Work-related Ill-health Research Articles

Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review.

Nurses, midwives and paramedics are the largest collective group of clinical staff in the National Health Service and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves. To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions. Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards' reporting guidelines. First round database searching in Medical Literature Analysis and Retrieval System Online Database ALL (via Ovid), cumulative index to nursing and allied health literature database (via EBSCO) and health management information consortium database (via Ovid), was undertaken between February and March 2021, followed by supplementary searching strategies (e.g. hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied. We built on seven key reports and included 75 papers in the first round (26 nursing, 26 midwifery, 23 paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 context mechanism and outcome configurations. The key findings identified the following: (1) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; (2) it is difficult to promote staff psychological wellness where there is a blame culture; (3) the needs of the system often override staff well-being at work ('serve and sacrifice'); (4) there are unintended personal costs of upholding and implementing values at work; and (5) it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors. Our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological well-being. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to (1) rebalance the working environment to enable healthcare professionals to recover and thrive; (2) invest in multi-level system approaches to promote staff psychological well-being; and use an organisational diagnostic framework, such as the NHS England and NHS Improvement Health and Wellbeing framework, to self-assess and implement a systems approach to staff well-being. Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with front-line staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs. The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder/expert suggestions to augment our sample. This study is registered as PROSPERO CRD42020172420. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172420. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129528) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information.

A mixed methods research study on occupational safety and health of tour guides

ABSTRACT Tour guiding is a profession that involves intensive one-to-one communication with tourists and employees from different sectors of the tourism industry along with long trips by bus, walks in different geographical and weather conditions, and overnight stays away from home. Under these conditions, tour guides (TGs) face serious risks in terms of work-related accidents (WRA) and work-related ill-health (WRIH) which may result from unsafe behaviours (UB) or unsafe conditions (UC). This study evaluates occupational safety and health (OSH) problems experienced by TGs and merges the findings of both the survey and focus group (FG) as part of Mixed Methods Research (MMR) to gain a better understanding. The explanatory sequential design was conducted with first quantitative and then qualitative research. According to the MMR results WRA-Type and Prevention were confirmed, WRIH-Reason was expanded in FG interviews. However, for the survey and FG findings, WRA-Reason and WRIH-Type are contradictory.

Have work-related accidents and ill-health in Brazil declined since the introduction of the accident prevention factor?

Have work-related accidents and ill-health in Brazil declined since the introduction of the accident prevention factor?

Statistički pokazatelji za nezgode na radu u poljoprivredom sektoru

Agricultural activity employs an estimated 1.3 billion workers worldwide, which is half of the world's labour force. In terms of fatalities, injuries and work-related ill-health, it is one of the four most hazardous sectors of activity (along with construction, transportation and storage and manufacturing). According to International Labour Organization (ILO) estimates, at least 170000 agricultural workers are dying each year. In this paper, the statistical indicators concerning non-fatal and fatal accidents at work in agriculture, forestry and fishing activity and an incidence rate in the Member State of the European Union (EU-27) and in the R.N. Macedonia during 2017÷2021 were presented. The performed statistical analysis shows that the number of non-fatal and fatal accidents at work in agriculture, forestry and fishing activity in EU-27, in 2020 was decreased in comparison with 2017. In the R.N. Macedonia in 2021, there was a decrease in the number of non-fatal accidents at work in comparison with 2017. During 2021 in the R.N. Macedonia, there were no recorded fatal accidents at work. This fact categorizes the R.N. Macedonia in the category of EU-27 Member States with zero fatal accidents at work.

Understanding how managers balance the paradoxical nature of occupational safety through a practice-driven institutional lens

There is an increasing interest in integrating occupational safety into contemporary organizations’ management systems for the continual prevention of work-related injury, ill-health, and death. However, we know little about the micro-processes of managerial safety practices, particularly in understanding how organizational members enact competing organizational goals in their everyday work activities. This paper examines the mundane day-to-day practices by which construction site and project managers balance seemingly paradoxical demands in their everyday work. Using a combination of observational, interview and documentary data collected from three Danish construction projects, this study shows how institutional complexity (logics of professionalism, production, and regulation) affects managers’ safety-related thinking, motivation, and practice, and how managers beneficially bridge multiple institutional logics through: 1) Silent acknowledgment, 2) A collaborative relational network, and 3) Dynamic decision-making. The paper contributes to the literature on safety management by outlining how managers on the ground balance safety paradoxes and, thus, transcend either-or understandings of safety. These insights are highly relevant as they show concrete ways in which managers attend to competing demands simultaneously and how safety can be integrated into managerial safety practices.

