Report of a system for diagnosis, categorizing and recording occupational mental ill-health

BACKGROUND: UK statutory systems for occupational disease recording do not include mental illness resulting from occupational stress. The issue is included within physician reporting systems, but there is no agreed set of criteria for diagnosis of occupational causation and no agreed system of categorization in terms of type of causation by workplace factors. METHOD: A multidisciplinary group of occupational health professionals, in conjunction with human resources staff, developed a system for the diagnosis, categorization and recording of occupational mental ill-health. RESULTS: The developed system was applied as a pilot and the outcome from its first year of use is presented. CONCLUSIONS: The system is considered to have operated well in pilot, and has now been adopted as a standard operating procedure by the occupational health provider who developed it. The system is proposed as a tool in the development of standardized NHS or UK national systems for the recording of occupational mental ill-health.     

The scale of perceived occupational stress

This article reviews previous research on the scale of occupational stress and describes in detail the Bristol Stress and Health at Work study. This study had three main aims: firstly, to determine the scale and severity of occupational stress in a random population sample; secondly, to distinguish the effects of stress at work from those of stress in general life; and finally, to determine whether objective indicators of health status and performance efficiency were related to perceived occupational stress. These aims were investigated by conducting an epidemiological survey of 17,000 randomly selected people from the Bristol electoral register, a follow-up survey 12 months later, and detailed investigation of a cohort from the original sample. The results revealed that approximately 20% of the sample reported that they had very high or extremely high levels of stress at work. This effect was reliable over time, related to potentially stressful working conditions and associated with impaired physical and mental health. The effects of occupational stress could not be attributed to life stress or negative affectivity. The cohort study also suggested that high levels of occupational stress may influence physiology and mental performance. The prevalence rate obtained in this study suggests that 5 million workers in the UK have very high levels of occupational stress.     

Occupational mental health: a brief history

This paper describes the development of occupational mental health in the United Kingdom. It looks at the increasing involvement of occupational health staff in this aspect of the workplace and the role played by organizational psychologists in exploring the relationship between work and mental well-being. It provides a background for the reviews of current knowledge described in the other papers in this issue of Occupational Medicine.     

Disability management through positive intervention in stakeholders' information asymmetry. A pilot study

BACKGROUND: One increasingly attractive hypothesis to account for prolonged sickness absence from work is the presence of 'information asymmetry' among stakeholders. Information asymmetry refers to a situation in which critical information is not (appropriately) exchanged, in this case among those involved in disability management. AIM: The purpose of this study was to intervene positively in the information asymmetry that currently exists between social insurance physicians and occupational physicians in Belgium. METHODS: We developed a novel model aimed at improving information exchange, and a pilot study protocol based on the model. Our first objective was to investigate feasibility of implementing the study protocol. Our second and main objective was to obtain preliminary results on whether improving information exchange between physicians would facilitate work resumption of employees out on sickness absence. RESULTS: Of 126 patients recruited, 91 were eligible and assigned to one of two groups: a control group, whose physicians used the standard Belgian evaluation protocol, and an intervention group, whose physicians used our new protocol. Outcome parameters from the 15 patients assigned to the intervention group revealed that enhanced inter-physician information exchange produced favourable work resumption rates (73%), suggesting that both the model and study protocol show promise. CONCLUSIONS: The issue of sharing information among all stakeholders involved in disability management is an important one. Moreover, professional reintegration of employees after a sickness absence is universally important to occupational health practitioners. Our preliminary results suggest that reducing information asymmetry among physicians should be investigated further in larger intervention trials.     

Surveillance of work-related diseases by occupational physicians in the UK: OPRA 1996-1999

The Occupational Physicians' Reporting Activity (OPRA) surveillance scheme for occupational physicians has now been in place for 4 years. During this period, an estimated 43,764 new cases of work-related disease have been reported. Musculoskeletal conditions make up nearly half (49%) of all cases; mental ill-health and skin disease account for 20% each, with respiratory conditions (8%) and hearing loss (5%) seen in lower proportions. Overall, eight of 42 diagnoses made up four-fifths of the new cases reported by occupational physicians. These were hand and arm disorders (8052 estimated cases), contact dermatitis (7104), disorders of the lumbar spine (6000), anxiety and depression (4788), work-related stress (3336), hearing loss (2100), elbow disorders (2040), and asthma (1680). Dermatitis and hearing loss were most frequent in manufacturing industries, lower back complaints in health care, and upper limb disorders in automotive manufacture. Psychiatric illnesses presented a different pattern, mainly affecting those in health, education and social service.     

