts: (a) functioning and disability and (b) contextual factors. According to the ICF, difficulty or limitations in lifting a 10 pound box, sitting or standing for long time periods, or typing are examples of activity limitations (WHO, 2001). Examples of participation restriction are the problems people may have working a fulltime 40-h job, maintaining a required level of productivity for their employer, or problems an individual has in communicating with their coworkers or supervisor. In addition, the ICF model proposes two qualifiers when assessing activity and participation outcomes: (a) capacity and (b) performance. Capacity is the ability of an individual to execute a task or action (WHO, 2001). It is an indication of the extent of activity limitation due to an individual’s inherent or intrinsic features without assistance or irrespective of the environment, such as how much difficulty do you have walking long distances, typing, or opening doors. The level of the capacity should be judged based on what is normally expected from that individual before they acquired their health condition. The performance qualifier pertains to what the individual actually does in his or her current work environment. An example would be: ‘How often are doors difficult to open at your place of employment due to your health condition?’. The ICF approach advocates for both capacity and performance to be assessed for the activity and participation domain. The ICF framework notes that both of these

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Work Activity and Participation Outcome Framework AlHeresh and Keysor 109

qualifiers are important to consider when measuring activity and participation outcomes, yet clearly there is varied use of these terms with some authors not using the qualifiers (Okochi et al., 2005) and others using them to distinguish between activity and participation (Jette et al., 2003). Although there is no consensus in how the qualifiers are applied, the notion that activity and participation outcomes should be viewed from both capacity and performance perspectives has some appeal in rehabilitation outcomes. The ICF provides a broad perspective on whether and how people perform daily tasks and activities as well as their involvement in life roles, but it has not been applied to work. On the other hand, the Beaton et al. (2009) and Koopmans et al. (2011) frameworks articulate important elements of work but neither interfaces with the ICF model. Thus, we propose a new model based prominently on the ICF but informed by other models in the field.

The Work Activity and Participation Outcome Framework We propose a new work outcomes framework with clear conceptual definitions – the Work Activity and Participation Outcome (Work APO) Framework – based on the ICF framework (Fig. 1). The Work APO framework has two parts: (1) Work functioning and disability (including body systems and structures, and work activity and participation). (2) Contextual factors (including personal factors and environmental factors). Work functioning is an umbrella term encompassing work activity and work participation. Work disability is an umbrella term describing work activity limitation and work participation restriction (Table 1). Thus, the term work disability broadly encompasses difficulties people

have performing job-related tasks as well as the ability to fulfill their desired career goals including career advancement and sustaining full employment. Work activity is the execution of a work-related task. Work activity limitation indicates difficulty an individual may have in executing work-related tasks or activities (e.g. reduced efficiency in completing activities and tasks required of the work role/presenteeism). Examples of work activity limitations include: difficulty or limitation in typing, difficulty or limitation in sitting for long periods of time, and completing fewer tasks than is expected or completing tasks at lower quality than what is expected. Work participation refers to involvement in work roles or the lived experience of work. Examples include: number of hours worked, maintaining desired employment (type and hours), and experiencing desired and equal career growth. Work participation restriction refers to problems an individual may experience at work. Examples include number of hours lost from work (i.e. absenteeism), underperforming job expectations, reduced desired employment (e.g. part-time employment, short-term disability, long-term disability, premature retirement or fewer working hours than desired), and reduced career growth. Similarly to the ICF, work activity limitation and participation restriction are not separated into distinct domains but represent a single domain with overlapping concepts. The activity and participation domains are further operationalized into capacity and performance. As defined by the ICF, work capacity refers to the ability of an individual to execute work-related tasks or actions (e.g. how much difficulty do you have communicating over the telephone at work?), and work performance pertains to what the individual does in his or her work situation (or work role) (e.g. how often do people complete the job tasks that are expected of them? Is a person working full-time, part-time, retired, on disability or unemployed?).

Fig. 1

Body systems and structures

Work activities/ activity limitations

Person factors

Work participation/ participation restriction

Environment factors

Work Activity and Participation Outcomes Framework.

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110 International Journal of Rehabilitation Research 2015, Vol 38 No 2

Table 1

Work Activity and Participation Outcomes Framework

Work outcome

Definition

Example

Work disability

A broad overarching term reflecting work activity limitation or work participation restriction Ability to perform work tasks and activities required of the job Execution of work tasks and activities required of the job Involvement in work roles Work productivity (the amount of goods or services produced over a specified period of time) Employment status (desired and expected level) Career advancement (desired and expected level) Job initiative (learning new skills; taking on new initiatives) Difficulties or limitations in performing work tasks and activities required of the job Execution of work tasks and activities below what is expected of the job (presenteeism – working with reduced efficiency) Absenteeism: lost hours worked per day/month/year Work productivity loss (the amount of goods or services not produced over a specified time) Reduced employment status, that is, part-time, short-term or long-term disability, premature retirement; unemployed Limited career advancement Reduced job initiative

Same examples as work activity limitations and work participation restrictions

Work activity

Work participation

Work activity limitations

Work participation restriction

Moreover, the individual’s work functioning has a direct relationship with contextual factors. Parallel to the ICF, the contextual factors include the personal factors of the worker and the work environmental factors. Examples of personal factors that can influence work include the individual’s persistence and ambition in achieving job growth, and the individuals’ level of satisfaction with their job. The work environmental factors include physical, social, and attitudinal factors in which people work. The support and relationships between the worker and their employer/coworkers and short term disability policies are examples of environmental factors that can influence the individuals’ work. In our Work APO framework, all outcomes have longitudinal and reciprocal relationships over time. We expect changes in the intrinsic abilities of the individual with job-related tasks and activities (e.g. difficulty carrying a heavy object), which could lead to reduced efficiency in completing work tasks (i.e. presenteeism), lost time from work (i.e. absenteeism), low work productivity, and ultimately premature work cessation. Similar to the Beaton and colleagues’ framework, the relationships with work outcomes are not linear and instead are dynamic and reciprocal over time with potential for people to cycle in and out of work activity limitations and participation restrictions. This longitudinal relationship between activity and participation-type outcomes is supported in several general aging as well as chronic musculoskeletal populations, although others note a dynamic relationship among activity and participation outcomes (Keysor, 2003; Jette et al., 2005). These feedback loops are recognized in the ICF framework and show the complex interplay of activities and participation outcomes (WHO, 2001).

Typing on computer, handing reports on time

Number of hours worked; meeting all expectations of the job; maintaining desired employment; experiencing desired and equal career growth

Difficulty sitting for long period of time; limitation in carrying heavy work-related objects; completing fewer tasks than is expected in work role or completing tasks at lower quality than what is expected

Number of hours lost from work (e.g. absenteeism); underperforming job expectations; reduced employment status (e.g. part-time employment, short-term disability, long-term disability, or premature retirement); reduced career growth

Rehabilitation programs aim to accomplish short and long-term goals. Changing the difficulty and quality of work tasks could be a short-term goal. Interventions aimed at addressing this goal by enhancing body structures and functions may have a more immediate effect on the activity and capacity-level items, particularly over the short-term periods. Longer time periods may be needed to experience changes in the broader work participation and performance to achieve the longer-term goals of rehabilitation. Our conceptual framework allows the presence of both short-term and long-term work outcomes, which is needed in rehabilitation sciences.

Discussion The Work APO framework provides enhanced clarity to field of work outcomes in several ways. First, it integrates terminology in the field with the ICF, a widely accepted framework in health and disability outcome research; thereby, fostering a more unified use of language, particularly in the rehabilitation sciences. Second, the Work APO conceptual framework highlights the importance of understanding both capacity – that is, the individual’s intrinsic ability – and performance – that is, what an individual actually does – regarding work-related activities and tasks as well as participating in the role of work among individuals with chronic conditions. Third, our framework begins to put work outcomes into a longitudinal timeframe whereby work limitations begin as more proximal outcomes in early stages of work disability and work participation restrictions occur as more distal outcomes of work disability. Similarly to others (Escorpizo et al., 2007; Wolfe et al., 2007), we use the term ‘work disability’ broadly to

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Work Activity and Participation Outcome Framework AlHeresh and Keysor 111

represent performance in several aspects of work outcomes. However, we propose two major domains in work outcomes – work activity and work participation. This approach can then be used to organize other outcomes such as absenteeism, presenteeism, and employment status as these terms relate to work activity and participation domains. In addition, focusing outcome perspectives on activity and participation domains can foster a thoughtful selection of assessments to optimally match the desired and expected outcomes of the intervention approach. The recognition that work activity and participation outcomes should be viewed through capacity and performance indicators supports a developing perspective in the field regarding measurement of activity and participation outcomes. Although this area is still developing, the applications to work outcomes have some value. For example, people clearly need to be able to perform workrelated activities and tasks so they can meet the expectations of their job. Few people will be successful in their job if they cannot successfully complete numerous and varied work activities. Ultimately, however, for people who are at risk of premature retirement or work loss, the focus should be on efforts to sustain their full employment, which may need to more specifically address what people actually do in their job role – the performance indicator. Successful intervention approaches that address both the work-related tasks and the performance in the work role have positively impacted employment retention among individuals with chronic musculoskeletal conditions (Allaire et al., 2003). Thus, addressing only capacity may not be adequate for ultimately sustaining full employment. In contrast, focusing on capacity may be important if that is the goal of the intervention and identified need of the target population. Our framework does not, however, address the ‘cost indicator’ outcomes proposed by Beaton et al. (2009). Identifying the economic cost outcomes of work disability is critical, and indeed, is an active aspect of research in occupational health among many people with many chronic conditions (Stewart et al., 2003; Woolf and Pfleger, 2003). The Work APO framework addresses the impact on the individual rather than the broader impact on society. It is feasible that the Work APO framework could be extrapolated to cost indicators, but the first critical need is to identify the important indicators and ways to assess them. In addition, the Work APO framework could also inform changes in the organization, environment, or policy in the work place. It could be used to organize interventions aimed at optimizing work activity and participation and could be useful in conceptualizing approaches to specifically target work activity and participation promotion. The Work APO framework may help unify terminology used among research and in scientific literature that will

foster a better understanding of work outcomes across studies and populations. Furthermore, the adoption of a unified framework will add conceptual clarity to outcome measurement. The framework was developed using the ICF as a guiding framework, which given the prominence of the ICF in rehabilitation disablement outcomes measurement does add some validity to the framework. Applying the framework to people at risk of work disability and evaluating their outcomes could advance the literature.

Acknowledgements The work is supported by Grant #H133B100003 from the National Institute on Disability and Rehabilitation Research. Conflicts of interest

There are no conflicts of interest.

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The Work Activity and Participation Outcomes Framework: a new look at work disability outcomes through the lens of the ICF.

Work disability is common among people with chronic conditions. The terminology in the field is variable and often used interchangeably and there is a...
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