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Chapter 15 - Health Protection and Promotion

HEALTH PROTECTION AND PROMOTION IN THE WORKPLACE: AN OVERVIEW

Leon J. Warshaw and Jacqueline Messite

It has often been said that the workforce is the most critical element in the productive  apparatus of the organization. Even in highly automated plants with their smaller number of workers, decrements in their health and well-being will sooner or later be reflected in impaired productivity or, sometimes, even in disasters.

Through governmental legislation and regulation, employers have been made responsible for maintaining the safety of the work environment and work practices, and for the treatment, rehabilitation and compensation of workers with occupational injuries and disease. In recent decades, however, employers have begun to recognize that disabilities and absences are costly even when they originate outside the workplace. Consequently, they have begun to provide more and more comprehensive health promotion and protection programmes not only for employees but for their families as well. In opening a 1987 meeting of a World Health Organization (WHO) Expert Committee on Health Promotion in the Worksetting, Dr. Lu Rushan, Assistant Director-General of WHO, reiterated that WHO viewed workers' health promotion as an essential component of occupational health services (WHO 1988).

Why the Workplace?

The rationale for employer sponsorship of health promotion programmes includes preventing loss of worker productivity due to avoidable illnesses and disability and their associated absenteeism, improving employee well-being and morale, and controlling the costs of employer-paid health insurance by reducing the amount of health care services required. Similar considerations have stimulated union interest in sponsoring programmes, particularly when their members are scattered among many organizations too small to mount effective programmes on their own.

The workplace is uniquely advantageous as an arena for health protection and promotion. It is the place where workers congregate and spend a major portion of their waking hours, a fact that makes it convenient to reach them. In addition to this propinquity, their camaraderie and sharing of similar interests and concerns facilitate the development of peer pressures that can be a powerful motivator for participation and persistence in a health promotion activity. The relative stability of the workforce-most workers remain in the same organization for long periods of time-makes for the continuing participation in healthful behaviours necessary to achieve their benefit.

The workplace affords unique opportunities to promote the improved health and well-being of the workers by:

·     integrating the health protection and promotion programme into the organization's efforts to control occupational diseases and injuries

·     modifying the structure of the job and its environment in ways that will make it less hazardous and less stressful

·     providing employer- or union-sponsored programmes designed to enable employees to cope more effectively with personal or family burdens that may impinge on their well-being and work performance (i.e., modified work schedules and financial assistance benefits and programmes that address alcohol and drug abuse, pregnancy, child care, caring for elderly or disabled family members, marital difficulties or planning for retirement).

Does Health Promotion Work?

There is no doubt of the efficacy of immunizations in preventing infectious diseases or of the value of good occupational health and safety programmes in reducing the frequency and severity of work-related diseases and injuries. There is general agreement that early detection and appropriate treatment of incipient diseases will reduce mortality and lower the frequency and extent of residual disability from many diseases. There is growing evidence that elimination or control of risk factors will prevent or, at least, substantially delay the onset of life-threatening diseases such as stroke, coronary artery disease and cancer. There is little doubt that maintaining a healthy lifestyle and coping successfully with psychosocial burdens will improve well-being and functional capacity so as to achieve the goal of wellness defined by the World Health Organization as a state beyond the mere absence of disease. Yet some remain sceptical; even some physicians, at least to judge by their actions.

There is perhaps a higher level of scepticism about the value of worksite health promotion programmes. In large part, this reflects the lack of adequately designed and controlled studies, the confounding effect of secular events such as the declining incidence of mortality from heart disease and stroke and, most important, the length of time required for most preventive measures to have their effect. However, in the Health Project report, Freis et al. (1993) summarize the growing literature confirming the effectiveness of worksite health promotion programmes in reducing health care costs. In its initial review of over 200 workplace programmes, the Health Project, a voluntary consortium of business leaders, health insurers, policy scholars and members of government agencies which advocate health promotion to reduce the demand and the need for health services, found eight with convincing documentation of savings in health care costs.

Pelletier (1991) assembled 24 studies of comprehensive worksite programmes published in peer-review journals between 1980 and 1990. (Reports of single-focus programmes, such as those dealing with hypertension screening and smoking cessation, even though demonstrated to have been successful, were not included in this review.) He defined "comprehensive programs" as those which "provide an ongoing, integrated program of health promotion and disease prevention that knits the particular components (smoking cessation, stress management, coronary risk reduction, etc.) into a coherent, ongoing program that is consistent with corporate objectives and includes program evaluation." All of the 24 programmes summarized in this review achieved improvement in employees' health practices, reductions in absenteeism and disability, and/or increases in productivity, while each of these studies that analysed for impact on health care and disability costs, cost-effectiveness or cost/benefit changes demonstrated a positive effect.

Two years later, Pelletier reviewed an additional 24 studies published between 1991 and the early part of 1993 and found that 23 reported positive health gains and, again, all of those studies which analysed cost-effectiveness or cost/benefit effects indicated a positive return (Pelletier 1993). Factors common to the successful programmes, he noted, included specific programme goals and objectives, easy access to the programme and facilities, incentives for participation, respect and confidentiality, support of top management and a corporate culture that encourages health promotion efforts (Pelletier 1991).

While it is desirable to have evidence confirming the effectiveness and value of worksite health promotion programmes, the fact is that such proof has rarely been required for the decision to initiate a programme. Most programmes have been based on the persuasive power of the conviction that prevention does work. In some instances, programmes have been stimulated by interest articulated by employees and, occasionally, by the unexpected death of a top executive or a key employee from cancer or heart disease and the fond hope that a preventive programme will keep "lightning from striking twice".

Structure of a Comprehensive Programme

In many organizations, particularly smaller ones, the health promotion and disease prevention programme consists merely of one or more largely ad hoc activities that are informally related to each other, if at all, that have little or no continuity, and that often are triggered by a particular event and abandoned as it fades into memory. A truly comprehensive programme should have a formal structure comprising a number of integrated elements, including the following:

·     a clear statement of goals and objectives that are approved by management and acceptable to the employees

·     explicit endorsement by top management and, where they exist, the labour organizations involved, with the continuing allocation of resources adequate to achieve desired goals and objectives

·     appropriate placement in the organization, effective coordination with other health-related activities, and communication of programme plans across divisions and departments to mid-level managers and employees. Some organizations have found it expedient to create a labour-management committee comprising representatives from all levels and segments of the workforce for "political" reasons as well as to provide input on programme design

·     designation of a "programme director," a person with the requisite administrative skills who also has had training and experience in health promotion or has access to a consultant who might supply the necessary expertise

·     a mechanism for feedback from participants and, if possible, non-participants as well, in order to confirm the validity of the programme design and to test the popularity and utility of particular programme activities

·     procedures for maintaining the confidentiality of personal information

·     systematic record-keeping to keep track of activities, participation and outcomes as a basis for monitoring and potential evaluation

·     compilation and analysis of available relevant data, ideally for a scientific evaluation of the programme or, when that is not feasible, to generate a periodic report to management to justify continuation of the resource allocation and to form a basis for possible changes in the programme.

Programme Objectives and Ideology

The basic objectives of the programme are to enhance and maintain the health and well-being of employees on all levels, to prevent disease and disability, and to ease the burden on individuals and the organization when disease and disability cannot be prevented.

The occupational health and safety programme is directed to those factors on the job and in the workplace that may affect employees' health. The wellness programme recognizes that their health concerns cannot be confined within the boundaries of the plant or office, that problems arising in the workplace inevitably affect the health and well-being of workers (and, by extension, also their families) in the home and in the community and that, just as inevitably, problems arising outside of work affect attendance and work performance. (The term wellness can be considered the equivalent of the expression health promotion and protection, and has been used increasingly in the field during the last two decades; it epitomizes the World Health Organization's positive definition of health.) Accordingly, it is quite appropriate for the health promotion programme to address problems that some argue are not proper concerns for the organization.

The need to achieve wellness assumes greater urgency when it is recognized that workers with diminished capacities, however acquired, may be potentially hazardous to their co-workers and, in certain jobs, to the public as well.

There are those who hold that, since health is fundamentally a personal responsibility of the individual, it is inappropriate, and even intrusive, for employers or labour unions (or both) to undertake involvement with it. They are correct insofar as overly paternalistic and coercive approaches are employed. However, health-promoting adjustments of the job and the workplace along with enhanced access to health-promoting activities provide the awareness, knowledge and tools that enable employees to address that personal responsibility more effectively.

Programme Components

Needs assessment

While the alert programme director will take advantage of a particular event that will create interest in a special activity (e.g., the unexpected illness of a popular person in the organization, reports of cases of an infectious disease that raise fears of contagion, warnings of a potential epidemic), the comprehensive programme will be based on a more formal needs assessment. This may simply consist of a comparison of the demographic characteristics of the workforce with morbidity and mortality data reported by public health authorities for such population cohorts in the area, or it may comprise the aggregate analyses of company-specific health-related data, such as health care insurance claims and the recorded causes of absenteeism and of disability retirement. Determination of the health status of the workforce through compilation of the results of health screenings, periodic medical examinations and health risk appraisal programmes can be supplemented by surveys of employees' health-related interests and concerns to identify optimal targets for the programme. (It should be borne in mind that health problems affecting particular cohorts of employees that warrant attention may be obscured by relying only on data aggregated for the entire workforce.) Such needs assessments are not only useful in selecting and prioritizing programme activities but also in planning to "market" them to the employees most likely to find them beneficial. They also provide a benchmark for measuring the effectiveness of the programme.

Programme elements

A comprehensive health promotion and disease prevention programme includes a number of elements, such as the following.

Promoting the programme

A constant stream of promotional devices, such as handbills, memoranda, posters, brochures, articles in company periodicals, etc., will serve to call attention to the availability and desirability of participating in the programme. With their permission, stories of the accomplishments of individual employees and any awards for achieving health promotion goals they may have earned may be highlighted.

Health assessment

Where possible, each employee's health status should be assessed on entering the programme to provide a basis for a "prescription" of personal objectives to be achieved and of the specific activities that are indicated, and periodically to assess progress and interim changes in health status. The health risk appraisal may be used with or without a medical examination as comprehensive as circumstances permit, and supplemented by laboratory and diagnostic studies. Health screening programmes can serve to identify those for whom specific activities are indicated.

Activities

There is a long list of activities that may be pursued as part of the programme. Some are continuing, others are addressed only periodically. Some are targeted to individuals or to particular cohorts of the workforce, others to the entire employee population. Prevention of illness and disability is a common thread that runs through each activity. These activities may be divided into the following overlapping categories:

·     Clinical services. These require health professionals and include: medical examinations; screening programmes; diagnostic procedures such as mammography; Pap smears and tests for cholesterol level; immunizations and so forth. They also include counseling and behaviour modification in relation to weight control, fitness, smoking cessation and other lifestyle factors.

·     Health education. Education to promote awareness of potential diseases, the importance of controlling risk factors, and the value of maintaining healthy lifestyles, for instance, through weight control, fitness training and smoking cessation. Such education should also point the way to appropriate interventions.

·     Guidance in managing medical care. Advice should be given with regard to the following concerns: dealing with the health care system and procuring prompt and high-quality medical care; managing chronic or recurrent health problems; rehabilitation and return to work after disease or injury; treatment for alcohol and drug abuse; prenatal care and so on.

·     Coping with personal problems. Coping skills to be developed include, for example, stress management, pre-retirement planning and outplacement. Help can also be provided for workers who need to deal with work and family problems such as family planning, prenatal care, dependant care, parenting, and so forth.

·     Workplace amenities and policies. Workplace features and policies supplementary to those addressing occupational health and safety activities would include personal washing-up and locker facilities, laundry service where needed, catering facilities offering nutrition advice and helpful food choices, and the establishment of a smoke-free and drug-free workplace, among others.

In general, as programmes have developed and expanded and awareness of their effectiveness has spread, the number and variety of activities have grown. Some, however, have been de-emphasized as resources have either been reduced because of financial pressures or shifted to new or more popular areas.

Tools

The tools employed in pursuing health promotion activities are determined by the size and location of the organization, the degree of centralization of the workforce with respect to geography and work schedules; the available resources in terms of money, technology and skills; the characteristics of the workforce (as regards educational and social levels); and the ingenuity of the programme director. They include:

·     Information gathering: employee surveys; focus groups

·     Print materials: books; pamphlets (these may be distributed or displayed in take-away racks); pay envelope stuffers; articles in company publications; posters

·     Audiovisual materials: audiotapes; recorded messages accessible by telephone; films; videos for both individual and group viewing. Some organizations maintain libraries of audiotapes and videos which employees may borrow for home use

·     Professional health services: medical examinations; diagnostic and laboratory procedures; immunizations; individual counselling

·     Training: first aid; cardiopulmonary resuscitation; healthy shopping and cooking

·     Meetings: lectures; courses; workshops

·     Special events: health fairs; contests

·     Self-help and support groups: alcohol and drug abuse; breast cancer; parenting; eldercare

·     Committees: an intramural task force or committee to coordinate health-related programmes among different departments and divisions and a labour-management committee for overall programme guidance are often useful. There may also be special committees centred on particular activities

·     Sports programmes: intramural sports; the sponsoring of individual participation in community programmes; company teams

·     Computer software: available for individual personal computers or accessed through the organization's network; health-promotion-oriented computer or video games

·     Screening programmes: general (e.g., health risk appraisal) or disease specific (e.g., hypertension; vision and hearing; cancer; diabetes; cholesterol)

·     Information and referral: employee assistance programmes; telephone resource for personal questioning and advice

·     Ongoing activities: physical fitness; healthful food selection in worksite catering facilities and vending machines

·     Special benefits: released time for health promotion activities; tuition reimbursement; modified work schedules; leaves of absence for particular personal or family needs

·     Incentives: awards for participation or goals achievement; recognition in company publications and on bulletin boards; contests and prizes.

Implementing the Programme

In many organizations, particularly smaller ones, health promotion activities are pursued on an ad hoc, haphazard basis, often in response to actual or threatened health "crises" in the workforce or in the community. After a time, however, in larger organizations, they are often pulled together into a more or less coherent framework, labelled "a programme," and made the responsibility of an individual designated as programme director, coordinator or given some other title.

Selection of activities for the programme may be dictated by the responses to employee interest surveys, secular events, the calendar or the suitability of the available resources. Many programmes schedule activities to take advantage of the publicity generated by the categorical voluntary health agencies in connection with their annual fund-raising campaigns, for example, Heart Month, or National Fitness and Sports Week. (Each September in the United States, the National Health Information Center in the Office of Disease Prevention and Health Protection publishes National Health Observances, a list of the designated months, weeks and days devoted to the promotion of particular health issues; it is now also available via electronic mail.)

It is generally agreed that it is prudent to install the programme incrementally, adding activities and topics as it gains credibility and support among the employees and to vary the topics to which special emphasis is given so that the programme does not become stale. J.P. Morgan & Co., Inc., the large financial organization based in New York City, has instituted an innovative "scheduled cyclical format" in its health promotion programme that emphasizes selected topics sequentially over a four-year period (Schneider, Stewart and Haughey 1989). The first year (the Year of the Heart) focuses on cardiovascular disease prevention; the second (the Year of the Body) addresses AIDS and early cancer detection and prevention; the third (the Year of the Mind) deals with psychological and social issues; and the fourth (the Year of Good Health) covers such significant topics as adult immunization, arthritis and osteoporosis, accident prevention, diabetes and healthy pregnancy.

At this point, the sequence is repeated. This approach, Schneider and his co-authors state, maximizes involvement of available corporate and community resources, encourages employee participation by sequential attention to different issues, and affords the opportunity for directing attention to programme revisions and additions based on medical and scientific advances.

Evaluating the Programme

It is always desirable to evaluate the programme both to justify continuation of its resource allocations and to identify any need for improvement and to support recommendations for expansion. The evaluation may range from simple tabulations of participation (including drop-outs) coupled with expressions of employee satisfaction (solicited and unsolicited) to more formal surveys. The data obtained by all these means will demonstrate the degree of utilization and the popularity of the programme as a whole entity and of its individual components, and are usually readily available soon after the end of the evaluation period.

Even more valuable, however, are data reflecting the outcomes of the programme. In an article pointing the way to improving evaluations of health promotion programmes, Anderson and O'Donnell (1994) offer a classification of areas in which health promotion programmes may have significant results (see figure 15.1).

Figure 15.1 Categories of health promotion outcomes

Outcome data, however, require an effort planned prior to the outset of the programme, and they have to be collected over a time sufficient to allow the outcome to develop and be measured. For example, one can count the number of individuals who receive an influenza immunization and then follow the total population for a year to demonstrate that those inoculated had a lower incidence of influenza-like respiratory infections than those who refused the inoculation. The study can be enlarged to correlate rates of absenteeism of the two cohorts and compare the programme costs with the direct and indirect savings accrued by the organization.

Furthermore, it is not too difficult to demonstrate individuals' achievement of more desirable profiles of risk factors for cardiovascular disease. However, it will take at least one and probably several decades to demonstrate a reduction in morbidity and mortality from coronary heart disease in an employee population cohort. Even then, the size of that cohort may not be large enough to make such data significant.

The review articles cited above demonstrate that good evaluation research can be done and that it is increasingly being undertaken and reported. There is no question of its desirability. However, as Freis and his co-authors (1993) said, "There are already model programs that improve health and decrease costs. It is not knowledge that is lacking, but penetration of these programs into a greater number of settings."

Comments and Caveats

Organizations contemplating the launching of a health promotion programme should be cognizant of a number of potentially sensitive ethical issues to be considered and a number of pitfalls to avoid, some of which have already been alluded to. They are comprised under the following headings:

Elitism versus egalitarianism

A number of programmes exhibit elitism in that some of the activities are limited to individuals above a certain rank. Thus, an in-plant physical fitness facility may be restricted to executives on the grounds that they are more important to the organization, they work longer hours, and they find it difficult to free up the time to go to an outside "health club". To some, however, this seems to be a "perk" (i.e., a special privilege), like the key to the private washroom, admission to the free executive dining room, and use of a preferred parking space. It is sometimes resented by rank-and-file workers who find visiting a community facility too expensive and are not allowed the liberty of taking time during the working day for exercise.

A more subtle form of elitism is seen in some in-plant fitness facilities when the quota of available memberships is taken up by "jocks" (i.e., exercise enthusiasts) who would probably find ways to exercise anyway. Meanwhile, those who are sedentary and might derive much greater benefit from regular supervised exercise are denied entry. Even when they make it into the fitness programme, their continued participation is often discouraged by embarrassment at being outperformed by lower-ranking workers. This is particularly true of the manager whose male self-image is tarnished when he finds that he cannot perform at the level of his female secretary.

Some organizations are more egalitarian. Their fitness facilities are open to all on a first-come, first-served basis, with continuing membership available only to those who use it frequently enough to be of value to them. Others go part of the way by reserving some of the memberships for employees who are being rehabilitated following an illness or injury, or for older workers who may require a greater inducement to participate than their younger colleagues.

Discrimination

In some areas, anti-discrimination laws and regulations may leave the organization open to complaints, or even litigation, if the health promotion programme can be shown to have discriminated against certain individuals on the basis of age, sex or membership in minority or ethnic groups. This is not likely to happen unless there is a more pervasive pattern of bias in the workplace culture but discrimination in the health promotion programme might trigger a complaint.

Even if formal charges are not made, however, resentment and dissatisfaction, which may be magnified as they are communicated informally among employees, are not conducive to good employee relations and morale.

Concern about allegations of sex discrimination may be exaggerated. For example, even though it is not recommended for routine use in asymptomatic men (Preventive Services Task Force 1989), some organizations offer screening for prostatic cancer to compensate for making Pap tests and mammography available to female employees.

Complaints of discrimination have come from individuals who are denied the opportunity of winning incentive awards because of congenital health problems or acquired diseases that preclude participation in health promotion activities or achieving the ideal personal health goals. At the same time, there is the equity issue of rewarding individuals for correcting a potential health problem (e.g., giving up smoking or losing excess weight) while denying such rewards to individuals who do not have such problems.

"Blaming the victim"

Growing out of the valid concept that health status is a matter of personal responsibility is the notion that individuals are culpable when health defects are found and are to be held guilty for failing to correct them on their own. This sort of thinking fails to take notice of the fact that genetic research is increasingly demonstrating that some defects are hereditary and, therefore, although they may sometimes be modified, are beyond the individual's capacity to correct.

Examples of "blaming the victim" are (a) the too-prevalent attitude that HIV/AIDS is a fitting retribution for sexual "indiscretions" or intravenous drug use and, therefore, its victims do not deserve compassion and care, and (b) the imposition of financial and bureaucratic barriers that make it difficult for unmarried young women to get adequate prenatal care when they become pregnant.

