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Yellow Flags
CHRISJ. MAIN
University of Manchester, Manchester, UK [email protected]
Synonyms
Psychosocial risk factors; Psychosocial Obstacles to Re- covery
Definition
Yellow Flags are psychosocial factors associated with risk of the development of chronicity in pa- tients/employees with low back pain The increasing costs of chronic low back pain, despite advances in technological medicine, stimulated the search for new solutions to the problem of low back disability.
Characteristics
In New Zealand, increasing costs of chronic non-specific low back pain had become an unmanageable burden.
This fuelled a new initiative designed to complement a slightly modified set of acute back pain management guidelines, with a psychosocial assessment system de- signed systematically to address the psychosocial risk factors that had been shown in the scientific literature to be predictive of chronicity (Kendall et al. 1997). The stated purposes of assessment of Yellow flags were to:
• Provide a method for screening for psychosocial fac-
• Provide a systematic approach to the assessment oftors psychosocial factors
• Suggest better strategies for better management for those with back pain who appear at a higher risk of chronicity
Focus on a number of key psychological factors:
• Belief that back pain is harmful or severely disabling
• Fear-avoidance behaviour patterns with reduced ac- tivity levels
• Tendency to low mood and withdrawal from social interaction
• Expectation that passive treatments rather than active participation will help
The Yellow flags consisted of integration into an assess- ment system, which included a screening questionnaire, interview guidelines and recommendations for early behavioural management in individuals with low back pain. They consisted of both psychological and socio- occupational risk factors. The main categories of the Yellow flags are:
• Attitudes and beliefs about back pain
• Behaviours
• Compensation issues
• Diagnostic and treatment issues
• Emotions
• Family
• Work
They also included a number of specific guidelines for behavioural management, including:
1. Provide a positive expectation that the individual will return to work
2. Be directive in scheduling regular reviews of progress 3. Keep the individual active and at work
4. Acknowledge difficulties of daily living 5. Help maintain positive co-operation
6. Communicate that having more time off work reduces the likelihood of successful return
7. Beware or expectations of “total cure” or expectation of simple “techno-fixes”
8. Promote self-management and self-responsibility 9. Be prepared to say “I don’t know”
10. Avoid confusing the report of symptoms with the presence of emotional distress
11. Discourage working at home
12. Encourage people to recognise that pain can be con- trolled
13. If barriers are too complex, arrange multidisciplinary referral
(Kendall et. al1997)
Examination of this list reveals that, in addition to current management, there are clear preventative components within the guidelines.
Beyond Yellow Flags: The Blue Flags and Black Flags Traditionally, clinical rehabilitation had focused primar- ily on clinical outcomes, with relatively little attention directed specifically at work. Although designed origi-
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Yellow Flags, Table 1 Selected Psychosocial Work factors and their Facets
Job demands Quantitative workloadVariance in workloadWork pressureCognitive demands Job content RepetitivenessChallengeUtilisation and development of skills
Job control Task/instrumental controlDecision/organisational controlControl over the physical environmentResource controlControl over workplace: machine-pacing
Social interactions Social support from supervisor andcolleaguesSupervisor complaint, praise, monitoringDealing with (difficult) clients/customers
Role factors Role ambiguityRole conflict Job future and career issues Job future ambiguityFear of job loss
Technology issues Computer-related problemsElectronic performance monitoringFear of job loss Organisational and management IssuesParticipationManagement style
(Adapted from Table 15.2 in Carayon and Lim (1999), p 278)
nally for a case-management system, the original Yellow Flags focused primarily on perceptions of health. Ini- tially, the prime reason for development of the flags was to offer a complementary analysis to the Red Flags (based exclusively on a medical model of illness). It was decided that the collective importance of psychosocial factors was such that it made sense to integrate them under a single heading. It became clear, however, that implicit within the Yellow Flag initiative was the pos- sibility of a range of different solutions, involving both health-care providers and occupational personnel. Main and Burton (1998), Burton and Main (2000) decided that insufficient attention had been given to specific occupa- tional factors, and it was therefore decided to subdivide the yellow flags into clinical Yellow Flags and occupa- tionally focused Blue Flags.
The Blue Flagshave their origins in the work stress literature and can be viewed in terms of characteristics of the working environment, physiological stress, or as a consequence of interaction between the individual and their environment. Some of the more important factors, according to Carayon and Lim (1999), are shown in Ta- ble 1.
The relationships between stress, well-being, and health is not as yet fully understood, but Griffiths (1998) identi- fied a large number of work organizational factors asso- ciated with poor health and well-being. The available ev- idence provides most support for influence of the follow- ing factors (Bongers et al. 1993; Vingaard and Nachem- son 2000):
• High demand and low control
• Time pressure/monotonous work
• Lack of job satisfaction
• Unsupportive management style
• Low social support from colleagues
• High perceived workload
In fact, it has been suggested, that workers’ reactions to psychosocial aspects of work may be more impor-
tant than the actual requirements of the job themselves (Davies and Heaney 2000), with stress acting as an in- termediary (Bongers et al. 1993).
These perceived features of work, generally associated with higher rates of symptoms, ill health and work loss have been termed Blue flags. In the context of injury, these factors may delay recovery or constitute a major obstacle to it; and for those at work there may be major contributory factors to sub-optimal performance or
“Presenteeism” (Shamansky 2000). They are charac- terised by features such as high demand/low control, unhelpful management style, poor social support from colleagues, perceived time pressure and lack of job satisfaction. Individual workers may differ in their perception of the same working environment.
