Health impacts with telework on workers: A scoping review before the COVID-19 pandemic

Background: Telework has dramatically increased due to the coronavirus disease 2019 (COVID-19) pandemic, and the health impacts related to telework have become major concerns. Some studies have shown that telework has both positive and negative impacts. However, during the pandemic, the influence of COVID-19 is too strong to estimate the health effects of telework. Therefore, this scoping review investigated a comprehensive overview of those impacts based on studies conducted before the COVID-19 pandemic.

Methods: We searched keywords related to telework in five databases: PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Ichu-Shi Web. We included articles written in English and Japanese and published from January 2009 to December 2020. One author extracted data, and four authors were paired into two groups. All authors independently conducted the first and second screening and checked the results in pairs. Any disagreements were resolved by reaching a consensus among all authors. All screening and strategies were performed with the consent of all authors.

Results: Twenty-nine quantitative studies published in 12 countries were extracted. The outcomes included 10 studies on physical and lifestyle outcomes, 25 studies on stress and mental health outcomes, and 13 studies on quality-of-life and wellbeing outcomes. Telework increased sitting time in one study, and two studies showed improvement in behavior, such as reducing smoking or drinking due to telework. While six studies reported subjective stress levels improved by telework, the results for depression, anxiety, and other disorders varied across those studies, and the social or individual factors further complicated the situation.

Conclusion: Telework is potentially associated with a shift to healthier lifestyles but also the potential for inverse correlation to extend sedentary time. Mental stress indicators depend on the social and individual situations, and very few intervention studies on teleworking existed prior to the COVID-19 pandemic. Our review identified a lack of intervention and comparative research on health problems with telework and revealed a need to conduct research with clear comparisons in post-COVID-19 studies.

Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021203104, identifier: CRD42021203104.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has changed the workstyle of individuals. Although the infection situations are different across countries and governments of various countries have implemented several measures, this pandemic has had a huge influence on people's lives, especially as it concerns their work styles. Most individuals, except the essential workers, have shifted to telework, and most workers realized that they could work without commuting to their offices (1, 2). This change in workstyle will not return to its original state even after the coronavirus epidemic ends and will become the main workstyle for post- and with COVID-19 in future.

Telework has changed drastically due to the COVID-19 pandemic, but the evolutionary circumstances differed among countries. In some western countries, telecommuting has been commonplace since the 1970s. People gradually gained interest in flexible work and working from home after the 1980s as women advanced into society (3). In addition, the telecommute concept expanded based on support for an employee with a disability, environmental protection, and business continuity plan (BCP) (3). Now, several companies and organizations have introduced the rules of telework. The European Foundation for the Improvement of Living and Working Conditions (Eurofound) and the International Labor Organization (ILO) released a joint report about working anytime and anywhere in 2017 (4). With the spread of high-speed Internet, “Telework/ICT-mobile work” can be defined as the use of ICT—such as smartphones, tablets, laptops, and desktop computers for the purpose of work outside the employer's premises (4). This report showed research results from 10 European Union (EU) countries (Belgium, Finland, France, Germany, Hungary, Italy, the Netherlands, Spain, Sweden, and the UK) and five ILO countries (Argentina, Brazil, India, Japan, and the USA). According to this report, there are more people among occasional teleworkers than among regular teleworkers in most countries and showed that the penetrating ability of telework depends on countries and occupations and ranged from 2 to 40% (4).

Previous studies have shown that telework has both positive and negative impacts (5–7). For example, the confirmed positive impacts include reduced commuting time, more work flexibility, and better work–life balance (5). However, negative impacts include long working hours and the increasing obscurity in the borderline between private life and official work (6). Also, people conflict between work and life balance, leading to increased stress affecting physical and mental health (7). To the best of our knowledge, there were no reviews of health issues related to telework published before the beginning of the COVID-19 pandemic, and many uncertainties remain regarding the positive and negative impacts of telework.

Telework is a recognized concept with several terms: telecommuting, telework, remote work, and flexible work. Allen et al. organized the concepts of telework in a table (3), and the concepts were strictly defined in different terms. According to Allen et al. (3), flexible work arrangement refers to the overall option of working beyond the standard operating days and locations. Remote work defines a form of full-time teleworker who lives and works outside the commuting area, and telework and telecommuting have set the broader concepts that include remote work from home or satellite office, and a form of work in partially or completely replace to commute.

Many studies on long-term health problems for telework during the COVID-19 pandemic are likely ongoing, but study population, work, and telework methods may not necessarily correspond to eligible targets among studies because of the diverse culture and acceptability for telework. This study aimed to systematically investigate any health impact on teleworkers. Along with the health impacts related to telework in the COVID-19 pandemic, the influences of COVID-19 are too strong to estimate the health effects of telework. Therefore, this review focused on studies published up to the early days of COVID-19 pandemic. The purpose of this review is to identify relevant health issues related to telework and what is missing in existing research and to add fundamental information for future systematic reviews.