Most important, focusing in the workplace on individuals' responsibility for their own health problems tends to obscure the employer's accountability for factors in job structure and work environment that may be hazardous to health and well-being. Perhaps the classic example is the organization that offers stress management courses to teach employees to cope more effectively but that does not examine and correct features of the workplace that are needlessly stressful.

It must be recognized that hazards present in the workplace may not only affect the workers, and by extension their families as well, but they may also precipitate and aggravate personal health problems generated away from the job. While retaining the concept of individual responsibility for health, it must be balanced by the understanding that factors in the workplace for which the employer is responsible may also have a health-related influence. This consideration highlights the importance of communication and coordination between the health promotion programme and the employer's occupational safety and health and other health-related programmes, especially when they are not in the same box on the organization chart.

Persuasion, not coercion

A cardinal tenet of worksite health promotion programmes is that participation should be voluntary. Employees should be educated about the desirability of suggested interventions, provided with access to them, and persuaded to participate in them. There often is, however, a narrow margin between enthusiastic persuasion and compulsion, between well-meaning paternalism and coercion. In many instances, the coercion may be more or less subtle: e.g., some health promotion professionals tend to be overly authoritarian; employees may be fearful of embarrassment, being ostracized or even penalized if they reject the advice given them; a worker's choices as to recommended health promotion activities may be overly limited; and executives may make it unpleasant for their subordinates not to join them in a favorite activity, such as jogging in the very early morning.

While many organizations offer rewards for healthy behaviour, for instance, certificates of achievement, prizes, and "risk-rated" health insurance (involving, in the United States, for example, a reduction in the employee's share of the premiums), a few impose penalties on those who do not meet their arbitrary standards of health behaviour. The penalties may range from refusing employment, withholding advancement, or even dismissal or denying benefits that might otherwise be forthcoming. An example of an American firm levying such penalties is E.A. Miller, a meat-packing plant located in Hyrum, Utah, a town of 4,000 inhabitants located some 40 miles north of Salt Lake City (Mandelker 1994). E.A. Miller is the largest employer in this small community and provides group health insurance for its 900 employees and their 2,300 dependants. Its health promotion activities are typical in many ways except that there are penalties for not participating:

·     Employees and spouses who do not attend prenatal seminars are not reimbursed for the cost of obstetrical care or of the baby's care in the hospital. Also, to qualify for the insurance benefits, the pregnant woman must visit a doctor during the first trimester.

·     If employees or their dependants smoke, they must contribute over twice as much to their share of group health insurance premiums: $66 per month instead of $30. The plant has had a smoke-free policy since 1991 and the company offers smoking cessation courses onsite or pays employees' tuition if they take the course in the community.

·     The company will not cover any of the medical costs if a covered employee or dependant was injured in an automobile accident while driving under the influence of drugs or alcohol or was not wearing a seat belt, nor will it cover injuries sustained while riding a motorcycle without a helmet.

One form of coercion that has wide acceptance is "job jeopardy" for employees whose alcohol or drug abuse has had an impact on their attendance and work performance. Here, the employee is confronted with the problem and told that disciplinary actions will be stayed as long as he or she continues with the prescribed treatment and remains abstinent. With allowance for an occasional relapse (in some organizations, this is limited to a specific number), failure to comply results in dismissal. Experience has amply shown that the threat of job loss, regarded by some as the most potent stressor encountered in the workplace, is an effective motivator for many individuals with such problems to agree to take part in a programme for their correction.

Confidentiality and privacy

Another hallmark of the successful health promotion programme is that personal information about participating employees -and non-participants as well-must be kept confidential and, particularly, out of personnel files. To preserve the privacy of such information when it is needed for evaluative tabulations and research, some organizations have set up data bases in which individual employees are identified by code numbers or by some similar device. This is particularly relevant to mass screening and laboratory procedures where clerical errors are not unknown.

Who participates

Health promotion programmes are criticized by some on the basis of evidence that participants tend to be younger, healthier and more health conscious than those who do not (the "coals to Newcastle" phenomenon). This presents to those designing and operating programmes the challenge of involving those who have more to gain through their participation.

Who pays

Health promotion programmes involve some costs to the organization. These may be expressed in terms of financial outlays for services and materials, time taken from work hours, distraction of participating employees, and the burden of management and administration. As noted above, there is increasing evidence that these are more than offset by reduced personnel costs and by improvements in productivity. There are also the less tangible benefits of embellishing the public relations image of the organization and of enhancing its reputation as a good place to work, thereby facilitating recruitment efforts.

Most of the time, the organization will cover the entire cost of the programme. Sometimes, particularly when an activity is conducted off the premises in a community-based facility, the participants are required to share its cost. In some organizations, however, all or part of the employee's portion is refunded on successful completion of the programme or course.

Many group health insurance programmes cover preventive services provided by health professionals including, for example, immunizations, medical examinations, tests, and screening procedures. Such health insurance coverage, however, presents problems: it may increase the cost of the insurance and the out-of-pocket costs of the deductible fees and co-payments usually required may constitute an effective obstacle to their use by low-salaried workers. In the last analysis, it may be less costly for employers to pay for preventive services directly, saving themselves the administrative costs of processing insurance claims and of reimbursement.

Conflicts of interest

While most health professionals exhibit exemplary integrity, vigilance must be exercised to identify and deal with those who do not. Examples include those who falsify records to make their efforts look good and those who have a relationship with an outside provider of services who provides kickbacks or other rewards for referrals. The performance of outside vendors should be monitored to identify those who underbid to win the contract and then, to save money, use poorly qualified personnel to deliver the services.

A more subtle conflict of interest exists when staff members and vendors subvert the needs and interests of employees in favor of the organization's goals or the agenda of its managers. This sort of reprehensible action may not be explicit. An example is steering troubled employees into a stress management programme without making a strenuous effort to persuade the organization to reduce inordinately high levels of stress in the workplace. Experienced professionals will have no difficulty in properly serving both the employees and the organization, but should be ready to move to a situation in which ethical values are more conscientiously observed whenever improper pressures on the part of management become too great.

Another subtle conflict that may affect employees adversely arises when a relationship of competition, rather than coordination and collaboration, develops between the health promotion programme and other health-related activities in the organization. This state of affairs is found not infrequently when they are placed in different areas of the organization chart and report to different lines of management authority. As has been said before, it is critical that, even when part of the same entity, the health promotion programme should not operate at the expense of the occupational safety and health programme.

Stress

Stress is probably the most pervasive health hazard encountered both in the workplace and away from it. In a landmark survey sponsored by the St. Paul Fire and Marine Insurance Company and involving nearly 28,000 workers in 215 diverse American organizations, Kohler and Kamp (1992) found that work stress was strongly related to employee health and performance problems. They also found that among personal life problems, those created by the job are most potent, showing more impact than purely off-the-job issues such as family, legal or financial problems. This suggests, they said, that "some workers become caught in a downward spiral of work and home life problems-problems on the job create problems at home, which in turn are taken back to work, and so on." Accordingly, while primary attention should be directed to the control of psychosocial risk factors intrinsic to the job, this should be complemented by health promotion activities aimed at personal stress factors most likely to affect work performance.

Access to health care

A subject worthy of attention in its own right, education in navigating the health care delivery system should be made part of the programme with an eye to future needs for health services. This begins with self-care-knowing what to do when signs and symptoms appear and when professional services are needed-and goes on to selecting a qualified health professional or a hospital. It also includes inculcating both the ability to distinguish good from poor health care and an awareness of patients' rights.

To save employees time and money, some in-plant medical units offer more or less extensive in-plant health services, (often including x rays, laboratory tests and other diagnostic procedures), reporting the results to the employees' personal physicians. Others maintain a roster of qualified physicians, dentists and other health professionals to whom employees themselves and sometimes also their dependants may be referred. Time off from work to keep medical appointments is an important adjunct where health professional services are not available outside of working hours.

In the United States, even where there is a good group health insurance programme, low-salaried workers and their families may find the deductible and coinsurance portions of covered charges to be barriers to procuring recommended health services in all but dire circumstances. Some employers are helping to overcome such obstacles by exempting these employees from such payments or by making special fee arrangements with their health care providers.

Worksite "climate"

Worksite health promotion programmes are presented, often explicitly, as an expression of the employer's concern for the health and well-being of the workforce. That message is contradicted when the employer is deaf to employees' complaints about working conditions and does nothing to improve them. Employees are not likely to accept or participate in programmes offered under such circumstances or at times of labour-management conflict.

Workforce diversity

The health promotion programme should be designed to accommodate to the diversity increasingly characteristic of today's workforce. Differences in ethnic and cultural background, educational levels, age and sex should be recognized in the content and presentation of health promotion activities.

Conclusion

It is clear from all of the above that the worksite health promotion programme represents an extension of the occupational safety and health programme which, when properly designed and implemented, can benefit individual employees, the workforce as a whole and the organization. In addition, it may also be a force for positive social change in the community.

Over the past few decades, worksite health promotion programmes have increased in number and comprehensiveness, in small and medium-sized organizations as well as in larger ones, and in the private, voluntary and public sectors. As demonstrated by the array of articles contained in this chapter, they have also increased in scope, expanding from direct clinical services dealing, for example, with medical examinations and immunizations, to involvement with personal and family problems whose relationship to the workplace may seem more tenuous. One should allow one's selection of programme elements and activities to be guided by the particular characteristics of the workforce, the organization and the community, keeping in mind that some will be needed only by specific cohorts of employees rather than by the population as a whole.

In considering the creation of a worksite health promotion programme, readers are advised to plan carefully, to implement incrementally, allowing room for growth and expansion, to monitor performance and programme quality and, to the extent possible, evaluate outcomes. The articles in this chapter should prove to be uniquely helpful in such an endeavour.

WORKSITE HEALTH PROMOTION

Jonathan E. Fielding

Rationale

Occupational settings are appropriate sites for the furtherance of such health-related aims as assessment, education, counselling and health promotion in general. From a public policy perspective, worksites provide an efficient locus for activities such as these, involving as they often do a far-ranging aggregation of individuals. Moreover, most workers are in a predictable work location for a significant portion of time almost every week. The worksite is usually a controlled environment, where individuals or groups can be exposed to educational programming or receive counselling without the distractions of a home setting or the often hurried atmosphere of a medical setting.

Health is an enabling function, that is to say, one that permits individuals to pursue other goals, including successful performance in their work roles. Employers have a vested interest in maximizing health because of its tight linkage with productivity at work, as to both quantity and quality. Thus, reducing the occurrence and burden of diseases that lead to absences, disability or sub-par job performance is a goal that warrants a high priority and considerable investment. Worker organizations, established to improve the welfare of members, also have an inherent interest in sponsoring programmes that can improve health status and quality of life.

Sponsorship

Sponsorship by employers usually includes full or partial financial support of the programme. However, some employers may support only planning or arranging for the actual health promotion activities for which individual workers must pay. Employer-sponsored programmes sometimes provide employee incentives for participation, programme completion, or successfully changing health habits. Incentives may include time off from work, financial rewards for participation or results, or recognition of achievement in reaching health-related goals. In unionized industries, particularly where workers are scattered among smaller workplaces too small to mount a programme, health promotion programmes may be designed and delivered by the labour organization. Although sponsorship of health education and counselling programmes by employers or worker organizations commonly involves programmes delivered at the worksite, they may take place in whole or in part at facilities in the community, whether run by government, non-profit-making or for-profit organizations.

Financial sponsorship needs to be complemented by employer commitment, on the part of top management and of middle management as well. Every employer organization has many priorities. If health promotion is to be viewed as one of these, it must be actively and visibly supported by senior management, both financially and by means of continuing to pay attention to the programme, including the emphasizing of its importance in addressing employees, stockholders, senior managers and even the outside investment community.

Confidentiality and Privacy

While employee health is an important determinant of productivity and of the vitality of work organizations, health in itself is a personal matter. An employer or worker organization that wishes to provide health education and counselling must build into the programmes procedures to ensure confidentiality and privacy. The willingness of employees to volunteer for work-related health education and counselling programmes requires that employees feel that private health information will not be revealed to others without their permission. Of particular concern to workers and their representatives is that information obtained from health improvement programmes not be utilized in any way in assessment of job performance or in managerial decisions about hiring, firing or advancement.

Needs Assessment

Programme planning usually begins with a needs assessment. An employee survey is often performed to obtain information on such matters as: (a) self-reported frequency of health habits (e.g., smoking, physical activity, nutrition), (b) other health risks such as stress, hypertension, hypercholesterolemia, and diabetes, (c) personal priorities for risk reduction and health improvement, (d) attitude toward alternative programme configurations, (e) preferred sites for health promotion programming, (f) willingness to participate in programmatic activities, and sometimes, (g) willingness to pay a portion of the cost. Surveys may also cover attitudes toward existing or potential employer policies, such as smoking bans or offering more nutritionally healthful fare in workplace vending machines or cafeterias.

The needs assessment sometimes includes analysis of the health problems of the employed group through examination of medical department clinical files, health care records, disability and worker's compensation claims, and absenteeism records. Such analyses provide general epidemiological information on the prevalence and cost of different health problems, both somatic and psychological, allowing assessment of prevention opportunities from both the programmatic and financial point of view.

Programme Structure

Results of needs assessments are considered in light of available monetary and human resources, past programme experience, regulatory requirements and the nature of the workforce. Some of the key elements of a programme plan that need to be clearly defined during a planning process are listed in figure 15.2 . One of the key decisions is identifying effective modalities to reach the target population(s). For example, for a widely dispersed workforce, community-based programming or programming via telephone and mail may be the most feasible and cost-effective choice. Another important decision is whether to include, as some programmers do, retirees and spouses and children of employees in addition to the employees themselves.

Figure 15.2 Elements of a health promotion programme plan

Responsibility for a worksite health promotion programme can fall to any of a number of pre-existing departments, including the following: the medical or employee health unit; human resources and personnel; training; administration; fitness; employee assistance and others; or a separate health promotion department may be established. This choice is often very important to programme success. A department with strong interest in doing its best for its clients, an appropriate knowledge base, good working relationships with other parts of the organization and the confidence of senior and line management has a very high likelihood of success in organizational terms. Employees' attitudes toward the department in which the programme is placed and their confidence in its integrity with particular reference to confidentiality of personal information may influence their acceptance of the programme.

Topics

The frequency with which diverse health promotion topics is addressed based on surveys of private employers with 50 or more employees is shown in figure 15.3 . A review of results from comparable surveys in 1985 and 1992 reveals substantial increases in most areas. Overall in 1985, 66% of the worksites had at least one activity, whereas in 1992, 81% had one or more. Areas with the largest increases were those to do with exercise and physical fitness, nutrition, high blood pressure and weight control. Several topic areas queried for the first time in 1992 showed relatively high frequencies, including AIDS education, cholesterol, mental health and job hazards and injury prevention. Symptomatic of the expansion of areas of interest, the 1992 survey found that 36% of worksites provided education or other programmes for abuse of alcohol and other drugs, 28% for AIDS, 10% for prevention of sexually-transmitted diseases, and 9% for prenatal education.

Figure 15.3 Health promotion information or activities offered by subject, 1985 and 1992

A broad topic category increasingly included within worksite health promotion programming (16% of worksites in 1992) is health care mediated by self-help programmes. Common to these programmes are materials that address ways in which to treat minor health problems and to apply simple rules for judging the seriousness of various signs and symptoms in order to decide whether it may be advisable to seek professional help and with what degree of urgency.

Creating better-informed consumers of health care services is an allied programme objective, and includes educating them such as how to choose a physician, what questions to ask the doctor, the pros and cons of alternative treatment strategies, how to decide whether and where to have a recommended diagnostic or therapeutic procedure, non-traditional therapies and patients' rights.

Health Assessments

Regardless of mission, size and target population, multidimensional assessments of health are commonly administered to participating employees during the initial stages of the programme and at periodic intervals thereafter. Data systematically collected usually cover health habits, health status, simple physiological measures, such as blood pressure and lipid profile, and (less commonly) health attitudes, the social dimensions of health, the use of preventive services, safety practices and family history. Computerized outputs, fed back to individual employees and aggregated for programme planning, monitoring and evaluation, usually provide some absolute or relative risk estimates, which range from the absolute risk of having a heart attack during the ensuing ten-year period (or how an individual's quantifiable risk of having a heart attack compares to the average risk for individuals of the same age and sex) to qualitative ratings of health and risks on a scale from poor to excellent. Individual recommendations are also commonly provided. For example, regular physical activity would be recommended for sedentary individuals, and more social contacts for an individual without frequent contact with family or friends.

Health assessments may be systematically offered at the time of hire or in association with specific programmes, and thereafter at fixed intervals or with periodicity defined by age, sex and health risk status.

Counselling

Another common element of most programmes is counselling to effect changes in such deleterious health habits as smoking, poor nutritional practices or high-risk sexual behaviour. Effective methods exist to assist individuals to increase their motivation and readiness to make changes in their health habits, to help them along in the actual process of making changes, and to minimize backsliding, often termed recidivism. Group sessions led by a health professional or lay person with special training are often used to help individuals make changes, while the peer support to be found in the workplace can enhance results in areas such as smoking cessation or physical activity.

Health education for workers may include topics that can positively influence the health of other family members. For example, education might include programming on healthy pregnancy, the importance of breast feeding, parenting skills, and how to effectively cope with the health care and related needs of older relatives. Effective counselling avoids stigmatizing programme participants who have difficulty making changes or who decide against making recommended lifestyle changes.

Workers with Special Needs

A significant proportion of a working population, particularly if it includes many older workers, will have one or more chronic conditions, such as diabetes, arthritis, depression, asthma or low back pain. In addition, a substantial subpopulation will be considered at high risk for a serious future health problem, for example cardiovascular disease due to elevation of risk factors such as total serum cholesterol, high blood pressure, smoking, significant obesity or high levels of stress.

These populations may account for a disproportionate amount of health services utilization, health benefits costs and lost productivity, but these effects can be attenuated through prevention efforts. Therefore, education and counselling programmes targeted at these conditions and risks have become increasingly common. Such programmes often utilize a specially trained nurse (or less commonly, a health educator or nutritionist) to help these individuals make and maintain necessary behavioural changes and work more closely with their primary care physician to utilize appropriate medical measures, especially as regards the use of pharmaceutical agents.

Programme Providers

Providers of employer-sponsored or worker-sponsored health promotion programming are varied. In larger organizations, particularly with significant geographic concentrations of employees, existing full- or part-time personnel may be the principal programme staff-nurses, health educators, psychologists, exercise physiologists and others. Staffing can also come from outside providers, individual consultants or organizations providing personnel in a wide range of disciplines. Organizations offering these services include hospitals, voluntary organizations (e.g., the American Heart Association); for-profit health promotion companies offering health screening, fitness, stress management, nutrition and other programmes; and managed care organizations. Programme materials may also come from any of these sources or they may be developed internally. Worker organizations sometimes develop their own programmes for their members, or may provide some health promotion services in partnership with the employer.

Many education and training programmes have been established to prepare both students and health professionals to plan, implement and evaluate worksite health promotion programmes. Many universities offer courses in these subjects and some have a special "worksite health promotion" major or area of specialization. A large number of continuing education courses on how to work in a corporate setting, programme management and advances in techniques are offered by public and private educational institutions as well as professional organizations. To be effective, providers must understand the specific context, constraints and attitudes associated with employment settings. In planning and implementing programmes they should take into account policies specific to the type of employment and worksite, as well as the relevant labour relations issues, work schedules, formal and informal organizational structures, not to mention the corporate culture, norms and expectations.

Technology

Applicable technologies range from self-help materials that include traditional books, pamphlets, audiotapes or videotapes to programmed learning software and interactive videodiscs. Most programmes involve interpersonal contact through groups such as classes, conferences and seminars or through individual education and counselling with an onsite provider, by telephone or even via computer link. Self-help groups may also be utilized.

Computer-based data collection systems are essential for programme efficiency, serving a variety of management functions-budgeting and use of resources, scheduling, individual tracking, and both process and outcome evaluation. Other technologies could include such sophisticated modalities as a direct bio-computer linkage to record physiological measures-blood pressure or visual acuity for instance-or even the subject's participation in the programme itself (e.g., attendance at a fitness facility). Hand-held computer-based learning aids are being tested to assess their ability to enhance behavioural change.

Evaluation

Evaluation efforts run the gamut from anecdotal comments from employees to complex methodologies that justify publication in peer-reviewed journals. Evaluations may be directed towards a wide variety of processes and outcomes. For example, a process evaluation could assess how the programme was implemented, how many employees participated and what they thought of it. Outcome evaluations may target changes in health status, such as the frequency or level of a health risk factor, whether self-reported (e.g., level of exercise) or objectively evaluated (e.g., hypertension). An evaluation may focus upon economic changes such as the use and cost of health care services or upon absenteeism or disability, whether this may be related to the job or not.

