Integrative prevention and coordinated action toward primary,secondary and tertiary prevention in workplaces: A scoping review

3.1.1 Musculoskeletal disorder (MSD) prevention

Integrative prevention approaches targeting MSDs comprise several elements described in Table 2. Of the eight articles concerning MSDs [22–28, 33], four discuss the Prevention and early active return to work safely (PEARS) program implemented in hospitals [22, 25–27]. The evaluation of this program demonstrated benefits related to reduced costs associated with workplace disability [22, 25]. In this program, the team’s prevention activities are communicated to a program leader and used to guide rehabilitation and return-to-work activities [27]. A bipartite steering committee oversees the program. A physiotherapist is on site to help employees stay at work and improvements to workstations can be made. Ouellette et al. [27] have shown that workplace assessment is an important element of the program to decrease work disability. This program emphasizes the organizational culture of safety involving the cooperative participation of stakeholders including a supportive work climate and cooperation and trust between management and labor (unions) [22, 26].

According to Roquelaure [33], one of the difficulties in preventing MSDs resides in the fact that stakeholders (e.g., managers, trades unions, workers, prevention practitioners, physicians, insurers) who need to collaborate to carry out primary, secondary or tertiary prevention have different understandings of MSD etiology and different prevention intervention models. Sharing common knowledge and understanding of workers’ activities among stakeholders would improve intervention outcomes. Thus, Roquelaure [33] puts forward a systemic approach that accounts for the fact that stressors experienced by people during their work activity can have causes or determinants derived from different sources, whether they are the work tools used, work organization or company culture. Roquelaure [33] emphasizes the need to describe the work activity and its stressors and to seek out the experience of one or more worker in order to carry out effective prevention measures, whether they be at the primary, secondary or tertiary level. This is an approach developed primarily by French-speaking researchers focused on the analysis of work activity and the improvement of working conditions [34]. Tremblay-Boudreault et al. [28] implemented this approach combining a systemic vision of work situations with a detailed work activity analysis. In this example, workplace training was used as a means to share responsibility for MSDs by different company stakeholders, both in terms of prevention and return-to-work. Tremblay-Boudreault et al. [28] showed that training led to changes in company stakeholders’ perceptions of MSDs. For example, whereas risk analysis targeted work habits of the injured worker following an accident or an MSD, an improved understanding of working conditions among company stakeholders led to the implementation of solutions to factors related to the working environment more generally.

3.1.2 Mental health prevention

Of the 16 articles, five deal with mental health [19, 29–32]. The main characteristics of these articles are presented in Table 2. All of the authors promote a holistic approach in workplaces and prioritize the participation of all stakeholders. For example, Chu and Dwyer [29] propose a process that requires management support, evaluation, needs assessment and the development and implementation of an action plan, all while ensuring active participation of workers and other stakeholders. For their part, the approach used by LaMontagne et al. [30, 31] is inspired by the University of Michigan job stress model developed by Israël et al. [19]. This model suggests putting in place nine principles during mental health prevention interventions. Among the principles are: “a context specific intervention, a comprehensive approach to prevention intervention to address the complex set of factors in the stress model, collective action and broad-scale change, participants’ involvement and control, multidisciplinary teams, and others”. One of the nine principles concerns integrating the three prevention levels (primary, secondary and tertiary). In the University of Michigan job stress model developed by Israël et al. [19], Quick et al.’s [35] definitions are used to delineate the prevention levels. According to the authors, the three prevention levels are needed for a comprehensive mental health approach. In 2014, LaMontagne et al. [30] expand on the approach presented in their 2007 [31] article with three threads for intervention: reduce work related risk factors, develop positive aspects of work and worker capacities, and address mental health problems regardless of cause. Finally, Memish et al. [32] evaluate around 20 guides from different countries that give recommendations from an authoritative source for prevention and/or management of mental health problems in the workplace and specifically developed for use by employers. This study evaluates both the quality of the proposed mental health workplace guides as well as whether LaMontagne et al.’s [30] criteria are taken into account in the guides targeting employers. The following integrative prevention elements were established to evaluate the guides: recommendations for the individual, recommendations for the organization, minimize risk factors, promote positive factors, primary prevention, secondary intervention and tertiary intervention [32].