Materials and methods

Search strategy

We chose a method of scoping review to search a wide range of literature about telework and health. Two research questions (RQ) were developed: (1) Did telework affect workers' health? and (2) what kind of health impact was associated with telework? Health impacts included any kind of condition associated with physical and mental health. We searched five databases related to occupational health impacts: PubMed/MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Ichu-Shi Web. Searched articles were limited to English and Japanese and to those published from January 2009 to December 2020. During the review process, careful consideration was given to exclude studies conducted after the COVID-19 pandemic. The reason for considering 2009 is that this was the year of change in world labor due to the public emergence of Wi-Fi, cloud service, and 2008 global recession (Lehman shock) (8, 9). This search process was carried out by two authors (YF and KF).

Keywords used in the search included “telework,” “remote work,” “work at home,” “work from home,” “telecommuting,” “work-home,” “teleworking,” and “health.” The authors agreed on search keywords and strategy, and study designs and article types were undesignated, but commentaries were excluded. We removed overlapping reports among the publications extracted from each database. This review was based on PRISMA extension for Scoping Reviews (PRISMA-ScR) (10).

Selection criteria

The extracted studies were required to focus on health impacts due to telework, including mental and physical health. First, studies that did not fulfill selection criteria were excluded based on the information in the title and abstracts as primary screening independently among four authors. They verified the results in pairs and retained studies that could not be determined in primary screening for a secondary screening. Next, full texts were screened by whether they matched the RQ during the secondary screening. As our criteria for the selection of this study, for physical health, we conceptualized conditions that could be considered as a disease by being examined and diagnosed, as for mental health, we targeted conditions that could be diagnosed as mental health diseases as well. Studies were included when workers were the study subjects but excluded when all subjects were students, homemakers, and nonemployee. Studies with an outcome related to productivity were also excluded. Two authors conducted the secondary screening in pairs, and any disagreements were resolved by reaching a consensus among all authors. The secondary screening results, as well as reasons for excluding some articles, were noted. The selection criteria were the following: (1) participants were wholly or partly workers, (2) all or parts of study outcomes answered the RQs, (3) exception of commentary, review articles, and qualitative studies, and (4) articles presented in English and Japanese languages. In cases where the broad concept was included in the exposure factor, yet no actual telework status was suspected based on the researcher's review, we excluded those studies under the criterion that they did not meet the RQ by the consensus of all researchers. This study was registered in the PROSPERO with registration no. CRD42021203104.

Results

The search process is shown in a PRISMA flow diagram (Figure 1). Because of the database search, 983 records were extracted. After excluding 177 duplicate records, 806 were subjected to primary screening by title and abstract, and 43 were subjected to secondary screening by full text. Next, we excluded 31 records because the articles included subjects who were not teleworking (n = 14) or had no health/wellbeing outcomes (n = 8). Also, we excluded review articles (n = 8) and qualitative studies (n = 1). Therefore, we included 12 records. During the secondary screening, we identified three review articles with similar objectives and outcomes of this study among the 43 records. Therefore, we selected 17 eligible records among the reference lists of these reviews. We reviewed a total of 29 records (11–39).

FIGURE 1

Figure 1. PRISMA flow diagram of the search process.

Table 1 summarizes eligible articles included in this scoping review. Overall candidates for full screening were 29 quantitative studies (23 cross-sectional studies, four cohort studies, and two non-randomized intervention studies). These records were published from 12 countries, and most of the records (11 in total) were published from the United States. Others were five from the Netherlands, two from Australia, Belgium, and Spain, and one from Germany, South Africa, Estonia, New Zealand, Hong Kong, India, and Japan. There were 12 records published in 2020, and the remaining records were published from 2009 to 2019. Overall, 10, 25, and 13 articles were related to physical and lifestyle outcomes, stress and mental health outcomes, and quality-of-life and wellbeing outcomes, respectively.

TABLE 1

Table 1. Study summary of selected articles (n = 29).