Evaluations may cover only programme participants or they may cover all at-risk employees. The former sort of evaluation can answer questions relating to the efficacy of a given intervention but the latter answers the more important question as to the effectiveness with which risk factors in an entire population may have been reduced. While many evaluations focus on efforts to change a single risk factor, others address the simultaneous effects of multicomponent interventions. A review of 48 published studies assessing outcomes of comprehensive health promotion and disease prevention in the worksite found that 47 reported one or more positive health outcomes (Pelletier 1991). Many of these studies have significant weaknesses in design, methodology or analysis. Nonetheless, their near-unanimity with respect to positive findings, and the optimistic results of the best designed studies, suggest that real effects are in the desired direction. What is less clear is the reproducibility of effects in replicated programmes, how long the initially observed effects endure, and whether their statistical significance translates into clinical significance. In addition, evidence of effectiveness is much stronger for some risk factors, such as smoking and hypertension, than for physical activity, nutritional practices and mental health factors, including stress.

Trends

Worksite health promotion programmes are expanding beyond the traditional topics of controlling alcohol and drug abuse, nutrition, weight control, smoking cessation, exercise and stress management. Today, activities generally cover a wider variety of health topics, ranging from healthy pregnancy or the menopause to living with chronic health conditions such as arthritis, depression or diabetes. Increased emphasis is being placed on aspects of good mental health. For example, under the rubric of employer-sponsored programmes may appear courses or other activities such as "improving interpersonal communications", "building self-esteem", "improving personal productivity at work and home", or "overcoming depression".

Another trend is to provide a wider range of health information and counselling opportunities. Individual and group counselling may be supplemented with peer counselling, computer-based learning, and use of interactive videodiscs. Recognition of multiple learning styles has led to a broader array of delivery modes to increase efficiency with a better match between individual learning styles and preferences and instructional approaches. Offering this diversity of approaches allows individuals to choose the setting, intensity and educational form that best fits their learning habits.

Today, health education and counselling are being increasingly offered to employees of larger organizations, including those who may work at distant locations with few co-workers and those that work at home. Delivery via mail and phone, when possible, can facilitate this broader reach. The advantage of these modes of programme delivery is greater equity, with field staff employees not disadvantaged compared to their home office counterparts. One cost of greater equity is sometimes reduced interpersonal contact with health professionals on health promotion issues.

Healthy Policies

Recognition is increasing that organizational policy and social norms are important determinants of health and of the effectiveness of health improvement efforts. For example, limiting or banning smoking at the workplace can yield substantial declines in per capita cigarette consumption among smoking workers. A policy that alcoholic beverages will not be served at company functions lays out behavioural expectations for employees. Providing food that is low in fat and high in complex carbohydrates in the company cafeteria is another opportunity to help employees improve their health.

However, there is also concern that healthful organizational policies or expressed social normative beliefs about what constitutes good health may stigmatize individuals who wish to engage in certain unhealthy habits, such as smoking, or those who have a strong genetic predisposition to an unhealthy state, such as obesity. It is not surprising that most programmes have higher participation rates by employees with "healthy" habits and lower risks.

Integration with Other Programmes

The promotion of health has many facets. It appears that growing efforts are being made to seek a closer integration among health education and counselling, ergonomics, employee assistance programmes, and particular health-oriented benefits like screening and fitness plans. In countries where employers can design their own health benefit plans or can supplement a government plan with defined benefits, many are offering clinical preventive services benefits, particularly screening and health-enhancing benefits such as membership in community health and fitness facilities. Tax policies that permit employers to deduct these employee benefits from taxes provide strong financial incentives for their adoption.

Ergonomic design is an important determinant of worker health and involves more than just the physical fit of the employee to the tools employed on the job. Attention should be directed to the overall fit of the individual to his or her tasks and to the overall working environment. For example, a healthful job environment requires a good match between job autonomy and responsibility and effective adaptations among individual work style, family needs and the flexibility of work requirements. Nor should the relationship between work stresses and individual coping capacities be left out of this account. In addition, health can be promoted by having workers, individually and in groups, help mould job content in ways that contribute to feelings of self-efficacy and achievement.

Employee assistance programmes, which generically speaking include employer-sponsored professionally directed activities that provide assessment, counselling and referral to any employee for personal problems, should have close ties with other health promoting programmes, functioning as a referral source for the depressed, the overstressed and the preoccupied. In return, employee assistance programmes can refer appropriate workers to employer-sponsored stress management programmes, to physical fitness programmes that help relieve depression, to nutritional programmes for those overweight, underweight, or simply with bad nutrition, and to self-help groups for those who lack social support.

Conclusion

Worksite health promotion has come of age owing largely to incentives for employer investment, positive reported results for most programmes, and increasing acceptance of worksite health promotion as an essential part of a comprehensive benefit plan. Its scope has broadened considerably, reflecting a more encompassing definition of health and an understanding of the determinants of individual and family health.

Well-developed approaches to programme planning and implementation exist, as does a cadre of well-trained health professionals to staff programmes and a wide variety of materials and delivery vehicles. Programme success depends on individualizing any programme to the corporate culture and to the health promotion opportunities and organizational constraints of a particular worksite. Results of most evaluations have supported movement toward stated programme objectives, but more evaluations using scientifically valid designs and methods are needed.

HEALTH PROMOTION IN THE WORKPLACE: ENGLAND

Leon Kreitzman

In its Health of the Nation policy declaration, the government of the United Kingdom subscribed to the twin strategy (to paraphrase their statement of aims) of (1) "adding years to life" by seeking an increase in life expectancy and a reduction in premature death, and (2) "adding life to years" by increasing the number of years lived free from ill-health, by reducing or minimizing the adverse effects of illness and disability, by promoting healthy lifestyles and by improving physical and social environments-in short, by improving the quality of life.

It was felt that efforts to achieve these aims would be more successful if they were exerted in already existent "settings", namely schools, homes, hospitals and workplaces.

While it was known that there was considerable health promotion activity at the workplace (European Foundation 1991), no comprehensive baseline information existed on the level and nature of workplace health promotion. Various small-scale surveys had been conducted, but these had all been limited in one way or another, either by being concentrated on a single activity such as smoking, or restricted to a small geographical area or based on a small number of workplaces.

A comprehensive survey of workplace health promotion in England was undertaken on behalf of the Health Education Authority. Two models were used to develop the survey: the 1985 US National Survey of Worksite Health Promotion (Fielding and Piserchia 1989) and a 1984 survey carried out by the Policy Studies Institute of Workplaces in Britain (Daniel 1987).

The survey

There are over 2,000,000 workplaces in England (the workplace is defined as a geographically contiguous setting). The distribution is enormously skewed: 88% of workplaces employ fewer than 25 people onsite and cover about 30% of the workforce; only 0.3% of workplaces employ more than 500 people, yet these few very large sites account for some 20% of total employees.

The survey was originally structured to reflect this distribution by over-sampling the larger worksites in a random sample of all workplaces, including both the public and private sectors and all sizes of workplace; however, those who were self-employed and were working from home were excepted from the survey. The only other exclusions were various public bodies such as defence establishments, police and prison services.

In total 1,344 workplaces were surveyed in March and April of 1992. Interviewing was carried out by telephone, with the average completed interview taking 28 minutes. Interviews were held with whatever person was responsible for health-related activities. At smaller workplaces, this was seldom someone with a health specialization.

Findings of the survey

Figure 15.4  shows the spontaneous response to the inquiry as to whether any health-related activities had been undertaken in the past year and the marked size relationship to type of respondent.

Figure 15.4 Whether any health-related activities were undertaken in last 12 months

A succession of spontaneous questions, and questions that were prompted in the course of interviewing, elicited from respondents considerably more information as to the extent and nature of health-related activities. The range of activities and incidence of such activity is shown in table 15.1 . Some of the activities, such as job satisfaction (understood in England as a catch-all term covering such aspects as responsibility for both the pace and content of the work, self-esteem, management-worker relationships and skills and training) are normally regarded as outside the scope of health promotion, but there are commentators who believe that such structural factors are of great importance in improving health.

Table 15.1 Range of health-related activities by size of workforce

 

Size of workforce (activity in %)

 

All

1-24

25-99

100-499

500+

Smoking and tobacco

31

29

42

61

81

Alcohol and sensible drinking

14

13

21

30

46

Diet

6

5

13

26

47

Healthy catering

5

4

13

30

45

Stress management

9

7

14

111

32

HIV/AIDS and sexual health practices

9

7

16

26

42

Weight control

3

2

4

12

30

Exercise and fitness

6

5

10

20

37

Heart health and heart disease-related activities

4

2

9

18

43

Breast screening

3

2

4

15

29

Cervical screening

3

2

5

12

23

Health screening

5

4

10

29

54

Lifestyle assessment

3

2

2

5

21

Cholesterol testing

4

3

5

11

24

Blood pressure control

4

3

9

16

44

Drugs and alcohol abuse-related activities

5

4

13

14

28

Women's health-related activities

4

4

6

14

30

Men's health-related activities

2

2

5

9

32

Repetitive strain injury avoidance

4

3

10

23

47

Back care

9

8

17

25

46

Eyesight

5

4

12

27

56

Hearing

4

3

8

18

44

Desk and office layout design

9

8

16

23

45

Interior ventilation andlighting

16

14

26

38

46

Job satisfaction

18

14

25

25

32

Noise

8

6

17

33

48

Unweighted base = 1,344.

Other matters that were investigated included the decision-making process, budgets, workforce consultation, awareness of information and advice, benefits of health promotion activity to employer and employee, difficulties in implementation, and perception of the importance of health promotion. There are several general points to make:

1.     Overall, 40% of all workplaces undertook at least one major health related activity in the previous year. Apart from activity on smoking in workplaces with more than 100 employees, no single health promotion activity occurs in a majority of workplaces ranked by size.

2.     In small workplaces the only direct health promoting activities of any significance are for smoking and alcohol. Even then, both are of minority incidence (29% and 13%).

3.     The immediate physical environment, reflected in such factors as ventilation and lighting, are considered to be substantively health related, as is job satisfaction. However, these are mentioned by less than 25% of workplaces with under 100 employees.

4.     As the workplace increases in size, it is not just that a higher percentage of workplaces undertake any activity, there is also a wider range of activity in any one workplace. This is shown in figure 15.5 , which illustrates the likelihood of one or more of the major programmes. Only 9% of the largest workplaces have no programme at all and over 50% have at least three. In the smallest workplaces, only 19% have two or more programmes. In between, 35% of 25-99 workplaces have two or more programmes, while 56% of 100-499 workplaces have two or more programmes and 33% have three or more. However, it would be too much to read into these figures any semblance of what might be called a "healthy workplace". Even if such a workplace were defined as one with 5+ programmes in place, there needs to a be an evaluation of the nature and intensity of the programme. In-depth interviewing suggests that in very few instances is the health activity integrated into a planned health promotion function and in even fewer cases, if any, is there modification of either the practices or objectives of the workplace to increase the emphasis on health enhancement.

Figure 15.5 Likelihood of number of major health promotion programmes, by size of workforce

5.     After smoking programmes, which get an 81% incidence in the largest workplaces, and alcohol, the next highest incidences are for eyesight testing, health screening and back care.

6.     Breast and cervical screening have a low incidence, even in workplaces with 60%+ of female employees (see table 15.2).

Table 15.2 Participation rates in breast and cervical cancer screening  (spontaneous and prompted) by percentage of female workforce

 

Percentage of the workforce that is female

 

More than 60%

Less than 60%

Breast screening

4%

2%

Cervical screening

4%

2%

Unweighted base = 1,344.

7.     Public sector workplaces show double the level of incidence for activities of those in the private sector. This holds across all the activities

8.     In regard to smoking and alcohol, foreign-owned companies have a higher incidence of workplace activity than British ones. However, the differential is relatively minor in most activities apart from health screening (15% against 5%) and the concomitant activities such as cholesterol and blood pressure.

9.     Only in the public sector is there a significant involvement in HIV/AIDS activity. In most of the activities the public sector outperforms the other industry sectors with the notable exception of alcohol.

10.     Workplaces which have no health promotion activity are virtually all small or medium-size in the private sector, British-owned and predominantly in the distribution and catering industries.

Discussion

The quantitative telephone survey and the parallel face-to-face interviewing revealed a considerable amount of information as to the level of health promotion activity at the workplace in England.

In a study of this nature, it is not possible to untangle all the confounding variables. However, it would seem that size of workplace, in terms of number of employees, public as opposed to private ownership, levels of unionization, and the nature of the work itself are important factors.

Communication of health promotion messages is largely through group methods such as posters, leaflets or videos. In larger workplaces there is a far greater likelihood of individual counselling being available, particularly for things like smoking cessation, alcohol problems and stress management. It is clear from the research methods used that health promotion activities are not "embedded" in the workplace and are highly contingent activities which, in the large majority of cases, are dependent for effectiveness on individuals. To date, health promotion has not made out the necessary cost/benefit base for its implementation. Such a cost/benefit calculation need not be a detailed and sophisticated analysis but simply an indication that it is of value. Such an indication may be of great benefit in persuading more private sector workplaces to increase their activity levels. There are very few of what might be termed "healthy workplaces". In very few instances is the health promotion activity integrated into a planned health promotion function and in even fewer cases, if any, is there modification of either the practice or objectives of the workplace to increase emphasis on health enhancement.

Conclusion

Health promotion activities seem to be increasing, with 37% of respondents claiming that such activity had increased in the previous year. Health promotion is considered to be an important issue, with even 41% of small workplaces saying it was very important. Considerable benefits to employee health and fitness were ascribed to health promotion activities, as was reduced absenteeism and sickness.

However, there is little formal evaluation, and while written policies have been introduced, they are by no means universal. While there is support for the aims of health promotion and positive advantages are perceived, there is yet too little evidence of institutionalization of the activities into the culture of the workplace. Workplace health promotion in England seems to be contingent and vulnerable.

HEALTH PROMOTION IN SMALL ORGANIZATIONS: THE US EXPERIENCE

Sonia Muchnick-Baku and Leon J. Warshaw

The rationale for worksite health promotion and protection programmes and approaches to their implementation have been discussed in other articles in this chapter. The greatest activity in these initiatives has taken place in large organizations that have the resources to implement comprehensive programmes. However, the majority of the workforce is employed in small organizations where the health and well-being of individual workers is likely to have a greater impact on productive capacity and, ultimately, the success of the enterprise. Recognizing this, small firms have begun to pay more attention to the relationship between preventive health practices and productive, vital employees. Increasing numbers of small firms are finding that, with the help of business coalitions, community resources, public and voluntary health agencies, and creative, modest strategies designed to meet their specific needs, they can implement successful yet low-cost programmes that yield significant benefits.

Over the last decade, the number of health promotion programmes in small organizations has increased significantly. This trend is important as regards both the progress it represents in worksite health promotion and its implication for the nation's future health care agenda. This article will explore some of the varied challenges faced by small organizations in implementing these programmes and describe some of the strategies adopted by those who have overcome them. It is derived in part from a 1992 paper generated by a symposium on small business and health promotion sponsored by the Washington Business Group on Health, the Office of Disease Prevention of the US Public Health Service and the US Small Business Administration (Muchnick-Baku and Orrick 1992). By way of example, it will highlight some organizations that are succeeding through ingenuity and determination in implementing effective programmes with limited resources.

Perceived Barriers to Small Business Programmes

While many owners of small firms are supportive of the concept of worksite health promotion, they may hesitate to implement a programme in the face of the following perceived barriers (Muchnick-Baku and Orrick 1992):

·     "It's too costly." A common misconception is that worksite health promotion is too costly for a small business. However, some firms provide programmes by making creative use of free or low-cost community resources. For example, the New York Business Group on Health, a health-action coalition with over 250 member organizations in the New York City Metropolitan Area regularly offered a workshop entitled Wellness On a Shoe String that was aimed primarily at small businesses and highlighted materials available at little or no cost from local health agencies.

·     "It's too complicated." Another fallacy is that health promotion programmes are too elaborate to fit into the structure of the average small business. However, small firms can begin their efforts very modestly and gradually make them more comprehensive as additional needs are recognized. This is illustrated by Sani-Dairy, a small business in Johnstown, Pennsylvania, that began with a home-grown monthly health promotion publication for employees and their families produced by four employees as an " extracurricular" activity in addition to their regular duties. Then, they began to plan various health promotion events throughout the year. Unlike many small businesses of this size, Sani-Dairy emphasizes disease prevention in its medical programme.  Small companies can also reduce the complexity of health promotion programmes by offering health promotion services less frequently than larger companies. Newsletters and health education materials can be distributed quarterly instead of monthly; a more limited number of health seminars can be held at appropriate seasons of the year or linked to annual national campaigns such as Heart Month, the Great American Smoke Out or Cancer Prevention Week in the United States.

·     "It hasn't been proven that the programmes work." Small businesses simply do not have the time or the resources to do formal cost-benefit analyses of their health promotion programmes. They are forced to rely on anecdotal experience (which may often be misleading) or on inference from the research done in large-firm settings. "What we try to do is learn from the bigger companies," says Shawn Connors, President of The International Health Awareness Center, "and we extrapolate their information. When they show that they're saving money, we believe the same thing is happening to us." While much of the published research attempting to validate the effectiveness of health promotion is flawed, Pelletier has found ample evidence in the literature to confirm impressions of its value (Pelletier 1991 and 1993).

·     "We don't have the expertise to design a programme." While this is true for most managers of small businesses, it need not present a barrier. Many of the governmental and voluntary health agencies provide free or low-cost kits with detailed instructions and sample materials (see figure 15.6) for presenting a health promotion programme. In addition, many offer expert advice and consulting services. Finally, in most larger communities and many universities, there are qualified consultants with whom one may negotiate short-term contracts for relatively modest fees covering onsite help in tailoring a particular health promotion programme to the needs and circumstances of a small business and guiding its implementation.

Figure 15.6 Examples of "do-it-yourself" kits for worksite health promotion programmes  in the United States

·     "We're not big enough-we don't have the space." This is true for most small organizations but it need not stop a good programme. The employer can "buy into" programmes offered in the neighborhood by local hospitals, voluntary health agencies, medical groups and community organizations by subsidizing all or part of any fees that are not covered by the group health insurance plan. Many of these activities are available outside of working hours in the evening or on weekends, obviating the necessity of releasing participating employees from the workplace.

Advantages of the Small Worksite

While small businesses do face significant challenges related to financial and administrative resources, they also have advantages. These include (Muchnick-Baku and Orrick 1992):

·     Family orientation. The smaller the organization, the more likely it is that employers know their employees and their families. This can facilitate health promotion becoming a corporate-family affair building bonds while promoting health.

·     Common work cultures. Small organizations have less diversity among employees than do larger organizations, making it easier to develop more cohesive programmes.

·     Interdependency of employees. Members of small units are more dependent on each other. An employee absent because of illness, particularly if prolonged, means a significant loss of productivity and imposes a burden on co-workers. At the same time, the closeness of members of the unit makes peer pressure a more effective stimulant to participation in health promotion activities.

·     Approachability of top management. In a smaller organization, management is more accessible, more familiar with the employees and more likely to be aware of their personal problems and needs. Furthermore, the smaller the organization, the more promptly the owner/chief operating officer is likely to become directly involved in making decisions about new programme activities, without the often stultifying effects of the bureaucracy found in most large organizations. In a small firm, that key person is more apt to provide the top-level support so vital to the success of worksite health promotion programmes.

·     Effective use of resources. Because they are usually so limited, small businesses tend to be more efficient in the use of their resources. They are more likely to turn to community resources such as voluntary, government and entrepreneurial health and social agencies, hospitals and schools for inexpensive means of providing information and education to employees and their families (see figure 15.6).

Health Insurance and Health Promotion in Small Businesses

The smaller the firm, the less likely it is to provide group health insurance to employees and their dependants. It is difficult for an employer to claim concern for employees' health as a basis for offering health promotion activities when basic health insurance is not made available. Even when it is made accessible, exigencies of cost restrict many small businesses to "bare bones" health insurance programmes with very limited coverage.

On the other hand, many group plans do cover periodic medical examinations, mammography, Pap smears, immunizations and well baby/child care. Unfortunately, the out-of-pocket cost of covering the deductible fees and co-payments required before insured benefits are payable often acts as a deterrent to using these preventive services. To overcome this, some employers have arranged to reimburse employees for all or part of these expenditures; others find it less troublesome and costly simply to pay for them as an operating expense.

In addition to including preventive services in their coverage, some health insurance carriers offer health promotion programmes to group policy holders usually for a fee but sometimes without extra charges. These programmes generally focus on printed and audio-visual materials, but some are more comprehensive. Some are particularly suitable for small businesses.

In a growing number of areas, businesses and other types of organizations have formed "health-action" coalitions to develop information and understanding as well as responses to the health-related problems besetting them and their communities. Many of these coalitions provide their members with assistance in designing and implementing worksite health promotion programmes. In addition, wellness councils have been appearing in a growing number of communities where they encourage the implementation of worksite as well as community-wide health promotion activities.

