Rose Meire Canhete Pereira1; Inês Monteiro2
Analysis of population growth trends and aging—which is associated with occurrence of chronic diseases, in addition to (work-related or not) diseases and accidents in general—points to an increasing need to implement rehabilitation services worldwide. Rehabilitation comprises three aspects: medical, vocational and social. The aim of the present study was to describe the state of the art in vocational rehabilitation approaches in several countries, as well as vocational rehabilitation-based return-to-work strategies for individuals with restrictions due to diseases and accidents in general developed in the past 30 years. We performed an integrative review of studies located in databases Virtual Health Library-Regional Library of Medicine (VHL-BIREME), PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Web of Science, Sociological Abstracts, Education Resources Information Center (ERIC) and SCOPUS. A total of 1,109 studies were initially retrieved, of which 12 were considered eligible on methodological assessment and included for review. The selected studies analyzed new approaches and the implementation of existing programs, new programs/projects, and educational measures for workers on sick leave. Most programs had multidisciplinary nature and included complementary educational approaches, early intervention, and possibility of workplace adjustments. The studies on new projects consisted in job retention and return-to-work programs for unemployed or temporary workers. The number of studies which describe occupational rehabilitation programs is small and evaluating their efficacy is difficult. Scientific research on this subject is still scarce vis-à-vis the current demands.
Keywords: rehabilitation, vocational; return to work; social security.
Analisando-se as tendências globais de crescimento populacional e o envelhecimento da população, que implica no aparecimento de doenças crônicas, além das doenças e acidentes em geral (relacionados ou não ao trabalho), observa-se crescente necessidade de implementação dos serviços de reabilitação no mundo. A reabilitação envolve três aspectos: reabilitação médica, profissional e social. Este estudo teve por objetivo identificar e apresentar a produção de conhecimento dos processos de reabilitação profissional em diversos países, bem como identificar estratégias para a reintegração ao trabalho de pessoas com restrições decorrentes de doenças ou acidentes em geral, por meio da reabilitação profissional durante os últimos 30 anos. Foi realizada uma revisão integrativa em portais de pesquisa em saúde - Biblioteca Virtual em Saúde - Biblioteca Virtual em Medicina (BVS-BIREME), PubMed -, bases de dados - Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Web of Science, Sociological abstracts, Education Resources Information Center (ERIC) - e banco de dados (SCOPUS). No total, 1.109 publicações foram identificadas. Após avaliação metodológica, 12 foram consideradas elegíveis e incluídas. Os estudos avaliaram novas abordagens e a implementação de programas existentes, novos projetos/programas e medidas educacionais para trabalhadores em licença médica. A maioria considerou a multidisciplinaridade, a abordagem educacional complementar, a intervenção precoce e a possibilidade de ajustes no ambiente de trabalho. As publicações sobre novos projetos foram relacionadas a programas de retenção no emprego e retorno ao trabalho para trabalhadores desempregados e temporários. Há um pequeno número de estudos descrevendo programas de reabilitação ocupacional e dificuldades em avaliar sua eficácia. A produção científica ainda é discreta quando comparada à necessidade relacionada a esse tema na atualidade.
Palavras-chave: reabilitação profissional; retorno ao trabalho; seguridade social.
According to the United Nations, understanding the demographic changes which will take place in the coming years, as well as challenges and opportunities to attain sustainable development is indispensable in the present time. The global population was 7.3 billions in mid-2015, with a growth of about 1 billion along the past 12 years. 901 millions were individuals aged 60 or over, corresponding to 12% of the global population, with a growth rate of 3.26%/year1.
The number of older adults is estimated to reach 1.4 billion in 2030, 2.1 billions in 2050 and possibly 3.2 billions by 2100. While Europe exhibits the largest proportion of individuals aged 60 or over (24%), the population is aging quickly also in other parts of the world1. Increased life expectancy and aging associated with low fecundity rates represent a call for specific public policies2. By 2050, one-fourth of the population in the main global regions, except for Africa, will be of people aged 60 or over1. These changes will have substantial impact on pension and social security systems worldwide.
According to a World Health Organization/World Bank report on disability,
more than 1 billion people, or about 15% of the world’s population, are estimated to be living with disability. Of these, 110–190 million adults have very significant difficulties in functioning. These numbers are expected to growth as a function of global population aging, increasing incidence of chronic diseases, and environmental factors, such as road traffic injuries, climate changes, natural disasters and conflict situations3.