Analysis of work-related accidents and ill-health in Brazil since the introduction of the accident prevention factor

BackgroundSince 2004, Brazil has had a national policy for occupational health and safety. This policy means companies’ tax burden is altered according to the numbers of work-related accidents and ill-health amongst their workers. In 2010, a multiplication factor was introduced to this policy, called the Accident Prevention Factor. The idea of this new multiplication factor is to encourage individual employers to take initiatives to prevent accidents and ill health in the workplace. This study was designed to investigate the incidence of work-related accidents and ill-health in Brazil according to their causes, their severity, and the economic activity in which they occur, and to compare the data before and after the introduction of the Accident Prevention Factor.MethodsAn ecological study was conducted by analyzing the time series of work-related accidents/ill-health between 2008 and 2014 from the Brazilian social security system (Previdência Social) statistical yearbooks. Incidences were calculated per cause, economic activity, and severity of the accident/ill-health. Data from before and after the introduction of the Accident Prevention Factor were compared using the Mann-Whitney test per cause and per economic activity. Statistical analyses were made using the SPSS software, with significance set at 5%.ResultsA reduction in the incidence of work-related accidents/ill-health was found across all the groups of causes analyzed, except for the groups “external causes of morbidity and mortality” and “factors influencing health status and contact with health services.” Greater reductions were found for diseases of the musculoskeletal system and connective tissue and diseases of the nervous system. Reductions in work-related accidents/ill-health were found in the different economic activities and in the different severity groups. The highest reduction after the introduction of the Accident Prevention Factor was in manufacturing and production (p < 0.05).ConclusionsOverall, the incidence of accidents/ill-health was found to be on decline, except those with external causes of morbidity and mortality and those involving factors influencing health status and contact with health services. The biggest reduction was found in manufacturing and production. However, generally speaking progress still needs to be made in accident prevention and occupational health across a whole range of work environments.

What about the workers? — Experiences of arrangements for safety and health in global container terminals

Container terminals are purpose built or substantially adapted ports virtually exclusively involved with the transport of containerised goods. They now exist everywhere and have redesigned dock-work to increase productivity and efficiencies in the handling of goods, making physical handling by dock-workers increasingly redundant. Conventional wisdom suggests that arrangements for the safety and health of those who remain in employment are generally improved in comparison with past conditions. Yet, reliable evidence of the effects of work on the occupational safety and health (OSH) of these workers is scarce. This paper is based on research which examined the OSH experiences of workers involved with operational tasks in terminals operated by global network terminal (GNT) companies in four countries situated in Asia-Pacific and Europe. It explored these experiences along with the respondents’ perceptions concerning the effectiveness of arrangements made to manage their OSH risks, and compared findings between countries. The research demonstrated a significant gap between managers’ understandings of the operation of arrangements for OSH and the perceptions and experiences of workers, both in relation to OSH outcomes and the effectiveness of the OSH arrangements. This was especially evident for work-related ill-health, workers’ representation and consultation on OSH, and in the differences in the experience of all these between directly employed workers and those employed by contractors. The paper discusses the implications for improved OSH arrangements and outcomes.

