Sustainable employability - definition, conceptualization, and implications: A perspective based on the capability approach

Contains fulltext : 168167.pdf (publisher's version ) (Open Access)OBJECTIVES: The aim of this paper is to propose a new model of sustainable employability based on the capability approach, encompassing the complexity of contemporary work, and placing particular emphasis on work-related values. METHODS: Having evaluated existing conceptual models of work, health, and employability, we concluded that prevailing models lack an emphasis on important work-related values. Amartya Sen's capability approach (CA) provides a framework that incorporates a focus on values and reflects the complexity of sustainable employability. RESULTS: We developed a model of sustainable employability based on the CA. This model can be used as starting point for developing an assessment tool to investigate sustainable employability. CONCLUSIONS: A fundamental premise of the CA is that work should create value for the organization as well as for the worker. This approach challenges researchers, policy-makers, and practitioners to investigate what people find important and valuable - what they would like to achieve in a given (work) context - and moreover to ascertain whether people are able and enabled to do so. According to this approach, it is not only the individual who is responsible for achieving this; the work context is also important. Rather than merely describing relationships between variables, as existing descriptive models often do, the CA depicts a valuable goal: a set of capabilities that constitute valuable work. Moreover, the CA fits well with recent conceptions of health and modern insights into work, in which the individual works towards his or her own goals that s/he has to achieve within the broader goals of the organization

Effectiveness and cost-effectiveness of an exposure-based return-to-work programme for patients on sick leave due to common mental disorders: design of a cluster-randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>To reduce the duration of sick leave and loss of productivity due to common mental disorders (CMDs), we developed a return-to-work programme to be provided by occupational physicians (OPs) based on the principles of exposure in vivo (RTW-E programme). This study evaluates this programme's effectiveness and cost-effectiveness by comparing it with care as usual (CAU). The three research questions we have are: 1) Is an RTW-E programme more effective in reducing the sick leave of employees with common mental disorders, compared with care as usual? 2) Is an RTW-E programme more effective in reducing sick leave for employees with anxiety disorders compared with employees with other common mental disorders? 3) From a societal perspective, is an RTW-E programme cost-effective compared with care as usual?</p> <p>Methods/design</p> <p>This study was designed as a pragmatic cluster-randomized controlled trial with a one-year follow-up and randomization on the level of OPs. We aimed for 60 OPs in order to include 200 patients. Patients in the intervention group received the RTW-E programme. Patients in the control group received care as usual. Eligible patients had been on sick leave due to common mental disorders for at least two weeks and no longer than eight weeks. As primary outcome measures, we calculated the time until full return to work and the duration of sick leave. Secondary outcome measures were time until partial return to work, prevalence rate of sick leave at 3, 6, 9, and 12 months' follow-up, and scores of symptoms of distress, anxiety, depression, somatization, and fatigue; work capacity; perceived working conditions; self-efficacy for return to work; coping behaviour; avoidance behaviour; patient satisfaction; and work adaptations. As process measures, we used indices of compliance with the intervention in the intervention group and employee-supervisor communication in both groups. Economic costs were calculated from a societal perspective. The total costs consisted of the costs of consuming health care, costs of production loss due to sick leave and reduced productivity, and out-of-pocket costs of patients for travelling to their OP.</p> <p>Discussion</p> <p>The results will be published in 2009. The strengths and weaknesses of the study protocol are discussed.</p> <p>Trial registration</p> <p>ISRCTN72643128</p

Prevention of recurrent sickness absence among employees with common mental disorders: design of a cluster-randomised controlled trial with cost-benefit and effectiveness evaluation

