Klaus Kuhl, Kooperationsstelle Hamburg IFE GmbH, Germany
- 1 Introduction
- 2 Definitions
- 3 Research methods
- 4 Diseases, figures and trends
- 4.1 Recognised occupational diseases
- 4.2 Work-related ill health
- 4.3 MSDs
- 4.4 Psychosocial health problems
- 4.5 Respiratory and skin diseases
- 4.6 Cardiovascular disorders
- 4.7 Occupationally-related cancers
- 4.8 Trends in short
- 5 Legal requirements
- 6 Causes, reasons
- 7 Burden of diseases
- 7.1 Work-related ill health
- 7.2 MSDs
- 7.3 Psychosocial health problems
- 7.4 Respiratory and skin diseases
- 7.5 Work-related cancers
- 7.6 Health surveillance
- 7.7 Compensation, rehabilitation, return to work strategies
- 8 Prevention and well-being at work
- 9 Outlook
- 10 References
- 11 Links for further reading
Occupational health comprises many aspects: research, reporting, legal requirements (i.e. confidentiality of diagnoses), prevention, treatment, rehabilitation and compensation of workers with occupational injuries and disease, developing/integrating health management into overall management systems, health promotion and protection programmes, participation of workers.
Occupational health principally means the absence of occupational diseases. In a strict sense, the concept of an occupational disease refers to cases for which the occupational origin has been approved by the national compensation authorities. This concept depends on the national legislation and compensation practice, which typically restrict the compensation to cases for which the occupational factor is the exclusive or principle cause .
In contrast, the concept of a work-related disease includes diseases where work played a role. The concept of a work-aggravated disease is one which is made worse by work, regardless of the original cause .
The WHO adopts a wider perspective, defining health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”  This holistic approach is in line with the joint ILO/WHO Committee’s definition of occupational health : ‘Occupational health should aim at: the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities; and, to summarize: the adaptation of work to man and of each man to his job.’
Adverse effects and conditions need appropriate investigation. For chemicals alone, there is at present a large discrepancy between the number of chemicals used in commerce and the number that have been evaluated for toxicity. Our knowledge about the harmful effects of exposure in the work environment may be obtained from studies in humans (mostly epidemiological studies), studies in experimental animals, and in vitro studies. All three types have advantages and disadvantages when it comes to identifying occupational factors . Epidemiological (human) studies are often cross-sectional in nature, i.e. they study exposure and effect at a single time point. They, therefore, do not provide information about causal relationships that may be obtained from prospective studies, which watch for effects during a longer period and relate these to potential exposure that could be responsible for causing the effects. Many studies lack appropriate exposure level assessments, meaning they cannot identify effect levels . Animal studies provide an important supplement to overcome the shortcomings of epidemiological studies. Apart from ethical considerations, the main drawback of animal studies in predicting effects in humans is the need to extrapolate findings in animal species to humans. Results must be interpreted with caution given that they are from a different species. The number of individuals is also smaller, and the doses or concentrations of the test factors are often considerably higher than in the workplace setting. Similar considerations apply to in vivo studies . This indicates that our current knowledge on work-related ill-health is limited and needs to be improved.
Diseases, figures and trends
Recognised occupational diseases
Eurostat published a statistical portrait on health and safety at work in Europe, covering the period 1999-2007. The authors found the highest proportion of (acknowledged) occupational diseases in the sectors :
- manufacturing (38%)
- construction (13%)
- wholesale retail trade, repair (7%)
- health and social work (5%)
The number of occupational diseases in the ‘manufacturing’ sector appeared to decrease with time, whereas the number of diseases in the other three sectors increased .
The European Occupational Diseases Statistics (EODS) recorded recognized and newly recorded occupational diseases, and found the highest occurrence for the following diagnostic groups: musculoskeletal diseases, neurologic diseases, lung diseases, diseases of the sensory organs, and skin diseases . However, diseases with a long latency, such as asbestosis or occupational cancers do not necessarily feature in formal statistics.