Occupational safety and health for service crew on passenger ships

The service crew is a vital part of the customer experience on board passenger ships, but also has important duties in the safety organization in case of emergencies. Yet, they are not always recognized as seafarers and have received less attention in research that addresses occupational safety and health in the maritime domain. This study explores the occupational safety and health for the service crew working on Swedish passenger ships. The purpose is to analyze causes of work-related ill-health, investigate and identify important aspects of the physical, organizational and social working conditions. The study has adopted a mixed methods approach, including survey questionnaires, register data on reported long-term sick leave, and field visits on board. Key findings show that service crew on passenger ships report the highest levels of perceived exertion. They also have the highest rates of long-term sick leave lasting 60 days or more. Most diagnoses are related to musculoskeletal and psychological disorders. Important factors in the shipboard work environment include high physical load and strenuous working postures, poor workplace design, long working hours, limited time for recovery, and the perceived mental and emotional load that comes with unclear boundaries between work and recreation and the social interaction with customers and colleagues. The most prominent health promotive factors to reduce the perceived exertion are appropriate manning, time to rest, working with managers that attend to problems and experiencing good working relations with other departments on board.

Work-related ill-health in construction: The importance of scope, ownership and understanding

Work-related ill-health in construction is a major concern worldwide, presenting significant risk management challenges. This three-year research project studied a multi-million pound regional construction project and a multi-billion pound infrastructure megaproject in the UK. It used interviews (n = 237) and meeting observations (n = 120) to examine contemporary approaches to managing occupational health in the industry and their limitations. It was found that the conceptualisation of ‘health’ is a significant issue: activities which focus on the general health and wellbeing of the workforce can distract from the reduction of work-related hazards at source. There are further challenges in the way health risk is perceived and tolerated by workers and organisations. This is partly because of the invisibility and latency of the associated health effects, but also reflects incomplete knowledge and a sense of resignation. Crucially, there is evidence of a lack of ownership of health within organisations and on the part of some managers, frontline workers and OSH professionals. These aspects are exacerbated by the way in which the construction industry operates, with high levels of self-employment and worker mobility; the temporary nature of projects which inevitably foregrounds immediate safety concerns over longer term health issues; and the cost of and limited access to health services. Health risks are challenging to manage because ‘health’ differs from ‘safety’; in terms of the hazards themselves but also in the way that the construction sector understands and manages risk. These differences need to be recognised and addressed to achieve lasting improvements to worker health in construction.

The preventable burden of work-related ill-health.

The fraction of ill-health overall attributable to occupational conditions has not been extensively evaluated, thus contributing to the perception of a lesser relevance of education and research in occupational health in respect to other fields of medical research and practice. To assess the relevance of work-related conditions on the aetiology of human ill-health in different health domains. We extracted the risk estimates associated with heritability and with occupational risk factors for chronic lymphocytic leukaemia (CLL), major depressive disorder (MDD) and long QT syndrome (LQTS) from 13 published international reports. The selection criteria for the eligible studies were: genome-wide studies, or studies of the occupational risk factors associated with one of the three diseases of interest. We calculated and compared the respective population attributable fraction for the combined occupational risk factors, and for heritability. We estimated that occupational risk factors would account for 12% (95% confidence interval (CI) 4-19) of CLL, 11% (95% CI 7-15) of MDD and 10% (95% CI 2-13) of LQTS burden in the general population. The corresponding figures for heritability would be 16% (95% CI 11-22), 28% (95% CI 20-5) and 17% (95% CI 7-27). More efforts in capacity building and research in occupational health are warranted aiming to prevent ill-health and to preserve a productive life for the ageing work population.

Work-related ill health in doctors working in Great Britain: incidence rates and trends.

BackgroundDoctors have a higher prevalence of mental ill health compared with other professional occupations but incidence rates are poorly studied.AimsTo determine incidence rates and trends of work-related ill health (WRIH) and work-related mental ill health (WRMIH) in doctors compared with other professions in Great Britain.MethodIncidence rates were calculated using an occupational physician reporting scheme from 2005-2010. Multilevel regression was use to study incidence rates from 2001 to 2014.ResultsAnnual incidence rates for WRIH and WRIMH in doctors were 515 and 431 per 100 000 people employed, respectively. Higher incidence rates for WRIH and WRMIH were observed for ambulance staff and nurses, respectively. Doctors demonstrated an annual average incidence rates increase for WRIH and WRMIH, especially in women, whereas the other occupations demonstrated a decreasing or static trend. The difference in trends between the occupations was statistically significant.ConclusionsWRIH and WRMIH incidence rate are increasing in doctors, especially in women, warranting further research.