Suggestions for Small Businesses

The following suggestions will help to ensure the successful initiation and operation of a health promotion programme in a small business:

·     Integrate the programme with other company activities. The programme will be more effective and less expensive when it is integrated with the employee group health insurance and benefit plans, the labour relations policies and the corporate environment, and the company's business strategy. Most important, it must be coordinated with the company's occupational and environmental health and safety policies and practices.

·     Analyse cost data for both employees and the company. What employees want, what they need, and what the company can afford can be vastly different. The company must be able to allocate the resources required for the programme in terms of both the financial outlays and the time and effort of employees involved. It would be futile to launch a programme that could not be continued for lack of resources. At the same time, budget projections should include increases in resource allocations to cover expansion of the programme as it takes hold and grows.

·     Involve employees and their representatives. A cross-section of the workforce-i.e., top management, supervisors and rank-and-file workers-should be involved in designing, implementing and evaluating the programme. Where there is a labour union, its leadership and shop stewards should be similarly involved. Often an invitation to co-sponsor the programme will defuse a union's latent opposition to company programmes intended to enhance employee welfare if that exists; it may also serve to stimulate the union to work for replication of the programme by other companies in the same industry or area.

·     Involve employees' spouses and dependants. Health habits usually are characteristics of the family. Educational materials should be addressed to the home and, to the extent possible, employees' spouses and other family members should be encouraged to participate in the activities.

·     Obtain top management's endorsement and participation. The company's top executives should publicly endorse the programme and confirm its value by actually participating in some of the activities.

·     Collaborate with other organizations. Wherever possible, achieve economies of scale by joining forces with other local organizations, using community facilities, etc.

·     Keep personal information confidential. Make a point of keeping personal information about health problems, test results and even participation in particular activities out of personnel files and obviate potential stigmatization by keeping it confidential.

·     Give the programme a positive theme and keep changing it. Give the programme a high profile and publicize its objectives widely. Without dropping any useful activities, change the programme's emphasis to generate new interest and to avoid appearing stagnant. One way to accomplish this is to "piggy back" on national and community programmes such as National Heart Month and Diabetes Week in the United States.

·     Make it easy to be involved. Activities that cannot be accommodated at the worksite should be located at convenient locations nearby in the community. When it is not feasible to schedule them during working hours, they may be held during the lunch hour or at the end of a work shift; for some activities, evenings or weekends may be more convenient.

·     Consider offering incentives and awards. Commonly used incentives to encourage programme participation and recognize achievements include released time, partial or 100% rebates of any fees, reduction in employee's contribution to group health insurance plan premiums ("risk-rated" health insurance), gift certificates from local merchants, modest prizes such as T-shirts, inexpensive watches or jewelry, use of a preferred parking space, and recognition in company newsletters or on worksite bulletin boards.

·     Evaluate the programme. The numbers of participants and their drop-out rates will demonstrate the acceptability of particular activities. Measurable changes such as smoking cessation, loss or gain of weight, lower levels of blood pressure or cholesterol, indices of physical fitness, etc., can be used to appraise their effectiveness. Periodic employee surveys can be used to assess attitudes toward the programme and elicit suggestions for improvement. And review of such data as absenteeism, turnover, appraisal of changes in quantity and quality of production, and utilization of health care benefits may demonstrate the value of the programme to the organization.

Conclusion

Although there are significant challenges to be overcome, they are not insurmountable. Health promotion programmes may be no less, and sometimes even more, valuable in small organizations than in larger ones. Although valid data are difficult to come by, it may be expected that they will yield similar returns of improvement with regard to employee health, well-being, morale and productivity. To achieve these with resources that are often limited requires careful planning and implementation, the endorsement and support of top executives, the involvement of employees and their representatives, the integration of the health promotion programme with the organization's health and safety policies and practices, a health care insurance plan and appropriate labour-management policies and agreements, and utilization of free or low-cost materials and services available in the community.

ROLE OF THE EMPLOYEE HEALTH SERVICE IN PREVENTIVE PROGRAMMES

John W.F. Cowell

The primary functions of the employee health service are treatment of acute injuries and illnesses occurring in the workplace, conducting fitness-to-work examinations (Cowell 1986) and the prevention, detection and treatment of work-related injuries and illnesses. However, it may also play a significant role in preventive and health maintenance programmes. In this article, particular attention will be paid to the "hands on" services that this corporate unit may provide in this connection.

Since its inception, the employee health unit has served as a focal point for prevention of non-occupational health problems. Traditional activities have included distribution of health education materials; the production of health promotion articles by staff members for publication in company periodicals; and, perhaps most important, seeing to it that occupational physicians and nurses remain alert to the advisability of preventive health counselling in the course of encounters with employees with incidentally observed potential or emerging health problems. Periodic health surveillance examinations for potential effects of occupational hazards have frequently demonstrated an incipient or early non-occupational health problem.

The medical director is strategically situated to play a central role in the organization's preventive programmes. Significant advantages attaching to this position include the opportunity to build preventive components into work-related services, the generally high regard of employees, and already established relationships with high-level managers through which desirable changes in work structure and environment can be implemented and the resources for an effective prevention programme obtained.

In some instances, non-occupational preventive programmes are placed elsewhere in the organization, for example, in the personnel or human resources departments. This is generally unwise but may be necessary when, for example, these programmes are provided by different outside contractors. Where such separation does exist, there should at least be coordination and close collaboration with the employee health service.

Depending upon the nature and location of the worksite and the organization's commitment to prevention, these services may be very comprehensive, covering virtually all aspects of health care, or they may be quite minimal, providing only limited health information materials. Comprehensive programmes are desirable when the worksite is located in an isolated area where community-based services are lacking; in such situations, the employer must provide extensive health care services, often to employees' dependants as well, to attract and retain a loyal, healthy and productive workforce. The other end of the spectrum is usually found in situations where there is a strong community-based health care system or where the organization is small, poorly resourced or, regardless of size, indifferent to the health and welfare of the workforce.

In what follows, neither of these extremes will be the subject of consideration; instead, attention will be focussed on the more common and desirable situation where the activities and programmes provided by the employee health unit complement and supplement services provided in the community.

Organization of Preventive Services

Typically, worksite preventive services include health education and training, periodic health assessments and examinations, screening programmes for particular health problems, and health counselling.

Participation in any of these activities should be viewed as voluntary, and any individual findings and recommendations must be held confidential between the employee health staff and the employee, although, with the consent of the employee, reports may be forwarded to his or her personal physician. To operate otherwise is to preclude any programme from ever being truly effective. Hard lessons have been learned and are continuing to be learned about the importance of such considerations. Programmes which do not enjoy employees' credibility and trust will have no or only half-hearted participation. And if the programmes are perceived as being offered by management in some self-serving or manipulative way, they have little chance of achieving any good.

Worksite preventive health services ideally are provided by staff attached to the employee health unit, often in collaboration with an in-house employee education department (where one exists). When the staff lacks time or the necessary expertise or when special equipment is required (e.g., with mammography), the services may be obtained by contracting with an outside provider. Reflecting the peculiarities of some organizations, such contracts are sometimes arranged by a manager outside the employee health unit-this is often the case in decentralized organizations when such service contracts are negotiated with community-based providers by the local plant managers. However, it is desirable that the medical director be responsible for setting out the framework of the contract, verifying the capabilities of potential providers and monitoring their performance. In such instances, while aggregate reports may be provided to management, individual results should be forwarded to and retained by the employee health service or maintained in sequestered confidential files by the contractor. At no time should such health information be allowed to form part of the employee's human resources file. One of the great advantages of having an occupational health unit is not only being able to keep health records separate from other company records under the supervision of an occupational health professional but, also, the opportunity to use this information as the basis of a discreet follow-up to be sure that important medical recommendations are not ignored. Ideally, the employee health unit, where possible in concert with the employee's personal physician, will provide or oversee the provision of recommended diagnostic or therapeutic services. Other members of the employee health service staff, such as physical therapists, massage therapists, exercise specialists, nutritionists, psychologists and health counsellors will also lend their special expertise as required.

The health promotion and protection activities of the employee health unit must complement its primary role of preventing and handling work-related injury and illness. When properly introduced and managed, they will greatly enhance the basic occupational health and safety programme but at no time should they displace or dominate it. Placing responsibility for the preventive health services in the employee health unit will facilitate the seamless integration of both programmes and make for optimal utilization of critical resources.

Programme Elements

Education and training

The goal here is informing and motivating employees-and their dependants-to select and maintain a healthier lifestyle. The intent is to empower the employees to change their own health behaviour so they will live longer, healthier, more productive and enjoyable lives.

A variety of communication techniques and presentation styles may be used. A series of attractive, easy-to-read pamphlets can be very useful where there are budget constraints. They may be offered in waiting-room racks, distributed by company mail, or mailed to employees' homes. They are perhaps most useful when handed to the employee as a particular health issue is being discussed. The medical director or the person directing the preventive programme must take pains to be sure that their content is accurate, relevant and presented in language and terms understood by the employees (separate editions may be required for different cohorts of a diverse workforce).

In-plant meetings may be arranged for presentations by employee health staff or invited speakers on health topics of interest. "Brown bag" lunch hour meetings (i.e., employees bring picnic lunches to the meeting and eat while they listen) are a popular mechanism for holding such meetings without interfering with work schedules. Small interactive focus groups led by a well-informed health professional are especially beneficial for workers sharing a particular health problem; peer pressure often constitutes a powerful motivation for compliance with health recommendations. One-on-one counselling, of course, is excellent but very labour-intensive and should be reserved for special situations only. However, access to a source of reliable information should always be available to employees who may have questions.

Topics may include smoking cessation, stress management, alcohol and drug consumption, nutrition and weight control, immunizations, travel advice and sexually-transmitted diseases. Special emphasis is often given to controlling such risk factors for cardiovascular and heart disease as hypertension and abnormal blood lipid patterns. Other topics often covered include cancer, diabetes, allergies, self-care for common minor ailments, and safety in the home and on the road.

Certain topics lend themselves to active demonstration and participation. These include training in cardiopulmonary resuscitation, first aid training, exercises to prevent repetitive strain and back pain, relaxation exercises, and self-defence instruction, especially popular among women.

Finally, periodic health fairs with exhibits by local voluntary health agencies and booths offering mass screening procedures are a popular way of generating excitement and interest.

Periodic medical examinations

In addition to the required or recommended periodic health surveillance examinations for employees exposed to particular work or environmental hazards, many employee health units offer more or less comprehensive periodic medical check-ups. Where personnel and equipment resources are limited, arrangements may be made to have them performed, often at the employer's expense, by local facilities or in private physicians' offices (i.e., by contractors). For worksites in communities where such services are not available, arrangements may be made for a vendor to bring a mobile examination unit into the plant or set up examination vans in the parking area.

Originally, in most organizations, these examinations were made available only to executives and senior managers. In some, they were extended down into the ranks to employees who had rendered a required number of years of service or who had a known medical problem. They frequently included a complete medical history and physical examination supplemented by an extensive battery of laboratory tests, x-ray examinations, electrocardiograms and stress tests, and exploration of all available body orifices. As long as the company was willing to pay their fees, examination facilities with an entrepreneurial bent were quick to add tests as new technology became available. In organizations prepared to offer even more elaborate service, the examinations were provided as part of a short stay at a popular health resort. While they often turned up important and useful findings, false positives were also frequent and, to say the least, examinations conducted in these surroundings were expensive.

In recent decades, reflecting growing economic pressures, a trend toward egalitarianism and, particularly, the marshalling of evidence regarding the advisability and utility of the different elements in these examinations, have led to their being simultaneously made more widely available in the workforce and less comprehensive.

The US Preventive Services Task Force published an assessment of the effectiveness of 169 preventive interventions (1989). Figure 15.7  presents a useful lifetime schedule of preventive examinations and tests for healthy adults in low-risk managerial positions (Guidotti, Cowell and Jamieson 1989) Thanks to such efforts, periodic medical examinations are becoming less costly and more efficient.

Figure 15.7 Lifetime health monitoring programme

Periodic health screening

These programmes are designed to detect as early as possible health conditions or actual disease processes which are amenable to early intervention for cure or control and to detect early signs and symptoms associated with poor lifestyle habits, which if changed will prevent or delay the occurrence of disease or premature aging.

The focus is usually towards cardiorespiratory, metabolic (diabetes) and musculoskeletal conditions (back, repetitive strain), and early cancer detection (colorectal, lung, uterus and breast).

Some organizations offer a periodic health risk appraisal (HRA) in the form of a questionnaire probing health habits and potentially significant symptoms often supplemented by such physical measurements as height and weight, skin-fold thickness, blood pressure, "stick test" urinalysis and "finger-stick" blood cholesterol. Others conduct mass screening programmes aimed at individual health problems; those aimed at examining subjects for hypertension, diabetes, blood cholesterol level and cancer are most common. It is beyond the scope of this article to discuss which screening tests are most useful. However, the medical director may play a critical role in selecting the procedures most appropriate for the population and in evaluating the sensitivity, specificity and predictive values of the particular tests being considered. Particularly when temporary staff or outside providers are employed for such procedures, it is important that the medical director verify their qualifications and training in order to assure the quality of their performance. Equally important are prompt communication of the results to those being screened, the ready availability of confirmatory tests and further diagnostic procedures for those with positive or equivocal results, access to reliable information for those who may have questions, and an organized follow-up system to encourage compliance with the recommendations. Where there is no employee health service or its involvement in the screening programme is precluded, these considerations are often neglected, with the result that the value of the programme is threatened.

Physical conditioning

In many larger organizations, physical fitness programmes constitute the core of the health promotion and maintenance programme. These include aerobic activities to condition the heart and lungs, and strength and stretching exercises to condition the musculoskeletal system.

In organizations with an in-plant exercise facility, it is often placed under the direction of the employee health service. With such a linkage, it becomes available not only for fitness programmes but also for preventive and remedial exercises for back pain, hand and shoulder syndromes, and other injuries. It also facilitates medical monitoring of special exercise programmes for employees who have returned to work following pregnancy, surgery or myocardial infarction.

Physical conditioning programmes can be effective, but they must be structured and guided by trained personnel who know how to guide the physically unfit and impaired to a state of proper physical fitness. To avoid potentially adverse effects, each individual entering a fitness programme should have an appropriate medical evaluation, which may be performed by the employee health service.

Programme Evaluation

The medical director is in a uniquely advantageous position to evaluate the organization's health education and promotion programme. Cumulative data from periodic health risk appraisals, medical examinations and screenings, visits to the employee health service, absences due to illness and injury, and so on, aggregated for a particular cohort of employees or the workforce as a whole, can be collated with productivity assessments, worker's compensation and health insurance costs and other management information to provide, over time, an estimate of the effectiveness of the programme. Such analyses may also identify gaps and deficiencies suggesting the need for modification of the programme and, at the same time, may demonstrate to management the wisdom of continuing allocation of the required resources. Formulas for calculating the cost/benefit of these programmes have been published (Guidotti, Cowell and Jamieson 1989).

Conclusion

There is ample evidence in the world literature supporting worksite preventive health programmes (Pelletier 1991 and 1993). The employee health service is a uniquely advantageous venue for conducting these programmes or, at the very least, participating in their design and monitoring their implementation and results. The medical director is strategically placed to integrate these programmes with activities directed at occupational health and safety in ways that will promote both aims for the benefit of both individual employees (and their families, when included in the programme) and the organization.

HEALTH IMPROVEMENT PROGRAMMES AT MACLAREN INDUSTRIES, INC.:  A CASE STUDY

Ian M.F. Arnold and Louis Damphousse

Introduction

The organization

James Maclaren Industries Inc., the industrial setting used for this case study, is a pulp and paper company located in the western part of the Province of Quebec, Canada. A subsidiary of Noranda Forest, Inc., it has three major divisions: a hardwood pulp mill, a groundwood newsprint mill and hydroelectric energy facilities. The pulp and paper industry is the predominant local industry and the company under study is over 100 years old. The work population, approximately 1,000 employees, is locally based and, frequently, several generations of the same family have worked for this employer. The working language is French but most employees are functionally bilingual, speaking French and English. There is a long history (over 40 years) of company-based occupational health services. While the services were initially of an older "traditional" nature, there has been an increasing trend towards the preventive approach during recent years. This is consistent with a "continual improvement" philosophy being adopted throughout the Maclaren organization.

Provision of occupational health services

The occupational health physician has corporate and site responsibilities and reports directly to the directors of health, safety and continuous improvement. The last position reports directly to the company president. Full-time occupational health nurses are employed at the two major sites (the pulp mill has 390 employees and the newsprint mill has 520 employees) and report directly to the physician on all health-related issues. The nurse working at the newsprint division is also responsible for the energy/forest division (60 employees) and the head office (50 employees). A full-time corporate hygienist and safety personnel at all three facilities round out the health, and health-related, professional team.

The Preventive Approach

Prevention of disease and injury is driven by the occupational health and industrial hygiene and safety team with input from all interested parties. Methods used frequently do not differentiate between work-related and non-work-related prevention. Prevention is considered to reflect an attitude or quality of an employee-an attitude that does not cease or start at the plant fence line. A further attribute of this philosophy is the belief that prevention is amenable to continual improvement, a belief furthered by the company's approach to auditing its various programmes.

Continual improvement of prevention programmes

Health, industrial hygiene, environment, emergency preparedness, and safety audit programmes are an integral part of the continuous improvement approach. The audit findings, although addressing legal and policy compliance concerns, also stress "best management practice" in those areas which are felt to be amenable to improvement. In this way, prevention programmes are being repeatedly assessed and ideas presented which are used to further the preventive aims of occupational health and related programmes.

Health assessments

Pre-placement health assessments are carried out for all new employees. These are designed to reflect the exposure hazards (chemical, physical, or biological) present in the workplace. Recommendations indicating fitness to work and specific job restrictions are made based on the pre-placement health assessment findings. These recommendations are designed to decrease the risk of employee injury and illness. Health teaching is part of the health assessment and is intended to better acquaint the employees with the potential human impact of workplace hazards. Measures to decrease risk, particularly those related to personal health, are also stressed.

Ongoing health assessment programmes are based on hazard exposure and workplace risks. The hearing conservation programme is a prime example of a programme designed to prevent a health impact. Emphasis is on noise reduction at the source and employees participate in the evaluation of noise reduction priorities. An audiometric assessment is done every five years. This assessment provides an excellent opportunity to counsel employees on the signs and symptoms of noise-induced hearing loss and preventive measures while assisting in the evaluation of the efficacy of the control programme. Employees are advised to follow the same advice off the job-that is, to use hearing protection and to diminish their exposure.

Risk-specific health assessments are also carried out for workers involved in special job assignments such as fire fighting, rescue work, water treatment plant operations, tasks requiring excessive heat exposure, crane operation and driving. Similarly, employees who use respirators are required to undergo an assessment to determine their medical fitness to use the respirator. Exposure risks incurred by contractors' employees are also assessed.

Health hazard communication

There is a statutory requirement to communicate health hazard and health risk information to all employees. This is an extensive task and includes teaching employees about the health effects of designated substances to which they may be exposed. Examples of such substances include a variety of respiratory hazards which may be either byproducts of other materials' reactions or may represent a direct exposure hazard: one might name in this connection such materials as sulphur dioxide; hydrogen sulphide; chlorine; chlorine dioxide; carbon monoxide; nitrogen oxides and welding fumes. Material Safety Data Sheets (MSDSs) are the prime source of information on this subject. Unfortunately, the suppliers' MSDSs often lack the necessary quality of health and toxicity information and may not be available in both official languages. This deficiency is being addressed at one of the company's sites (and will be extended to the other sites) through the development of one-page health information sheets based on an extensive and well-respected database (using a commercially available MSDS generation software system). This project was undertaken with company support by members of the joint labour-management health and safety committee, a process which not only solved a communication problem, but encouraged participation by all workplace parties.

Cholesterol screening programmes

The company has made a voluntary cholesterol screening programme available to employees at all sites. It offers advice on the health ramifications of high cholesterol levels, medical follow-up when indicated (done by family physicians), and nutrition. Where onsite cafeteria services exist, nutritious food alternatives are offered to the employees. The health staff also makes pamphlets on nutrition available for employees and their families to assist them to understand and diminish personal health risk factors.

Blood pressure screening programmes

Both in conjunction with annual community programmes ("Heart Month") on heart health, and on a regular basis, the company encourages employees to have their blood pressure checked and, when necessary, monitored. Counselling is provided to employees to assist them, and indirectly their families, to understand the health concerns surrounding hypertension and to seek help through their community medical resources if further follow-up or treatment is needed.