BACKGROUND: Common mental disorders, such as depression, anxiety disorder, and adjustment disorder, have emerged as a major public and occupational health problem in many countries. These disorders can have severe consequences such as absenteeism and work disability. Different interventions have been developed to improve the return-to-work of employees with common mental disorders, but still a large proportion of employees experiences health and work problems after their return-to-work. For this reason, the SHARP-at work intervention is developed to prevent a relapse of sickness absence among employees who have returned to work after a period of sickness absence because of common mental disorders. We aim to evaluate the effectiveness, cost-benefit and process of the intervention compared to care as usual. METHODS/DESIGN: The study is designed as a cluster-randomised controlled trial with randomisation at the level of the occupational physician. Employees who have returned to work after a period of sickness absence because of a common mental disorder are included in the study. Employees in the intervention group will receive the SHARP-at work intervention. The intervention focusses on active guidance of employees by occupational physicians during the first weeks of work after sickness absence. Employees in the control group will receive care as usual. Outcomes will be assessed at baseline and at 3, 6, and 12 months follow-up. The primary outcome is cumulative recurrent sickness absence days. Secondary outcome measures are mental health, work functioning, and coping. Adherence to the protocol, communication between stakeholders, and satisfaction with the treatment are the process measures assessed in both study groups. Cost-benefit is calculated from a societal perspective. Finally, prognostic factors for a relapse of sickness absence are investigated. DISCUSSION: This study goes beyond return-to-work by focussing on the prevention of recurrent sickness absence. The study incorporates not only outcomes on sickness absence and mental health but also on health-related work functioning. The results of this study can contribute to a further development of practice guidelines and the promotion of sustainable work participation. TRIAL REGISTRATION: NTR1963

The Four-Dimensional Symptom Questionnaire (4DSQ): a validation study of a multidimensional self-report questionnaire to assess distress, depression, anxiety and somatization

BACKGROUND: The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire that has been developed in primary care to distinguish non-specific general distress from depression, anxiety and somatization. The purpose of this paper is to evaluate its criterion and construct validity. METHODS: Data from 10 different primary care studies have been used. Criterion validity was assessed by comparing the 4DSQ scores with clinical diagnoses, the GPs' diagnosis of any psychosocial problem for Distress, standardised psychiatric diagnoses for Depression and Anxiety, and GPs' suspicion of somatization for Somatization. ROC analyses and logistic regression analyses were used to examine the associations. Construct validity was evaluated by investigating the inter-correlations between the scales, the factorial structure, the associations with other symptom questionnaires, and the associations with stress, personality and social functioning. The factorial structure of the 4DSQ was assessed through confirmatory factor analysis (CFA). The associations with other questionnaires were assessed with Pearson correlations and regression analyses. RESULTS: Regarding criterion validity, the Distress scale was associated with any psychosocial diagnosis (area under the ROC curve [AUC] 0.79), the Depression scale was associated with major depression (AUC = 0.83), the Anxiety scale was associated with anxiety disorder (AUC = 0.66), and the Somatization scale was associated with the GPs' suspicion of somatization (AUC = 0.65). Regarding the construct validity, the 4DSQ scales appeared to have considerable inter-correlations (r = 0.35-0.71). However, 30–40% of the variance of each scale was unique for that scale. CFA confirmed the 4-factor structure with a comparative fit index (CFI) of 0.92. The 4DSQ scales correlated with most other questionnaires measuring corresponding constructs. However, the 4DSQ Distress scale appeared to correlate with some other depression scales more than the 4DSQ Depression scale. Measures of stress (i.e. life events, psychosocial problems, and work stress) were mainly associated with Distress, while Distress, in turn, was mainly associated with psychosocial dysfunctioning, including sick leave. CONCLUSION: The 4DSQ seems to be a valid self-report questionnaire to measure distress, depression, anxiety and somatization in primary care patients. The 4DSQ Distress scale appears to measure the most general, most common, expression of psychological problems

Exposure-in-vivo containing interventions to improve work functioning of workers with anxiety disorder: a systematic review