Actions centered on disease prevention in and outside the workplace, through occupational health and safety and public health interventions, respectively, are essential. Measures focused on rehabilitation and return to work have paramount importance when disease does occur.
Work is considered a significant means for people to meet their basic needs. In addition, it is extremely relevant to their financial, psychological and emotional well-being, besides being crucial for the development of self-esteem, social status, feeling of personal accomplishment, independence, freedom and security4.
Return to work encompasses all procedures and initiatives to facilitate the reintegration to work of persons with reduced work capacity or capability, whether this is due to invalidity, illness or aging5. This notion is relevant within the present-day political context, in which the focus is on maintaining the sustainability of social security systems and reducing the economic impacts of sick leaves and improperly managed return to work, which lead to unemployment, disability pension or early retirement4.
In many countries, the entry point for the question of return to work at policy level is the lack of sustainability of social security systems and the need to reform the management of sickness absence and disability5. Sick leaves due to chronic diseases and early retirement result in salary losses and have physical and emotional consequences for workers. In turn, employers have to meet the additional costs of high employee turnover rates and the time lost in managing absenteeism, besides the overall costs to society at large.
Disability retirement poses a heavy burden to society, to be added to the challenges presented by workforce aging5. Disabled workers retire while they still are relatively young, which considerably reduces the overall effective age of retirement. In addition to the costs to society, early retirement has significant impact on the workers themselves, inasmuch as work is a relevant source of material and psychological well-being.
A study performed in the European Union affords a wider perspective of vocational rehabilitation. According to the authors, while many international organizations discuss rehabilitation within the context of individuals with disabilities, in this study the authors considered all workers who were potentially at risk of exclusion from the labor market because of a health problem, rather than only those with an officially recognized disability. This is to say, all previously healthy workers requiring medium- to long-term sick leaves or regular shorter sick leaves (due to chronic diseases) and who needed support to go back to work at their previous or a different workplace, even when not been formally recognized as disabled5.
The high risk of contracting a disease while employed influences the rates of labor market exit due to health problems. And while not all cases of early retirement are due to health problems, they do make a substantial contribution5.
According to the Organization for Economic Cooperation and Development (OECD) many individuals with work incapacity leave permanently the labor market and few are able to return or remain in it6. Therefore, fostering inclusion and enlarging the workforce is a relevant item in scientific and political agendas, and there is strong interest in encouraging people to work with their residual capacity and avoid leaving the labor market permanently7.
Rehabilitation services should be increased worldwide, particularly in medium- and low-income countries. Rehabilitation should be available to all workers who need it8.
Rehabilitation… consists of three different aspects. Medical rehabilitation aims to restore the functional or mental ability and the quality of life of people with physical or mental impairments or disabilities; vocational (or occupational) rehabilitation aims to enable persons with physical or mental impairments or disabilities to overcome barriers to accessing, maintaining or returning to employment or other useful occupation; and social rehabilitation aims to facilitate the participation of people with disabilities in social life8.
The aims of the present study were to describe the state of the art in vocational rehabilitation, with emphasis on return to work, in different countries, and to analyze returnto- work strategies based on vocational rehabilitation for individuals with restrictions due to diseases or accidents in general developed in the past 30 years.
Integrative reviews summarize the available empirical or theoretical information on a given subject9 and contribute to theoretical developments, in addition to having direct applicability in practice and policies10. Integrative reviews seek to synthesize and develop new knowledge out of the results of previous studies11-13. It is the single approach that allows combining different methods, and this methodological combination plays a significant role in evidence-based practice14.
In the present integrative review we followed the steps described by Whittemore and Knafl10. To ensure methodological rigor and enable reproducibility, we describe each individual step.
Searched databases were: Virtual Health Library – Regional Library of Medicine (VHL-BIREME), PubMed, MEDLINE, Embase, Latin American and Caribbean Health Sciences Literature (LILACS), Cumulative Index to Nursing and Allied Healthcare Literature (CINAHL), PsycINFO, Web of Science, Sociological Abstracts, Education Resources Information Center (ERIC) and SCOPUS. Controlled search terms were obtained from Health Sciences Descriptors (DeCS)–BVS-BIREME, Medical Subject Headings (MeSH)–MEDLINE/PubMed and Emtree–Embase, combined by means of Boolean operators (AND, OR, NOT). No filters were selected. We included qualitative and quantitative studies published in Portuguese, English, Spanish, Italian, French or German from 1 January 1988 through 5 April 2018 (past 30 years). We also included studies retrieved by handsearching in the aforementioned databases independently from the defined search strategy. Chart 1 describes the eligibility criteria (inclusion and exclusion).