Blue flags incorporate not only issues related to the per- ception of job characteristics, such as job demand, but also perception of social interactions (whether with man- agement or fellow-workers). From a work retention or work rehabilitation perspective, however, a further dis- tinction has been made between two types of occupa- tional risk factors: those concerning the perception of work (Blue Flags) and organisational obstacles to recov- ery, including objective work characteristics and con- ditions of employment (Black flags) (Main and Burton 1998; Burton and Main 2000). The distinction is simi- lar to the distinction between intrinsic and extrinsic fac- tors by Herzberg (1974), but with a focus on obstacles to recovery (i.e. potential targets for some sort of biopsy- chosocial intervention).
Black Flagsare not a matter of perception, and affect all workers equally. They include both nationally estab- lished policy concerning conditions of employment and sickness policy and working conditions specific to a par- ticular organisation. Some examples are shown in Ta- ble 2.
It is not always possible to make an absolute distinction between Black and Blue flags, since there are also spe- cific objective job characteristic aspects of work, which
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Yellow Flags, Table 2 Occupational Black Flags I: Job context and working conditions
National Rates of payNationally negotiated entitlementsSick certificationBenefit systemWage re-imbursement rate Local Sickness PolicyEntitlements to sick leaveRole of occupational health in “signing off” (?) and “signing
on”Requirement for full fitnessPossibility of sheltered workRestricted duties Management style
Trades Union support/involvement Organisational size and structure
are associated with higher rates of illness, injury or work loss. They are shown in Table 3.
The features of work following injury may require a higher level of working capacity for successful work retention. After certain types of injury, such jobs may be specifically contra-indicated and therefore constitute an absolute obstacle to return-to-work. It might be hoped that many such risk factors could be “designed” out of the working environment, but such factors certainly need to be evaluated in the context of work retention or rehabilitation. Specifically, in terms of prevention they are a matter primarily for legislation, establishment of satisfactory job design, and adherence to recommended work practices, in negotiation, where appropriate, be- tween employers and employee organizations.
The Yellow Flag initiative has been important in two ma- jor ways:
Firstly, in promulgation of a “systems approach”, involv- ing all key stakeholders, in addressing issues of clinical and occupational rehabilitation, with emphasis on the need for better clinical-occupational interfaces, and sec- ondly in attempting to identify and reduce risk factors for chronic incapacity, whether in health-care or in oc- cupational settings.
Arguably, the strength of the Yellow Flags initiative has been the fact that it has offered a conceptual alternative to the bio-medical model of low back pain disability. The development of the Blue and Black Flags, has offered a more detailed conceptual framework within which a range of initiatives may be linked. At the core of the
“flag” construct is a conceptual shift from risks (many of which may be immutable), to obstacles, to recovery.
This may be individual clinical factors or perceptions of work or organization, which in turn require a range of solutions from individual clinical interventions and work re-integration strategies to fundamental redesign of the individual-organization interface.
Yellow Flags, Table 3 Occupational Black Flags II: Content-specific as- pects of work
Ergonomic Job heavinessLifting
frequencyPosturesSitting/standing postural requirements
Temporal characteristics Number of working hoursshift pattern
The conceptual framework of the “Flags” approach now needs to supported by further empirical research in five key areas:
• The statistical construction and validation of screen- ing strategies
• Refinement of cognitive-behavioural strategies ap- propriate for different contexts
• Identification of appropriate competenciesfor the de- livery of psychosocial interventions
• Integrationofsickness/disabilitymanagementstrate- gies with the development and enhancement of pos- itive/adaptive coping strategies
• Developing an evidence-base of context-specific in- terventions; including bench-marking of successful initiatives
In conclusion, the Yellow Flags initiative has offered a way of understanding and addressing psychosocial ob- stacles to recovery (or to optimal function). In its more recent conceptual development (incorporating both Blue and Black Flags) it may also offer a framework within which to consider opportunities for change.
References
1. Bongers PM, de Winter CR, Kompier MAJ, Hildebrandt VH (1993) Psychosocial Factors at Work and Musculoskeletal Dis- ease. Scand J Work Environ Health 19:297–312
2. Burton AK, Main CJ (2002) Obstacles to Recovery from Work- related Musculoskeletal Disorders In: Karwowski W (ed) Inter- national Encyclopedia of Ergonomics and H Factors. Taylor and Francis, London, pp 1542–1544
3. Carayon P, Lim S-Y (1999) Psychosocial Work Factors. In:
Karwowski W, Marras W (eds) The Occupational ErgonomicsS Handbook. Boca Raton, CRC, pp 275–283
4. Davis KG, Heaney CA (2000). The Relationship between Psy- chosocial Work Characteristics and Low Back Pain: Underlying Methodological Issues. Clin Biomech 15:389–406
5. Griffiths A (1998) The Psychosocial Work Environment. In Mc- Caig R, Harrington M (eds) The Changing Nature of Occupa- tional Health. HSE Books, Sudbury Suffolk, pp 213–232 6. Herzberg E (1974) The Wise Old Turk. Harvard Business Rev
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7. Kendall NAS, Linton SJ, Main CJ (1997) Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long Term Disability and Work Loss. Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National Health Committee. Wellington, NZ
8. Linton SJ (2000) A Review of Psychological Risk Factors in Back Pain and Neck Pain. Spine 25:1148–1156
9. Main CJ, Burton AK (1998) Pain Mechanisms. In: McCaig R, Harrington M (eds) The Changing Nature of Occupational Health, HSE Books, Sudbury Suffolk, pp 233–254
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10. Shamansky SL (2000) Editorial: Presenteeism. Or When Being There is Not Being There. Public Health Nurs 19:79–80 11. Vingard E, Nachemson (2000) A Work Related Influences on
Neck and Low Back Pain. In: Nachemson A, Jonsson E (eds).
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12. Waddell G (1998) The Back Pain Revolution. Churchill- Livingstone, Edinburgh
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