The changing role of the occupational physician in the private sector: the Canadian experience

The role of the occupational physician in the private sectoris changing. Fewer large corporations maintain medical departmentsfollowing the ‘downsizing’ trend of the late 1980'sand early 1990's and those that do have extensively redefinedthe duties of the corporate medical director, often extendingthese duties to include responsibility for environmental health.Occupational medical services for employees previously coveredby in-house services are now often provided by outsourcing.The private practice of occupational medicine has become themajor growth area of the speciality in both the US and Canada.These trends have been driven primarily by economic imperativesand new management philosophies; the trend may have gone toofar and a ‘rightsizing’ correction may be in progress.However, it is not clear that corporations in general are derivingthe greatest value they can from their physicians or that thecurrent generation of senior managers is utilizing its healthprofessionals as effectively as they might. This is in partbecause the training, qualifications and capabilities of occupationalphysicians are not well understood. At least as important, however,is persistent confusion over desirable and appropriate rolesthat obscures the potential contribution of the medical professionalwithin a management structure. We suggest that the greatestvalue in occupational medical services may be in the anticipationof risk related to health issues and the flexibility this givesthe organization to manage the problem.     

Occupational epidemiology

The epidemiological literature for assessing risk in many, if not most, modern occupations has now become sufficiently obsolete that it can no longer be depended upon to guide either prevention or adjudication of compensation. This obsolescence must be dealt with by developing new sources of information pertinent to occupational hazards and the risks associated with most occupations. Ideally, a comprehensive surveillance mechanism that would be automatically updated for the changing risk in a changing economy would be ideal and may be attainable with further developments in health information technology. The characteristics of such a system are described. However, there are many obstacles to such a system which appear insurmountable in the short term. A more eclectic plan for cooperation and data-sharing would help in the short term and would establish a pattern of collaboration that could both place adjudication on a more solid foundation and avoid allegations of collusion in business. The general outline for a practical programme of collaboration along these lines is presented.     

Cohort study of art glass workers in Tuscany, Italy: mortality from non-malignant diseases

This investigation studies cause-specific mortality of art glass workers employed in 17 industrial facilities in Tuscany, Italy. A cohort of 3,390 workers employed for at least 1 year was enumerated from company payrolls. Follow-up was between the start of employment in each factory and 31 December 1993. The cause-specific expected mortality was computed relative to Tuscany rates and specified for gender, 5-year age groups and calendar year. Separate analyses were carried out for the jobs of makers and formers and for batch mixers. Among males (3, 180 individuals) observed mortality for non-cancer causes was higher than expected for hypertensive disease [standardized mortality ratio (SMR) = 178, 90% confidence interval (90% CI) = 96-301], pneumoconiosis (SMR = 200, 90% CI = 94-376) and diseases of the genitourinary system (SMR = 169, 90% CI = 95-279). Increases for the above causes were shown also among makers and formers: hypertensive disease (SMR = 182, 90% CI = 85-341), pneumoconiosis (SMR = 250, 90% CI = 109-493) and diseases of the genitourinary system (SMR = 224, 90% CI = 121-380). For batch mixers an increase was present for cerebrovascular disease. The observed mortality for cancer causes was above the expected for cancers of the larynx, lung, stomach and brain. This study points to the existence for Tuscan glass workers of health effects in addition to cancer; previously observed carcinogenic effects were also confirmed.     

Methods to persuade higher management to invest in health promotion programmes in the workplace

This study was conducted to find effective methods to persuadehigher management to invest in workplace health promotion (WHP)programmes. The study included 639 occupational health professionalsselected from the directory of the Japan Society for OccupationalHealth. A questionnaire survey was mailed to health professionalsthroughout Japan in 1992, and all respondents were asked toidentify themselves. We received 242 replies, which constituteda response rate of 38%. Eighty-one per cent of the respondentshad attempted to persuade higher management to implement a WHPprogramme. Health professionals frequently presented their caseto higher management through a safety and health committee (SHC),and advice provided at the SHC was perceived to be the mosteffective method by occupational nurses (ONs) and safety andhealth supervisors (SHSs). This method was rated second by occupationalphysicians (OPs), who thought recommendations from OPs stipulatedby the Industrial Safety and Health Law to be most effective.Statistics on medical examinations constituted the data mostfrequently used to persuade higher management, followed by reportson worksite inspections and health care plans. Nearly 90% ofOPs and 80% of ONs and SHSs felt that the above methods werefairly successful.     

Work-related injuries and occupational health and safety factors in smaller enterprises--a prospective study

The aim of this study was to determine whether any of the health, environmental and safety (HES) factors registered by visiting small mechanical enterprises in Norway at the start of the study could predict the risk of occupational injuries in subsequent years. Twelve HES factors, including injury awareness, programme for action, employee participation, training and use of personal safety devices, were registered. A questionnaire was completed by interviewing the employer and observing production. Two variables based on observation of the use of safety equipment were significantly correlated with occupational injuries. There is potential for prevention in smaller enterprises by increasing the use of personal protection devices and safety equipment on machines. Frequent inspection with feedback to the workers is probably the most effective means of attaining the desired result of reducing injuries.     