In the Labour Force Survey (LFS) ad hoc module 2007, 15 to 64 year olds that work or had previously worked were asked whether they suffered from one or more health problems caused or made worse by work in the past 12 months. In total, 8.6% of the respondents in the EU-27 had a work-related health problem, corresponding to approximately 23 million people .
Whereas the accident statistics show a downward trend, the proportion of persons with a work-related health problem increased from 4.7% in 1999 to 7.1% in 2007, according to the LFS ad hoc modules .
The EU LFS ad hoc module 2007 provides the following breakdown of respondents’ most serious work-related health problems :
- Musculoskeletal disorders 60.4%
- Stress, depression or anxiety 14%
- Breathing or lung problems 5%
- Heart disease or attack, or other problems in the circulatory system 4.9%
- Headache and/or eyestrain 4.7%
- Infectious disease 2.8%
- Hearing problem 1.4%
- Skin problem 1.4%
- Other types 5.5%
(all figures approximate)
Preliminary data from the 2013 module suggests that the relative importance of most problems remains unchanged, with MSDs first and stress, etc. second. In most instances, the percentages appear to remain largely unchanged or have fallen slightly.
The LFS ad hoc module 2007 found that 8.6% of respondents had a work-related health problem, corresponding to approximately 23 million people in the EU 27. Of these, 61% stated that musculoskeletal problems (bone, joint or muscle) were their main work-related health problem .
Most workers (17%) reported exposure to difficult work postures, work movements, or handling heavy loads as the main risk factor affecting their physical health. This was followed by exposure to risk of an accident (10%), exposure to chemicals, dusts, fumes, smoke, or gases (8%), and exposure to noise or vibration (5%) . Data from the 2013 module suggests that the percentages have generally fallen slightly, although the relative ordering (postures, accidents, chemicals) remains the same.
According to the LFS ad hoc module 2007, (EU 27) workers in the following sectors are affected by musculoskeletal problems (in descending order) :
- Wholesale retail trade, repair
- Hotels and restaurants
- Other community, social and personal service activities
- Transport, storage and communication
- Health and social work
- Real estate, renting and business activities
- Public administration and defense; compulsory social security
- Financial intermediation
When comparing data from 9 countries for 1999 and 2007, it was found that the proportion of musculoskeletal problems had increased in all sectors . The positive technological developments, which have reduced the lifting of heavy loads, have not lead to the expected decrease in the number of back disorders – neither for workers in the highest risk groups nor the general working population as a whole. Repetition and monotony combined with working conditions such as low individual control of the work and high work-pace can also lead to an increase in the risk of musculoskeletal disorders .
In large and small firms (less than 10 staff), musculoskeletal health problems contributed significantly to work-related health problems, occurring slightly more often in small firms, according to both the LFS ad hoc module 2007 and the EWCS 2005 .
Recognized occupational musculoskeletal diseases
Regarding musculoskeletal diseases, the European Schedule of Occupational Diseases considers specific conditions linked to vibration, local pressure and overuse of tendons, peritendonous tissues, and tendon insertions. However, only a few Member States accept disorders of the lower back and neck and shoulder region as occupational diseases, and then only for specific forms of disease. It is, therefore, difficult to collect comprehensive European-level data on recognised occupational musculoskeletal disorders. According to the 2001 EODS data collection, where 12 Member States provided data on recognised cases of occupational diseases, the most common musculo-skeletal occupational diseases were tenosynovitis of the hand or wrist (5,379 cases) and epicondylitis of the elbow (4,585 cases). There were also 2,483 cases of carpal tunnel syndrome - a neurological disease of the wrist. If extrapolated to EU-15 in the ratio of the workforce and the participating countries, there would be around 8,900 cases of tenosynovitis, 7,600 cases of epicondylitis and 4,100 cases of carpal tunnel syndrome .
In the LFS ad hoc module 2007, 14% of those with a work-related health problem reported stress, depression or anxiety as the main complaint. This constituted the second most frequently reported work-related health problem (after musculoskeletal health problems) .