<p>Abstract</p> <p>Background</p> <p>Anxiety disorders are associated with functional disability, sickness absence, and decreased productivity. Effective treatments of anxiety disorders can result in remission of symptoms. However the effects on work related outcomes are largely unknown. Exposure in vivo is potentially well fit to improve work-related outcomes. This study systematically reviews the effectiveness of exposure-in-vivo containing interventions in reducing work-related adverse outcomes in workers with anxiety disorders.</p> <p>Methods</p> <p>A systematic study search was conducted in Medline, Cinahl, Embase and Psycinfo. Two reviewers independently extracted data and from each study assessed the quality of evidence by using the GRADE approach. We performed a meta-analysis if data showed sufficient clinical homogeneity.</p> <p>Results</p> <p>Seven studies containing 11 exposure-in-vivo interventions were included. Four studies were focused on Obsessive Compulsive Disorder (OCD), two on Post Traumatic Stress Disorder (PTSD), and one on a mixed group of OCD and severe phobias. The studies were grouped according to type of anxiety disorder and subsequently according to type of comparisons. For OCD, exposure-in-vivo containing interventions can yield better work-related outcomes compared to medication (SSRIs) and relaxation but not better compared to response prevention. The results on anxiety outcomes were similar. The net contribution of exposure in vivo in two OCD intervention programs is also presented as a meta-analysis and shows significant positive results on work role limitations. The calculated pooled effect size with 95% confidence interval was 0.72 (0.28, 1.15). For PTSD, exposure-in-vivo containing interventions can yield better work-related and anxiety-related outcomes compared to a waiting-list but not better compared to imaginal exposure.</p> <p>Conclusions</p> <p>Exposure in vivo as part of an anxiety treatment can reduce work-related adverse outcomes in workers with OCD and PTSD better than various other anxiety treatments or a waiting-list. We recommend that it should be studied how the results of these studies can be transferred to the practice of occupational health professionals and how clinicians can make better use of them to improve work-related outcomes. In future research, priority should be given to high-quality randomised controlled trials (RCTs) in which exposure-in-vivo containing interventions are applied to a variety of anxiety disorders and compared with other clinical anxiety treatments such as SSRIs. Work-related outcomes, in particular work functioning and sickness absence, need to be assessed with reliable and valid measures.</p

Gender and age differences in the recurrence of sickness absence due to common mental disorders: a longitudinal study

Background: Common mental disorders (CMDs) are an important cause of sickness absence and long-term work disability. Although CMDs are known to have high recurrence rates, little is known about the recurrence of sickness absence due to CMDs. The aim of this study was to investigate the recurrence of sickness absence due to CMDs, including distress, adjustment disorders, depressive disorders and anxiety disorders, according to age, in male and female employees in the Netherlands. Methods: Data on sickness absence episodes due to CMDs were obtained for 137,172 employees working in the Dutch Post and Telecommunication companies between 2001 and 2007. The incidence density (ID) and recurrence density (RD) of sickness absence due to CMDs was calculated per 1000 person-years in men and women in the age-groups of < 35 years, 35-44 years, 45-54 years, and >= 55 years. Results: The ID of one episode of CMDs sickness absence was 25.0 per 1000 person-years, and the RD was 76.7 per 1000 person-years. Sickness absence due to psychiatric disorders (anxiety and depression) does not have a higher recurrence density of sickness absence due to any CMDs as compared to stress-related disorders (distress and adjustment disorders): 81.6 versus 76.0 per 1000 person-years. The ID of sickness absence due to CMDs was higher in women than in men, but the RD was similar. Recurrences were more frequent in women < 35 years and in women between 35 and 44 years of age. We observed no differences between age groups in men. Recurrences among employees with recurrent episodes occurred within 3 years in 90% of cases and the median time-to-onset of recurrence was 11 (10-13) months in men and 10 (9-12) months in women. Conclusions: Employees who have been absent from work due to CMDs are at increased risk of recurrent sickness absence due to CMDs and should be monitored after they return to work. The RD was similar in men and in women. In women < 45 years the RD was higher than in women >= 45 years. In men no age differences were observed

The performance of the K10, K6 and GHQ-12 to screen for present state DSM-IV disorders among disability claimants