Differential reporting of work-related mental ill-health in doctors.

Evidence suggests that the medical profession is reluctant to report mental ill-health despite its high prevalence. To compare differential reporting patterns in the incidence of work-related mental ill-health (WRMIH) affecting doctors with selected comparison occupational groups, as determined by surveillance by general practitioners (GPs), specialist psychiatrists and occupational physicians (OPs). New cases of medically reported WRMIH were reported prospectively between 2006 and 2009 by GPs, psychiatrists and OPs as part of The Health and Occupation Research (THOR) network. For GP and psychiatry reporting schemes, incidence rates (IRs) for doctors, nurses, teachers, corporate managers and protective service workers were calculated using information from the Labour Force Survey as the denominator. In OP surveys, participating reporters provided denominator information to calculate IRs for doctors, nurses and teachers. Average annual IRs expressed per 100000 person/years employed as reported by GPs, psychiatrists and OPs, respectively, were: doctors (309, 971, 430), nurses (891, 208, 670), teachers (1040, 136, 210) and for GPs and psychiatrists, respectively, were: protective service workers (1432, 721) and corporate managers (428, 90). Psychiatrists reported a higher incidence of WRMIH in doctors, whereas GPs reported higher incidences of WRMIH in other occupations (chi-squared test, P < 0.001). The distribution of the incidence of new cases reported across different schemes suggests a differential reporting pattern of WRMIH in doctors. The higher IR for doctors in psychiatrist-reported WRMIH could be due to factors such as disease severity and bypassing formal referral channels.

EELAB: an innovative educational resource in occupational medicine.

Postgraduate education, training and clinical governance in occupational medicine (OM) require easily accessible yet rigorous, research and evidence-based tools based on actual clinical practice. To develop and evaluate an online resource helping physicians develop their OM skills using their own cases of work-related ill-health (WRIH). WRIH data reported by general practitioners (GPs) to The Health and Occupation Research (THOR) network were used to identify common OM clinical problems, their reported causes and management. Searches were undertaken for corresponding evidence-based and audit guidelines. A web portal entitled Electronic, Experiential, Learning, Audit and Benchmarking (EELAB) was designed to enable access to interactive resources preferably by entering data about actual cases. EELAB offered disease-specific online learning and self-assessment, self-audit of clinical management against external standards and benchmarking against their peers' practices as recorded in the research database. The resource was made available to 250 GPs and 224 occupational physicians in UK as well as postgraduate OM students for evaluation. Feedback was generally very favourable with physicians reporting their EELAB use for case-based assignments. Comments such as those suggesting a wider range of clinical conditions have guided further improvement. External peer-reviewed evaluation resulted in accreditation by the Royal College of GPs and by the Faculties of OM (FOM) of London and of Ireland. This innovative resource has been shown to achieve education, self-audit and benchmarking objectives, based on the participants' clinical practice and an extensive research database.

The Health and Occupation Research Network: An Evolving Surveillance System.

Vital to the prevention of work-related ill-health (WRIH) is the availability of good quality data regarding WRIH burden and risks. Physician-based surveillance systems such as The Health and Occupation Research (THOR) network in the UK are often established in response to limitations of statutory, compensation-based systems for addressing certain epidemiological aspects of disease surveillance. However, to fulfil their purpose, THOR and others need to have methodologic rigor in capturing and ascertaining cases. This article describes how data collected by THOR and analogous systems can inform WRIH incidence, trends, and other determinants. An overview of the different strands of THOR research is provided, including methodologic advancements facilitated by increased data quantity/quality over time and the value of the research outputs for informing Government and other policy makers. In doing so, the utility of data collected by systems such as THOR to address a wide range of research questions, both in relation to WRIH and to wider issues of public and social health, is demonstrated.

Reporting and prediction of work-related sickness absence by general practitioners.