The proportion of stress, depression or anxiety was highest in these sectors:
- Education (27%)
- Financial intermediation (25%)
- Public administration and defence (24%)
- Real estate, renting and business activities (22%)
In the European Survey on Working Conditions (EWCS) 2005, the occurrence of stress and anxiety was also high in the ‘education’ and ‘health and social work’ sectors .
Because of a lack of knowledge on the mechanisms of work-related psychosocial disorders, very few if any such disorders are included in the national systems of reporting or compensating occupational diseases. In 2000, a methodological survey was conducted in the 15 EU Member States to collect metadata and plan a statistical data collection on occupational diseases. At that time, no Member State included such disorders in their national list of occupational diseases. In some countries, post-traumatic stress disorder and burnout were included in the reporting system, and post-traumatic stress disorder may be accepted under the system of compensating accidents at work in some instances (e.g. victims of assaults during work) .
Respiratory and skin diseases
In the LFS ad hoc module 2007, 5.2% reported breathing or lung problems as the main work-related health problem. The EWCS 2005 showed that 4.7% experienced breathing difficulties related to work .
The LFS ad hoc module notes that skin problems were reported as the main work-related health problem in 1.3% of cases. This was supported by the EWCS 2005, which found that 6.6% have skin problems .
For these health risks, the prevalence is highest in agriculture, construction, manufacturing and health and social work, and lowest in financial intermediation and education. The difference between the highest and the lowest prevalence by sector is typically 10-fold .
Recognized occupational respiratory and skin diseases
For 2001 Eurostat estimated about 10,000 respiratory and almost 8,000 skin diseases for the EU-15 . The European Agency for Health and Safety at Work states in a 2009 press release: “It is estimated that chemicals are responsible for 80-90% of skin diseases, which rank second (13.6%) on the scale of occupational diseases, following musculoskeletal disorders.” 
Tobacco smoke is widely recognised as a cause of respiratory disease (amongst other effects) and work-related exposures to such smoke is recognised as a significant hazard.
The most important risk factors associated with cardiovascular disorders are non-occupational. However, shift work and stress-related factors have been found to increase the risk of ischaemic heart disease. Long-term exposure to vibration is a well-established risk factor for peripheral circulation impairment in the hands (so-called vibration white-finger). Only 1% of European workers think their work affects their health in the form of heart disease. The prevalence of such risk is low, between 0.5 and 1.7 % in all sectors of economic activity. According to the ad hoc module of the 1999 LFS, less than 0.2% of respondents suffered from a cardiovascular health problem, which, according to their own judgement, was caused or made worse by work. This means that about 320,000 European workers (current or past) have such cardiovascular health problems. Based on scientific evidence, the above-mentioned work-related risk factors could contribute much more to cardiovascular morbidity and mortality (see chapter 3.8.). It is probably more difficult for workers to recognise the link between work-related exposure and cardiovascular diseases than to recognise the work-related risks of musculoskeletal, respiratory or skin disease .
A large number of workers in the EU are potentially exposed to carcinogenic substances. For example, the SHEcan report collected available published information about the uses and/or circumstances of exposure for each of 25 occupational carcinogenic substances. In summary it indicated that for six of these substances (Benzo[a]pyrene, Diesel engine exhaust emissions, Hard wood dust, Hydrazine, Mineral oils as used engine oil, and 4, 4' methylenedianiline (MDA)) there are probably more than a million workers in the EU currently exposed, with fewer likely exposed to the others.
Trends in short
The ranking in the occurrence of occupational diseases across sectors has remained stable from 2001 - 2007. Whilst the number of occupational diseases in the ‘manufacturing’ sector appeared to decrease with time, the number of diseases in the sectors ‘construction’, ‘wholesale retail trade, repair’, ‘health and social work’, seemingly increased .
The proportion of persons with a work-related health problem increased from 4.7% in 1999 to 7.1% in 2007.
Increasing numbers of MSD cases in both SMEs and larger firms.