The application of Ontario human rights legislation to the practice of occupational medicine

Although human rights legislation has important implications for occupational physicians, these implications may be overlooked in the practice of occupational medicine in other countries where human rights legislation may be different. The potential for significant oversights becomes greater as organizations continue to centralize international business support functions, such as occupational health services, operating from a single site. Human rights legislation has important implications with respect to policy decisions upon which an occupational physician has influence. This includes decisions about whether to conduct drug and alcohol testing; the performance of medical examinations; evaluating issues related to health and safety concerns of pregnant employees; and the need to work accommodate those with handicaps as defined by human rights legislation. This article examines the application of the Ontario human rights legislation in these areas.     

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.     

Applicability of survey feedback for an occupational health method in stress management

The main stressors in work organizations have been determinedin the research on mental stress. This has prompted occupationalhealth personnel to actively look for new tools in reducingstress. However, only a few workplaces have implemented actionmodels for health promotion by reducing stressors. The aim ofthis project was to investigate the applicability of surveyfeedback for an occupational health method of stress management.The survey feedback process, which has been one of the mainapproaches in organization development, was applied for stressorreduction. The employee's commitment to the programme was confirmedby participation. The occupational health personnel were responsiblefor carrying out the programme. The project was carried outin selected departments of one factory of an international papercompany. On the basis of the survey feedback, the departmentsmade changes in their action models, environment and instructionand guidance systems. According to the follow-up in one department,the variability of work increased, and overall mental and physicalstrenousness decreased. The OH personnel shifted their workingmodel towards more active co-operation with the work units.Today the survey feedback is a routine method of the occupationalhealth service of the company.     

The general practitioners' view

General practitioners have patients on their lists who work in a variety of occupations, but the doctor is most unlikely to have had any training in occupational medicine. As a result, occupational causes for illness are rarely considered by GPs. Little contact occurs between occupational health physicians and GPs leading to a lack of understanding of the occupational physician's role. These two factors, when combined, may lead to patients receiving sub-optimal treatment. This could be remedied by better undergraduate and postgraduate training, and by greater professional contact.     

Burnout as a clinical entity--its importance in health care workers

Burnout, viewed as the exhaustion of physical or emotional strengthas a result of prolonged stress or frustration, was added tothe mental health lexicon in the 1970s, and has been detectedin a wide variety of health care providers. A study of 600 Americanworkers indicated that burnout resulted in lowered production,and increases in absenteeism, health care costs, and personnelturnover. Many employees are vulnerable, particularly as theAmerican job scene changes through industrial downsizing, corporatebuyouts and mergers, and lengthened work time, Burnout producesboth physical and behavioural changes, in some instances leadingto chemical abuse. The health professionals at risk includephysicians, nurses, social workers, dentists, care providersin oncology and AIDS-patient care personnel, emergency servicestaff members, mental health workers, and speech and languagepathologists, among others. Early identification of this emotionalslippage is needed to prevent the depersonalization of the provider-patientrelationship. Prevention and treatment are essentially parallelefforts, including greater job control by the individual worker,group meetings, better up-and-down communication, more recognitionof individual worth, job redesign, flexible work hours, fullorientation to job requirements, available employee assistanceprogrammes, and adjuvant activity. Burnout is a health careprofessional's occupational disease which must be recognizedearly and treated.     

Variations in self-reported health by occupational grade in the British Post Office: the Q-health project

Between 1995 and 1998 a national sample of 58,501 (42,885 males, 15,616 females) Post Office employees (29%) completed and returned a postal questionnaire survey providing information on demographic characteristics, physical and psychological health, health and lifestyles and health screening behaviour. Response rates by occupational grade were as follows: manual (male 69.3%, females 43.6%); clerical (male = 11.8%, female, 42.3%); middle management (males 15.5%, females 10.7%) and senior management (males 3.4%, females 3.3%). A number of differences in health status occurred with occupational grade. Angina, high blood pressure, obesity, smoking, arthritis, disability, GP consultations and abnormal smears were all more prevalent in lower occupational grades. Height, job satisfaction, seat belt use and breast self-examination were also lower in lower status jobs. Some findings were unexpected: GHQ scores indicated better mental health in lower grades, whilst knowledge and frequency of testicular self-examination and attendance for mammograms were higher in lower grades. Self-reports for asthma, diabetes and family history of bowel cancer were also greater in higher grades. These findings are considered in terms of response bias, health selection, the psychosocial work environment, occupational health interventions and the nature, meaning and organization of social position within the Post Office.     

Sexual health and HIV in travellers and expatriates

Travellers engaging in sexual contact with a new partner abroad may be at high risk of acquiring a sexually transmitted infection. This review examines the impact of travel on sexual health and provides prevention, management and treatment recommendations to practising occupational health physicians.     