Employee and family assistance programmes

Problems that have an impact on employee performance are frequently the result of difficulties outside the workplace. In many cases, these reflect difficulties related to the employee's social sphere, either home or community. Internal and external referral systems exist. The company has had a confidential employee (and, more recently, family) assistance programme in place for over five years. The programme assists about 5% of the employee population annually. It is well publicized and early use of the programme is encouraged. Feedback received from the employees indicates that the programme has been a significant factor in minimizing or preventing deterioration of work performance. The primary reasons for using the assistance programme reflect family and social issues (90%); alcohol and drug problems account for only a small percentage of the total cases assisted (10%).

As part of the employee assistance programme, the facility has instituted a serious-incident debriefing process. Serious incidents, such as fatalities or major accidents, can have an extremely unsettling effect on employees. There is also the potential for significant long-term consequences, not only to the efficient functioning of the company but, more particularly, to the individuals involved in the incident.

Wellness programmes

A recent development has been the decision to take the first steps towards the development of a "wellness" programme that targets disease prevention in an integrated approach. This programme has several components: cardiorespiratory fitness; physical conditioning; nutrition; smoking cessation; stress management; back care; cancer prevention and substance abuse. Several of these topics have been mentioned previously in this case study. Others (not discussed in this article) will, however, be implemented in a stepwise fashion.

Special communication programmes

1.     HIV/AIDS. The advent of HIV/AIDS in the general population signalled a need to communicate information to the workplace community for two reasons: to allay fear of contagion should a case become known from among the employee population and to ensure that employees are cognizant of preventive measures and the "real" facts about communicability. A communication programme was organized to meet these two objectives and made available to the employees on a voluntary basis. Pamphlets and literature could also be obtained from the health centres.

2.     Communication of research study results. The following are examples of two recent communications about health research studies in areas that were considered to be of special concern to employees.

·     Electromagnetic field studies. The results of the electromagnetic field study undertaken by Electricité (E.D.F.), Hydro Quebec, and Ontario Hydro (Thériault 1994), were communicated to all exposed and potentially exposed employees. The objectives behind the communication were to prevent unwarranted fear and to ensure that employees had firsthand knowledge of issues affecting their workplace and, potentially, their health.

·     Health outcome studies. Several studies in the pulp and paper industry relate to health outcomes from working in this industry. The outcomes being investigated include cancer incidence and cancer mortality. Communications to employees are planned to ensure their awareness of the existence of the studies, and, when available, to share the results. The objectives are to alleviate fear and ensure that employees have the opportunity to know the results of studies pertinent to their occupations.

3.     Community interest topics. As part of its preventive approach, the company has reached out to community physicians and invited them to tour the workplace and meet with the occupational health and hygiene staff. Presentations related to issues relevant to health and the pulp and paper industry have been made at the same time. This has assisted the local physicians to understand the working conditions, including potential hazardous exposures, as well as the job requirements of the employees. As a result, the company and the physicians have worked in concert to diminish the potential ill effects of injury and illness. Community meetings have also been held to provide the communities with information on environmental issues related to the company's operations and to give the local citizens an opportunity to ask questions on matters of concern (including health issues). Prevention is thus carried to the community level.

4.     Future trends in prevention. Behaviour modification techniques are being considered to further improve the overall level of worker health and to diminish injuries and illness. Not only will these modifications have a positive effect on the health of the worker in the workplace, they will also carry over to the home environment.

Employee involvement in safety and health decision making already exists through the Joint Health and Safety Committees. Opportunities to extend the partnership to employees in other areas are being actively pursued.

Conclusions

The essential elements of the programme at Maclaren are:

·     a firm management commitment to health promotion and health protection

·     integration of occupational health programmes with those aimed at non-occupational health problems

·     involvement of all workplace parties in programme planning, implementation and evaluation

·     coordination with community-based health care facilities and providers and agencies

·     an incremental approach to programme expansion

·     audits of programme effectiveness to identify problems that need addressing and areas where programmes may be strengthened, combined with action plans to ensure appropriate follow-up activities

·     effective integration of all environmental, health, hygiene and safety activities.

This case study has focused on existing programmes designed to improve employee health and prevent unnecessary and unwanted health effects. The opportunities to further enhance this approach are boundless and particularly amenable to the company's continual improvement philosophy.

ROLE OF THE EMPLOYEE HEALTH SERVICE IN PREVENTION PROGRAMMES:  A CASE STUDY

Wayne N. Burton

First Chicago Corporation is the holding company for the First National Bank of Chicago, the eleventh largest bank in the United States. The corporation has 18,000 employees, 62% of whom are women. The average age is 36.6 years. Most of its employees are based in the states of Illinois, New York, New Jersey and Delaware. There are approximately 100 individual worksites ranging in size from 10 to over 4,000 employees. The six largest, each with over 500 employees (comprising in aggregate 80% of the workforce), have employee health units managed by the head office Medical Department in collaboration with the local manager for human resources. The small worksites are served by visiting occupational health nurses and participate in programmes via printed materials, videotapes, and telephone communication and, for special programmes, by contract with providers based in the local community.

In 1982, the company's Medical and Benefits Administration Departments established a comprehensive Wellness Program that is managed by the Medical Department. Its goals included improving the overall health of employees and their families in order to reduce unnecessary health and disability costs as much as possible.

Need for Health Care Data

For First Chicago to gain any degree of control over the escalation of its health care costs, the company's Medical and Benefits Departments agreed that a detailed understanding of the sources of expense was required. By 1987, its frustration with the inadequate quality and quantity of the health care data that were available led it to strategically design, implement and evaluate its health promotion programmes. Two information system consultants were hired to help construct an in-house database which eventually became known as the Occupational Medicine and Nursing Information (OMNI) System (Burton and Hoy 1991). To maintain its confidentiality, the system resides in the Medical Department.

OMNI databases include claims for inpatient and outpatient health services and for disability and worker's compensation benefits, services provided by the Bank's employee assistance program (EAP), absenteeism records, wellness programme participation, health risk appraisals (HRAs), prescription medications, and findings of laboratory tests and physical examinations. The data are analysed periodically to evaluate the impact of the Wellness Program and to indicate any changes that may be advisable.

First Chicago's Wellness Program

The Wellness Program comprises a broad range of activities that include the following:

·     Health education. Pamphlets and brochures on a wide range of topics are made available to employees. A Wellness Newsletter sent to all employees is supplemented by articles which appear in the Bank's publications and on cafeteria table cards. Videotapes on health topics may be viewed at the workplace and many are available for home viewing. Lunchtime workshops, seminars, and lectures on topics such as mental wellness, nutrition, violence, women's health and cardiovascular disease are offered weekly at all major worksites.

·     Individual counselling. Registered nurses are available in person to answer questions and provide individual counselling at the employee health units and by telephone to employees at the smaller worksites.

·     Health risk assessment. A computerized health risk appraisal (HRA), including blood pressure and cholesterol testing, is offered to most new employees and periodically to current employees where there is an employee health unit. It is also offered periodically to employees of some satellite bank facilities.

·     Periodic physical examinations. These are offered on a voluntary basis to management employees. Annual health examinations, including Pap smears and breast examinations, are available to female employees in Illinois. Mass screenings for hypertension, diabetes, breast cancer and cholesterol levels are conducted at worksites that have employee health units.

·     Pre-retirement. Pre-retirement physical examinations are offered to all employees, starting at age 55 and continuing every three years thereafter until retirement. A comprehensive pre-retirement workshop is offered that includes sessions on healthy ageing.

·     Health promotion programmes. Discounted fees are negotiated with community providers for employees participating in physical fitness programmes. Worksite programmes on prenatal education, smoking cessation, stress management, weight reduction, childhood wellness, cardiovascular risk factor reduction, and training for skin cancer and breast self-examination are provided at no cost.

·     Cardiopulmonary resuscitation (CPR) and first aid training. CPR training is provided to all security personnel and designated employees. Infant CPR and first aid classes are also offered.

·     Immunization programmes. Hepatitis B vaccination is offered to all health service workers who may become exposed to blood or body fluids. Foreign travellers are provided with immunizations, including routine tetanus-diphtheria boosters, as dictated by the risk of infection in the areas they will visit. Education is provided to employees on the value of flu shots. Employees are referred to their primary care physician or the local health department for this immunization.

Women's Health Programme

In 1982, The First National Bank of Chicago found that over 25% of health care costs for employees and their families were related to women's health. In addition, over 40% of all employee short-term disability absences (i.e., lasting up to six months) were due to pregnancy. To control these costs by helping to ensure low-cost, high-quality health care, a comprehensive programme was developed to focus on prevention and early detection and control of women's health problems (Burton, Erikson, and Briones 1991). The programme now includes these services:

·     Worksite obstetrical and gynaecologic programme. Since 1985, the Bank has employed a part-time consulting gynaecologist from a major university teaching hospital at its home office in Chicago. Periodically, this service has been offered at two other locations and plans are in progress to establish the programme at another health service location. Voluntary annual health examinations are offered at the home office Medical Department to all female employees enrolled in the Bank's self-insured benefit plan (employees electing enrolment in a health maintenance organization (HMO) may have these examinations carried out by their HMO doctors). The examination includes a medical history, gynaecological and general physical examinations, laboratory tests such as a Pap smear for cervical cancer, and other testing as may be indicated.

·     In addition to providing examinations and consultations, the gynaecologist also conducts seminars on women's health concerns. The worksite gynaecological programme has proven to be a convenient and cost-effective way to encourage preventive health care for women.

·     Preconception and prenatal education. The United States ranks twenty-fourth among developed nations in infant mortality. At First Chicago, pregnancy-related claims accounted for about 19% of all health care costs in 1992 paid by the medical plan for employees and dependants. In 1987, to address this challenge, the Bank, in cooperation with the March of Dimes, began to offer a series of worksite classes led by a specially trained occupational health nurse. These are held during working hours and emphasize prenatal care, healthy lifestyles, proper nutrition, and indications for Caesarean section. On entering the programme, employees complete a pregnancy-related health risk appraisal questionnaire which is analysed by computer; both the women and their obstetricians receive a report highlighting potential risk factors for complications of pregnancy, such as adverse lifestyles, genetic diseases and medical problems.

·     To encourage participation, female employees or spouses who complete the classes by the sixteenth week of pregnancy are eligible to have the 400 US$ deductible fee for the newborn's health costs waived.

·     Preliminary results of the prenatal education programme for employees in the Chicago, Illinois, area include the following:

·     The Caesarean section rate is 19% for employees who participated in the worksite prenatal education programme compared to 28% for nonparticipants. The regional average Caesarean section rate is about 24%.

·     The average cost of delivery in the Chicago, Illinois, area for employees who participated in the prenatal education classes was $7,793 compared to $9,986 for employees who did not participate.

·     Absences from work for pregnancy (short-term disability) tend to be slightly reduced for employees who participate in the prenatal education classes.

·     Breast feeding (lactation) programme. The Medical Department offers a private room and refrigerator to store breast milk to employees who wish to breast feed. Most employee health units have electric breast pumps and provide lactation supplies to employees in the Bank's medical plan at no cost (and at cost to employees who are enrolled in HMOs).

·     Mammography. Since 1991, mammography screening for breast cancer has been offered at no cost at employee health units in the United States. Mobile mammography units from fully accredited local providers are brought to all the six sites with employee health units from one to several times per year depending on need. Approximately 90% of eligible employees are within a 30 minute automobile drive of a screening mammography location. Female employees and wives of employees and of retirees are eligible to participate in the programme.

The American Cancer Society guidelines for screening mammography are followed: they currently recommend mammography screening beginning at age 40, every one to two years for ages 40 to 49, and annually for ages 50 and over. Employees with abnormal mammograms receive both written and telephone follow-up with a copy of the report going to the employee's personal physician. Over 3,000 screening mammograms have been performed between 1991 and 1994, the time of this writing, and six cases of early-stage breast cancer have been detected.

Employee Assistance Programme and Mental Health Care

In 1979, the Bank implemented an employee assistance programme (EAP) that provides consultation, counselling, referral, and follow-up for a wide range of personal problems such as emotional disorders, interpersonal conflict, alcohol and other drug dependencies and addictive disorders in general. Employees may refer themselves for these services or they may be referred by a supervisor who discerns any difficulties that they may be experiencing in performance or interpersonal relationships in the workplace. The EAP also provides workshops on a variety of topics such as stress management, violence and effective parenting. The EAP, which is a unit of the Medical Department, is now staffed by six full and part-time clinical psychologists. The psychologists are located at each of the six medical departments and in addition travel to satellite bank facilities where there is a need.

In addition, the EAP manages psychiatric short-term disability cases (up to six months of continuous absence). The goal of EAP management is to ensure that employees receiving disability payments for psychiatric reasons are receiving appropriate care.

In 1984, a comprehensive programme was initiated to provide quality and cost-effective mental health care services for employees and dependants (Burton et al. 1989; Burton and Conti 1991). This programme includes four components:

·     the EAP for prevention and early intervention

·     a review of the patient's possible need for inpatient psychiatric hospitalization

·     case management of mental health-related short-term disability by the EAP staff

·     a network of selected mental health professionals who provide outpatient (i.e., ambulatory) services.

Despite enhancement of mental health insurance benefits to include 85% (instead of 50%) reimbursement for alternatives to inpatient hospitalization (e.g., partial hospitalization programmes and intensive outpatient programmes), First Chicago's mental health care costs have dropped from nearly 15% of total medical costs in 1983 to under 9% in 1992.

Conclusion

More than a decade ago, First Chicago initiated a comprehensive wellness programme with a motto - "First Chicago is Banking on Your Health". The Wellness Program is a joint effort of the Bank's Medical and Benefits Departments. It is regarded as having improved the health and productivity of employees and reduced avoidable health care costs for both the employees and the Bank. In 1993, First Chicago's Wellness Program was awarded the C. Everett Koop National Health Award named in honour of the former Surgeon General of the United States.

WORKSITE HEALTH PROMOTION IN JAPAN

Toshiteru Okubo

Health promotion in the workplace in Japan was substantially improved when the Occupational Health and Safety Law was amended in 1988 and employers were mandated to introduce health promotion programmes (HPPs) in the workplace. Although the law as amended makes no provision for penalties, the Ministry of Labour at this time began actively encouraging employers to establish health promotion programmes. For instance, the Ministry has provided support for training and education to increase the numbers of specialists qualified to work in such programmes; among the specialists are occupational health promotion physicians (OHPPs), health care trainers (HCTs), health care leaders (HCLs), mental health counsellors (MHCs), nutrition counsellors (NCs) and occupational health counsellors (OHCs). While employers are encouraged to establish health promotion organizations within their own enterprises, they can also elect to procure service from outside, especially if the business is small and it cannot afford to provide a programme in-house. The Ministry of Labour furnishes guidelines for the operation of such service institutions. The newly conceived and mandated occupational health promotion programme authorized by the Japanese government is called the "total health promotion" (THP) plan.

Recommended Standard Health Promotion Programme

If an enterprise is sufficiently large to provide all the specialists listed above, it is strongly recommended that the company organize a committee comprising those specialists and make it responsible for the planning and execution of a health promotion programme. Such a committee must first analyse the health status of the workers and determine the highest priorities that are to guide the actual planning of an appropriate health promotion programme. The programme should be a comprehensive one, based on both group and individual approaches.

On a group basis various health education classes would be offered, for example, on nutrition, life style, stress management and recreation. Cooperative group activities are recommended in addition to lectures in order to encourage workers to become involved in actual procedures so that information provided in class can result in behavioural changes.

As the first step to the individual approach, a health survey should be conducted by the OHPP. The OHPP then issues a plan to the individual based on the results of the survey after taking into account information obtained through counselling by the OHC or MHC (or both). Following this plan, relevant specialists will supply the necessary instructions or counselling. The HCT will design a personal physical training programme based on the plan. The HCL will provide practical instruction to the individual in the gym. When necessary, an NC will teach personal nutrition and the MHC or OHC will meet the individual for specific counselling. The results of such individual programmes should be evaluated periodically by the OHPP so the programme can be improved over time.

Training of Specialists

The Ministry has appointed the Japan Industrial Safety and Health Association (JISHA), a semi-official organization for the promotion of voluntary safety and health activities in the private sector, to be the official body for conducting the training courses for health promotion specialists. To become one of the above six specialists a certain background is required and a course for each specialty must be completed. The OHPP, for instance, must have the national licence for physicians and have completed a 22-hour course on conducting the health survey that will direct the planning of the HPP. The course for the HCT is 139 hours, the longest of the six courses; a prerequisite for taking the course is a bachelor's degree in health sciences or athletics. Those who have three or more years' practical experience as an HCL are also eligible to take the course. The HCL is the leader responsible for actually teaching workers according to the prescriptions drawn up by the HCT. The requirement for becoming an HCL is that he or she be 18 years of age or older and have completed the course, which covers 28.5 hours. To take the course for the MHC, one of the following degrees or experience is required: a bachelor's degree in psychology; social welfare or health science; certification as a public health or registered nurse; HCT; completion of JISHA's Health Listener's Course; qualification as a health supervisor; or five or more years' experience as a counsellor. The length of the MHC course is 16.5 hours. Only qualified nutritionists can take the NC course, which is 16.0 hours long. Qualified public health nurses and nurses with three or more years of practical experience in counselling can take the OHC course, which is 20.5 hours long. The OHC is expected to be a comprehensive promoter of the health promotion programme in the workplace. As of the end of December 1996, the following numbers of the specialists were registered with the JISHA as having completed the assigned courses: OHPP-2,895; HCT-2,800; HCL- 11,364; MHC-8,307; NC-3,888; OHC-5,233.

Service Institutions

Two kinds of health promotion service institutions are approved by JISHA and a list of the registered institutions is available to the public. One kind is authorized to conduct health surveys so that the OHPP can issue a plan to the individual. This type of institution can provide comprehensive health promotion service. The other kind of service institution is only permitted to provide physical training service in accordance with a programme developed by an HCT. As of the end of March 1997 the number qualifying as the former type was 72 and that as the latter was 295.

Financial Support from the Ministry

The Ministry of Labour has a budget to support the training courses offered by JISHA, the establishment of new programmes by enterprises and the acquisition by service institutions of equipment for physical exercise. When an enterprise establishes a new programme, the expenditure will be supported by the Ministry through JISHA for a maximum of three years. The amount depends on size; if the number of employees of an enterprise is less than 300, two-thirds of the total expenditure will be met by the Ministry; for businesses of over 300 employees, financial support covers one-third of the total.

Conclusion

It is too early in the history of the THP project to make a reliable evaluation of its effectiveness, but a consensus prevails that THP should be part of any comprehensive occupational health programme. The general status of Japanese occupational health service is still undergoing improvement. In advanced workplaces, that is, chiefly those of the large companies, THP has already developed to a level that an evaluation of the degree of health promotion among the workers and of the extent of improvement in productivity can be done. However, in smaller enterprises, even though the major part of the necessary expenditures for THP can be paid for by the government, the health care systems that are already in place very frequently are not able to undertake the introduction of additional health maintenance activities.

HEALTH RISK APPRAISAL

Leon J. Warshaw

Introduction

Over the last few decades, the health risk appraisal (HRA), also known as a health hazard appraisal or a health risk assessment, has become increasingly popular, primarily in the United States, as an instrument for promoting health awareness and motivating behavioural change. It is also used as an introduction to periodic health screening or as a substitute for it and, when aggregated for a group of individuals, as the basis for identifying targets for a health education or health promotion programme to be designed for them. It is based on the following concept:

·     Ostensibly healthy, asymptomatic individuals may be at risk of developing a disease process that can cause morbidity in the future and may lead to premature death.

·     Factors that lead to such risk can be identified.

·     Some of those risk factors can be eliminated or controlled thereby preventing or attenuating the disease process and preventing or delaying the morbidity and mortality.

The development of the HRA in the 1940s and 1950s is credited to Dr. Lewis Robbins, working at the Framingham prospective study of heart disease and later at the National Cancer Institute (Beery et al. 1986). The 1960s saw additional models developed and, in 1970, Robbins and Hall produced the seminal work that defined the technique, described the survey instruments and the risk computations, and outlined the patient feedback strategy (Robbins and Hall 1970).

Interest in HRA and health promotion in general was stimulated by a growing awareness of the importance of risk factor control as a basis element in health promotion, the evolving use of computers for data compilation and analysis and, especially in the United States, increasing concern over the escalating cost of health care and the hope that preventing illness might slow its upward spiral of growth. By 1982, Edward Wagner and his colleagues at the University of North Carolina were able to identify 217 public and private HRA vendors in the United States (Wagner et al. 1982). A good many of these have since faded from the scene but they have been replaced, at least to a limited extent, by new entrants into the marketplace. According to a 1989 report of a survey of a random sample of US worksites, 29.5% have conducted HRA activities; for worksites with more than 750 employees, this figure rose to 66% (Fielding 1989). HRA use in other countries has lagged considerably.