3.1.3 General health prevention in the workplace

Many characteristics emerge from integrative prevention approaches that do not target a particular health problem (Table 2). Rieth et al.’s [20] early article describes “workplace integrated disability management” inspired by the concept of “Total health management developed by the Ohio based Fortune 500 company.” The objective of this article was to support occupational health nursing practices. The authors emphasized the importance of coordinated actions and gave the example of companies implementing a program that incorporated several elements of a process aiming to manage employee disabilities. The authors classified the actions needing to be coordinated according to primary, secondary and tertiary prevention levels, but the program aimed mostly “to coordinate a team effort to holistically manage employees.” The following activities are explained in detail: case management, disability resolution process, rehabilitation plan development and return to work programs/accommodations. On the other hand, few measures pertaining to the environment or work organization are given.

Amick et al. [18] measure the impact of organizational behaviors on work disability prevention and management. The authors use the American Counseling Association (1998)’s conceptual model, “Organizational influences on work disability” in which organizational policies and practices correlate with workplace disability incidence. There are two prevention levels in this model, which are not named explicitly as primary, secondary or tertiary, but which correspond to before injury behaviors and after injury responses. The articulation between disability prevention and management of interventions in this model exemplifies strategies to minimize the incidence and disability consequences of injuries and diseases arising in the workplace. However, this model is used to develop questionnaires based on indicators that measure organizational behavior as evaluated by employers and employees and is not focused on workplace interventions. Further, the dimensions are measured independently even though they coexist in the workplace, as the authors point out in their own discussion.

Rudolph et al. [21] target occupational physicians and appeal to the responsibility that they have to patients who are suffering from workplace related health problems. Their focus is to promote the linkage between prevention and treatment. They demonstrate the need to improve clinical occupational health preventive services. They describe several instances in which this linkage was beneficial, but they also identify numerous challenges and barriers to such integration. According to the authors, prevention in occupational health can be characterized as primary, secondary, or tertiary. Weeks et al.’s [36] definitions are used to differentiate the levels of prevention. According to Rudolph et al. [21], if primary prevention is not effective, secondary and tertiary prevention will be required. The authors highlight that cases of occupational illness or injury should serve as indicators for targeted primary prevention measures to be taken in the workplace. For this reason, the authors believe that prevention measures across different levels should be coordinated and that close working relationships between occupational health service providers and the workplace should exist.

The terms primary, secondary and tertiary prevention are used differently in the varied integrative prevention approaches presented here, whether they be in MSD prevention, for mental health prevention or in the case of occupational health more generally. It is worthwhile to examine authors’ definitions as well as the measures associated with the three prevention levels in these integrative prevention approaches.

3.2.1 Articles that explicitly define prevention levels

Of the 16 articles analyzed, nine give explicit definitions of prevention levels (Table 3). For each level, the approach’s characteristics, the objectives, as well as the suggested prevention measures were extracted from the article. The objectives and the prevention measures were defined according the whether they oriented around improved workplace conditions or individual health.

3.2.1.1.Primary prevention: Primary prevention is more developed in articles dealing with mental health [19, 30–32]. For these authors, primary prevention is proactive, work-oriented and focused on the workers before they feel symptoms. Objectives are principally oriented to the workplace. They aim to eliminate or reduce risk factors or job stressors [19, 33]. Articles concerned with mental health offer precise measures to implement in the workplace. For example, activities to reduce job demands are: increase time or other resource allocations to complete specific tasks, redesign the physical work environment to reduce musculoskeletal load and noise, and provide breaks from client-based work [31]. Some of the measures are less proactive, for example those that propose to modify the work environment [30] or to reduce job demands [19], both of which imply that exposure to certain risks is already present and that the prevention measures are a reaction to a problem.

Articles on MSD prevention identify the same primary prevention characteristics and objectives as the articles on mental health, but go into less detail on the workplace measures to implement [23, 33].

Health-focused goals are covered as much in mental health prevention articles as in MSD prevention or general occupational health articles [20, 30–33]. Using a more general workplace health prevention perspective, Rieth et al. [20] propose prevention programs for injuries whether they are related to work or not. Rudoph et al. [21] suggest identifying workers with health conditions which place the worker or co-workers at substantial risk in a particular work environment.