Increasing numbers of psychosocial health problems (2nd most frequently reported main work-related health problem). Not, however, reflected in the accepted list of acknowledged occupational diseases . Knowledge gap on mechanisms of work-related psychosocial disorders mean few (if any) are included in the national systems for reporting and/or compensating occupational diseases.
In general, the Framework Directive applies, in addition to other European OSH Directives, e.g. on chemicals, physical/biological factors, workload and ergonomics. No specific directives have addressed psychosocial risk factors, although 'problems of mental stress' are referred to in the DSE Directive (90/270/EEC). In addition, aspects of some non-OSH directives may also apply, e.g. working time.
During an EU-OSHA survey, it was established that workers in small companies were more at risk, because their employers have fewer resources available for both monitoring and implementing suitable control measures to combat occupational diseases at work.  Although a limited response, an EU-OSHA survey identified the age category 55+ to be at most risk from occupational diseases at work.  Older workers and their specific health problems need special attention.
Although not widely recognised in statistics as a 'cause' there is evidence to suggest that shift working can have an adverse effect on physical health, as well as increasing the risk of accidents.
There are numerous established work-related risk factors for the various types of musculoskeletal disorders. These include physical, ergonomic and psychosocial factors .
The positive technological development, which has reduced the lifting of heavy loads, did not bring about the expected decrease in the number of back disorder incidents. In an article published in 2009, Hartmann and Spallek argue that physical work can have a clear positive effect on physical health (salutogenic effect).  They recommend that extreme demands (both high and low) be avoided, and that an individual optimum should be aimed for. This means that general preventive measures are not enough; individual measures for each workplace are needed.
However, one challenge is that many MSDs are multifactorial and not exclusively work-related. For example, although work factors do appear to play a part, there is clear evidence from studies of twins that a significant proportion of the degeneration of intervertebral discs is familial with a strong genetics and early life influence. Similarly, although widely acknowledged as work-related, there is strong evidence that factors such as gender, obesity and age make a significant contribution to the risk of carpal tunnel syndrome
According to the LFS ad hoc module 2007, 27.9% of the workers reported exposure affecting mental well-being, corresponding to 55.6 million workers in the EU-27. Exposure to time pressure or work overload was most often selected as the main risk factor (23%), followed by harassment or bullying (2.7%), and violence or threat of violence (2.2%). 
Older studies state that the problems are linked to a whole set of factors, rather than just exposure to a specific risk . Key figures for four indicators are given by Eurostat : high speed work, unforeseen interruptions at work, unable to choose working methods, and mismatch of skills and work demands.
Some socio-economic trends in Europe can also be used to explain trends in occupational health, such as increasing work intensity, temporary and part-time work, the aging workforce, and more migrant workers. For more information, see: Sectors and occupations.
Burden of diseases
The burden of disease (BOD) refers to the impact of health problems (including accidents) measured by premature mortality and morbidity. These represent costs to employees, employers, companies, insurance companies, and society at large. For more information, see: Burden of occupational diseases
In a 2009 presentation, the EU-OSHA’s Takkala and Schneider noted that about 167,000 deaths attributable to work occur annually in the EU-27. The figure is based on Finnish and EU-OSHA research and on ILO estimates . It includes accidents and violence (5%). Of 160,000 deaths, almost 74,000 can be attributed to dangerous substances, with a large portion to asbestos.
In the EU, an estimated 350 million working days were lost due to health problems annually. Based on the results of the EWCS, a very similar estimate of 340 million days lost was calculated for self-reported sickness absence caused by work (other than accidents) in 2000 .
The Eurostat study, ‘Statistical analysis of socio-economic costs of accidents at work in the European Union’ only covered accidents . However, the authors state that work-related diseases “quite probably cause even more losses of working time or costs of health care. Depending on the survey such problems are estimated to cause 1.6 to 2.2 times more days of temporary incapacity to work than do accidents at work, while there are 2.4 times more people reporting long-standing health problems or disability due to work-related diseases than due to accidents at work. This indicates that work-related non-accidental health problems may cause at least two times more temporary and permanent incapacity as compared to accidents at work.”