What is the HRA?

For purposes of this article, an HRA is defined as a tool for assessing health risks that has three essential elements:

1.     A self-administered questionnaire inquiring about the individual's demographic profile, medical background, family history, personal habits and lifestyle. This information is frequently supplemented by biomedical measurements such as height, weight, blood pressure, and skin-fold thickness, and data regarding the results of urinalysis, blood cholesterol level and other laboratory tests, either as reported by the individual or taken as part of the process.

2.     A quantitative estimation of the individual's future risk of death or other adverse outcomes from specific causes based on a comparison of the individual's responses to epidemiological data, national mortality statistics and actuarial calculations. Some questionnaires are self-scored: points are assigned to the response to each question and then added to derive a risk score. With the appropriate computer software, the responses may be entered into a microcomputer that will calculate the score. Most often the completed questionnaires are forwarded to a central point for batch processing and the individual results are mailed or delivered to the participants.

3.     Feedback to the individual with suggestions for changes in lifestyle and other actions that would improve well-being and reduce the risk of disease or premature death.

Originally, the total risk estimate was presented as a single number that could be targeted for reduction to a "normal" value or even to lower-than-normal values (vis-à-vis the general population) by implementing the suggested behavioural changes. To make the results more graphic and compelling, the risk is now sometimes expressed as a "health age" or "risk age" to be compared with the individual's chronological age, and an "achievable age" as the target for the interventions. For example, a report might say, "Your present age is 35 but you have the life expectancy of a person aged 42. By following these recommendations, you could reduce your risk age to 32, thereby adding ten years to your projected life span."

Instead of comparing the individual's health status with the "norm" for the general population, some HRAs offer an "optimal health" score: the best attainable score that might be achieved by following all of the recommendations. This approach appears to be particularly useful in guiding young people, who may not yet have accumulated significant health risks, to an optimally desirable lifestyle.

The use of a "risk age" or a single number to represent the individual's composite risk status may be misleading: a significant risk factor may be statistically offset by "good" scores on most other areas and lead to a false sense of security. For example, a person with normal blood pressure, a low blood cholesterol level, and a good family history who exercises and wears automobile seat belts may earn a good risk score despite the fact that he smokes cigarettes. This suggests the desirability of focussing on each "greater than average" risk item instead of relying on the composite score alone.

The HRA is not to be confused with health status questionnaires that are used to classify the eligibility of patients for particular treatments or to evaluate their outcomes, nor with the variety of instruments used to assess degree of disability, mental health, health distress or social functioning, although such scales are sometimes incorporated into some HRAs.

HRA Questionnaire

Although the HRA is sometimes used as a prelude to or part of a periodic, pre-employment or pre-placement medical examination, it is usually offered independently as a voluntary exercise. Many varieties of HRA questionnaires are in use. Some are limited to core questions that feed directly into the risk age calculations. In others, these core questions are interspersed with additional medical and behavioural topics: more extensive medical history; stress perceptions; scales to measure anxiety, depression and other psychological disorders; nutrition; use of preventive services; personal habits and even interpersonal relationships. Some vendors allow purchasers to add questions to the questionnaire, although responses to these are not usually incorporated into the health-risk computations.

Almost all HRAs now use forms with boxes to be checked or filled in by pencil for computer entry by hand or by an optical scanner device. As a rule, the completed questionnaires are collected and batch-processed, either in-house or by the HRA vendor. To encourage trust in the confidentiality of the programme, completed questionnaires are sometimes mailed directly to the vendor for processing and the reports are mailed to the participants' homes. In some programmes, only "normal" results are mailed to participants, while those employees with results calling for intervention are invited for private interviews with trained staff persons who interpret them and outline the corrective actions that are indicated. Greater access to personal computers and more widespread familiarity with their use have led to the development of interactive software programs that allow direct entry of the responses into a microcomputer and immediate calculation and feedback of the results along with risk reduction recommendations. This approach leaves it up to the individual to take the initiative of seeking help from a staff person when clarification of the results and their implications is needed. Except when the software programme allows storage of the data or their transfer to a centralized data bank, this approach does not provide information for systematic follow-up and it precludes the development of aggregate reports.

Managing the Programme

Responsibility for managing the HRA programme is usually assigned to the respective directors of the employee health service, the wellness programme or, less frequently, the employee assistance programme. Quite often, however, it is arranged and supervised by the personnel/human resources staff. In some instances, an advisory committee is created, often with employee or labour union participation. Programmes incorporated into the organization's operating routine appear to run more smoothly than those that exist as somewhat isolated projects (Beery et al. 1986). The organizational location of the programme may be a factor in its acceptance by employees, particularly when confidentiality of personal health information is an issue. To preclude such a concern, the completed questionnaire is usually mailed in a sealed envelope to the vendor, who processes the data and mails the individual report (also in a sealed envelope) directly to the participant's home.

To enhance participation in the programme, most organizations publicize the programme through preliminary hand-outs, posters and articles in the company newsletter. Occasionally, incentives (e.g., T-shirts, books and other prizes) are offered for completion of the exercise and there may even be monetary awards (e.g., reduction in the employee's contribution to health insurance premiums) for successful reduction of excess risk. Some organizations schedule meetings where employees are told about the programme's purposes and procedures and are instructed in completing the questionnaire. Some, however, simply distribute a questionnaire with written instructions to each employee (and, if included in the programme, to each dependant). In some instances, one or more reminders to complete and mail the questionnaire are distributed in order to increase participation. In any case, it is important to have a designated resource person, either in the organization or with the HRA programme provider, to whom questions can be directed in person or by telephone. It may be important to note that, even when the questionnaire is not completed and returned, merely reading it can reinforce information from other sources and foster a health consciousness that may favorably influence future behaviour.

Many of the forms call for clinical information that the respondent may or may not have. In some organizations, the programme staff actually measures height, weight, blood pressure and skin-fold thickness and collects blood and urine samples for laboratory analysis. The results are then integrated with the questionnaire responses; where such data are not entered, the computer processing programme may automatically insert figures representing the "norms" for persons of the same sex and age.

Turnaround time (the time between completing the questionnaire and receiving the results) may be a significant factor in the value of the program. Most vendors promise delivery of the results in ten days to two weeks, but batch processing and post office delays may extend this period. By the time the reports are received, some participants may have forgotten how they responded and may have disassociated themselves from the process; to obviate this possibility, some vendors either return the completed questionnaire or include key responses of the individual in the report.

Reports to the Individual

The reports may vary from a single-page statement of results and recommendations to a more than 20-page brochure replete with multicolour graphs and illustrations and extended explanations of the relevance of the results and the importance of the recommendations. Some rely almost entirely on preprinted general information while in others the computer generates an entirely individualized report. In some programmes where the exercise has been repeated and the earlier data have been retained, comparisons of current results with those recorded earlier are provided; this may provide a sense of gratification that can serve as further motivation for behaviour modification.

A key to the success of a programme is the availability of a health professional or trained counsellor who can explain the importance of the findings and offer an individualized program of interventions. Such personalized counselling can be extremely useful in allaying needless anxiety that may have been generated by misinterpretation of the results, in helping individuals establish behavioural change priorities, and in referring them to resources for implementation.

Reports to the Organization

In most programmes, the individual results are summarized in an aggregate report sent to the employer or sponsoring organization. Such reports tabulate the demography of the participants, sometimes by geographic location and job classification, and analyse the range and levels of health risks discovered. A number of HRA vendors include projections of the increased health care costs likely to be incurred by high-risk employees. These data are extremely valuable in designing elements for the organization's wellness and health promotion programme and in stimulating consideration of changes in job structure, work environment and workplace culture that will promote the health and well-being of the workforce.

It should be noted that the validity of the aggregate report depends on the number of employees and the level of participation in the HRA programme. Participants in the programme tend to be more health conscious and, when their number is relatively small, their scores may not accurately reflect the characteristics of the entire workforce.

Follow-up and Evaluation

The effectiveness of the HRA programme may be enhanced by a system of follow-up to remind participants of the recommendations and encourage compliance with them. This can involve individually addressed memoranda, one-on-one counselling by a physician, nurse or health educator, or group meetings. Such follow-up is particularly important for high-risk individuals.

HRA programme evaluation should start with a tabulation of the level of participation, preferably analysed by such characteristics as age, sex, geographic location or work unit, job and educational level. Such data may identify differences in acceptance of the programme that might suggest changes in the way it is presented and publicized.

Increased participation in risk-reduction elements of the wellness programme (e.g., a fitness programme, smoking cessation courses, stress management seminars) may indicate that HRA recommendations are being heeded. Ultimately, however, evaluation will involve determination of changes in risk status. This may involve analysing the results of the follow-up of high-risk individuals or repetition of the programme after an appropriate interval. Such data may be fortified by correlation with data such as utilization of health benefits, absenteeism or productivity measures. Appropriate recognition, however, should be given to other factors that may have been involved (e.g., bias reflecting the sort of person who returns for retest, regression to the mean, and secular trends); truly scientific evaluation of the programme impact requires a randomized prospective clinical trial (Schoenbach 1987; DeFriese and Fielding 1990).

Validity and Utility of the HRA

Factors that may affect the accuracy and validity of an HRA have been discussed elsewhere (Beery et al. 1986; Schoenbach 1987; DeFriese and Fielding 1990) and will only be listed here. They represent a checklist for workplace decision makers evaluating different instruments, and include the following:

·     accuracy and consistency of self-reported information

·     completeness and quality of the epidemiological and actuarial data on which the risk estimates are based

·     limitations of the statistical methods for calculating risk, including combining risk factors for different problems into a single composite score and the distortions produced by substituting "average" values either for missing responses in the questionnaire or for measurements not taken

·     reliability of the method for calculating the benefits of risk reduction

·     applicability of the same mortality calculations to the young whose death rates are low and to older individuals for whom age alone may be the most significant factor in mortality. Furthermore, the validity of the HRA when applied to populations different from those on whom most of the research has been done (i.e., women, minorities, people of different educational and cultural backgrounds) must be regarded from a critical point of view.

Questions have also been raised about the utility of the HRA based on considerations such as the following:

1.     The primary focus of HRA is on life expectancy. Until recently, little or no attention has been paid to factors primarily influencing morbidity from conditions that are not usually fatal but which may have an even greater impact on well-being, productivity and health-related costs (e.g., arthritis, mental disorders, and long-term effects of treatments intended to reduce specific risks). The problem is the lack of good morbidity databases for the general population, to say nothing of subgroups defined by age, sex, race or ethnicity.

2.     Concern has been expressed about the ill effects of anxiety generated by reports of high-risk status reflecting factors which the individual is unable to modify (e.g., age, heredity, and past medical history), and about the possibility that reports of "normal" or low-risk status may lead individuals to ignore potentially significant signs and symptoms that were not reported or which developed after the HRA was completed.

3.     Participation in an HRA programme is usually voluntary, but allegations of coercion to participate or to follow the recommendations have been made.

4.     Charges of "blaming the victim" have rightfully been levelled at employers who offer HRA as part of a health promotion programme but do little or nothing to control health risks in the work environment.

5.     Confidentiality of personal information is an ever-present concern, especially when an HRA is conducted as an in-house programme and abnormal findings appear to be a trigger for discriminatory actions.

Evidence of the value of health-risk reduction has been accumulating. For example, Fielding and his associates at Johnson and Johnson Health Management, Inc., found that the 18,000 employees who had completed the HRA provided through their employers used preventive services at a considerably higher rate than a comparable population responding to the National Health Interview Survey (Fielding et al. 1991). A five-year study of almost 46,000 DuPont employees demonstrated that those with any of the six behavioural cardiovascular risk factors identified by an HRA (e.g., cigarette smoking, high blood pressure, high cholesterol levels, lack of exercise) had significantly higher rates of absenteeism and use of health care benefits as compared to those without such risk factors (Bertera 1991). Furthermore, applying multivariate regression models to 12 health-related measures taken mainly from an HRA allowed Yen and his colleagues at the University of Michigan Fitness Research Center to predict which employees would generate higher costs for the employer for medical claims and absenteeism (Yen, Edington and Witting 1991).

Implementing an HRA Programme

Implementing an HRA programme is not a casual exercise and should not be undertaken without careful consideration and planning. The costs of an individual questionnaire and its processing may not be great but the aggregate costs to the organization may be considerable when such items as staff time for planning, implementation and follow-up, employee time for completing the questionnaires, and adjunct health-promotion programmes are included. Some factors to be considered in implementation are presented in figure 15.8 .

Figure 15.8 Checklist for health risk appraisal (HRA) implementation

Should we have an HRA programme?

An increasing number of companies, at least in the United States, are answering this question in the affirmative, abetted by the growing number of vendors energetically marketing HRA programmes. The popular media and "trade" publications are replete with anecdotes describing "successful" programmes, while in comparison there is a paucity of articles in professional journals offering scientific evidence of the accuracy of their results, their practical reliability and their scientific validity.

It seems clear that defining one's health risk status is a necessary basis for risk reduction. But, some ask, does one need a formal exercise like the HRA to do this? By now, virtually everyone who persists in cigarette smoking has been exposed to evidence of the potential of adverse health effects, and the benefits of proper nutrition and physical fitness have been well publicized. Proponents of HRA counter by pointing out that receiving an HRA report personalizes and dramatizes the risk information, creating a "teachable moment" that can motivate individuals to take appropriate action. Further, they add, it can highlight risk factors of which the participants may have been unaware, allowing them to see just what their risk reduction opportunities are and to develop priorities for addressing them.

There is general agreement that HRA has limited value when used as a stand-alone exercise (i.e., in the absence of other modalities) and that its utility is fully realized only when it is part of an integrated health promotion programme. That programme should offer not only individualized explanations and counselling but also access to intervention programmes that address the risk factors that were identified (these interventions may be provided in-house or in the community). Thus, the commitment to offer HRA must be broadened (and perhaps may become more costly) by offering or making available such activities as smoking cessation courses, fitness activities and nutrition counselling. Such a broad commitment should be made explicitly in the statement of objectives for the programme and the budget allocation requested to support it.

In planning an HRA programme, one must decide whether to offer it to the entire workforce or only to certain segments (e.g., to salaried or hourly workers, to both, or to workers of specified ages, lengths of service or in specified locations or job categories); and whether to extend the programme to include spouses and other dependants (who, as a rule, account for more than half of the utilization of health benefits). A critical factor is the need to secure the availability of at least one person in the organization sufficiently knowledgeable and appropriately positioned to supervise the design and implementation of the programme and the performance of both the vendor and the in-house staff involved.

In some organizations in which full-scale annual medical examinations are being eliminated or offered less frequently, HRA has been offered as a replacement either alone or in combination with selected health screening tests. This strategy has merit in terms of enhancing the cost/benefit ratio of a health promotion programme, but sometimes it is based not so much on the intrinsic value of the HRA but on the desire to avoid the ill-will that might be generated by what could be perceived as elimination of an established employee benefit.

Conclusion

Despite its limitations and the paucity of scientific research that confirms the claims for its validity and utility, the use of HRA continues to grow in the United States and, much less rapidly, elsewhere. DeFriese and Fielding, whose studies have made them authorities on HRA, see a bright future for it based on their prediction of new sources of risk-relevant information and new technological developments such as improvements in computer hardware and software that will permit direct computer entry of questionnaire responses, allow modelling of the effects of changes in health behaviour, and produce more effective full-colour reports and graphics (DeFriese and Fielding 1990).

HRA should be used as an element in a well-conceived, continuing programme of wellness or health promotion. It conveys an implicit commitment to provide activities and changes in the workplace culture that offer opportunities to help control the risk factors it will identify. Management should be aware of such a commitment and be willing to make the requisite budget allocations.

While much research remains to be done, many organizations will find HRA a useful adjunct to their efforts to improve the health of their employees. The implicit scientific authority of the information it provides, the use of computer technology, and the personalized impact of the results in terms of chronological versus risk age seem to enhance its power to motivate participants to adopt healthy, risk-reducing behaviours. Evidence is accumulating to show that employees and dependants who maintain healthy risk profiles have less absenteeism, demonstrate enhanced productivity, and use less medical care, all of which have a positive effect on the organization's "bottom line".

PHYSICAL TRAINING AND FITNESS PROGRAMMES: AN ORGANIZATIONAL ASSET

James Corry

Physical training and fitness programmes are generally the most frequently encountered element in worksite health promotion and protection programmes. They are successful when they contribute to the goals of the organization, promote the health of employees, and remain pleasing and useful to those participating (Dishman 1988). Because organizations around the world have widely diverse goals, workforces and resources, physical training and fitness programmes vary greatly in how they are organized and in what services they provide.

This article is concerned with the reasons for which organizations offer physical training and fitness programmes, how such programmes fit within an administrative structure, the typical services offered to participants, the specialized personnel who offer these services, and the issues most often involved in worksite fitness programming, including the needs of special populations within the workforce. It will focus primarily on programmes conducted onsite in the workplace.

Quality and Fitness Programming

Today's global economy shapes the goals and business strategies of tens of thousands of employers and affects millions of workers around the world. Intense international competition requires organizations to offer products and services of higher value at ever lower costs, that is, to pursue so-called "quality" as a goal. Quality-driven organizations expect workers to be "customer oriented," to work energetically, enthusiastically and accurately throughout the entire day, to continually train and improve themselves professionally and personally, and to take responsibility for both their workplace behaviour and their personal well-being.

Physical training and fitness programmes can play a role in quality-driven organizations by helping workers to achieve a high level of "wellness". This is particularly important in "white-collar" industries, where employees are sedentary. In manufacturing and heavier industries, strength and flexibility training can enhance work capacity and endurance and protect workers from occupational injuries. In addition to physical improvement, fitness activities offer relief from stress and carry a personal sense of responsibility for health into other aspects of lifestyle such as nutrition and weight control, avoidance of alcohol and drug abuse, and smoking cessation.

Aerobic conditioning, relaxation and stretching exercises, strength training, adventure and challenge opportunities and sports competitions are typically offered in quality-driven organizations. These offerings are often structured within the organization's wellness initiatives-"wellness" involves helping people to actualize their full potential while leading a lifestyle that promotes health-and they are based on the awareness that, since sedentary living is a well-demonstrated risk factor, regular exercise is an important habit to foster.

Basic Fitness Services

Participants in fitness programmes should be instructed in the rudiments of fitness training. The instruction includes the following components:

·     a minimum number of exercise sessions per week to achieve fitness and good health (three or four times a week for 30 to 60 minutes per session)

·     learning how to warm up, exercise and cool down

·     learning how to monitor heart rate and how to safely raise one's heart rate to a training level appropriate for one's age and fitness level

·     graduating training from light to heavy to ultimately achieve a high level of fitness

·     techniques for cross training

·     The principles of strength training, including resistance and overload, and combining repetitions and sets to achieve strengthening goals

·     strategic rest and safe lifting techniques

·     relaxation and stretching as an integral part of a total fitness programme

·     learning how to customize workouts to suit one's personal interests and lifestyle

·     achieving an awareness of the role that nutrition plays in fitness and overall good health.

Besides instruction, fitness services include fitness assessment and exercise prescription, orientation to the facility and training in the use of the equipment, structured aerobic classes and activities, relaxation and stretching classes, and back-pain prevention classes. Some organizations offer one-on-one training, but this can be quite expensive since it is so staff-intensive.

Some programmes offer special "work hardening" or "conditioning," that is, training to enhance workers' capacities to perform repetitive or rigorous tasks and to rehabilitate those recovering from injuries and illnesses. They often feature work breaks for special exercises to relax and stretch overused muscles and strengthen antagonistic sets of muscles to prevent overuse and repetitive injury syndromes. When advisable, they include suggestions for modifying the job content and/or the equipment used.

Physical Training and Fitness Personnel

Exercise physiologists, physical educators, and recreational specialists make up the majority of the professionals working in worksite physical fitness programmes. Health educators and rehabilitation specialists also participate in these programmes.

The exercise physiologist designs personalized exercise regimens for individuals based on a fitness assessment which generally includes a health history, a health risk screening, assessment of fitness levels and exercise capacity (essential for those with handicaps or recovering from injury), and confirmation of their fitness goals. The fitness assessment includes the determination of resting heart rate and blood pressure, body composition. muscle strength and flexibility, cardiovascular efficiency and, often, blood lipid profiles. Typically, the findings are compared with norms for people of the same sex and age.

None of the services offered by the physiologist are meant to diagnose disease; employees are referred to the employee health service or their personal physicians when abnormalities are found. In fact, many organizations require that a prospective applicant obtain clearance from a physician before joining the programme. In the case of employees recovering from injuries or illness, the physiologist will work closely with their personal physicians and rehabilitation counsellors.

