Health

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Klaus Kuhl, Kooperationsstelle Hamburg IFE GmbH, Germany

Introduction

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 prevention programmes, participation of workers.


Definitions

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 [1].

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 [2].

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.” [3] This holistic approach is in line with the joint ILO/WHO Committee’s definition of occupational health [4]: ‘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.’ Occupational health is closely linked to occupational safety and in workplace practices and also in legislation (e.g. the Framework Directive 89/391/EEC) both disciplines come together in 'occupational safety and health' (OSH).

Research methods

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

Impact of work on health

Work can have a negative, a positive or no impact at all on the health of workers. Data from the Sixth European Working Conditions Survey (EWCS 2015)[5] show that almost 2 out of 3 workers considers that their work has no impact on their health but 1 out of 4 means that work has a negative impact. This percentage is highest in the Construction and transport sector, where 33% of workers state that work has a negative impact on their health. The number of workers who perceive that their work has a positive influence on their health is lower in all sectors (between 9 and 14%) and with little or no difference between sectors.

Fig1 ewcs.jpg

Source: EWCS, 2015 – Data visualisation tool[5]

Recognised occupational diseases

Occupational disease statistics in Europe are not always comprehensive or totally reliable because of under-reporting and system differences between the member states [6] [7].

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 (recognised) occupational diseases in the sectors [1]:

  • 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 [1].

The European Occupational Diseases Statistics (EODS) gathers national data in a database and provides trends on the most recognised occupational diseases in the European Union.[8] The data for the EU are based on information for 24 EU Member States (excluding Germany, Greece and Portugal) for a ‘core-list’ of occupational diseases. The occupational diseases included in the core list were selected from those most commonly reported by all participating countries combined. The statistical data are analysed as a development over time (represented by an index, 2013 = 100) for the core-list of diseases for the EU, and not in terms of the absolute number of people recognised as having an occupational disease[9].

Figure 2 shows the development of the total index of the number of people with a recognised occupational disease, as well as the information for four groups of diseases. Between 2013 and 2018, the overall index decreased by 14 %. Among the four groups of diseases, there was a stronger decrease for selected occupational cancers (-18%) and pneumoconiosis (-27%). For contact dermatitis (-2%) and selected musculoskeletal diseases, there was little difference between the 2013 and 2018 figures[9].

Figure 2 – Development of occupational diseases, EU, 2013 – 2018 (2013 = 100)

Fig2 eods.jpg

Source: Eurostat, Statistics explained, Occupational diseases statistics[9]

Work-related health problems

Data on work-related health problems and risk factors for people at work were collected within the framework of the 2007, 2013 and 2020 ad hoc modules of the EU labour force survey (EU-LFS) and cover people aged 15 to 64[10]. Work-related health problems include "all health problems (physical or mental health problems, illnesses, disabilities) which the respondent had suffered during the year before the end of the reference week of the survey and which the respondent considered as being caused or made worse by his/her current or past job." The survey thus brings together data on health problems and their causality as perceived by the respondents themselves. This does not necessarily mean that the health problems are associated with sick leave, medical treatment or that they are conditions recognised as occupational diseases.

The data show that in 2020, 10.3 % of people in the age group 15-64 reported having had work-related health problems during the previous 12 months, a higher rate than that recorded in 2013 (8.8 %), but substantially lower than in 2007 (14.6 %).[10]

Musculoskeletal disorders (i.e. bone, joint or muscle problems - MSDs) are the most frequently reported work-related health problem (figure 3). 6.0% of all employed or previously employed people aged 15-64 in the EU report that they have suffered from MSDs during the last 12 months. There is no significant difference for men and women as the proportion is similar for both genders (5.9% for men and 6.0% for women). The second largest group was work-related health problems related to stress, depression or anxiety, which were mentioned by 1.9% of the respondents. For these health problems, gender differences are slightly larger, as stress, depression or anxiety is reported by 1.5% of men compared to 2.2% of women. Finally, headaches, eye disorders or migraines were the third most common work-related health problem; this share amounted to 0.5 % for men and 0.8 % for women.[10]

Figure 3 – People reporting a work-related health problem by gender, age and type of problem, EU, 2020

Fig3.jpg

Source: Eurostat, Statistics explained, Self-reported work-related health problems and risk factors - key statistics

The LFS ad hoc module 2020 found that 6.0% of respondents reported that they have suffered from MSDs during the last 12 months.