About 60% of all short-term (< 1 month) and long-term (at least 1 month) sickness absence in the EU27 can be attributed to musculoskeletal problems . One in five persons with work-related musculoskeletal problems faced considerable limitations as a result.
An EU-OSHA report  found it difficult to assess and compare the true extent of MSDs costs at the workplace in Member States, due to differently organised insurance systems, the lack of standardised assessment criteria and verified reported data. The report does mention that studies estimate the cost of work-related upper-limb musculoskeletal disorders (WRULD) at between 0.5% and 2% of Gross National Product (GNP). More recent figures from Austria, Germany and France show the increasing cost impact of musculoskeletal disorders. In France 7m workdays were lost due to MSDs in 2006, about 710m EUR of enterprises’ contributions .
One of the challenges faced is that, regardless of their recognised causation, the prevalence of many degenerative MSDswill increase with age and, with an aging workforce, the prospect of the work abilities of older workers being impaired will increase. Positive action will be required to compensate for this if the full potential of such older workers is to be fulfilled.
The European Agency survey lists health effects of excessive stress: “fatigue, anxiety, sweating panic attacks and tremors. … difficulty in relaxing, loss of concentration, impaired appetite and disrupted sleep patterns. Some people become depressed or aggressive and stress increases susceptibility to ulcers, mental ill health, heart disease and some skin disorders.” 
About 44% of workers affected reported some limitations, and 24% considerable limitations. Sick leave due to stress, depression or anxiety was observed in 59% of the respondents in the LFS ad hoc module 2007. Remarkably, long-term sick leave (at least one month) occurred more often than short-term sick leave (< 1 month) (32% versus 27%). According to one expert, this is because it is more difficult to find short-term therapy facilities than long-term. Sufferers from stress, depression or anxiety were more likely to experience long-term sick leave than those with musculoskeletal problems (32% versus 26%) .
Respiratory and skin diseases
Reinhold Rühl from the German statutory accident insurance association for the construction sector (BG BAU) estimates the costs for occupational epoxy resin diseases at a minimum of 40mEUR in 2008 in the EU (including costs for the accident insurance association, the public authorities, and the companies) .
A high proportion of workers whose main health complaint is breathing or lung problems experienced sickness absence in the past 12 months, according to the LFS ad hoc module 2007 (71%). 45% had sickness absence of less than one month, and 26% had sickness absence of at least one month. Hence, breathing or lung problems more often resulted in short-term sick leave (< 1 month) compared to musculoskeletal health problems (35%) and stress, depression or anxiety (27%). However, the reverse was found for long-term absence (at least 1 month) .
As noted earlier, diseases with a long latency, such as asbestosis or occupational cancers do not necessarily feature in formal statistics. It has been estimated that, of all cancer deaths in Britain in 2005, 8010 (5.3%) could be attributed to past occupational exposures (6073 excluding mesothelioma), with 13,598 of all cancer registrations in 2004 attributable to occupation (11,661 excluding mesothelioma). Even with the exclusion of mesothelioma cases, any extrapolation of such figures to the EU-28 suggests a major long-term burden from occupationally-related cancers.
Workers who have to work under certain adverse conditions, e.g. handling carcinogenic substances, working with respiratory protection, exposure to certain biological agents, have to be put under health surveillance. They have to be examined at certain intervals by occupational physicians, following specified procedures for the early identification of conditions that could mean an increased risk of adverse health effects. Most of these examinations have to be continued even if the worker is no longer exposed. This concept is based on the European framework directive and is transformed into national legislation. Specifications can also be found in accident insurance association rules.
This concept is running into more and more practical problems, as working contracts become increasingly shorter and jobs frequently changed, often interrupted by unemployment. Small companies may close down. All this makes it difficult to maintain accurate exposure and surveillance records.