Physical and lifestyle outcomes

Table 2 shows the findings of physical and lifestyle outcomes. Physical outcomes included overall physical health issues, hypertension, musculoskeletal pain, gastrointestinal disturbances, complaints related to tired eyes, poor nutrition and obesity, physical activity, physical inactivity and sitting time, sleeping time, alcohol use, and tobacco use. One record reporting overall physical health issues revealed that telework was related to some previously unencountered health problems. One reported a worsened condition from the two available records on hypertension, while the other documented an improved situation than non-teleworkers. Three records were related to pain complaints wherein two of the records showed lower pain levels or prevalence, and the third showed that pain increased, especially in fathers. Increased gastrointestinal disturbances were documented in one report, while two reports showed an increase in screen viewing time and tired eyes complaints. Three records indicated poor nutrition and obesity. The older age group had a risk of obesity, and the younger age group and/or men had an increased risk of poor nutrition. Four records investigated physical activity, physical inactivity, and sitting time. These records on physical activity showed positive, negative, or no associations. However, one record reported that sitting times consistently increased. Of the three reports that investigated sleep issues, two showed an increase in sleeping time, but one displayed a decreasing trend. Two reports showed that alcohol and tobacco use decreased, and this tendency was positively associated with the intensity of telework.

TABLE 2

Table 2. Summary of physical and lifestyle outcomes (n = 10).

Mental and stress outcomes

Table 3 shows the findings of mental outcomes. Mental outcomes were reported as mental health issues, stress, fatigue and exhaustion, psychological strain, burnout, depression, anxiety, sadness, and relaxation. Findings on specific stress indicators, such as depression, anxiety, and fatigue, were complex. There were 12 reports on specific subjective stress indicators. Six reports indicated inverse trends, while five studies showed an increase and one showed no changes. The details were the following: Telework lowered subjective stress in men but elevated stress in women. Holiday and weekend telework for women and telework as overwork increased stress. These reports showed that voluntary teleworkers with social connections had adverse stress but teleworkers with low Internet of things (IoT) literacy were fragile for technostress. Eleven records were related to fatigue and exhaustion. Six records showed that telework lessened fatigue, two indicated increased fatigue, and two showed no changes. These records indicated that men had less fatigue, older-aged men had strong fatigue, and women tended to have a high level of fatigue. Mothers bringing overtime work at home on weekends showed exhaustion. However, these findings have various associations with telework intensity. All two records studied on overall mental health issues exhibited a worsened tendency.

TABLE 3

Table 3. Summary of mental health and stress outcomes (n = 25).

Three records reported the issue of psychological strain. These reports showed that psychological strain was associated with work overload, invasion of privacy, and role ambiguity. Women and workers with salary <100,000 were more likely to have mental strain. However, one record on burnout did not show significant associations. Four records reported on depression. A record showed a lower depression score, while increments appeared in the others.

Interestingly, telework intensity showed U shape; younger aged group and pajama-wearing individuals during work from home had a high risk of depression. One record reported that anxiety negatively correlated with longer work experience, and two records reported sadness. Men showed a general tendency to lower the level of sadness, but a father working at home was positively associated with the level of sadness. Relaxation time was reported in two records, of which one article showed that telework allowed for easier relaxation, but one reported lesser time for relaxation.

Wellbeing and quality-of-life (QOL) outcomes

Table 4 shows the findings of wellbeing and QOL outcomes. Wellbeing and QOL outcomes were self-reported overall health, QOL, wellbeing, happiness, and engagement. Two records focused on self-reported overall health showed negative correlations with teleworkers' health.

TABLE 4

Table 4. Summary of wellbeing and quality-of-life (QOL) outcomes (n = 13).

In total, two, three, and four records reported QOL, wellbeing, and happiness, respectively. Almost all manuscripts, excluding one on wellbeing and two on happiness, reported getting better based on QOL and wellbeing. Two records on happiness recorded that those teleworking got better in happiness than non-teleworkers, while one record indicated that telework was not directly associated with happiness. The blurring of work–life boundaries led to negative change, and bringing work home on weekdays by fathers and those on weekends by mothers reduced happiness. Of the four records on engagement, two showed improvements and the other two reported no changes. Engagement tends to improve together with a high level of social capital.

Discussion

We estimated health impacts related to telework in this review. Most studies were observational, with only two being interventional. Our analysis showed that the most common outcomes were related to mental health and stress, and the next was QOL-related outcomes. The outcomes related to physical health and symptoms were present in few settings. The articles from 2009 to 2019 included two articles on physical health outcomes, 14 articles with mental health outcomes, and eight articles with QOL-related outcomes. In contrast, the number of articles on telework health problems increased sharply in 2020. There were eight articles with physical health outcomes, 11 articles with mental health outcomes, and five articles with QOL-related outcomes.

In this review, most studies were published from the United States because the United States was the birthplace of telework, followed by the Netherlands, Finland, Sweden, etc. The EU has a Framework Agreement on Telework, and about 17% of employees in the EU engage in telework on average (4). Telework was more common among managers, professionals, clerical support, and sales workers in occupations, and women were reported to be teleworking more regularly than men (4). This report suggests that the work–family model, including gender roles, is associated with the implementation rate of telework in each country (4). These differences in the background might have different effects between teleworking and health.