Data from the Sixth European Working Conditions Survey (EWCS 2015) show that approximately three out of every five workers in the EU-28 reported suffering from MSDs. Within the EU, backache seems to be the most prevalent health problem, closely followed by neck and upper limb problems. 43% of the workers reported backache and 41% muscular pains in shoulders, neck and/or upper limbs. Muscular pains in lower limbs are reported less often (29 % in 2015). It should be noted that the EWCS include data of self-reported MSDs, not only work-related MSDs.[11]

MSDs are most prevalent in construction, water supply (sewerage and waste supply) and agriculture, forestry and fishing. MSD prevalence is also above average in human health and social work activities. MSDs are least likely to occur in financial and insurance activities, professional, scientific and technical activities, education, and arts, entertainment and recreation.

More statistical data on MSDs can be found in the EU-OSHA report Work-related musculoskeletal disorders: prevalence, costs and demographics in the EU (2019) [16]

Legal requirements

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.

Causes, reasons

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. [6] Although a limited response, an EU-OSHA survey identified the age category 55+ to be at most risk from occupational diseases at work. [6] 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.

MSDs

There are numerous established work-related risk factors for the various types of musculoskeletal disorders. These include physical, ergonomic and psychosocial factors [12].

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). [13] 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[14]. 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[15]

Work-related psychosocial health problems

The LFS ad hoc module 2020 shows that 44.6 % of the total employed population aged 15-64 report facing risk factors for their mental well-being at work. Time pressure or work overload was the most frequently mentioned risk factor for mental well-being at work, reported by almost one-fifth (19.5 %) of EU workers. Dealing with difficult customers, patients, pupils, etc. and job insecurity were the second and third most frequent risk factors for mental well-being that people reported having at work, mentioned by, respectively 10.4 % and 6.1 %.[10]

Data from ESENER 2019 show the psychosocial risk factors according to the sector. Especially the sector of Human health and social work activities reports high figures with scores above the average for all risk factors (figure 4).[16]

Figure 4 - Psychosocial risk factors present in the establishment (% according to sector) – ESENER 2019

Esener psr.jpg

Source: EU-OSHA, ESENER 2019[16]

Socio-economic trends

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

Each year about 3500 fatal work accidents and more than 200000 fatal work-related illness cases occur in the EU. This means that work-related illnesses account for 98% of all deaths related to work in the EU. This brings about a cost of approximately 476 billion. In the majority of the EU28 and Iceland and Norway, the main part of the cost is due to cancer, followed by musculoskeletal disorders (MSD).[17]

According to ICOH (International Commission on Occupational Health) the burden caused by work-related diseases, disorders and injuries still seems to be increasing[18]. In many countries, especially in industrialised countries, the burden is gradually shifting from work-related injuries and other easily diagnosed short-term consequences to work-related disorders and diseases with a long latency period (e.g. occupational cancers). The overall rates of work-related injuries and illnesses   are increasingly influenced by several aspects:

  • Improved living conditions mean longer lives, longer exposures and a higher number of long-latency illnesses;
  • Improved knowledge and registration of work-related causes and exposures;
  • Increasing globalisation resulting in dangerous jobs being relocated to poorer countries;
  • Protection, health and safety measures, policies and enforcement, and occupational health services cannot keep up with these labour market changes and emerging risks.

These changes lead to an increased burden of occupational injuries and illnesses in the world. Fatal accidents are declining but in contrast, occupational illnesses are increasing. The COVID-19 pandemic in 2020 and 2021 also contributed to higher numbers of occupational deaths (see figure 5). [18]

Figure 5 - Global trends on the burden of disease

Global.jpg

Source: ICOH [18]

Health surveillance

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 transposed into national legislation.

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.

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 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 [19]. 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 [20]. Although the measures are part of regulations for disabled workers, this particular part also addresses the non-disabled.

Prevention and well-being at work

There are two important supplementary strategies for achieving healthy working conditions:

  1. to prevent work-related ill health
  2. to promote well-being at work

Prevention

Preventing work-related health problems requires a comprehensive approach based on technical and organisational measures. But, in many cases, a general approach does not suffice and has to be complemented by measures tailored at the individual worker. Such individual programmes rely on adequate information on the health status of the worker. 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. [21] For instance, persons at risk of developing musculoskeletal disorders need early interventions that are individually tailored for their job. The current practice of general measures is proving insufficient to tackle the increase in the number of MSDSs.

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 [17]. 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 [22]. 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.

Outlook

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 [23] 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.