Psychosocial risk assessment: problems and prospects

Health and safety legislation now requires organizations to undertake risk assessments for psychosocial hazards in the workplace. Despite this, there is relatively little guidance on what constitutes a psychosocial risk assessment and how one should be conducted. The approaches that do exist are not without problems. This paper examines some of the difficulties with current approaches and looks at possible areas for development to improve understanding and performance in this important area of health and safety management.     

Employers' awareness and compliance with occupational health and safety regulations in Taiwan

An investigation of employers' awareness and compliance withoccupational health and safety (OHS) regulations was conductedin a representative group of employers randomly selected fromthe manufacturing industry in Taiwan. A total of 1,003 employerswere interviewed by trained public health personnel. Ten questionsrelated to perceptions of general OHS and five practices onOHS regulations were measured. The results of this study showthat the employers were better aware of their responsibilityfor posting safety warnings, personal protection and providingsafety and health equipment. They were less aware of their responsibilityin minimizing injuries and accidents in the workplace and innot hiring someone who was found unfit for a certain job frompre-employment physical examination. Less than half of employersknew about regulations of environmental monitoring and evenfewer had heard of Material Safety Data Sheets. Level of educationand size of the plant were highly associated with employers'awareness of OHS and the awareness was the most significantpredictor in the five practices of OHS regulations in this study.Promotion of employers' awareness of OHS in small sized industriesitt particular, is warranted to enhance better compliance, anda focus for these efforts is identified by this investigation.     

Occupational health in the USA in the 21st century

Comparable to the confusion encountered in the birth of the machine age is the perplexing reconfiguration of the United States' health care system. Paralleling the advances in medicine have been the divesting mergers and downsizing of industry, coupled with globalization, which have released millions of long-time workers. The labour contingent is changing, with the addition of great numbers of women and immigrant workers, and the manufacturing economy has become one of service and information. Serving the occupational health (OH) needs of such a force have been the professional societies of physicians, nurses, and industrial hygienists, with their members providing care in a broad variety of facilities. It is possible that a national organization, including all these disciplines, would have a greater voice in the protection of workers' health. Immediate leadership of an occupational health service (OHS) can be rotated among the disciplines, so that competition for primacy among the professionals would end. The new workforce demands culture sensitivity among OH personnel and polylingual capabilities may be demanded in the future. Management skills will be required of all in OH, and greater participation of employees in OH policy will characterize the decades ahead. Nearly neglected up to now, occupational mental health programming will be required to meet the real needs of workers, and to counter the move to outsource OH services, where little patient contact results. Behavioural safety, total quality management, and application of the rapidly developing technologies in health care will define the 21st century efforts in OH. Remaining issues, such as violence, telecommuting injuries, the inclusion of alternative medicine, and women's health, among others, will see carry-over for resolution into the year 2000.     

Activity profiles of the occupational health services in a multinational company

The management of the European division of a multinational company was aware of possible differences in the occupational health services (OHS) at their different locations. The objective of this study was to carry out a baseline assessment of these OHS. Structured interviews with representatives of the OHS were conducted at 20 locations in 11 countries. The OHS Recommendation from the International Labour Organization (ILO) was used as a standard for the organization and functions of the OHS. Considerable differences in the activity profiles of the OHS were detected. The inter-enterprise, multidisciplinary OHS spent most of their time on surveillance of workers' health in relation to work and on preventive activities in the working environment. Little time was spent on curative services for individual workers. OHS made up of individual physicians and nurses generally spent much of their time on treatment of occupational and non-occupational diseases. This study has clarified the status of the OHS providers and the potential for improvements in order to meet the needs of the company's locations and to comply more closely with the ILO recommendation.     

The management of occupational health by NHS Trusts in the north of England

This paper reports the findings of an audit of the management of occupational health arrangements in 36 NHS Trusts in the Northern and Yorkshire region of England. A questionnaire was designed based on a national NHS occupational health standard to obtain data on eight categories of occupational health activity: health and safety; pre-employment assessments; Infection Control; health surveillance; sickness absence; ill-health retirement; health promotion and record storage. The management arrangements for occupational health were varied. Assessments of workplace hazards, prevention of HIV-positive workers from performing exposure-prone invasive procedures and the assessment of pregnant workers were identified as issues for further consideration. Provision of competent and effective occupational health services will assist in the management of sickness absence and in the protection and promotion of health of staff. It will also contribute to the health and safety of patients.     