Abstract Background Screening for mental disorders among disability claimants is important, since mental disorders seem to be seriously under-recognized in this population. However, performance of potentially suitable scales is unknown. We aimed to evaluate the psychometric properties of three scales, the 10- and 6-item Kessler Psychological Distress Scale (K10, K6) and the 12-item General Health Questionnaire (GHQ-12), to predict present state mental disorders, classified according to the Diagnostic and Statistical Manual of Mental Disorders, 4thEdition (DSM-IV) among disability claimants. Methods All scales were completed by a representative sample of persons claiming disability benefit after two years sickness absence (n=293). All diagnoses, both somatic and mental, were included. The gold standard was the Composite International Diagnostic Interview (CIDI 3.0) to diagnose present state DSM-IV disorder. Cronbach’s α, sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and the areas under the Receiver Operating Characteristic curve (AUC) were calculated. Results Cronbach’s alpha’s were 0.919 (K10), 0.882 (K6) and 0.906 (GHQ-12). The optimal cut-off scores were 24 (K10), 14 ( K6) and 20 (GHQ-12). The PPV and the NPV for the optimal cut point of the K10 was 0.53 and 0.89, for the K6 0.51 and 0.87, and for the GHQ-12 0.50 and 0.82. The AUC’s for 30-day cases were 0.806 (K10; 95% CI 0.749-0.862), 0.796 (K6; 95% CI 0.737-0.854) and 0.695 (GHQ-12; 95% CI 0.626-0.765). Conclusions The K10 and K6 are reliable and valid scales to screen for present state DSM-IV mental disorder. The optimal cut-off scores are 24 (K10) and 14 (K6). The GHQ-12 (optimal cut-off score: 20) is outperformed by the K10 and K6, which are to be preferred above the GHQ-12. The scores on separate items of the K10 and K6 can be used in disability assessment settings as an agenda for an in-depth follow-up clinical interview to ascertain the presence of present state mental disorder.</p

Sustainable employability -definition, conceptualization, and implications: A perspective based on the capability approach Citation for published version (APA): Sustainable employability -definition, conceptualization, and implications: A perspective base