Physical educators have been trained to lead exercise sessions, to teach the principles of healthy and safe exercise, to demonstrate and coach various athletic skills, and to organize and administer a multifaceted fitness programme. Many have been trained to perform fitness assessments although, in this age of specialization, that task is performed more often by the exercise physiologist.

Recreational specialists carry out surveys of participants' needs and interests to determine their lifestyles and their recreational requirements and preferences. They may conduct exercise classes but generally focus on arranging trips, contests and activities that instruct, physically challenge and motivate participants to engage in wholesome physical activity.

Verifying the training and competence of physical training and fitness personnel often presents problems to organizations seeking to staff a program. In the United States, Japan and many other countries, government agencies require academic credentials and supervised experience of physical educators who teach in school systems. Most governments do not require certification of exercise professionals; for example, in the United States, Wisconsin is the only state that has enacted legislation dealing with fitness instructors. In considering an involvement with health clubs in the community, whether voluntary like the YMCAs or commercial, special caution should be taken to verify the competence of the trainers they provide since many are staffed by volunteers or poorly trained individuals.

A number of professional associations offer certification for those working in the adult fitness field. For example, the American College of Sports Medicine offers a certificate for exercise instructors and the International Dance Education Association offers a certificate for aerobics instructors. These certificates, however, represent indicators of experience and advanced training rather than licences to practice.

Fitness Programmes and the Organization's Structure

As a rule, only medium-sized to large-sized organizations (500 to 700 employees is generally considered the minimum) can undertake the task of providing physical training facilities for their employees at the worksite. Major considerations other than size include the ability and willingness to make the necessary budgetary allocations and availability of space to house the facility and whatever equipment it may require, including dressing and shower rooms.

Administrative placement of the programme within the organization usually reflects the goals set for it. For example, if the goals are primarily health-related (e.g., cardiovascular risk reduction, reducing illness absences, prevention and rehabilitation of injuries, or contributing to stress management) the programme will usually be found in the medical department or as a supplement to the employee health service. When the primary goals relate to employee morale and recreation, it will usually be found in the human resources or employee relations department. Since human resources departments are usually charged with implementing quality improvement programmes, fitness programmes with a wellness and quality focus will often be located there.

Training departments rarely are assigned responsibility for physical training and fitness programmes since their mission is usually limited to specific skill development and job training. However, some training departments offer outdoor adventure and challenge opportunities to employees as ways to create a sense of teamwork, build self-confidence and explore ways to overcome adversity. When jobs involve physical activity, the training program may be responsible for teaching proper work techniques. Such training units will often be found in police, fire and rescue organizations, trucking and delivery firms, mining operations, oil exploration and drilling companies, diving and salvage organizations, construction firms, and the like.

Onsite or Community-based Fitness Programmes

When space and economic considerations do not allow comprehensive exercise facilities, limited programmes may still be conducted in the workplace. When not in use for their designed purposes, lunch and meeting rooms, lobbies and parking areas may be used for exercise classes. One New York City-based insurance company created an indoor jogging track in a large storage area by arranging a path between banks of filing cabinets containing important but infrequently consulted documents. In many organizations around the world, work breaks are regularly scheduled during which employees stand at their work stations and do calisthenics and other simple exercises.

When onsite fitness facilities are not feasible (or when they are too small to accommodate all the employees who would use them), organizations turn to community-based settings such as commercial health clubs, schools and colleges, churches, community centres, clubs and YMCAs, town- or union-sponsored recreation centres, and so on. Some industrial parks house an exercise facility shared by the corporate tenants.

On another level, fitness programmes may consist of uncomplicated physical activities practised in or about the home. Recent research has established that even low to moderate levels of daily activity may have protective health effects. Activities like recreational walking, biking or stair-climbing which require the person to dynamically exercise large muscle groups for 30 minutes five times a week, may prevent or delay the advance of cardiovascular disease while providing a pleasant respite from daily stress. Programmes that encourage walking and bicycling to work can be developed for even very small companies and they cost very little to implement.

In some countries, workers are entitled to leaves that may be spent at spas or health resorts which offer a comprehensive programme of rest, relaxation, exercise, healthful diet, massage and other forms of restorative therapy. The aim, of course, is to have them maintain such a healthful lifestyle after they return to their homes and jobs.

Exercise for Special Populations

Older workers, the obese and especially those who have been sedentary for long can be offered low-impact and low-intensity exercise programmes in order to avert orthopaedic injuries and cardiovascular emergencies. In onsite facilities, special times or separate workout spaces may be arranged to protect the privacy and dignity of these populations.

Pregnant women who have been physically active may continue to work or exercise with the advice and consent of their personal physicians, keeping in mind the medical guidelines concerning exercise during pregnancy (American College of Obstetricians and Gynecologists 1994). Some organizations offer special reconditioning exercise programmes for women returning to work after delivery.

Physically challenged or handicapped workers should be invited to participate in the fitness programme both as a matter of equity and because they may accrue even greater benefits from the exercise. Programme staff, however, should be alert to conditions that may entail greater risk of injury or even death, such as Marfan's syndrome (a congenital disorder) or certain forms of heart disease. For such individuals, preliminary medical evaluation and fitness assessment is particularly important, as is careful monitoring while exercising.

Setting Goals for the Exercise Programme

The goals selected for an exercise programme should complement and support those of the organization. Figure 15.9  presents a checklist of potential programme goals which, when ranked in order of importance to a particular organization and aggregated, will help in shaping the programme.

Figure 15.9 Suggested organizational goals for a fitness and exercise programme

Eligibility for the Exercise Programme

Since the demand may exceed both the programme's budget allocation and the available space and time, organizations have to carefully consider who should be eligible to participate. It is prudent to know in advance why this benefit is being offered and how many employees are likely to take advantage of it. Lack of preparation in this regard may lead to embarrassment and ill will when those who desire to exercise cannot be accommodated.

Particularly when providing an onsite facility, some organizations limit eligibility to managers above a certain level in the organization chart. They rationalize this by arguing that, since such individuals are paid more, their time is more valuable and it is proper to give them priority of access. The programme then becomes a special privilege, like the executive dining room or a conveniently located parking space. Other organizations are more even-handed and offer the programme to all on a first-come, first-served basis. Where demand exceeds the facility's capacity, some use length of service as a criterion of priority. Rules setting minimum monthly use are sometimes used to help manage the space problem by discouraging the casual or episodic participant from continuing as a member.

Recruiting and Retaining Programme Participants

One problem is that the convenience and low cost of the facility may make it particularly attractive to those already committed to exercise, who may leave little room for those who may need it much more. Most of the former will probably continue to exercise anyway while many of the latter will be discouraged by difficulties or delays in entering the programme. Accordingly, an important adjunct to recruiting participants is simplifying and facilitating the enrolment process.

Active efforts to attract participants are usually necessary, at least when the programme is initiated. They include in-house publicity via posters, flyers and announcements in available intramural communications media, as well as open visits to the exercise facility and the offer of experimental or trial memberships.

The problem of dropout is an important challenge to programme administrators. Employees cite boredom with exercise, muscular aches and pains induced by exercise, and time pressure as the major reasons for dropping out. To counter this, facilities entertain members with music, videotapes and television programmes, motivational games, special events, awards such as T-shirts and other gifts and certificates for attendance or reaching individual fitness goals. Properly designed and supervised exercise regimens will minimize injuries and aches and pains and, at the same time, make the sessions efficient and less time-consuming. Some facilities offer newspapers and business publications as well as business and training programmes on television and videotape to be accessed while exercising to help justify the time spent in the facility.

Safety and Supervision

Organizations offering worksite fitness programmes must do so in a safe manner. Potential members must be screened for medical conditions that might be affected adversely by exercise. Only well-designed and well-maintained equipment should be available and participants must be properly instructed in its use. Safety signs and rules on the appropriate use of the facility should be posted and enforced, and all staff should be trained in emergency procedures, including cardiopulmonary resuscitation. A trained exercise professional should oversee the operation of the facility.

Record Keeping and Confidentiality

Individual records containing information about health and physical status, fitness assessment and exercise prescription, fitness goals and progress toward their accomplishment and any relevant notes should be maintained. In many programmes, the participant is allowed to chart for himself or herself what was done on each visit. At a minimum, the content of records should be kept secure from all but the individual participant and members of the programme staff. Except for the staff of the employee health service, who are bound to the same rules of confidentiality and, in an emergency, the participant's personal physician, details of the individual's participation and progress should not be revealed to anyone without the individual's express consent.

Programme staff may be required to make periodic reports to management presenting aggregate data regarding participation in the programme and the results.

Whose Time, Who Pays?

Since most worksite exercise programmes are voluntary and established to benefit the worker, they are considered an extra benefit or privilege. Accordingly, the organization traditionally offers the programme on the worker's own time (during lunch time or after hours) and he or she is expected to pay all or part of the cost. This is generally applicable also to programmes provided offsite in community facilities. In some organizations, the employees' contributions are indexed to salary level and some offer "scholarships" to those who are low paid or those with financial problems.

Many employers allow participation during working hours, usually for higher-level employees, and pick up most if not all of the cost. Some refund employees' contributions if certain attendance or fitness goals are attained.

When programme participation is mandatory, as in training to prevent potential work injuries or to condition workers to perform certain tasks, government regulations and/or labour union agreements require it to be provided during work hours with all costs borne by the employer.

Managing Participants' Aches and Pains

Many people believe that exercise must be painful in order to be beneficial. This is frequently expressed by the motto "No pain, no gain". It is incumbent on the programme staff to counter this erroneous belief by changing the perception of exercise through awareness campaigns and educational sessions and by ensuring that the intensity of the exercises is graduated so that they remain pain-free and enjoyable while still improving the participant's level of fitness.

If participants complain of aches and pains, they should be encouraged to continue to exercise at a lower level of intensity or simply to rest until healed. They should be taught "RICE," the acronym for the principles of treating sports injuries: Rest; Ice down the injury; Compress any swelling; and Elevate the injured body part.

Sports Programmes

Many organizations encourage employees to participate in company-sponsored athletic events. These may range from softball or football games at the yearly company picnic, to intramural league play in a variety of sports, to inter-company competitions such as the Chemical Bank's Corporate Challenge, a competitive distance run for teams of employees from participating organizations that originated in New York City and now has spread to other areas, with many more corporations joining as sponsors.

The key concept for sports programmes is risk management. While the gains from competitive sports can be considerable, including better morale and stronger "team" feelings, they inevitably entail some risks. When workers engage in competition, they may bring to the game work-related psychological "baggage" that can cause problems, particularly if they are not in good physical condition. Examples include the middle-aged, out-of-shape manager who, seeking to impress younger subordinates, may be injured by exceeding his or her physical capabilities, and the worker who, feeling challenged by another in competing for status in the organization, may convert what is meant to be a friendly game into a dangerous, bruising mêlée.

The organization wishing to offer involvement in competitive sports should seriously consider the following advice:

·     Be sure that participants understand the purpose of the event and remind them that they are employees of the organization and not professional athletes.

·     Establish firm rules and guidelines governing safe and fair play.

·     Although signed informed consent and waiver forms do not always protect the organization from liability in the event of injury, they help participants to comprehend the extent of the risk associated with the sport.

·     Offer conditioning clinics and practice sessions prior to the opening of the competition so that participants can be in good physical shape when they begin to play.

·     Require, or at least encourage, a complete physical examination by the employee's personal physician if not available in the employee health service. (Note: the organization may have to accept financial responsibility for this.)

·     Perform a safety inspection of the athletic field and all of the sports equipment. Provide or require personal protective equipment such as helmets, clothing, safety pads and goggles.

·     Make sure that referees and security personnel as needed are on hand for the event.

·     Have first aid supplies on hand and a pre-arranged plan for emergency medical care and evacuation if needed.

·     Be sure that the organization's liability and disability insurance coverage covers such events and that it is adequate and in force. (Note: it should cover employees and others who attend as spectators as well as those on the team.)

For some companies, sports competition is a major source of employee disability. The above recommendations indicate that the risk may be "managed," but serious thought should be given to the net contribution that sports activities can reasonably be expected to provide to the physical fitness and training programme.

Conclusion

Well-designed, professionally managed workplace exercise programmes benefit employees by enhancing their health, well-being, morale and work performance. They benefit organizations by improving productivity qualitatively and quantitatively, preventing work-related injuries, accelerating employees' recovery from illness and injury, and reducing absenteeism. The design and implementation of each programme should be individualized in accord with the characteristics of the organization and its workforce, with the community in which it operates, and with the resources that can be made available for it. It should be managed or at least supervised by a qualified fitness professional who will consistently be mindful of what the programme contributes to its participants and to the organization and who will be ready to modify it as new needs and challenges arise.

WORKSITE NUTRITION PROGRAMMES

Penny M. Kris-Etherton and John W. Farquhar

Diet, physical activity and other lifestyle practices such as not smoking cigarettes and reduction of stress are important in the prevention of chronic diseases. Proper nutrition and other healthy lifestyle practices also aid in maintaining individual well-being and productivity. The worksite is an ideal place to teach people about good health habits, including sound nutrition, weight control and exercise practices. It is an excellent forum for efficiently disseminating information and monitoring and reinforcing changes that have been made (Kaplan and Brinkman-Kaplan 1994). Nutrition programmes rank among the most commonly included activities in wellness programmes sponsored by employers, labour unions and, sometimes, jointly. In addition to formal classes and programmes, other supportive educational efforts such as newsletters, memos, payroll inserts, posters, bulletin boards, and electronic mail (e-mail) can be offered. Nutrition education materials can also reach employees' dependants through mailings to the home and making classes and seminars available to homemakers who are the gatekeepers of their families' food intake practices and habits. These approaches provide useful information that can be applied easily both at the worksite and elsewhere and can help reinforce formal instruction and encourage workers to enroll in programmes or make informed and profitable use of worksite facilities (such as the cafeteria). Moreover, carefully targeted materials and classes can have a very significant impact on many people, including the families of workers, especially their children, who can learn and adopt good nutrition practices that will last a lifetime and be passed on to future generations.

Successful worksite intervention programmes require a supportive environment that enables workers to act on nutrition messages. In this context, it is essential that employees have access to appropriate foods in cafeterias and vending machines that facilitate adherence to a recommended diet. For those whose lunches depend on "brown bags" or lunch boxes, worksite arrangements for storing the lunch bags or boxes are part of a supportive environment. In addition, employer-provided or entrepreneurial lunch wagons can offer nourishing food on the spot at field worksites remote from feeding facilities. Facilities for light personal washing before eating are also important. These employer-sponsored activities express a strong commitment to the health and well-being of their employees.

In-plant Catering Programmes, Vending Machines, and Coffee and Tea Breaks

Many employers subsidize in-plant food services partially or totally, making them attractive as well as convenient. Even where there is only one shift, many cafeterias serve breakfasts and dinners as well as lunches and refreshments at breaks; this is of particular value to those who live alone or whose food preparation in the home may be less than adequate. Some worksite cafeterias are open to employees' friends and families to encourage "lunching-in" rather than using more expensive and often less nutritionally desirable facilities in the community.

Modifying foods that are offered at the worksite provides support and encouragement of healthy eating patterns (Glanz and Mullis 1988). In fact, cafeteria interventions are one of the most popular worksite nutrition programmes as they allow point-of-choice nutrition information to be readily made available (Glanz and Rogers 1994). Other interventions include modifying menu choices to provide low-fat, low-calorie and high-fibre foods or to highlight "heart healthy" foods (Richmond 1986). Worksites also can implement healthy catering policies and offer nutrient-dense foods that are low in fat, cholesterol and sodium (American Dietetic Association 1994). Negotiations can be conducted with food service vendors to also provide low-fat food items, including fruit, in vending machines. One such programme resulted in a greater selection by employees of low-calorie foods (Wilber 1983). Food service management, caterers and vendors may realize greater sales and increased participation in the food service activities at the worksite especially when tasty, attractive, healthy foods are served (American Dietetic Association 1994).

Coffee and tea breaks with nutrient-dense snack foods available can help employees meet nutritional needs. Many "lunch hours" are only 30 or 40 minutes long and because some employees use that time for shopping, socializing or personal business, they skip eating. A supportive environment may require lengthening the lunch period. Moreover, maintaining proper hygiene in the in-plant catering facility and ensuring the health and proper training of all food service personnel (even when the facility is operated under contract with an outside vendor) demonstrates the worksite's commitment to employee health, thereby increasing workers' interest in supporting the onsite food service establishments as well as other programmes.

General Nutrition Guidance

The basic dietary recommendations that have been issued by government agencies of different countries encourage health promotion and the prevention of diet-related, noncommunicable diseases (FAO and WHO 1992). The dietary guidelines adopted include the following principles:

·     Adjust energy intake to meet energy expenditure in order to achieve and maintain desirable body weight.

·     Avoid excessive fat intake and, especially, intake of saturated fat and cholesterol.

·     Increase intake of complex carbohydrates and dietary fibre and limit sugar intake to moderate levels.

·     Limit salt intake to a moderate level.

·     Limit alcohol intake.

·     Offer a variety of foods from all food groups.

There is compelling scientific evidence to support these dietary recommendations. Not only is abnormal body weight a risk factor for many chronic diseases, but fat distribution is also important to health (Bray 1989). Android obesity, or excess fat in the abdomen, is a greater health risk than gynoid obesity, the presence of excess weight below the waist (i.e., in the hips and thighs). A waist-to-hip ratio close to or above one is associated with a greater risk of hypertension, hyperlipidaemia, diabetes and insulin resistance (Seidell 1992). Thus, both body mass index (BMI)-that is, body weight (kilograms) divided by height (meters) squared-and the waist-to-hip ratio are useful in assessing weight status and the need to lose weight. Figure 15.10 presents BMI classifications of underweight, desirable weight, overweight and obesity.

Figure 15.10 Body mass index (BMI) classifications

Essentially everyone, even individuals who are at an ideal body weight, would benefit from nutrition guidance aimed at preventing the weight gain that typically occurs with ageing. An effective weight control programme integrates nutrition, exercise, and behaviour modification principles and techniques.

A diet that provides less than 30% of calories from fat, less than 10% of calories from saturated fat, and less than 300 milligrams of cholesterol daily is typically recommended to help maintain a desirable blood cholesterol level (i.e., <200 mg/dl) (National Institutes of Health 1993b). Saturated fat and cholesterol raise blood cholesterol levels. A diet relatively low in total fat facilitates achieving the saturated fat recommendation. A 2,000-calorie diet can include 67 grams of total fat and less than 22 grams of saturated fat per day. A diet low in total fat also facilitates reducing calories for weight management and may be implemented by including a variety of foods in the diet so that nutrient needs are met without exceeding calorie needs.

Diets high in complex carbohydrates (the sort of carbohydrate found in grains, legumes, vegetables, and, to some extent, fruits) are also high in many other nutrients (including B vitamins, vitamins A and C, zinc and iron) and low in fat. The recommendation to use sugar in moderation has been made because sugar, despite being a source of energy, has limited nutrient value. Thus, for persons with low calorie needs, sugar should be used sparingly. In contrast, sugar can be used as a source of calories, in moderation, in higher calorie (nutritionally adequate) diets. Although sugar promotes dental caries, it is less cariogenic when consumed with meals than when consumed in frequent between-meal snacks.

Because of the association between sodium intake and systolic hypertension, dietary salt and sodium are recommended only in moderation. A diet that provides not more than 2,400 milligrams of sodium daily is recommended for the prevention of hypertension (National Institutes of Health 1993a). A high-sodium diet also has been shown to promote calcium excretion and, thus, may contribute to the development of osteoporosis, a female-predominant risk (Anderson 1992). The major sources of sodium in the diet include processed foods and salt (or high-sodium condiments such as soy sauce) added to food during cooking or at the table.

If alcohol is consumed, it should be used in moderation. This is because excessive alcohol consumption may cause liver and pancreatic disease, hypertension and damage to the brain and heart. Further adverse consequences associated with heavy alcohol consumption include addiction, increased risk of accidents and impaired job performance.

Another common recommendation is to consume a variety of foods from all food groups. More than 40 different nutrients are required for good health. Since no single food provides all nutrients, including a variety of foods facilitates achieving a nutritionally adequate diet. A typical food guide provides recommendations for the number of "servings" of foods from the different food groups (figure 15.11). The range of servings listed represents the minimum that should be consumed daily. As energy needs increase, the range should increase correspondingly.

Figure 15.11 Example of a good daily nutrition guide

Other specific dietary recommendations have been made by different countries. Some countries recommend water fluoridation, breastfeeding, and iodine supplementation. Many also recommend that protein intake be adequate but that excess protein be avoided. Some have guidelines for the relative proportion of animal to vegetable protein in the diet. Others have emphasized vitamin C and calcium intake. Implicit to these country-specific recommendations is that they are targeted to the special needs identified for a particular area. Other nutritional issues that are important and relevant to individuals worldwide include those relating to calcium, hydration, and antioxidant vitamins and minerals.