The estimated workforce served by occupational physicians in the UK

During the past decade, an occupational disease surveillance scheme has been created in the UK, based on systematic reporting of newly diagnosed cases by six groups of clinical consultants and by specialist occupational physicians. Labour Force Survey statistics have proved a reasonably satisfactory denominator for the former, but not for the occupational physicians, who provide services for only a selected subsection of the employed population. To remedy this deficiency, approximately 700 occupational physicians who were recorded as having been a reporter at some time were invited to provide their best estimate of the number of employees for whom they were responsible. After various exclusions--mainly physicians who were not, or were no longer, responsible for any defined workforce, and others who had not reported for at least 3 years--the number of active participants for whom data, by industry, occupation and sex, were obtained or estimated was 503. The resulting total number of employees served was estimated at 3.2 million, comprising 12% of the general working population. The proportion with access to an occupational physician varied enormously, from 43% in the health and social services to 1% in agriculture, forestry and fishing, and 6% in the rest of industry. Numbers estimated for each industrial sector were fairly reliable, but by occupation less so, especially in the health and social services.     

Ethical issues in occupational medicine practice: knowledge and attitudes of occupational physicians

Views on ethical conduct in occupational medicine practice canvary from country to country and even between occupational healthpractitioners. However, there are many areas of common agreement,and this is apparent on comparing guidance documents on ethicsproduced by several different organizations. The usefulnessof these documents will depend in part on how aware practitionersare of their existence. A standardized questionnaire administeredto 70 occupational physicians in the Netherlands, UK, and Singaporeshowed that there was a lack of awareness of guidance documentson ethics, even for publications from their own countries. Onlyfive of the 70 respondents consulted an ethics document in thepast year. In addition to publications, other avenues were usedfor advice on ethical issues. There was a difference in opinionbetween the physicians from Singapore and those from the twoEuropean countries on whether specific occupational health activitieswere ethical. These findings reinforce the need for internationalguidance on ethics to take into account differences in attitudesand practice between countries. On many issues there was nounanimity of opinion, even between occupational physicians fromthe same country. This may be an indication of the complexityof ethical matters, and provides a rationale for publishingguidance on ethics in occupational medicine.     

Occupational contact dermatitis in the UK: a surveillance report from EPIDERM and OPRA

Since February 1993 the EPIDERM surveillance scheme has collected data on occupational skin disease from consultant dermatologists in the UK. Reporting by occupational physicians to the scheme began in May 1994 and was superseded in January 1996 by the Occupational Physicians Reporting Activity (OPRA). The schemes currently receive reports on incident cases from 244 dermatologists and 790 occupational physicians. An estimated total of 9937 cases of contact dermatitis reported by dermatologists was calculated from surveillance data; 8129 contact dermatitis cases were estimated from reports by occupational physicians. The annual incidence of occupational contact dermatitis from dermatologist reports was 6.4 cases per 100,000 workers and 6.5 per 100,000 from reports by occupational physicians, an overall rate of 12.9 cases per 100,000 workers. Manufacturing industries account for the greatest number of cases seen by both sets of reporting physicians, with health care employment second. Reports from dermatologists also indicate high rates of dermatitis in the personal service industries (mainly hairdressers and barbers) and in agriculture. With the exception of an increase in cases seen in nurses in both schemes, the numbers and proportions of cases of contact dermatitis within occupations have remained fairly constant over the 6-year reporting period. Agents accounting for the highest number of allergic contact dermatitis cases were rubber (23.4% of allergic cases reported by dermatologists), nickel (18.2), epoxies and other resins (15.6), aromatic amines (8.6), chromium and chromates (8.1), fragrances and cosmetics (8.0), and preservatives (7.3). Soaps (22.0% of cases), wet work (19.8), petroleum products (8.7), solvents (8.0), and cutting oils and coolants (7.8) were the most frequently cited agents in cases of irritant dermatitis. The national scope of the data, together with the parallel structure by which both dermatologists and occupational physicians report incident cases, is useful in determining the extent of skin hazards in UK industry and may help in better targeting efforts to reduce the burden of skin disease at work.     

Psychological and occupational predictive factors for back pain among employees of a university hospital in southern Spain

OBJECTIVES: To identify the individual and occupational factors that are predictors for low back pain among the employees of a university hospital in southern Spain. METHODS: A transverse study was conducted in which the population used was the hospital employees who volunteered to participate. The information was obtained by using a questionnaire, which included demographic and anthropometric variables, habits, characteristics of the work done, and of any pain experienced. The mental health condition of subjects was measured using the GHQ-28, using a score of > or = 6 as the cut-off point. To study the variables associated with pain, crude odds ratios (ORs) were calculated (+/- 95% CI) and adjusted according to a logistic regression model. RESULTS: One thousand one hundred and four subjects participated in the study but only 890 of these completed the questionnaire in full (rate of response, 35.7% of total employees). The population studied was notable for the high proportion of women, for subjects > 41 years of age, and subjects who undertook little or no physical exercise. In addition, according to the GHQ-28 test, 29.9% of the total were 'probable psychiatric cases'. The crude ORs were high in all the occupational categories in comparison with the doctors, with the exception of the maintenance, cleaning, and catering group. They were also higher among women, among subjects with poor mental health, and among women with one or more children. The adjusted ORs showed that having a GHQ-28 score of > or = 6, and belonging to the auxiliary technician category, were independent risk factors for suffering low back pain. Being older than 41 years and in temporary employment were protective variables. CONCLUSIONS: The presence of probable mental illness is the variable most strongly associated with the presence of low back pain in the population studied. Its diagnostic confirmation and appropriate treatment could contribute to reducing the prevalence of vertebral pains in this occupational group.     