Physical health outcomes

Almost all studies on the outcomes of physical health consistently showed an inverse association in the volume of alcohol consumption and numbers of tobacco smoking (17, 29) and in the complaint of pain (31, 36), and an positive association in sitting time (35). Telework could have some role on the decrease in drinking and smoking habits. As for pain relief, factors causing pain might be related to commuting time and pain could have been relieved possibly due to reducing the commuting time.

Telework was consistently associated positively with sitting time, but interestingly, there was no consistent tendency in physical activities (17, 31, 32, 35). We suspected that workers who shifted to telework could not affirm their overall physical activity had decreased because they were doing intellectual work using IoT tools in the office. Their sitting time had already become longer before the pandemic. Recently, sedentary behavior is a major concern about several health issues, particularly resulting in death (40). Therefore, the sedentary work style will be one of the emerging topics on occupational health.

Mental health and QOL-related outcome

Mental health and QOL-related outcomes were generally inconsistent and did not show clear results. The possible reasons considered are that the effects may differ mainly from gender and family structures. In several studies, mental health outcomes were worsened among females and/or females having children (17, 24, 30, 31, 39). Gender plays different roles in society, and the blurring of the borderline between work and life and levels of support from colleagues or superiors resulted differently, suggesting that mental health outcomes might be strictly affected by the social and/or individual situations.

Subjective stress showed a decreasing and reducing trend among articles published from 2009 to 2019 (15, 16, 18, 27). There was a report that people with low IoT literacy were more likely to feel stressed (22), and another report showed that people with high social capital have higher telework-engagement and less burnout (25). This suggests that teleworker literacy, including social capital, is related to the adaptation to telework.

Telework has spread all at once by the COVID-19 pandemic. Thus, considering the impacts on health problems of workers, especially mental health, it is difficult to assess these because the influences of the pandemic, such as behavioral restrictions, economic distress, and future uncertainties, are considered to be intricately involved. Although our review estimated qualitative studies, important issues to be evaluated and to be stratified were specified. When future studies evaluate outcomes, individual stress indicators are complex. Thus, the social and personal environment should be stratified in future studies, especially in mental health. Furthermore, to consider the health effects of telework, it may be necessary to evaluate the consistency with not only one marker but also several indicators or scales.

Strength and limitation

Our study has several strengths. One strength of this study is ensuring objectivity by the evaluation method used. The review was conducted according to an established protocol. The primary and secondary screening processes and the risk of bias assessment were evaluated independently and examined by all authors in case of disagreement between author pairs. In addition, we also extracted articles from references that were incorporated into articles on review with similar objectives published within the study period. We were able to extract many relevant articles by incorporating these articles into this study.

However, there are some limitations. First, we could not conduct a comprehensive review of the eligible articles as we excluded documents written in languages other than English and Japanese. Second, the majority of the articles included in this study were conducted in a cross-sectional design, which does not allow us to identify any causal relationships. Future cohorts and intervention studies should be conducted to address the points discussed in this review. For example, telework tends to be used more by certain groups, such as highly educated, ICT-skilled workers (41), so the possibility of multi-biases cannot be ruled out since eligible studies were mainly from observational studies. Third, we completely cannot deny some possible influences in published studies of 2020 although we tried to avoid the impacts of the COVID-19 pandemic as much as possible and extract only the impacts of telework. Fourth, telework is not necessarily limited to telecommuting, but is a concept that encompasses all forms of working outside main offices. Our study cannot eliminate the possibility that reflected each study's outcome by the differences in their respective expressions. However, despite these limitations, few reviews have examined the health impacts of telework (42–44), and this scoping review could have importance as basic information on examining the health impacts of telework in future.

Conclusion

Our findings indicated that telework could associate inversely with mental stress and influence a shift to healthier lifestyles, although it was positively correlated with the risk of a sedentary lifestyle. However, the associations differed among family environment, gender, age, personal literacy, including IoT, and support from others. These points are useful for occupational health practice. However, we found that the associations varied by individual attributes. Telework was more likely to have a negative association on mental health for women than for men, suggesting the possibility of an interaction effect by gender, depending on environment for child care and other factors. The associations on mental health also differed depending on the level of literacy, including IoT, and social connections. The current review could not present enough evidence to withstand meta-analysis targeting each attribute due to the lack of intervention studies. Therefore, future intervention studies are required to measure health impact with adequate collection of information on such attributes.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

Author contributions

YF and SN wrote the first draft of the article. KF and MT supervised this manuscript. All authors prepared the inclusion and exclusion criteria, screened articles, and checked for the risk of bias in all articles. All authors contributed to the article and approved the submitted version.

Funding

This work was supported by the Ministry of Health, Labor, and Welfare under Grant (Industrial Disease Clinical Research Grants, No. 210801-01).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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