Work and health play an entirely different role in the life course than before, necessitating new models. A definition and model of sustainable employability is presented based on Amartya Sen&apos;s capability approach, challenging researchers, policy-makers and practitioners to look for what is important and valuable in a given (work) context and whether people are able and enabled to realize this. Affiliation 71 Discussion paper Scand J Work Environ Health 2016;42(1):71-79. doi:10.5271/sjweh.3531 Sustainable employability -definition, conceptualization, and implications: A perspective based on the capability approach By Jac JL van der Klink, PhD, Objectives The aim of this paper is to propose a new model of sustainable employability based on the capability approach, encompassing the complexity of contemporary work, and placing particular emphasis on work-related values. Methods Having evaluated existing conceptual models of work, health, and employability, we concluded that prevailing models lack an emphasis on important work-related values. Amartya Sen&apos;s capability approach (CA) provides a framework that incorporates a focus on values and reflects the complexity of sustainable employability. Results We developed a model of sustainable employability based on the CA. This model can be used as starting point for developing an assessment tool to investigate sustainable employability. Conclusions A fundamental premise of the CA is that work should create value for the organization as well as the worker. This approach challenges researchers, policy-makers, and practitioners to investigate what people find important and valuable -what they would like to achieve in a given (work) context -and moreover to ascertain whether people are able and enabled to do so. According to this approach, it is not only the individual who is responsible for achieving this; the work context is also important. Rather than merely describing relationships between variables, as existing descriptive models often do, the CA depicts a valuable goal: a set of capabilities that constitute valuable work. Moreover, the CA fits well with recent conceptions of health and modern insights into work, in which the individual works towards his or her own goals that s/he has to achieve within the broader goals of the organization. Correspondence to JJL van der Klink, Tilburg University, Tilburg School of Social and Behavioral Sciences, Tranzo, Scientific Center for Care and Welfare, PO Box 90153, 5000 LE Tilburg. The Netherlands. [E-mail: [email protected]] In his recent book, The Strength of Paradise, Jonathan Holslag indicates work has become trivial and unattractive for many people in modern societies (1). He argues for a stronger focus on values that are essential to human existence and contends that values such as meaning, recognition, and security can be met in the workplace. In addition, we propose that if such values actually materialize in the work setting, people are more likely to be capable and willing to continue to work. In other words, they will be more sustainably employable. If this notion is correct, it would become important for professionals in the field of work and health to pay greater attention to such value dimensions of work. In this paper, we propose a conceptual model of how resources, context, sustainable employability, and values might be related. This model is based on the concept of capability, as developed by Amartya Sen (2-4). Briefly, this model holds that an individual&apos;s sustainable employability is Key terms 72 Scand J Work Environ Health 2016, vol 42, no 1 Sustainable employability as capability determined by how he or she succeeds in converting resources into capabilities, and subsequently into work functioning, in such a way that values such as security, recognition and meaning are met. In this paper, we elaborate on the nature of these resources and conversion factors. We also explore how the different elements of this model relate to existing concepts in the field of occupational health such as employability, the framework of the International Classification of Functioning, Disability and Health (ICF) (5), and psychological models of work and stress. We provide a research agenda for testing, validation, and operationalization, as well as discussing implications for practice. In an accompanying paper also published in this issue, we report on the development and validation of a questionnaire that allows for the assessment of sustainable employability, based on the concept of capability (6). Our model aims to encompass the complexity of contemporary work, especially the value-related aspects of work. For present-day workers in the Western world, work is a life domain in which they want to achieve important goals and values, in addition to income security. Work should offer the opportunities to actually achieve those goals and values. Participating in work is important from both a societal and a personal perspective. On a societal level, in all European countries, greater and prolonged labor-force participation throughout a worker&apos;s life is necessary in order to confront the social and economic realities and challenges of an aging society. Workers will need to work until an older age, and those with disabilities will need to be integrated or reintegrated into the workforce (7-10). On a personal level, earning a living has been the most important work-related value throughout history, and only recently, in the post-industrial economy, have other values connected to work become attainable for a considerable number of workers. For Jahoda, income remains the central value; however, she stresses the importance of other work-related values, which she calls &quot;latent benefits&quot;, such as personal identity, self-esteem, and social contacts (11). Hannah Arendt formulates three central work values, resembling those of Aristotle, of which a person&apos;s livelihood (labor) is one. The other two values are creativity (work) and participation (action) (12). In our own research, reported elsewhere in this issue, we identified seven values or work capabilities, of which income is one (6). Thus, for workers in the postindustrial economy, although demanding, work is also an important domain of life in which ambitions and values can be realized (13-15). Moreover, work can contribute to health, if basic conditions and values are met In summary, work is an important means of achieving societal and personal goals and values, of which generating income is only one, albeit an important one. In developed economies, employment -including selfemployment -is one important way in which work is embedded in society. A person&apos;s ability to gain and maintain employment is referred to as his or her &quot;employability&quot; (18). As argued above, present-day workers require a wider range of valued outcomes from their work than an income alone. For these workers, work -and in line with that, employment and employability -is sustainable if it can provide those broader values. We use the term &quot;sustainable employability&quot; to incorporate a focus on values in the concept of employability. In the following sections, we will introduce a framework, based