Incidence by occupation and industry of work-related skin diseases in the United Kingdom, 1996-2001

BACKGROUND: Work-related skin disease is common but few cases are documented in statutory reports or disability systems. Voluntary reporting by specialist physicians provides more complete information. AIMS: To summarize incidence rates of work-related skin diseases reported by consultant dermatologists and occupational physicians, with emphasis on contact and allergic dermatitis by occupation and industry. METHODS: Cases reported in 1996-2001 to the EPIDERM and OPRA national surveillance schemes were analysed by causal agent, occupation and industry, with incidence rates calculated against appropriate denominators. RESULTS: Average annual incidence rates based on data from dermatologists were 97 per million overall, 74 for contact dermatitis and 14 for neoplasia. The corresponding rates for occupational physicians were 623 overall, 510 and 2, respectively. For infective disease, the rates for occupational physicians were 28 compared to 2 for dermatologists. Contact dermatitis was most frequently attributed to rubber chemicals, soaps and cleaners, wet work, nickel and acrylics; most cases of contact urticaria were attributed to rubber chemicals or foods and flour. The pattern of incidence rates by occupation and industry was complex, but correlated with the probable type of exposure. Rates of contact dermatitis were highest among skilled workers in the petrochemical and rubber and plastic manufacturing industries, with machine operators and technical workers in metal and automotive industries also at increased risk. High proportions of cases attributed to rubber chemicals were in nurses and technicians in the health and social services. CONCLUSIONS: These findings identify jobs and types of work where contact with causal agents is common and potentially preventable.     

Improved communication between doctors and with managers would benefit professional integrity and reduce the occupational medicine workload

BACKGROUND: Professional expectations for communication skills are explicit. These skills are needed for professional integrity and personal morale. Nevertheless, occupational physicians see doctors as patients for whom communication among between doctors and with their managers are the principal cause of their presenting health problems. AIM: To describe the frameworks of professionalism in medicine and the duty to care for good communication; present issues surrounding competency in communication skills; identify health problems among doctors associated with poor communication; and consider roles of economic appraisal and preventive strategies. METHOD: A literature review identified key publications of professional expectations and requirements of doctors for their communication skills. Health problems among doctors associated with poor communication and presenting at least twice in a National Health Service (NHS) occupational health (OH) department during January-December 2002, were sought by manual retrieval of all doctor-patient records. The categories of communication difficulty were agreed in the focus group discussion of the presenting problems with occupational physicians. RESULTS: Nine categories of communication difficulties among doctors resulting in their presentation in OH departments with health problems were identified. CONCLUSIONS: Personal health problems caused by poor communication involve considerable time and potential litigation costs. Doctors need to be reminded of their responsibilities. Opportunity cost studies would help to strengthen an evidence base for the need of doctors to adhere to the professional requirements of good communication skills.     

Surveillance of Australian workplace Based Respiratory Events (SABRE): notifications for the first 3.5 years and validation of occupational asthma cases

AIMS: In Australia, the SABRE programme, a notification scheme, has been established to collect incidence data on occupational lung disease. This paper reports the first 3.5 years of this scheme and the results of an occupational asthma validation study. METHODS: A notification form is mailed regularly to thoracic physicians and occupational physicians in the Australian states of Victoria and Tasmania, who use this to report new cases of occupational lung disease. The validation study was performed by a blinded panel of two doctors, who reviewed information extracted from the medical files of a sample of reported cases of occupational asthma. RESULTS: A total of 520 diagnoses were reported. The mean (+/- SD) age of the 448 patients notified was 55.7 +/- 16.2 years. There were 394 (88%) males and 54 females. The most common single condition was asthma for which the most common causative agent was wood dust. However, the most commonly reported agent overall was asbestos. The validation study of occupational asthma found only fair agreement (kappa = 0.4) between the panel and notifying doctors. However, agreement was better (kappa = 0.5) when the analysis was restricted to those cases where the reporting doctor considered the likelihood of the diagnosis was high. CONCLUSIONS: Occupational asthma is the most common occupational respiratory condition reported, which suggests increasing importance for this disease over more traditional forms of occupational lung disease. The validation study suggests that such schemes should restrict notifications only to those cases where the likelihood of the diagnosis is considered high.