For more information, see e.g.: Occupational exposure limit values
Related to health surveillance is the issue of substance abuse which can cause serious problems at the workplace, especially (but not exclusively) in respect of safety-critical work. National constraints and practices in relation to monitoring or testing for such substances is very complex. Understanding (and addressing) the complex reasons for such abuse can provide a valuable adjunct to any such action.
Compensation, rehabilitation, return to work strategies
Worker compensation systems are usually part of the social security schemes of the European Union Member States. They were introduced to insure workers against the consequences of work-related injuries, and relieve employers from financial liability. The details of each system are different regarding organisation, funding, coverage and membership. The systems also include compensation for acknowledged occupational diseases. However, such systems can be quite slow to adapt to new developments. For example, few work-related psychosocial disorders are included in the national systems of reporting or compensating occupational diseases, because cause-effect relations are not yet analysed sufficiently.
Diagnosing and compensation of occupational diseases is described in detail under the national OSH systems, for example: OSH system at national level - Slovakia of the specific member state of interest.
Rehabilitation is another important activity of the compensation system. First comes medical rehabilitation, i.e. to return the patient to the same state as before the event (this may include prosthetics). Vocational rehabilitation may also be necessary to ease the return to work for the victim through appropriate training and exercises, or perhaps to change occupation. Finally, possible social rehabilitation, e.g. household assistance or help back into society.
In the UK, occupational rehabilitation - sometimes referred to as managing sickness absence and return to work (or managing attendance) - includes work plans that can be negotiated by the employer and the worker in case of long-term sickness absence (often defined as 4 weeks or more). They can agree on simple adjustments that may enable workers to return to work safely before their symptoms completely disappear. Workers can normally return before they are 100% fit, and as their fitness increases, the work load can increase, too . See also: Return to Work after sick leave due to mental health problems
Reintegration system, German example
Rehabilitation and return to work is increasingly being recognised as an important aspect of managing OSH in the workplace. Germany has a special regulation (Sozialgesetzbuch– SGB - IX) for workers who are sick for a total of 6 weeks or more annually. It stipulates that employers have to offer consultancy for improving the situation and finding their way back to their usual work level, or indeed if there is a need for less demanding work. The worker may decline this offer. If they accept, they are often accompanied by a worker representative and/or representative for disabled workers. These meetings are often perceived as an attempt to get rid of the sick person. Employers should make it clear that they want to give the worker a chance to continue under beneficial conditions . Although the measures are part of regulations for disabled workers, this particular part also addresses the non-disabled.
For more information, see the specific Member State, e.g. OSH system at national level - Belgium.
Adapting work to people with health problems, example from UK
The UK’s Equality Act sets a definition for disabled persons. Impairments such as migraines, dyslexia, asthma and back pain can count as disabilities if the adverse effects on the individual are substantial and long-term. For the purposes of The Equality Act, some conditions automatically count as disabilities from first diagnosis – these are cancer, HIV and multiple sclerosis (MS). Employers are required to make 'reasonable adjustments' to jobs and workplaces for disabled workers. This is to ensure disabled people have equal opportunities to apply for and stay in work. Workplace adjustments may also be made on a temporary basis .
Reasonable adjustments may include :
- adjustments to the workplace to improve access or layout
- giving some of the disabled person’s duties to another person, e.g. employing a temp
- transferring the disabled person to fill a vacancy
- changing the working hours, e.g. flexi-time, job-share, starting later or finishing earlier
- time off, e.g. for treatment, assessment, rehabilitation
- training for disabled workers and their colleagues
- getting new or adapting existing equipment, e.g. chairs, desks, computers, vehicles
- modifying instructions or procedures, e.g. providing written material in bigger text or Braille
- improving communication, e.g. providing a reader or interpreter, having visual as well as audible alarms;
- providing alternative work (this should usually be a last resort).
Prevention and well-being at work
There are two important supplementary strategies for achieving healthy working conditions:
- to prevent work-related ill health
- to promote well-being at work
The latest reviews on MSDs state that individual preventive measures are needed, a fact which is underlined by the multiple causes, including psychosocial factors. Health promotion is beneficial, but this is by no means enough. The social partners (supported by governments) must provide a framework so that diagnoses from the GP can be passed on to the occupational physician, such as the 'Fitnote' system in the UK. This has two advantages: the occupational physician does not need to carry out the same examinations again (cost saving) and they can react better, prescribing individual measures for the workplace that could also help at home.