on the CA, in which an emphasis on values is added to notions of work and employability. To put our framework into perspective, we will first briefly discuss recent changes in theories of work, health and employability. The changing world of work, health, &amp; employability Our conceptualization and appreciation of health and work are changing rapidly. The World Health Organization&apos;s (WHO) 1948 definition of health The centrality of work in people&apos;s lives has also changed considerably with the transition from industrial to post-industrial labor In this process, the average worker has developed from a more-or-less passive performer of predefined tasks to an increasingly autonomous and responsible entrepreneur in his or her work (&quot;intrapreneur&quot;) (29), who proactively sets his/her own goals and makes his/ her own choices and (shared) decisions (27). For many people, work is now a life domain in which they can fulfill their ambitions and achieve important goals. Meanwhile, health has become a condition or resource that enables workers to carry out their work. Thus, work and health have changed places. In the past, work was the determinant and health was a state that people strove to maintain despite the burden of work. Nowadays, health is the resource, and employment or work is the state that people want to preserve, sometimes despite the burden of suboptimal health. This has implications for the field of occupational health, an important goal of which is to influence the work situation in order to optimize health. In view of the changing and dynamic conception of health -in which health, on the one hand, should enable people to pursue and achieve valuable goals and, on the other hand, will be positively influenced by that process -it is important that the role of the occupational health worker reflects these changes. This role should now include advising workers and their organizations how important values can be met and goals achieved. This will in turn contribute to health and sustainability and to an individual&apos;s choice and ability to take later retirement. This counts for all workers; particularly for specific subgroups of the labor market -predominantly precarious (often low-skilled) workers -for whom, notwithstanding the trends depicted above, there is a tendency towards a deterioration in working conditions, especially since the start of the economic crisis (30-33). In summary, values constitute an important aspect of work, and by extension, of employment and employability. Most definitions of employability stress the individual aspects of the concept A different approach emerged in France in the 1960s, focusing primarily on the demand side and the accessibility of employment, with employability defined as &quot;the objective expectation, or more or less high probability, that a person looking for a job can have of finding one&quot; [Ledrut, quoted in Gazier (p44, 37)]. Another trend, identified by Gazier and which emerged in the 1970s, focuses on measurable labor market outcomes, such as the period of time an individual is employed, hours worked, and wage rates that result from specific policy interventions. Finally, the notion of interactive employability has been put forward, whereby employers and policy-makers interact with individuals in order to gain and maintain employment. While accepting the importance of individual agency, this notion sought to balance personal efforts with structural factors (37). If, in this last and most recent notion of employability, workers and the work environment strive to gain and maintain employment in work that is valuable for the worker and valued by the work context, then, in our view, work, and -by extension -employability, can be seen as sustainable. The capability approach The capability approach (CA), introduced by Amartya Sen (2-4), offers a framework in which an emphasis on values can be added to work and employability. The CA states that individuals should have the capabilities to conceive, pursue, and revise their life plans According to Sen, freedom is, on the one hand, the possibility to shape one&apos;s life and living environment (process) and, on the other hand, the possibility to achieve valued goals (opportunity) (4 of individuals to do what they wish to do and to be what they want to be Alkire As with cycling, in work, all these different aspects of capability -from identifying a valued functioning to being able and enabled -are crucial. In other words, the individual worker must be both able and motivated to work. Moreover, the context in which the work is performed must enable the execution of valued tasks, contributing to goals that are personally significant and valued by the organization. Central to this definition is a set of tangible opportunities (capabilities) for achieving and maintaining valuable functioning at work (ie, employment in valuable work). It is essential that there are personal and environmental (work) conditions which enable workers to convert personal input and work input into these capabilities (real opportunities for valuable work functioning). In line with this definition, we have developed a model of sustainable employability (figure 1), in which the notion of a capability set plays a crucial role. The model (especially the central line in the model, from inputs on the left side to functionings on the right side) is derived from models by Sen, Robeyns, Morris, and Welch Saleeby The model represents the process whereby an individual worker in his/her context can convert inputs or resources into opportunities to make choices to achieve valuable goals. At the center of the model is the capability set: the set of tangible opportunities that can be used to achieve various valuable functionings. This set, in our view, represents the best possible operationalization of sustainabile employability. An example of a valuable work functioning, important for many workers and one of the seven work values we identified in our research, is the opportunity to develop knowledge and skills. This value can be considered to be a (work) capability for a person if: (i) it is an important value for this person in his/her particular work situation; (ii) s/he is enabled by the work context (eg, challenging tasks and an adequate HRM policy); and (iii) s/he is able to achieve it (eg, the ability to learn). This combination of experiencing a value, being enabled, and being able, by means of both inputs and conversion factors (see below), constitutes a (work) capability. On the left side of the model, personal and work inputs or resources at the worker&apos;s disposal are depicted. On the personal level, this refers to personal capacity; on the work level, this embraces work characteristics such as task structure and work demands. In our example of the opportunity to develop knowledge and skills, the personal resources that a worker can draw upon include his/her knowledge and ability to learn. Of course, other more general inputs and resources are important too, such as health, education, and general competency and abilities. Relevant workplace inputs and resources, in our example, include a diversity of tasks involving different levels of required