Occupational health in the Andalusian Fisheries Sector

BACKGROUND: The conditions of work in the fisheries sector are arduous with high rates of occupational accidents. Numerous factors are known that can directly influence the health of the sailor or fisherman both in fishing and merchant fleets. AIM: To evaluate the health status, safety and working conditions in the Andalusian fishing sector. METHODS: Cross-sectional questionnaire study with proportional sampling of the health and lifestyles of fishery workers in 19 of the 23 Andalusian ports. RESULTS: A total of 247 workers employed on 202 craft fishing boats responded. In all 87% of workers reported a current medical condition. The main problems reported were musculoskeletal disorders, respiratory diseases, diseases of the digestive system, eye problems and skin problems. A total of 72% reported taking some self-prescribed medication, and 60% of fishery workers smoked. Nine per cent of fishery workers admitted taking illicit drugs and 3% reported using illicit drugs on board. Diets on board were poorly balanced. While on board, 62% of crews reported a subjective significant worsening of previous health. The lifetime prevalence of accidents was 76%. CONCLUSIONS: Fishery workers had a high prevalence of self-reported medical problems, a high prevalence of self-medication, poor diets and frequently smoked. Self-medication and some medical conditions (diabetes, angina and depression) may reflect a potential failing of health checks and pre-employment checks. National health services and insurance companies dealing with occupational health should focus more on appropriate health checks, illness prevention and health promotion activities for this population.     

Is occupational dermatitis being taken seriously by UK industries?

Occupational dermatitis is a considerable burden but little is documented concerning industry response to this. A postal questionnaire survey of 1,100 UK companies was conducted to investigate skin care provision. The response rate was 51%. The person primarily responsible for health and safety had a professional qualification in only 34% of responding companies. In all, 75% of companies responded that they were required to conduct COSHH risk assessments and, of these, 71% mentioned skin hazards. Only 27% of companies had a skin care policy but 71% had procedures requiring glove use. Seventy-seven per cent of companies did not conduct regular skin checks. Twenty-six per cent had either been aware of a skin problem in the workforce in the last 12 months or had had to modify work practices. Improvement of skin care in UK industry could be facilitated by the establishment of a minimum recommended training qualification; assistance with compliance with COSHH legislation; and guidelines to design and implement a skin policy, provide worker protection and detect skin problems.     

A follow-up study on the association of working conditions and lifestyles with the development of (perceived) mental symptoms in workers of a telecommunication enterprise

AIM: This study investigated the association of working conditions and lifestyle with mental health in Japanese workers. METHODS: A follow-up study was carried out in the Kanto district of Japan of workers in a telecommunications enterprise who received their first annual health check-up between 1992 and 1996 and were between 20 and 54 years old. Workers who reported mental symptoms, had a past history of disease, or current illness at their first check-up were excluded from the analysis. In total, the study included 23 837 workers. The association between working conditions and lifestyle and the development of mental symptoms was investigated by pooled logistic regression analyses. RESULTS: Working long hours and part-time work, as opposed to normal daytime hours of work, were factors associated with the development of mental symptoms in males, as were smoking, short sleeping hours, little physical exercise, rarely taking three meals a day, frequently eating within 1 h before sleep, much preference for salty meals and little preference for vegetables. Consumption of alcohol was negatively associated with the development of mental symptoms in males. Overall, the results suggested that the lower the Healthy Work and Lifestyle Score, the higher the risk of developing mental symptoms. CONCLUSIONS: Working conditions and lifestyle, especially food preferences, have an apparent influence on the mental health of Japanese workers. Moreover, the Healthy Work and Lifestyle Score indicates that working conditions and lifestyle appear to have a cumulative influence upon the mental health of Japanese workers.     

A risk-based system to penalize and reward line management for occupational safety and health performance

Penalizing line management for the occurrence of lost time injuries has in some cases had unintended negative consequences. These are discussed. An alternative system is suggested that penalizes line management for accidents where the combination of the probability of recurrence and the maximum reasonable consequences such a recurrence may have exceeds an agreed limit. A reward is given for prompt effective control of the risk to below the agreed risk limit. The reward is smaller than the penalty. High-risk accidents require independent investigation by a safety officer using analytical techniques. Two case examples are given to illustrate the system. Continuous safety improvement is driven by a planned reduction in the agreed risk limit over time and reward for proactive risk assessment and control.     