To combat increasing psychosocial problems, the focus must be on socio-economic trends such as:
- Work organisation
- Work contracts
- Migrant labour force
In addition, SMEs need more guidance (e.g. internet based tools) and assistance from labour inspectors and accident insurers.
Risk assessment for psychosocial health problems are often overlooked in companies. It seems that a tripartite approach is needed. This issue is increasingly addressed in national OSH strategies.
Health monitoring as a pro-active concept
It can be hard for occupational physicians to get diagnosis information from GPs. However, this information could be important for planning a programme of individual prevention measures. This applies to Germany, where occupational physicians do not receive diagnoses when a worker reports sick. This is due to strict data laws, and the fact that trade unions do not want diagnoses to be known to the employer, as this may lead to termination of the contract. This results in a perception gap between work-related ill-health and the tailor-made measures to treat it . As previously mentioned, persons at risk of developing musculoskeletal disorders need early interventions that are individually tailored for their job. The current practice of implementing general measures does not prevent the spread of these disorders.
The above-mentioned re-integration system only comes into force after six weeks’ sick leave. As many employees only report sick as a last resort, it is usually too late for preventive measures. Despite wanting to protect the employment contracts of their members, it should also be in the interest of trade unions and workers’ representatives to intervene as early as possible, because the health of the worker could deteriorate until they are eventually unfit for work. Improvements in communication are urgently needed. Unions, workers representatives and employers could establish collective agreements that would allow workers to choose if their diagnoses should be passed on to their occupational physician.
Health promotion at the workplace
The workplace is nowadays considered as an important setting to promote health. This has led to a broad concept of workplace health promotion. An extensive network has been developed by such organisations as the European Network for Workplace Health Promotion . Quality criteria have been established, and many good practice examples are available.
As well as statistical analyses, the work ability index (WAI) can be used to evaluate the effectiveness of measures . It is an instrument used in clinical occupational health and research (examinations and surveys) to assess a person’s ability to work. The index is determined on the basis of the demands of work, the worker’s health status and personal resources.
Although companies in Europe have done a lot to reduce the number of accidents at work, work-related ill-health is still on the rise. Great efforts are still needed to make workplaces healthy. The benOSH research has suggested that companies (both small and large) can save large amounts of money  by adopting sound prevention strategies. There is more research indicating this. There are important barriers preventing the development of such strategies, which must be addressed in a tripartite approach at European, national and company level.
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- ENWHP - The European Network for Workplace Health Promotion, Working together towards better health at work (undated). Retrieved 16 February 2013, from: 
- FIOH – Finnish Institute of Occupational Health, Workability index (2011). Retrieved 24 February 2013, from: 
- Van den Broek, K., De Greef, M., Van Der Heyden, S., Kuhl, K., Schmitz-Felten, E., Socio-economic costs of accidents at work and work-related ill health – Full study report, published by the European Commission, Directorate-General for Employment, Social Affairs and Inclusion, Luxembourg 2011. Retrieved 15 February 2013, from: 
Links for further reading
Warshaw, L.J., Messite, J., ‘Health protection and promotion in the workplace: An overview‘, ILO (Ed.), Encyclopaedia of Occupational Health and Safety, ILO, Geneve, 2003. Available at: 
Warshaw, L.J., ‘Health risk appraisal‘, ILO (Ed.), Encyclopaedia of Occupational Health and Safety, ILO, Geneve, 2003. Available at: 
EU-OSHA - European Agency for Safety and Health at Work (undated), Workplace Health Promotion. Retrieved 14 February 2013, from: 
EU-OSHA - European Agency for Safety and Health at Work (undated), Monitoring of Occupational Safety and Health in the European Union. Retrieved 14 February 2013, from: