Is there value in routinely obtaining a report from the general practitioner as part of pre-entry health screening of students for nursing studies?

BACKGROUND: Reports from general practitioners (GPs) are requested on applicants for nurse training, but there is no published evidence of the merit of this practice. AIMS: To assess the benefit of GP report in health assessments of student nurse applicants. METHODS: An audit was made of information obtained by health declaration form (HDF), nurse's assessment, GP report and, when performed, a physician's assessment for each applicant. Agreement between the health questionnaire and GP report was analysed by kappa statistics. RESULTS: Of 254 applicants, 246 (97%) were declared 'fit to work', four (1.6%) were deemed 'fit with restrictions' and four (1.6%) were considered 'unfit to work'. The most common problems declared were psychiatric and skin problems. The agreement between health declaration and the information provided by GPs was classed as almost perfect for diabetes and only fair to moderate for all other measures. The reports provided additional information on problems not declared by applicants, but all of these were passive problems. The four unfit candidates all had psychiatric illness, but in all cases the occupational health assessment was sufficient to make this decision or to request further information. In the 'fit with restrictions' category, three of the four GP reports (75%) helped in correctly assigning the applicants to this category. In one of these eight cases a passive problem had not been declared. CONCLUSIONS: The additional information in GP reports does not affect the conclusion regarding fitness for training in most cases and does not provide sufficient information to merit it being sought routinely.     

Variation in licensing authority standards for diabetic taxi drivers in the United Kingdom. Driving and Employment Working Party of the British Diabetic Association

In the UK, prospective taxi-drivers with diabetes are licensed locally according to variable criteria. In order to determine the criteria used for licensing, questionnaires were sent to all 422 local licensing authorities. Responses were obtained from 372 authorities (88% response rate). Only 201 (54%) currently issue licences to drivers on insulin treatment, and 260 (70%) to those on diet and/or oral hypoglycaemic agents. Most local authorities would prefer taxi-licensing to operate centrally rather than locally. It is apparent that the current UK system for licensing diabetic taxi drivers is variable and not evidence-based. A nationally organized system with clearly defined criteria and the capacity for individual consideration, would be more fair and consistent, and would be unlikely to compromise road safety.     

Fitness to drive forms - a guide for GPs

The effect of medical conditions on fitness to drive and crash risk has long been recognised. Therefore doctors and other health professionals play an important role in public health and safety when advising patients about fitness to drive and when providing information to driver licensing authorities to support their decision making in this regard. Various forms support communication between the doctor, patient and driver licensing authority.     

Audit in occupational medicine: an audit of fitness to drive among voluntary drivers in an NHS trust

BACKGROUND: A health surveillance programme, to assess fitness to drive, was initiated for voluntary drivers in an NHS Trust because of reports of increasing frailty and slow reactions among some drivers. After discussion between the occupational health department, voluntary services manager and personnel department it was considered appropriate to apply Driver and Vehicle Licensing Authority (DVLA) Group 2 fitness to drive standards to those voluntary drivers who drove the Trusts minibuses. RESULTS: An audit of the initial health surveillance of 47 drivers is presented. The mean age of the voluntary drivers was 66.4 years. A large number of medical problems with the potential to affect driving were discovered (average of 1.9 medical problems per driver).The outcome was that five voluntary drivers were found unfit to drive the hospital minibus and one voluntary driver was found unfit for car driving. CONCLUSIONS: A fitness assessment form for drivers is presented. This form is primarily for the use of occupational health nurses, to help them to decide when referral to an occupational health physician is indicated.     

Good medical practice: guidance for occupational physicians

Following a catalogue of serious, highly publicized medical misdemeanours, the General Medical Council (GMC) has introduced plans for a new system of medical licensing in the UK called 'revalidation'. Under this, the onus will fall on individual doctors, including occupational physicians, to demonstrate their continuing fitness to practice. Doctors will need to show that they meet basic minimum standards in terms of the care they provide, their own continuing professional development, and other aspects of professional life like probity and ethical behaviour. As part of the process, the Faculty of Occupational Medicine, Royal College of Physicians, has produced its own guidance on good medical practice for occupational physicians, following an extensive consultation exercise. This paper summarizes the background to the initiative, the development process and the standards that have been recommended to aid professional accountability.     

Comparison of three methods of pre-employment medical evaluations

BACKGROUND: Increasing efforts are being made to prevent sickness absence and to increase worker efficiency, including the use of costly pre-employment medical assessment of white-collar workers and labourers, excluding occupations for which medical supervision is required by law. AIM: To investigate whether filling out an occupational health questionnaire (OHQ) as pre-employment assessment was more efficient than previously used protocols which included a physical examination and laboratory tests performed for each applicant. METHODS: Retrospective study comparing three groups of job applicants: Group A--applicants examined by an occupational physician (OP); Group B--applicants examined by a general practitioner (GP) whose medical records were subsequently evaluated by an OP and Group C--the applicant filled out an OHQ which was evaluated by an OP. RESULTS: The study included 1940 pre-employment assessments divided into groups A (618), B (256) and C (1066). The restriction rate was 2.1, 1.2 and 2.3%, respectively. The lowest restriction rate (1.4%) was among applicants 29 years old and younger and the highest one (3.6%) among 50 years and older. The most frequent diagnoses among restricted applicants were musculoskeletal and circulatory diseases (15 and 12%, respectively). CONCLUSIONS: The restriction rate achieved by medical examinations either done by an OP (Group A) or by a GP (Group B) was the same as in OHQ (Group C). The use of a self-administered questionnaire evaluated by an OP is the preferred method of pre-employment evaluation for non-hazardous occupations.     

Medical emergencies at sea and injuries among Scottish fishermen

BACKGROUND: It has long been known that fishing is one of the most dangerous occupations. In 2001, 33 boats were lost and 10 fishermen killed in UK waters. Despite the dangerous nature of the occupation, very little research has been conducted on fishermen's health and safety. Aims To address this gap in current knowledge, research was conducted to gain an understanding of health and lifestyle issues affecting Scottish fishermen. It was hoped that the study would identify aspects of fishermen's health that could be improved. This paper considers medical emergencies at sea and injuries among fishermen. METHODS: Data were collected using a postal questionnaire sent to the Scottish fishermen population and health diaries in a small sub-sample. RESULTS: In total, 1157 usable responses were received, giving a response rate of 57%. One-fifth of respondents had been involved in a medical emergency at sea that required them to be evacuated to shore for immediate treatment. The incidence of injuries was high, and one-third of the injuries experienced were to the back. The likelihood of evacuation for a medical emergency or experiencing an injury was increased both for certain occupations and with increasing number of boats worked on during the fisherman's career. CONCLUSION: Groups identified as being at a high risk of experiencing medical emergencies or injuries should be targeted in training initiatives or accident awareness and prevention initiatives.     

The prevalence of eating disorders in female health care students

Previous research has suggested a raised prevalence of eating disorders amongst female medical students. This study aimed to test the belief, commonly held by occupational physicians, that there is also an increased prevalence of eating disorders amongst female applicants to nurse training. If correct, it implies the need for additional support and may predict increased failure to complete the course. Three groups of female students were compared: applicants to a university nurse training course, first-year medical students and a comparison group of first-year university students on courses not related to health care. Possible eating disorders were identified using two self-report instruments, the EAT-26 and the BITE questionnaires, and the body mass index. No significant statistical difference was found in the prevalence of eating disorders between the three groups, using the above measures. After controlling for age and ethnicity, 20% of the nurse applicants were found to have disordered eating patterns meriting further investigation, compared with 19% of medical students and 21% of arts students. The nursing students are being followed up to compare the progress of those with and without disordered eating patterns.     

Occupational factors associated with low back pain in urban taxi drivers

BACKGROUND: Urban taxi drivers differ from other professional drivers in their exposures to physical and psychosocial hazards in the work environment. Epidemiological data on low back pain (LBP) of this occupational group are very scarce. AIMS: To examine LBP in taxi drivers and its association with prolonged driving and other occupational factors. METHODS: We analyzed the cross-sectional data from the Taxi Drivers' Health Study. Standardized instruments were used to collect information on personal factors, work-related physical and psychosocial factors and driving time profiles. LBP prevalence was assessed using the modified Nordic Musculoskeletal Questionnaire. Multiple logistic regression models were employed for statistical analyses. RESULTS: Of 1242 drivers, 51% reported LBP in the past 12 months, significantly (P < 0.001) higher than other professional drivers (33%) in Taiwan. After adjusting for the effects of demographic characteristics, lifestyle factors, anthropometric measures and socioeconomic positions, we found that driving time >4 h/day [prevalence odds ratio (POR) 1.78; 95% CI 1.02-3.10], frequent bending/twisting activities while driving (adjusted OR 1.86; 95% CI 1.15-2.99), self-perceived job stress (POR 1.75; 95% CI 1.20-2.55), job dissatisfaction (POR 1.44; 95% CI 1.05-1.98) and registration type were the major occupational factors significantly associated with higher LBP prevalence in taxi drivers. CONCLUSIONS: We have identified that long driving time and several physical and psychosocial factors are associated with high prevalence of LBP in taxi drivers. This should be further investigated in prospective studies. Future studies are needed to examine the potential adverse effects of prolonged exposure to low levels of whole-body vibration.     

Failing firefighters: a survey of causes of death and ill-health retirement in serving firefighters in Strathclyde, Scotland from 1985-94

During the decade beginning 1 January 1985, 887 full-time firefighters, all male, left the service of Strathclyde Fire Brigade (SFB). There were 17 deaths--compared to 64.4 expected in the Scottish male population aged 15-54 years--giving a standardized mortality ratio (SMR) of 26, and 488 ill-health retirements (IHR). None of the deaths was attributable to service, the major causes being: myocardial infarction--five, (expected = 17.3; SMR = 29); cancers--three (colon, kidney and lung) (expected = 13.6; SMR = 22); road traffic accidents--two (expected = 4.17; SMR = 48) and suicide--two (expected = 4.9; SMR = 41). Amalgamating the deaths and IHRs showed that the six most common reasons for IHR were musculoskeletal (n = 202, 40%), ocular (n = 61, 12.1%), 'others' (n = 58, 11.5%), injuries (n = 50, 9.9%), heart disease (n = 48, 9.5%) and mental disorders (n = 45, 8.9%). Over 300 IHRs (over 60%) occurred after 20 or more years service. When the IHRs were subdivided into two quinquennia, there were 203 and 302 in each period. Mean length of service during each quinquennium was 19.4 vs. 21.3 years (p = 0.003) and median length was 21 years in both periods; interquartile range was 12-26 years in the first and 17-27 years in the second period (p = 0.002), but when further broken down into diagnostic categories, the differences were not statistically significant, with the exception of means of IHRs attributed to mental disorders (14.5 vs. 19 years, p = 0.03).     

A cross-sectional study of employer and employee occupational health needs and priorities within the Irish Civil Service

BACKGROUND: This study aimed to establish how important an occupational health unit (OHU) is to its clients, and to identify the perceived needs and priorities for such a service. METHODS: A cross-sectional postal survey of a stratified, randomly selected group of employees (n = 760) and all human resources (HR) managers (n = 34) was conducted in the Irish Civil Service. Each participant was requested to rate the overall importance of the OHU and to prioritize eight proposed functions for the unit: medical surveillance, general health education, pre-employment/promotion medical assessments, ill-health retirement assessments, return-to-work (after sick leave) assessments, occupational health education, research, and general medical screening. The results were analysed according to age group, gender, grade and occupation. RESULTS: There was a response rate of 69% from employees and 74% from personnel managers. Significantly more HR managers than employees (92 versus 81%) thought an occupational health service was either important or very important. There were also differences in prioritization of functions by employees and HR managers. HR managers prioritized those functions concerned with assessing individuals' fitness for work, notably pre-employment/promotional health assessments, whereas employees consider group-directed 'preventative' functions to be more important, i.e. general medical screening, health education and medical surveillance. Both sets of opinions are not mutually exclusive, and considerable overlap exists, notably in the areas of occupational and general health education.     

Effects of driving on low back pain

BACKGROUND: Many previous studies have demonstrated that driving a car is a risk factor for low back pain (LBP). We have frequent contact with medical representatives who often drive cars for business, and have noticed that many of them suffer from LBP. AIMS: To investigate how driving affected the occurrence of LBP in medical representatives. METHODS: Questionnaire survey of all medical representatives working in Mie Prefecture (Japan). RESULTS: A total of 551 medical representatives replied (92%). We divided the subjects into Group A (with LBP) and Group B (without LBP). There was no significant difference in mean age, height, weight or duration of continuous employment between the two groups. Mean total mileage was 342 539 km in Group A and 251 945 km in Group B (P < 0.05). There was no significant difference in estimated daily mileage or estimated daily driving time between the two groups. As for backrest inclination, most of the respondents in Group A chose 105 degrees and the majority in Group B chose 120 degrees (P < 0.001). CONCLUSION: The total mileage was significantly higher in Group A than in Group B. We considered that the risk for LBP increased as the lumbar spine load accumulated day by day while driving a car almost every day without a holiday.     

Medical Examinations for Public Safety

Driving buses in London is an occupation in which the standards of fitness have been defined and in which the frequency of, and clinical reason for, exclusion from the occupation have been recorded.

The criteria of fitness to drive a passenger vehicle are physical capability to handle controls (including good eyesight) and absence of conditions liable to cause sudden collapse or excessive fatigue with consequent liability to accidents. Some factors which may be overlooked as causes of collapse are idiopathic epilepsy which may first appear in middle life, carcinoma of the bronchus which commonly metastasizes in the brain and may cause fits, and laryngeal vertigo (cough syncope) which is much commoner in chronic bronchitis than is often realized.

When medical standards to maintain public safety and the man's own health were applied to applicants to drive London's buses, 5·3% of the applicants were rejected on general medical grounds and a further 13·3% were rejected for sub-standard vision and colour vision. All the applicants had experience of driving heavy vehicles and were otherwise acceptable as drivers.

Continued surveillance during working life, especially after sickness absence, of those involved in public safety is essential. During 1956, 23% of the examinations of bus drivers, who had been off sick for 28 days or more or for certain specified conditions, resulted in temporary or permanent exclusion from driving. This compares with 1·5% of examinations for licence renewal and 5·7% at age 65 and above.

Cardiovascular disorders accounted for 26% of the causes of rejection during 1956, one-third of these being due to hypertension and one-half to coronary heart disease. No one who has had clinical coronary heart disease is allowed to drive London Transport buses because of the known increased chance of recurrence. Periodic examinations revealed a number of hypertensives but the majority of the “coronary cases” were revealed by sickness absence. Electrocardiography at periodic examinations does not, at the present, enable those who will have coronary heart disease to be recognized.

Experience shows that the standards adopted are practicable and effective so far as bus drivers are concerned, and that careful assessment of fitness after sickness is as important as routine medical examination in maintaining public safety.

     

Screening for pre-diabetes and diabetes in the workplace

BACKGROUND: Diabetes is an increasingly prevalent and burdensome disease in working populations. In settings with established occupational medical programmes, there may be opportunities to intervene in a positive way to reduce the burden of this disease. AIM: To integrate diabetes screening and prevention into an existing occupational medical programme. METHODS: Screening to detect potential cases of pre-diabetes and diabetes was conducted in a large working population using differing criteria to define risk groups over a 2-year period. Classification of new cases was based on fasting plasma glucose, random plasma glucose or oral glucose tolerance test (OGTT). RESULTS: Among 13,086 employees screened via fasting or random glucose, there were 96 diabetes and 650 pre-diabetes cases detected. Among high-risk employees, 20 new cases of pre-diabetes and 8 cases of diabetes were detected in 84 employees assessed by OGTT. The percentage of employees with new findings increased with increasing age (2.3%, under age 40 compared to 11.4% for age 50 years and above) and body mass index (2.6, 6.1 and 11.4% among normal weight, overweight and obese employees, respectively). CONCLUSIONS: Given the likely magnitude of unrecognized diabetes and pre-diabetes cases, further interventions are being implemented targeting all employees and not just those who require routine occupational medical examinations.     

Occupational fitness standards for beach lifeguards. Phase 2: the development of an easily administered fitness test

BACKGROUND: No task-based fitness standard currently exists for beach lifeguards (BLGs). AIM: To formulate an easily administered fitness test for BLGs based on the physical demands identified in Phase 1 of the project (previous paper). METHODS: A range of anthropometric and land- and water-based (swimming pool and flume) fitness assessments were administered to 25 male and female volunteer subjects (13 BLGs from the UK). RESULTS: The mean (SD) VO(2max) (l/min) were 3.04 (0.61) for towing a casualty, 2.08 (0.53) for board paddling with a casualty and 2.97 (0.67) for freestyle swimming. A significant correlation (r = -0.82, P < 0.001) was identified between distance paddled in the sea in 3.5 min (established in Phase 1) and pool 400-m front crawl swim time and between towing VO(2max) and deltoid circumference/log(10) 400-m front crawl swim time (r = -0.83, P < 0.001). CONCLUSIONS: The regression identified allows the conclusion that if a BLG can swim 400-m front crawl in a pool in <7.5 min, he/she should be able to paddle 310 m in the sea in <3.5 min. Final recommendations for a fitness test for potential BLGs are presented.     

Benchmarking self-reported practice regarding Scottish Executive guidance on hepatitis C-infected health care workers

BACKGROUND: The 2002 Scottish Executive guidance 'hepatitis C-infected health care workers' advised NHS Scotland occupational health departments regarding screening health care workers (HCW) who perform or who may perform exposure-prone procedures (EPPs) for hepatitis C virus (HCV) infection. In 2004, 2 years following the launch of the guidance, there was anecdotal evidence of challenges to implementation and clinical and ethical concerns regarding the screening process. AIM: To benchmark the implementation of the Executive guidance on hepatitis C-infected HCW in NHS Scotland. METHODS: Lead occupational health practitioners in 15 Scottish NHS Boards completed a questionnaire and provided relevant local policies. RESULTS: All 15 NHS Boards responded: 87% (n = 13) had implemented the guidance with partial implementation in the remaining boards. While 87% required identified and validated samples (IVS), no consistent method was reported for how results from an IVS were recorded. There was also no consensus as to the duration a result was considered valid or consistency in charging for tests required by other employers. Across Scotland, some employee groups were being screened over and above those recommended within the guidance. Overall, there was agreement on the value of a standardized NHS hepatitis C status certificate and the importance of explicit screening criteria and identifying EPP workers. CONCLUSION: The survey confirms the challenges in implementing the guidance on managing HCV-infected HCW within NHS Scotland. These include lack of clarity regarding who, when and how frequently a HCW should be screened and how the results of such tests should be recorded.     

Low back pain among Iranian industrial workers

BACKGROUND: Most epidemiological data concerning low back pain (LBP) are from high-income countries and there is very little information about LBP in the working population in developing countries. OBJECTIVES: To determine the prevalence of LBP in Iranian industrial workers. To explore associations between LBP and physical and psychosocial factors at work, as well as lifestyle factors. METHODS: Cross-sectional study of the largest car-manufacturing group in Iran. The prevalence of LBP, work exposures and lifestyle factors were recorded using the standardized Nordic questionnaire for analysis of musculoskeletal symptoms. Demographic data and lifestyle factors (age, sex, education, weight, work experience, smoking and fitness training) were also collected. RESULTS: Of the 18,031 employees, 78% participated. The majority of subjects in this study population were young males (<30 years) and a small proportion was female (4%). The 1-year prevalence of self-reported LBP in this Iranian industrial population was 21% (20% males and 27% females). The prevalence rate of absence due to LBP was 5% per annum. The multiple logistic regression models indicated that the following remained risk indicators for LBP in the previous 12 months: increasing age, no regular exercise, heavy lifting, repetitive work and monotonous work. CONCLUSION: LPB is a common problem in the working population even in a developing country. Age and gender as well as certain work-related physical and psychosocial factors influenced the prevalence of LBP but the differences between different categories of workers were small.     

Ill-health retirement: a survey of decision making by occupational physicians working for local authority fire and police services

AIMS: To investigate the effect of qualifications, experience and service on ill-health retirement decisions made by police force and fire brigade medical advisers. METHODS: Doctors advising UK fire and police authorities attending a conference were given 16 case summaries from experienced fire and police advisers and asked to predict the outcome in terms of return to work or ill-health retirement. The answers were scored by assessing whether the outcome predicted by the participant agreed with the case setter. Correlation coefficients were calculated and a kappa coefficient was determined for assessing inter-participant variation. RESULTS: Forty-seven doctors attended, 44 participated and the responses of 39 (86%) were analysed. Over half the doctors participating had held their post for less than 5 years. The majority (>50%) agreed with the case setter in 11 case summaries and in five cases the agreement was strong (>75%). The majority disagreed in five cases, with < or =80% dissenting in three cases. There was wide variation in the inter-participant variation (kappa = -0.333 to +0.5) but the total agreed score correlated significantly (P < 0.05) with experience and service as a fire or police adviser (kappa = 0.33) and ill-health retirement agreement correlated significantly with experience (kappa = 0.49). There was no correlation between the level of qualification and total correct decisions. CONCLUSIONS: Whilst we found general agreement overall, our results suggest that there is inconsistency in ill-health retirement decision making by police and fire service medical advisers in certain cases. Experience appears to improve the likelihood of agreement in decision making.     

Correlates of physical activity among middle-aged Finnish male police officers

BACKGROUND: Few studies exist on adherence to exercise within specific occupational groups. AIMS: This study aimed at identifying factors explaining leisure-time physical activity among middle-aged Finnish police officers. METHODS: Middle-aged police officers (n = 103) participated in the study in 1981 and 1996. Frequency of and adherence to leisure-time physical activity and fitness were assessed. RESULTS: The factor 'enjoyment' was the most powerful determinant for both physical activity and fitness, but all the factors studied accounted for only 10% of the variability. Leisure-time physical activity in 1981 correlated significantly with leisure-time physical activity in 1996. CONCLUSIONS: The physical activity of the middle-aged police officers can be in part predicted from their physical activity in early adulthood. Enjoyment related to physical activity seems to be important with respect to enhancing adherence. Perhaps, being fit increases the feeling of enjoyment during exercise.     

Reasons for Rejection: Why People Fail to Qualify as Firefighters

In the decade beginning 1 January 1985, 916 individuals (includingfive females) were medically examined with a view to joiningthe full-time service of Strathclyde Fire Brigade (SFB). Onehundred and nine (11.9%), including two females, were rejected.The five main causes of failure were: ocular (n = 46, 42.2%);lack of stamina (n = 21, 19.2%); ‘others’ (n = 12,11.0%); cardiovascular (n = 9, 8.3%) and orthopaedic (n = 6,5.5%). Thirty-two had chest X-rays. One abnormality was found— an azygous lobe — but it played no part in thedecision to decline the applicant. There was little life- orhealth-threatening pathology found. The most serious cases weremurmurs consistent with mitral stenosis and regurgitation (oneeach), one case of ocular melanoma, four cases of hypertensionand two cases of haematuria/ proteinuria (++). This study showsthat potentially serious findings can occasionally be detectedin a population of 18–30 year olds who might be expectedto be of better than average fitness, and that routine chestX-rays are not helpful in the selection process.