skills and complexity, which constitute a learning environment. Between inputs and capabilities, the so-called &quot;conversion factors&quot; play an important role. In order to reach their goals, workers should not only be able to draw upon inputs but they should also be able to convert those inputs into tangible opportunities in order to achieve valuable work-related goals. Returning to the example of the two individuals owning a bike, individual B possesses a bike (the resource) but experiences negative &quot;conversion factors&quot; that prevent her/him from using the bike. In our example of developing knowledge and skills, relevant conversion factors include the attitude and motivation to learn and acquire new skills on the personal level, coupled with an HRM policy of employee development on the organizational level. Thus, in our model, work inputs and personal inputs are not mere determinants of sustainabile employability in the classical sense, but they are factors that can lead to a set of potentials (the capability set) to achieve valuable work functioning, provided that appropriate personal and contextual conversion factors are present. On the right side of the model, the actual (work) functioning of the worker is depicted -the valuable functionings that s/he chooses to achieve from his/her wider capability set. This achievement is the outcome of choice on the part of the worker along with his or her work context. The environment plays an integral role in determining the achievement of functionings by influencing aspects such as choice, preference, and importance. Sen speaks of &quot;constrained choice&quot; when external forces (eg, social forces like stigma or attitudes) constrain personal choice. Exactly because of this, the CA emphasizes the need to move beyond what individuals are doing, which might be influenced by constrained choice, to assessing what individuals are able to do or to be -their individual capabilities. Well-being, in this case quality of working life, is also depicted on the right side of the model. Well-being is not only related to what an individual achieves, but also to the options which he/she has had the opportunity to choose from. This element is also regarded as a less important proxy for sustainable employability than the capability set because the perception of a situation can be subject to a &quot;response shift&quot;, that is an adaptation of norms to the prevailing situation, while capabilities represent factual opportunities and freedoms. Contextual factors are important because they can influence inputs, conversion factors, and decisions or choice, according to which capabilities are achieved in actual work functionings. The complementary value of the CA to models of work and health Although the primary focus of the ICF was on disability, the WHO has positioned it as a universal framework of health and its related states (50). Due to its focus on functioning, the ICF is also widely used in occupational health. It is a diagnostic framework designed for classification purposes and not a conceptual model aimed at understanding aspects of reality. As such, the two systems (ICF and CA) are complementary to each other. In a thorough discussion of the parallels between the CA and the ICF, Welch Saleeby advocates using the ICF classification scheme to operationalize the capability theoretical framework (46). The CA adds the elements of value, opportunity of functioning, freedom, and choice to the ICF. 76 Scand J Work Environ Health 2016, vol 42, no 1 Sustainable employability as capability Psychological models of work and health focusing on work stress have been developed since the 1960s. The Michigan Stress Model (51) identified workload, job control, and social support as unidimensional determinants of work stress. In the next phase, balance models were developed. Karasek developed a two-dimensional model that assumed that job control, the freedom that workers have to make choices in their work, may balance the stress of high work demands and can even lead to a situation in which demanding work is challenging, as in a learning environment (52). Other models focus on the importance of a good fit between person and environment (PE-Fit) and, more specifically, between person and job Importantly, by considering both value and context, the CA can add to and extend existing models that have been developed over the past decades and are undoubtedly valuable in identifying sources of stress. A good balance is still relevant and necessary, and contributes to sustainable employability (58). However, for modern workers, it is not sufficient to have just a good balance between demands and resources, demands and abilities, or efforts and rewards; they also need to have a good fit or balance with regard to what they consider to be important values in their work. For sustainable employability, in the current work setting, it is crucial that workers are able and enabled to attain significant goals in their work, which are concordant with their core values. The concept of value adds to existing models by providing direction to (and within) the balance and fit models: what aspects of a fit are important? What goal is the motivation aimed at? What resources are needed, and what aspects of work are rewarding and contribute positively to the effort-reward balance of a worker? Most elements of the psychological models can be easily integrated into our model of sustainable employability, either as inputs or as conversion factors. Research agenda and implications for science and practice Having proposed a definition and a model -the focus of this article -the next steps should be to test the validity of the model and the assumptions underlying it. Part of this has already been done and is reported separately in this issue (6). The first step of a research agenda is to operationalize the core elements of the model. In our model, instruments are needed to identify whether an individual has a capability set that allows him/her to achieve valuable work functionings. To this end, we developed a new instrument based on our model. The core and most innovative part of this instrument is a set of capability questions [questionnaire and its validation (6)]. In order to identify relevant capabilities, we used a mixed method approach. The core of this approach was to conduct qualitative interviews so that we could ascertain exactly what workers value in their work. We identified seven work values: (i) the use of knowledge and skills, (ii) the development of knowledge and skills; (iii) involvement in important decisions; (iv) building and maintaining meaningful contacts at work; (v) setting own goals; (vi) having a good income; and (vii) contributing to something valuable. In our assessment, we kept close to the basic idea of the capability concept by asking, in relation to each of the seven values: (i) &quot;How important is &lt;the value&gt; for you?&quot;, (ii) &quot;Does your work offer you the opportunities to achieve &lt;the value&gt;?&quot; (iii) &quot;To what extent do you actually realize &lt;the value&gt;?&quot;. We determined whether each value comprises part of a worker&apos;s capability set (ie, whether it is consider