Information on sickness absence (SA) duration in general practice is difficult to record. The duration of absence certified by general practitioners (GPs) can be viewed as a prognosis for return to work. The Health and Occupation Research network in General Practice (THOR-GP) collects SA information from GPs associated with cases of work-related ill-health. A sample of these cases is followed up 1 year retrospectively to gather information on the duration of absence. To examine the extent of the underestimation of SA in routinely reported data and to investigate how well GPs predict patients' return to work. THOR-GPs submit case and SA information using a web-based form. GPs who submitted selected cases were asked about the total number of days of SA and whether the patient had returned to work. THOR-GPs' routine SA data collection underestimated absence duration by 61%. According to the retrospective data, a much larger proportion of periods of absence due to work-related mental ill-health developed into long-term SA (60%) than episodes attributed to musculoskeletal disorders (32%). In over half the reported cases, the return to work was longer than the GP initially predicted. THOR-GP prospectively reported SA data underestimated the total length of absence; however, these data can examine the episodic rates of absence within different groups. More accurate longitudinal data can be collected retrospectively. GPs' ability to predict the length of time a patient will be away from work is important to enable treatment and rehabilitation planning in order to decrease the likelihood of a patient falling into long-term SA.

Use of GIS in visualization of work-related health problems.

BackgroundOccupational health and safety (OHS) information is often complex, diverse and unstructured and suffers from a lack of integration which usually precludes any systemic insight of the situation.AimsTo analyse to what extent the use of geographical information systems (GISs) can help to integrate, analyse and present OHS data in a comprehensive and communicable way relevant for surveillance purposes.MethodsWe first developed a ‘macro-approach’ (from national to local level), mapping data related to economic activity (denominator of active workers displayed by activity sectors), as well as work-related ill-health (numerators of workers suffering from work-related ill-health). The latter data are composed of compensated occupational diseases on the one hand and work-related diseases investigated by specialized clinics on the other hand. Then, a ‘micro-approach’ was worked out, integrating at a plant level, using computer-aided drawing, occupational risks data and OHS surveillance data (e.g. use of medication and sickness absence data).ResultsAt the macro-level, microelectronics companies and workers were mapped at different scales. For the first time, we were able to compare, up to the enterprise level, complementary data showing different pictures of work-related ill-health, allowing a better understanding of OH issues in this sector. At the micro-level, new information arose from the integration of risk assessment data and medical data.ConclusionsThis work illustrates to what extent GIS is a promising tool in the OHS field, and discusses related challenges (technical, ethical, biases and interpretation) and research perspectives.

The utility of information collected by occupational disease surveillance systems.

The Health and Occupation Research (THOR) network in the UK and the Republic of Ireland (ROI) is an integrated system of surveillance schemes collecting work-related ill-health (WRIH) data since 1989. In addition to providing information about disease incidence, trends in incidence and the identification of new hazards, THOR also operates an ad hoc data enquiry service enabling interested parties to request information about cases of WRIH reported to THOR. To examine requests for information made to a network of surveillance schemes for WRIH in the UK. Analysis via SPSS of data requests received by THOR between 2002 and 2014. A total of 631 requests were received by THOR between 2002 and 2014. Requests were predominantly submitted by participating THOR physicians (34%) and the main THOR funder-the UK Health & Safety Executive (HSE) (31%). The majority (67%) of requests were for information about work-related respiratory or skin disease with relatively few requests for other diagnoses, such as musculoskeletal or mental ill-health. Requests frequently related to a specific industry and/or occupation (42%) and/or a specific causal agent (58%). Data collected by occupational disease surveillance systems such as THOR are an extremely useful source of information, the use of which extends beyond informing government on disease incidence and trends in incidence. The data collected provide a framework that can assist a wide range of enquirers with clinical diagnoses, identification of suspected causative agents/exposures and to highlight growing risks in particular industrial and occupational sectors.