3.2.1.2.Secondary prevention: Compared to primary prevention, secondary prevention is more oriented to the worker than the workplace [30, 32]. This is a phase in which people begin to have health impacts [19, 32]. In several of the articles, spanning all three categories of health impact, intervening in injury progression is given as a goal, e.g. to stop or slow progression of disease or to reduce the risk of work disability [21, 33].

Several workplace measures are evoked specifically for MSD prevention, such as, stay at work programs, active surveillance for early detection or enhanced reporting systems for those with early symptoms [23]. Mental health articles [19, 32] place more emphasis on measures targeting modification to the workplace or workers’ ability to deal with stressors, whereas MSD prevention articles more often discuss symptom surveillance programs [23].

3.2.1.3.Tertiary prevention: Tertiary prevention is the prevention level that is defined most similarly across articles. Cole et al. [23] contend that tertiary prevention is a misnomer because it is in fact a treatment phase. It is reactionary and concerns affected workers who are returning to work [19, 30–33]. MSDs and more general approaches to workplace health prevention emphasize measures supporting return and stay at work, and rehabilitation programs [20, 33]. While citing the above-mentioned elements in the definitions given, mental health prevention articles also put forward examples of actions to take to safeguard affected worker’s health [19, 30–32].

3.2.2 Articles that depart from the three prevention levels

Seven studies depart from the three-tiered prevention level schema used by other articles. Of these seven articles, five only use two levels, explicitly or not. Two do not use the nomenclature of primary, secondary and tertiary prevention or depart from it to prioritize a more holistic approach.

Five studies only refer to two prevention levels [18, 25–27]. Four of these articles are related to the PEARS program, which is an integrated workplace-based program in disability prevention that coordinates primary prevention activities with onsite early intervention activities (prompt follow-up of injured workers) [25]. Maiwald et al.’s [26] article evaluating one aspect of the PEARS program presents primary prevention as having the following goal: to prevent work disability from occurring prior to reporting sick (including a work assessment). Secondary and tertiary prevention are combined into one level with the goal of reducing time-loss and supporting return-to-work after a sickness absence [26]. Moreover, Cole et al. [23] give definitions for three prevention levels but use the nomenclature ‘secondary +/- tertiary’ when discussing authors who use only two levels. Amick et al.’s [18] article uses a conceptual model that only provides two prevention levels “before injury behavior” and “after injury responses,” and they do not make use of the terms primary, secondary or tertiary prevention. Reference to disability management indicates that the terminology “after injury” refers to tertiary prevention rather than secondary.

Tremblay-Boudreault et al. [28] give definitions of the three prevention levels in the introduction but prefer to group all measures under the term “MSD prevention”, whether they are targeting preventing the manifestation of MSDs (primary prevention), maintaining workers who present with symptoms in their jobs (secondary prevention) or encouraging return-to-work by injured workers (tertiary prevention). The authors employ the term “return-to-work process” to designate the actions taken by the company to accommodate a worker who suffered an injury (tertiary prevention) [28]. Chu et Dwyer [29] also have a more general vision of prevention. The three levels are not explicitly named in the article; rather, concepts affiliated with the different prevention levels are presented, such as: prevent and manage physical and mental health problems, reduce risk factors and health and safety hazards, and improve health and rehabilitation [29].

For each of the prevention levels presented in the articles, associated measures can be directed at the source (eliminate the problem), between the source and the exposed person (adding a protection layer between the worker and the hazard source) or toward the exposed person (awareness raising or training on the hazards to which they are exposed). However, only measures taken at the source are explicitly addressed in primary prevention definitions, and these are comprised of eliminating or reducing the risk factors at the source for those authors who refer to them [28, 33]. Measures aimed at modifying the work environment, irrespective of prevention level, do not indicate whether this action is really located at the source (replacement of equipment or modification of a process) or between the source and the exposed person (addition of individual protection such as protective clothing or collective protection such as security guards).

Finally, the definitions offer as many measures targeting the workplace, whether they be at the source or between the person and the hazard, as they do measures aimed at individuals (exposed persons).