Perception and provision of occupational health services in the UK

BACKGROUND: There is difficulty in defining occupational health services among stakeholders of the service. Concurrently, there are concerns about the state of occupational health provision in the UK. AIMS: To determine stakeholders' perception of the services that occupational health encompasses and the level as well as the rationale behind the provision of these services. METHODS: The research was undertaken as a postal questionnaire survey of the FTSE 350 companies and selected public sector organizations in the UK. This was followed up by telephone calls to a random selection of non-respondents to obtain non-respondent data. RESULTS: There is a difference in opinion among managers and occupational health professionals about the services provided by occupational health. Taking into account non-respondent data to partially adjust for overestimation biases, the level of provision of occupational health services among the FTSE 350 companies is 69% and in public sector organizations is 95%, giving an average provision of 72%. Sixteen per cent of respondents thought there was a trend towards outsourcing of services. The most frequently cited reason for provision of an occupational health service was that it was for the benefit of employees. CONCLUSIONS: There remains room for improvement in the level of occupational health services provision in large UK private sector organizations. By bridging the gap between the different stakeholders' perceptions of the remit and benefits of the service, a higher level of provision in the private sector similar to that of public sector organizations can be achieved.     

Occupational exposure and health problems in small-scale industry workers in Dar es Salaam, Tanzania: a situation analysis

BACKGROUND: Workers in informal small-scale industries (SSI) in developing countries involved in welding, spray painting, woodwork and metalwork are exposed to various hazards with consequent risk to health. Aim To assess occupational exposure and health problems in SSI in Dar es Salaam, Tanzania. METHODS: Focused group discussions (FGD) were conducted among SSI workers. Participants were assessed for exposure to occupational and environmental hazards, the use of protective equipment and health complaints by interview. The findings were discussed with participants and potential interventions identified. RESULTS: Three hundred and ten workers were interviewed (response rate 98%). There was a high level (>90%) of self-reported exposure to either dust, fumes, noise or sunlight in certain occupational groups. There was low reported use of personal protective equipment. There was a high level of self-reported occupational health problems, particularly amongst welders and metalworkers. Workers reported their needs as permanent workplaces, information on work related hazards, water and sanitation, and legislation for SSI. CONCLUSIONS: In SSI in Tanzania, our study suggests that workers have high levels of exposure to multiple health hazards and that use of protective equipment is poor. This group of workers warrants improved occupational health and safety provision.     

Occupational health management: an audit tool

BACKGROUND: Organizations must manage occupational health risks in the workplace and the UK Health & Safety Executive (HSE) has published guidance on successful health and safety management. AIMS: This paper describes a method of using the published guidance to audit the management of occupational health and safety, first at an organizational level and, secondly, to audit an occupational health service provider's role in the management of health risks. The paper outlines the legal framework in the UK for health risk management and describes the development and use of a tool for qualitative auditing of the efficiency, effectiveness and reliability of occupational health service provision within an organization. The audit tool is presented as a question set and the paper concludes with discussion of the strengths and weaknesses of using this tool, and recommendations on its use.     

Exploring the need for an occupational health service for those working in primary care

A research nurse interviewed 55 practice staff in 11 generalpractices to ascertain their views about their needs for occupationalhealth care. In a second parallel study, a specialist in occupationalmedicine undertook an in-depth audit of occupational healthprovision in five other general practices with respect to theorganization, the health and safety process, the services andthe working environment. In the first study, the majority ofpractice staff reported the need for various aspects of occupationalhealth care, particularly stress at work. In the second study,general practitioners and practice managers possessed a basicawareness of occupational health matters such as Health andSafety legislation, but their limited knowledge was not translatedinto effective management. General practice staff did not knowwhere to obtain occupational health advice; most practices hadno policies or procedures in place to manage health and safety.Both studies illustrate the need for expert occupational healthadvice in primary care.     

Bladder tumours in rubber workers: a factory study 1946-1995

BACKGROUND: Prior to December 1949, some British rubber industry workers were inadvertently exposed to the human bladder carcinogen beta-naphthylamine, which was present as a contaminant (at 0.25%) in antioxidants used in manufacturing. This study follows a composite cohort of 6450 men employed at a large tyre factory either during the 'at-risk' period or just after it. METHODS: A group of 2090 at-risk men (employed 1945-1949) and 3038 men, first employed only after January 1950, when the carcinogen had been removed, were followed for their bladder cancer morbidity and mortality experiences. RESULTS: Fifty-eight tumours were registered for those at risk, whereas only 33.9 were expected at national standardized registration rates [SRRN = 171 and 95% confidence interval (CI) = 130-221]. Thirty-nine bladder tumours were reported for the post-1950 intake, whereas 38.3 were expected (SRRN = 102 and 95% CI = 72-139). The use of mortality data did not reveal any underlying hazard because 12 of the 58 at-risk workers with tumours were still alive at the study end date. In only 16 instances was bladder cancer actually certified as the underlying cause of death. Plotting cases by their location of work on a factory plan assisted the interpretation. CONCLUSIONS: A statistically significant elevated risk of bladder cancer for the exposed workforce was evident, but this reversed when the carcinogen was removed from processing in October 1949. The use of morbidity (incidence) data in long-term studies of occupational bladder cancer should be the required methodology if the hazard and risk are not to be underestimated.