Proactive occupational safety and health management: Promoting good health and good business

This research assessed the impact of organisational approaches to occupational safety and health (OSH) management on organisational performance, safety climate, employee attitudes, health and well-being. Interviews with health and safety personnel, company directors and worker representatives were used to categorise the organisations according to their approaches to OSH management, using the Continuous Improvement Cycle model (Budworth and Khan, 2003). A cross-sectional survey of 2067 employees from these organisations examined the impact of company size, industrial sector and approach to OSH management on indicators of organisational performance and employee outcomes. A structured questionnaire assessed demographic characteristics, organisation and job tenure, job satisfaction, organisational commitment, intention to quit and job motivation, safety climate, self-reported absence, performance and work-related ill-health. Organisations were also asked to provide data on profit, performance, accidents and absence indices. Organisations adopting a proactive approach to OSH management reported higher profit margins and lower accident rates, however these differences were not statistically significant. Organisations classified as ‘very good’ were found to show significantly more positive safety climate perceptions across eight out of the nine safety climate dimensions. Employees in proactive organisations were significantly more committed to their organisations and showed greater job satisfaction than employees in organisations categorised as ‘yet to be fully engaged/complier’. Positive safety climate perceptions and organisational attitudes were associated with better self-reported physical and mental health. The findings add to the validation of the CIC model as an assessment and learning tool which may support the transition of organisations from reactive to proactive safety culture.

Child Workers and Industrial Health in Britain, 1780–1850. By Peter Kirby (Woodbridge: The Boydell Press, 2013. 224 pp. $29.99)

Peter Kirby's new book addresses the neglect of a detailed examination of the occupational health of children in the “classic” Industrial Revolution period in Britain. Such inattention to the health of working children is perhaps unsurprising given the numerous methodological difficulties for such a study, for which Kirby's innovative solution is to use modern research into occupational health. He concludes the text with a call for historians to “challenge ingrained attitudes to child labour, both past and present,” and his nuanced approach to the complex causes and outcomes of poor health in child workers reminds us that the employment of children must be understood in context. In this sense, the book acts as a caution against the “othering” of states where child labor is common through its mental consignment to a horrific practice of the past in more “progressive” nations.1 An assessment of the impact of employment on children must always take account of the balance between costs and compensations. Cheap child labor could undercut and drive down adult wages, and thus did not necessarily increase the overall family wage, but as child workers were most likely to come from the very poorest families and particularly those where one or both parents were absent, the contribution a child could make might be the difference between starvation and survival.2 Focusing in particular on factory labor, Kirby's book seeks to offer “a major challenge to the predominantly pessimistic historiography of industrial child employment” (161). Kirby argues that historians have relied too heavily on the biased reports of factory reform commissions to the exclusion of dissenting voices, which often came from observers with more experience of factory communities. He contends that factories were, if anything, less dangerous to the health of child workers than was domestic industry, and that they were certainly safer than work in coalmines. Kirby finds the greatest body of direct evidence of work-related ill-health in the mining industry, demonstrated most startlingly in the growth differences between children employed in coalmines and those with other occupations (117–120). Given that other recent authors on the subject have concluded that industrialisation increased the extent and intensity of child labor, with consequent negative effects for health3, Kirby's alternative viewpoint contributes to a debate which shows few signs of abating.

Has the fit note reduced general practice sickness certification rates?

In 2010, the fit note replaced the sick note to help focus on what people are capable of doing, rather than signing patients 'off sick'. To compare proportions of work-related ill-health issued with sickness certification pre- and post-fit note introduction and assess sickness absence trends. General practitioners (GPs) report data on work-related ill-health and sickness absence via The Health and Occupation Research network in General Practice. The proportion of cases issued with sickness certification 4 years before and 3 years after the fit note introduction were compared. Changes in certification incidence rate ratios were measured over time. Participating GPs reported 5517 cases of work-related ill-health. Pre-fit note introduction 50% of cases were certified sick. There was no change in the proportion of cases certified sick in the first year post-fit note, despite 13% of cases classified as 'maybe fit'. However, in the second year, the proportion of cases certified sick had reduced significantly (41%) and a larger proportion (19%) was advised on workplace adjustments. In the third year post-introduction, there was a slight rise in the proportion of cases certified sick; therefore, although there was a fall of 2% per annum in certification rates, this was not significant. In the first year post-fit note introduction, modifications to work were recommended for people who would previously have been declared fit. Trends analyses showed a slight decrease in the certification rate, possibly indicating GPs will become more practised in advising on workplace adjustments.