References

  1. 1.0 1.1 1.2 Eurostat, Health and safety at work in Europe (1999-2007). Available at: [1]
  2. Eurostat, Statistical analysis of socio-economic costs of accidents at work in the European Union, 2004. Available at [2]
  3. WHO - World Health Organization, WHO definition of Health, Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
  4. Alli, B.O. Fundamental principles of occupational health and safety, International Labour Office, Geneva, 2008. Available at: [3]
  5. 5.0 5.1 Eurofound, European Working Conditions Survey, EWCS 2015. Available at: [4]
  6. 6.0 6.1 6.2 EU-OSHA - European Agency for Safety and Health at Work, Monitoring the State of Occupational Safety and Health in the European Union, Pilot Study, 2000. Available at: [5]
  7. Eurogip, Survey on under-reporting of occupational diseases in Europe, 2002, priced publication.
  8. Eurostat, Why do we need the European Occupational Diseases Statistics (EODS)? Available at: [6]
  9. 9.0 9.1 9.2 Eurostat, Statistics explained, Occupational diseases statistics. Available at: [7]
  10. 10.0 10.1 10.2 10.3 Eurostat, Statistics explained, Self-reported work-related health problems and risk factors - key statistics. Available at: [8]
  11. EU-OSHA – European Agency for Safety and Health at Work, Work-related musculoskeletal disorders: prevalence, costs and demographics in the EU, 2019. Available at: [9]
  12. Eurostat, Work and health in the European Union - A statistical portrait based on statistical data collected over the period 1994-2002, 2004.
  13. Hartmann, B., Spallek, M., ‘Arbeitsbezogene Muskel-Skelett-Erkrankungen – Eine Gegenstandsbestimmung‘,Arbeitsmedizin Sozialmedizin Umwelt, Organ der wissenschaftlichen Gesellschaften für Arbeitsmedizin in Deutschland, Österreich und der Schweiz sowie des Verbandes Deutscher Betriebs- und Werksärzte und der Akademien für Arbeits- und Sozialmedizin, Alfons W. Gentner Verlag GmbH & Co. KG, Stuttgart, 44, 8, 2009, p. 429.
  14. Battié MC, Videman T, Gibbons LE, Fisher LD, Manninen H, Gill K. (1995) Determinants of lumbar disc degeneration: A study relating lifetime exposures and magnetic resonance imaging findings in identical twins. Spine,  20, 2601-2612
  15. Violante FS, Farioli A, Graziosi F, Marinelli F, Curti S, Armstrong TJ, Mattioli S, Bonfiglioli R. (2016) Carpal  tunnel  syndrome  and  manual  work:  the  OCTOPUS cohort, results of a ten-year longitudinal study. Scand J Work Environ Health. 2016; 42(4): 280–290. doi:10.5271/sjweh.3566
  16. 16.0 16.1 EU-OSHA, European Agency for Safety and Health at Work, ESENER 2019. Available at: [10]
  17. EU-OSHA - European Agency for Safety and Health at Work. The economics of occupational safety and health – the value of OSH to society. Data visualisation. Available at: [11]
  18. 18.0 18.1 18.2 ICOH - International Commission on Occupational Health, ICOH Triennial Report 2018-2021. Available at: [12]
  19. HSE – Health and Safety Executive (UK), Occupational rehabilitation in the food manufacturing industry (undated). Retrieved 14 February 2013, from: [13]
  20. Bundesrepublik Deutschland, Sozialgesetzbuch (SGB)NeuntesBuch (IX) - Rehabilitation und Teilhabebehinderter Menschen, Stand: Zuletztgeändertdurch Art. 13 Abs. 26 G v. 12.4.2012 I 579. Available at: [14]
  21. Rushton et al (2012) Occupational cancer burden in Great Britain. British Journal of Cancer (2012) 107, S3 – S7
  22. FIOH – Finnish Institute of Occupational Health, Workability index (2011).
  23. 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: [15]


Links for further reading

EU-OSHA - European Agency for Safety and Health at Work, Alert and sentinel approaches for the identification of work-related diseases in the EU, 2018. Available at: [18]

EU-OSHA - European Agency for Safety and Health at Work, Factsheet 93 - Workplace Health Promotion for Employers, 2010. Available at: [19]

EU-OSHA - European Agency for Safety and Health at Work, The value of occupational safety and health and the societal costs of work-related injuries and diseases. Available at: [20]

EU-OSHA - European Agency for Safety and Health at Work, Research review on rehabilitation and return to work, 2016. Available at: [21]