Article selection was independently performed by two reviewers (first and second authors). Duplicates were excluded using EndNote® and manually when it failed to detect them due to differences in spelling or use of abbreviations. Studies were initially selected following analysis of titles and abstracts as per the inclusion and exclusion criteria. The thus selected articles were subjected to full-text analysis as per the exclusion criteria. The extracted information was summarized for later analysis.
Reporting was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to improve its quality15,16. We applied two search strategies which combined the most frequently used search terms related to the subject of interest:
• Search strategy #1: Return to Work AND Rehabilitation, Vocational;
• Search strategy #2: Return to Work AND Rehabilitation, Vocational AND Social Security.
The search strategies were developed from headings representing the subject of interest, and a protocol was created to guide the review, which also included the results of cross-checking both strategies to broaden the scope of the search.
The strength of evidence of the selected studies was established following the Johns Hopkins Nursing Evidencebased Practice: Model and Guidelines17.
The selected search strategies allowed retrieving 2,642 studies. Duplicates were excluded using EndNote® and manually. A total of 1,109 studies were selected for title and abstract analysis, of which 33 were subjected to full-text analysis. As a result, 11 studies were selected for integrative review. Through handsearching we located 5 further studies, one of which was selected for analysis. Therefore, 12 studies were finally included for integrative review.
Table 1 describes the results of the search strategies applied to the selected databases. Figure 1 consists in a flowchart representing article selection following PRISMA.
The vast majority of the 1,109 preselected studies following title and abstract analysis dealt with return to work and corresponding strategies, and many described medical rehabilitation. However, most did not describe or provide details on vocational rehabilitation, but merely cited this topic as part of a wider perspective on return to work.
The subjects most frequently addressed in the excluded studies were spinal cord injury, stroke, acute myocardial infarction and orthopedic conditions. The analyzed studies were conducted in several countries: Germany (2), Norway, Netherlands, United Kingdom, France, Australia, Denmark, United States and China (1 each).
Two studies addressed rehabilitation programs for workers with musculoskeletal problems, 2 neurological problems, 1 mental disorders, 1 cancer and 2 diseases in general. Systematic reviews focused on return to work and chronic diseases, and 1 study analyzed educational “trainings.”
Chart 2 describes the studies included in the integrative review according to author, publication year, country, aims, sample, study design, type of analysis and results.
Chart 3 describes the included studies according to sample, vocational rehabilitation program, multidisciplinary approach or not, complementary educational approaches, early intervention, and possibility of workplace adjustments.
The systematic review performed in Denmark25 was not included in Chart 3 because it exclusively dealt with educational trainings for return to work.
Analysis of Chart 3 shows that multidisciplinarity was a striking characteristic of all the selected studies, followed by early intervention and possibility of workplace adjustments. Complementary educational approaches were not mentioned in the studies performed in China26, Netherlands29 and the United Kingdom21.
In Table 2 the studies are categorized according to subject, whether there was an ongoing vocational rehabilitation program, whether program implementation was discussed, whether differential approaches were included in available programs, or the programs/project were new. Only 2 studies described new initiatives for employment retention and unemployed or temporary workers; all the other studies analyzed already implemented programs with new approaches or proposals for implementation
We initially located a large number of studies, but most addressed return to work generically, without any description of implemented vocational programs. Only a small number of studies described implemented vocational rehabilitation programs.
Comparative analysis between countries was difficult due to variability in approach, in addition to cultural differences and in public policies. This difficulty to analyze the targeted programs was evidenced in a systematic review performed in 201423.
Many European countries developed an holistic view on the subject of interest and approach vocational rehabilitation in a broadly encompassing manner with individualized strategies, affording possibilities for reintegration to the labor market. The European Union is making further advances through discussions of safe and healthy work for workers of any age, in which a preventive culture of workplace health and safety is given the due value, while also taking the population aging into account. Disease-centered cultures hinder the overall development of rehabilitation programs, while broader scoped approaches which consider the residual capacity, skills and perceptions of workers yield better outcomes.
Analysis of the available literature evidenced an interest in the identification of return-to-work predictors, studies having been conducted in cardiology, orthopedics, neurology, oncology and mental health. Sex-related differences were considered by some authors.
Critical analysis of the selected studies enabled comparing the data to the available theoretical information. All 12 selected studies described positive strategies which facilitated return to work for workers on sick leave for variable reasons. The following stand out among the observed aspects: joint design of vocational rehabilitation programs with the targeted workers, with clear and well-defined goals and deadlines; coordination between the various actors involved; early intervention; individualized approach (case management); psychological support combined with multidisciplinary approaches; possibility of workplace/workstation adjustments as a function of the workers’ restrictions; vocational training; and parttime return to work.
Several studies and surveys were conducted in the European Union on rehabilitation systems for ill or injured workers, which are used to ground national policies on workforce aging. A study performed by the European Agency for Safety and Health at Work (EU-OSHA) made an inventory of rehabilitation and return-to-work systems in member countries. The results allowed establishing which factors may have a relevant role in the design and implementation of rehabilitation and return-to-work systems and may be considered as reasons for success5. The participating countries were categorized according to the following criteria: employers’ duties vis-à-vis rehabilitation and return to work, access to vocational rehabilitation, approaches to disability, length of intervention, focus on prevention, coordination of actors and/or multidisciplinary staffs involved in rehabilitation, and external support to employers5.
Germany, Denmark, Austria, the Netherlands, Norway and Sweden stood out by their comprehensive and mature rehabilitation/return-towork frameworks5. The countries with comprehensive rehabilitation and return-to-work programs accounted for the largest scientific production on this subject, as was found in the present review: Germany, 2 studies, Norway, Denmark and Netherlands, 1 study each. Germany developed a distinct vocational rehabilitation approach. The study from 201618 shows that continuous improvement should be systematically anticipated. The authors describe the implementation of a new counseling and management concept, in which coordination among the various involved actors is a relevant part of the process. Adequate and early support during return-to-workcentered vocational rehabilitation behaves as a facilitator, as shown in the study performed in 2013 with cancer patients19.
The relevance of multidisciplinary approaches in rehabilitation programs was evidenced in the study conducted in Norway20, which reported significant outcomes with direct impact on return to work.
Although rehabilitation programs established in the United Kingdom and France were not rated comprehensive or mature in the EU-OSHA report, several authors performed research on this subject and discussed new policies for return to work; two such studies21,22 were included in the present review. One of them21 addresses employment retention, which is a challenge to be overcome by vocational rehabilitation programs, but is scarcely considered in those available. In turn, the study performed in France22 considered also social rehabilitation, thus broadening the scope of rehabilitation. It was conducted long time after the onset of the analyzed vocational rehabilitation program, and for this reason affords a wider view of its efficacy.
The included studies mentioned and described relevant aspects of the vocational rehabilitation process, such as adequate structure, strategies to integrate and reintegrate workers with chronic diseases, employment retention, placement for unemployed or temporary workers, autonomy to orient self-training, and educational programs.
The results indicate that the process of rehabilitation has many facets, which need to be continuously considered and implemented.
The relevance of early intervention was addressed in the study performed in Australia24. Two studies20,28 found that outcomes were better when structured vocational rehabilitation programs including worker autonomy to choose training modalities to improve their work capacity were implemented. These results suggest that a previously well-defined structure might lead to greater benefits for workers.
The systematic review performed in 201827 found positive and facilitating return-to-work strategies, such as early ergonomic interventions, counseling, coordinated multidisciplinary interventions centered on return to work, active labor market policies to enhance employment, and passive measures (as e.g. pension).
Given the broad scope of the present review, we were able to locate also strategies to reintegrate workers after sick leave due to diseases or accidents, and to identify the best practices available.
The one limitation of the present study derives from the choice of the language in which the eligible studies were published. Thus we excluded, for instance, studies performed in Japan and published in Japanese only.
In the present review we detected gaps in the divulgation of existing successful rehabilitation programs, notwithstanding the difficulties to evaluate the efficacy of this type of process. Despite problems inherent to the return to work process in different countries, scientific studies on this subject should be encouraged to contribute to the development of programs, particularly in countries with still precarious approaches. Once again, scientific studies are still scarce vis-à-vis the magnitude of the ongoing challenge. Such studies are necessary for the implementation of public policies to enhance the reintegration of workers to the labor market. Equally relevant is the challenge posed by the implementation of vocational rehabilitation programs for unemployed or temporary workers.
To conclude, studies on vocational rehabilitation should be encouraged to contribute to a wider discussion of this subject and raise awareness in several countries as to the urgent need to implement measures to enhance vocational rehabilitation and return to work based on the needs of workers, to thus improve their quality of life, reduce functional impairments related to aging and to sequelae of health problems, and ensure the sustainability of social security systems.
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7 de Dezembro de 2018.
Aceito em 10 de Julho de 2019.
Fonte de financiamento: nenhuma