An adequate calcium intake is important throughout life to build a strong skeleton and achieve a maximum peak bone mass (bone mass peaks between the ages of 18 and 30) and help retard age-associated bone mass loss that often leads to osteoporosis. At least 800 milligrams of calcium daily is recommended from age one year through old age. For adolescents, when bones are growing rapidly, 1,200 milligrams of calcium per day are recommended. Some authorities believe that young adults, postmenopausal women and men over 65 years of age need 1,500 milligrams of calcium per day and that the diet of all other adults should provide 1,000 milligrams. Pregnant and lactating women need 1,200 milligrams of calcium per day. Dairy products are rich sources of calcium. Low fat dairy products are recommended to control blood cholesterol levels.

Maintaining adequate hydration is essential for achieving maximal work performance. One serious consequence of dehydration is an inability to dissipate heat effectively, with a consequent increase in body temperature. Thirst usually is a good indicator of hydration status, except during heavy physical exertion. Workers always should respond to thirst and drink fluids liberally. Cool, dilute fluids replace water losses fastest. Labourers also should drink fluids liberally; for every 0.5 kilogram of weight lost per day due to exertion, one-half litre of water is recommended to replace the water lost via sweat.

Antioxidants have received a great deal of attention lately because of the growing evidence that suggests they may protect against the development of cancer, heart disease, cataracts and even slow the ageing process. The antioxidant vitamins are beta-carotene and vitamins A, E, and C. The mineral selenium also is an antioxidant. Antioxidants are thought to prevent the formation of harmful free radicals which destroy cell structures over time in a process that leads to the development of various diseases. The evidence to date suggests that antioxidants may protect against the development of cancer, heart disease and cataracts, although a causal relationship has not been established. Food sources of beta-carotene and vitamin A include green leafy vegetables, and red, orange and yellow fruits and vegetables. Grains and fish are significant sources of selenium. Citrus fruits are important sources of vitamin C, and vitamin E is found in sources of polyunsaturated fat, including nuts, seeds, vegetable oil and wheat germ.

The remarkable similarity in the dietary recommendations made by different countries underscores the consensus among nutritionists about the ideal diet for promoting health and well being. The challenge that lies before the nutrition community now is to implement these population-based dietary recommendations and assure proper nutrition globally. This will require not only providing a safe and adequate food supply to all persons everywhere, but also necessitates developing and implementing nutrition education programmes worldwide that will teach virtually everyone the principles of a healthy diet.

Cultural and Ethnic Approaches to Foods and Diet

Effective nutrition education approaches must address cultural issues and ethnic food habits. Cultural sensitivity is important in planning nutrition intervention programmes and in eliminating barriers to effective communication in individual counselling, as well. Given the current emphasis on cultural diversity, exposure to different cultures in the worksite, and a keen interest among individuals to learn about other cultures, pace-setting nutrition programmes that embrace cultural differences should be well received.

Societies have vastly different beliefs about the prevention, cause, and treatment of disease. The value placed on good health and nutrition is highly variable. Helping people adopt healthy nutrition and lifestyle practices requires an understanding of their beliefs, culture and values (US Department of Health and Human Services 1990). Nutrition messages must be targeted to the specific practices of an ethnic population or group. Moreover, the intervention approach must be planned to address widely held beliefs about health and nutrition practices. For example, some cultures disapprove of alcohol whereas others consider it to be an essential part of the diet even when taken with meals eaten at the worksite. Thus, nutrition interventions must be specialized not only to meet the particular needs of a target group, but to embrace the values and beliefs that are unique to their culture.

Overweight

The key environmental factors that contribute to the development of overweight and obesity are principally caloric excess and lack of physical activity.

Overweight and obesity are most often classified on the basis of BMI, which is correlated with body composition (r = 0.7-0.8). Weight status classifications according to BMI for men and women less than 35 and greater than 35 years of age are presented in figure 15.10. The health risks associated with overweight and obesity are clear. Data from a number of studies have shown a J-shape relationship between body weight and all-cause mortality. Although the mortality rate increases when BMI exceeds 25, there is a pronounced increase when BMI is greater than 30. Interestingly, underweight also increases risk of mortality, albeit not to the extent as does overweight. Whereas overweight and obese individuals are at higher risk of death due to cardiovascular disease, gallbladder disease and diabetes mellitus, underweight persons are at higher risk for the development of digestive and pulmonary diseases (Lew and Garfinkel 1979). The incidence of overweight and obesity in some developed countries may be as high as 25 to 30% of the population; it is even higher in certain ethnic groups and in groups of low socioeconomic status.

A low caloric diet that leads to a weight loss of 0.2 to 0.9 kilograms (0.5 to 2 pounds) per week is recommended for weight reduction. A low-fat diet (about 30% of calories from fat or lower) that is also high in fibre (15 grams per 1000 calories) is recommended to facilitate decreasing calories and providing bulk for satiety. A weight loss programme should include both exercise and behaviour modification. A slow, steady weight loss is recommended to successfully modify eating behaviours in order to maintain weight loss. Guidelines for a sound weight-reduction programme appear in figure 15.12.

Figure 15.12 Guidelines for a sound weight-reduction programme

A random-digit telephone survey of 60,589 adults across the United States revealed that approximately 38% of women and 24% of men were actively trying to lose weight. Reflecting the marketing efforts of what has become a veritable weight-reduction industry, the methods employed ranged from periodic fasting, participating in organized weight-reduction programmes, often with commercially prepared foods and special supplements, and taking diet pills. Only half of those trying to lose weight reported using the recommended method of calorie restriction combined with exercise demonstrating the importance of worksite nutrition education programmes (Serdula, Williamson et al. 1994).

Weight loss in overweight or obese persons beneficially affects various chronic disease risk factors (NIH 1993a). Weight loss leads to reductions in blood pressure, plasma lipids and lipoproteins (i.e., total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides) and increases high density lipoprotein (HDL) cholesterol, all of which are major risk factors for coronary heart disease (figure 15.13). Furthermore, blood glucose, insulin and glycosylated haemoglobin levels are favourably affected. With weight losses as modest as about four kilograms, even when some excess weight is regained, improvements in these parameters have been observed.

Figure 15.13 Major coronary heart-disease risk factors

Weight control is essential for reducing chronic disease morbidity and mortality. This has formed the basis of the dietary recommendations of many groups worldwide to achieve and maintain a healthy body weight. These recommendations have been made mainly for developed countries where overweight and obesity are major public health concerns. While diet, exercise, and behaviour modification are recommended for weight loss, the key to reducing the incidence of overweight and obesity is to implement effective prevention programmes.

Underweight

Underweight (defined as a body weight of 15 to 20% or more below accepted weight standards) is a serious condition that results in a loss of energy and an increased susceptibility to injury and infection. It is caused by an insufficient food intake, excessive activity, malabsorption and poor utilization of food, wasting diseases or psychological stress. High-energy diets are recommended for a gradual, steady weight gain. A diet that provides 30 to 35% of calories from fat and an additional 500 to 1,000 calories per day is recommended. Underweight persons can be encouraged to eat calorie-dense meals and snacks at the worksite by offering them access to a wide variety of palatable, popular foods.

Special Diets

Special diets are prescribed for the treatment of certain diseases and conditions. In addition, dietary modifications should accompany preventive lifestyle and nutrition programmes and should be implemented during various stages of the life cycle, such as during pregnancy and lactation. An important aspect of successfully implementing special diets is recognizing that a number of different strategies can be utilized to achieve the nutrient specifications of the special diet. Thus, individualizing diet plans to meet the unique needs of persons is essential for attaining long-term dietary adherence and, thereby, realizing the health benefits of the diet.

Low-fat, low-saturated fat, low-cholesterol diet

The recommended diets for the treatment of an elevated blood cholesterol level are the Step-One diet (<30% of calories from fat, 8 to 10% of calories from saturated fat and <300 milligrams of cholesterol) and the Step-Two diet (<30% of calories from fat, <7% of calories from saturated fat, and <200 milligrams of cholesterol) (NIH 1993b). These diets are designed to progressively reduce intake of saturated fat and cholesterol and to decrease total fat intake. The major sources of fat in the diet are meat, poultry; full-fat dairy products and fats and oils. In general, for most persons in developed countries, adherence to a Step-One diet requires reducing total fat and saturated fat by about 20 to 25%, whereas following a Step-Two diet requires decreasing total fat similarly but decreasing saturated fat by approximately 50%. A Step-One diet can be achieved rather easily by applying one or more fat reduction strategies to the diet, such as substituting lean meat, poultry and fish for higher-fat varieties, substituting low-fat and skim milk products for full-fat dairy products, using less fat in food preparation and adding less fat to food prior to consumption (e.g., butter, margarine or salad dressing) (Smith-Schneider, Sigman-Grant and Kris-Etherton 1992). A Step-Two diet requires more careful diet planning and the intensive nutrition education efforts of a qualified nutritionist.

Very low-fat diet

A diet that provides 20% or less of calories from fat is recommended by some nutritionists for the prevention of certain cancers that have been associated with diets high in fat (Henderson, Ross and Pike 1991). This diet is rich in fruits and vegetables, grains, cereals, legumes and skim milk dairy products. Red meat can be used sparingly, as can fats and oils. Foods are prepared with little or no added fat and are cooked by baking, steaming, boiling or poaching.

A diet that provides minimal amounts of saturated fat (3% of calories) and total fat (10% of calories), together with major lifestyle changes (smoking cessation, exercise and meditation) has been shown to result in the regression of atherosclerosis (Ornish et al. 1990). This particular diet requires major lifestyle changes (i.e., a change in habitual cuisine), including adopting a largely vegetarian diet and using meat, fish and poultry as a condiment, if at all, and emphasizing grains, legumes, fruits, vegetables, and skim milk dairy products. Adherence to this diet can require the purchase of special foods (fat-free products) while avoiding most commercially prepared foods. While this regimen is an option for some persons at high risk for cardiovascular disease, especially as an alternative to drug therapy, it requires a very high level of motivation and commitment.

Diet for workers with diabetes

An individually developed dietary prescription based on metabolic, nutrition, and lifestyle requirements is recommended (American Dietetic Association 1994). In general, dietary protein provides 10 to 20% of calories. Saturated fat should account for less than 10% of total caloric intake. The distribution of remaining energy from carbohydrate and fat varies according to the patient's condition and reflects the specific glucose, lipid and weight outcomes chosen for him or her. For those who are at or close to ideal weight, 30% of calories from fat is recommended. For overweight persons, a reduction in total fat facilitates reducing calories, resulting in a corresponding weight loss. For persons who have an elevated triglyceride level, a diet higher in total fat, and, in particular, monounsaturated fat is recommended, together with close supervision; the higher-fat diet may perpetuate or aggravate obesity. The new model for the medical nutrition therapy for diabetes includes assessment of the individual's metabolic and lifestyle parameters, an intervention plan and monitoring therapeutic outcomes.

Diet for pregnancy and lactation

Pregnancy and lactation represent periods when both energy and nutrient demands are high. For pregnancy, a diet should provide sufficient calories for adequate weight gain (National Research Council 1989). The calories and nutrients needed to maximally support pregnancy and lactation for as long as several years during multiple pregnancies and lengthy lactation periods can be obtained from a diet that includes the basic food groups. Other recommendations for both pregnant and lactating women include selecting a variety of foods from each food group, consuming regular meals and snacks, and including ample dietary fibre and fluid. Alcoholic beverages should be avoided or at least markedly restricted by pregnant and lactating women. Salt to taste is also recommended for pregnant women. An adequate diet during pregnancy and lactation is essential to assure normal foetal and infant growth and development and maternal health and well-being, and should be emphasized in worksite nutrition education programmes and catering facilities.

Lactose Intolerance and Gluten Sensitivity

Many adults, especially those of certain ethnic groups, must restrict lactose in their diet due to a lactase deficiency. The major source of lactose in the diet is dairy products and foods prepared with them. It is important to note that the excipient in many medications is lactose, a circumstance that could pose problems to those who take a number of medications. For the small number of people who have a gluten sensitivity (coeliac disease), foods containing gluten must be eliminated from the diet. Sources of gluten in the diet include wheat, rye, barley and oats. Whereas many individuals with a lactose intolerance can tolerate small amounts of lactose, especially when eaten with foods that do not contain lactose, persons with a gluten sensitivity must avoid any food that contains gluten. Worksite catering facilities should have appropriate foods available if there are employees with these special conditions.

Summary

The worksite is an ideal setting for implementing nutrition programmes aimed at teaching the principles of good nutrition and their application. There is a variety of programmes that can be developed for the worksite. In addition to providing classes and nutrition education materials for all employees, special programmes can be targeted to workers at high risk for different chronic diseases or for selected groups based on ethnic or demographic characteristics. Chronic disease risk reduction requires a long-term commitment by both workers and their employers. Effective worksite nutrition programmes are beneficial in reducing the risk of chronic diseases in countries worldwide.

SMOKING CONTROL IN THE WORKPLACE

Jon Rudnick

Introduction

Awareness of the adverse effects associated with cigarette smoking has increased since the 1960s when the first US Surgeon General's report on this topic was released. Since that time, attitudes towards cigarette smoking have steadily grown towards the negative, with warning labels being required on cigarette packages and advertisements, bans on television advertising of cigarettes in some countries, the institution of non-smoking areas in some public places and the complete prohibition of smoking in others. Well-founded public health messages describing the dangers of tobacco products are increasingly widespread despite the tobacco industry's attempts to deny that a problem exists. Many millions of dollars are spent each year by people trying to "kick the habit". Books, tapes, group therapy, nicotine gum and skin patches, and even pocket computers have all been used with varying degrees of success in aiding those with nicotine addiction. Validation of the carcinogenic effects of passive, "second-hand" smoking has added impetus to the growing efforts to control the use of tobacco.

With this background, it is natural that smoking in the workplace should become a growing concern for employers and employees. On the most basic level, smoking represents a fire hazard. From a productivity standpoint, smoking represents either a distraction or an annoyance, depending on whether the employee is a smoker or a non-smoker. Smoking is a significant cause of morbidity in the workforce. It represents a drain in productivity in the form of the loss of work days due to illness, as well as a financial drain on an organization's resources in terms of health-related costs. Furthermore, smoking has either an additive or multiplicative interaction with environmental hazards found in certain workplaces increasing significantly the risk of many occupational diseases (figure 15.14).

Figure 15.14 Examples of interactions between occupation and cigarette smoking causing disease

This article will concern itself with the rationale for smoking control in the workplace and suggest a practical attitude and approach to managing it, recognizing that mere exhortation is not enough. At the same time, the terrible, addictive nature of nicotine and the human difficulties associated with quitting will not be underestimated. One hopes that it represents a more realistic approach to this complicated problem than some of those taken in the past.

Smoking in the Workplace

Organizations are increasingly associating unhealthy habits such as smoking with higher operating costs, and employers are taking measures to reduce the excess costs associated with employees who smoke. People who smoke one or more packs of cigarettes a day account for 18% higher medical claim costs than non-smokers, according to a study of the impact of various lifestyle risks compiled by the Ceridian Corporation, a technology services company based in Minneapolis, Minnesota. Heavy smokers spend 25% more days as inpatients in hospitals and are 29% more likely than non-smokers to have annual health care claims costs that exceed US$5,000, the study shows (Lesmes 1993).

The impact of smoking on the health of the population and the health care system is unparalleled (US Department of Health and Human Services 1989). According to the World Health Association (1992), tobacco kills at least 3 million people each year worldwide: in countries where smoking has been a long-established behaviour, it is responsible for about 90% of all lung cancer deaths; 30% of all cancers; over 80% of cases of chronic bronchitis and emphysema; and some 20 to 25% of coronary heart disease and stroke deaths. Numerous other adverse health conditions, including respiratory diseases, peptic ulcers and pregnancy complications, are also attributable to smoking. Smoking remains the leading cause of avoidable death in many countries, so pervasive that it is responsible for about one sixth of deaths from all causes in the United States, for example (Davis 1987).

The combined effect of smoking and occupational hazards has been demonstrated by the significant differences in morbidity of smokers and non-smokers in many occupations. The interaction of the two types of hazards increases the risk of many diseases, particularly the chronic obstructive pulmonary diseases, lung cancer, cardiovascular diseases, as well as disabilities (figure 15.14).

Well-recognized complications resulting from exposure to tobacco-related hazards are outlined in great detail throughout the technical literature. Recent attention has focussed on the following:

·     Female risks. Changes in oestrogen metabolism, menstrual disorders, early menopause, delayed conception or infertility, cancer of the cervix.

·     Maternal and pregnancy risks. Spontaneous abortion, ectopic pregnancy, placental irregularities, placenta praevia, abruptio placentae, vaginal bleeding, foetal mortality, preterm birth, retardation of foetal development, low birth weight, congenital anomalies and chronic hypoxia.

·     Childhood complications. Increased neonatal mortality, sudden infant death syndrome (SIDS), impaired physical and intellectual development.

Environmental Tobacco Smoke (ETS)

Tobacco smoking is not only dangerous to the smoker but to non-smokers as well. ETS ("passive smoking" and "second-hand smoke") is a unique risk for people, such as office workers, working in a closed environment. In developed countries, the World Health Organization (1992) points out, tobacco smoke is the most common pollutant of indoor air and is usually present at higher concentrations than other air pollutants. Besides the acute effects of eye and throat irritation, ETS increases the risk of lung cancer and possibly of cardiovascular disease. It is particularly troublesome to individuals with pre-existing health conditions, such as asthma, bronchitis, cardiovascular disease, allergies and upper respiratory infections, and also is a vexatious challenge to those who have recently given up smoking and are struggling to maintain their abstinence.

The US National Institute for Occupational Safety and Health, NIOSH, concluded that (1991):

·     ETS is a potential carcinogen.

·     Exposure to ETS should be reduced to the lowest possible concentration.

·     Employers should minimize occupational exposure to ETS by using all available control measures.

·     Worker exposure to ETS is most efficiently and completely controlled by simply eliminating tobacco smoke from the workplace.

·     Employers should prohibit smoking at the workplace and provide sufficient disincentives for those who do not comply.

Except where legislation has mandated the smoke-free workplace, the protection of non-smoking employees from the health risks associated with exposure to ETS remains a formidable challenge for many public and private sector employees. Smokers, with encouragement from the tobacco industry, have maintained that continuation of smoking is inherently an individual right, despite the fact that eliminating tobacco smoke from the workplace has required innovations in ventilation engineering and expense by the employer. Legal precedents have established a clear duty for employers to provide workplaces free from hazards such as ETS and courts of law in some countries have found employers liable for the adverse health effects of ETS exposure on the job.

Surveys of public knowledge and attitudes about the risks of ETS and the desirability of workplace smoking restrictions show widespread concern about this sort of exposure and increasingly strong support for significant restrictions among both non-smokers and smokers (American Lung Association 1992). Governments have adopted an increasing number of ordinances and regulations limiting smoking in public and private workplaces (Corporate Health Policies Group 1993).

Impact of Smoking on Employers' Costs

Historically, employers' efforts to reduce smoking in the workplace have been driven by issues of cost and productivity losses related to smoking behaviour. A number of studies have compared employers' costs associated with smoking and non-smoking employees. For example, in one study of employees in a large-scale group health insurance plan, tobacco users had higher average outpatient medical care costs ($122 versus $75), higher average insured medical costs ($1,145 versus $762), more hospital admissions per 1,000 employees (174 versus 76), more hospital days per 1,000 employees (800 versus 381), and longer average lengths of hospital stay (6.47 versus 5.03 days) (Penner and Penner 1990).

Another study, undertaken over a period of three and one-half years by the Dow Chemical Company and covering 1,400 employees (Fishbeck 1979), showed that smokers were absent 5.5 days more per year than non-smokers, costing Dow over $650,000 annually in excess wages alone. This figure did not include extra health care costs. In addition, smokers had 17.4 disability days per year compared with 9.7 days for non-smokers. Smokers also had twice the frequency of circulatory disease problems, three times more pneumonia, 41% more bronchitis and emphysema, and 76% more respiratory diseases of all types. For every two non-smokers who died during the study period, seven smokers died.

A study by the United States Steel Corporation found that employees who smoke have more work-loss days than those who have never smoked. It also showed that in every age group, as the number of cigarettes smoked per day by confirmed smokers increased, so did the number of absences due to illness. Additionally, male smokers of more than two packs per day had nearly twice as much absence as their non-smoking counterparts. In a study on how much individual behavioural risk factors contribute to the total disability and health care costs of a large, multi-location industrial company, smokers had 32% greater absenteeism and $960 excess average annual illness costs per employee (Bertera 1991).

The annual report of the Kansas State Employees Health Care Commission found that smokers incurred 33% more hospital admissions than non-smokers (106.5 versus 71.06 hospital admissions per 1,000 persons). The total average claim payment per employee was $282.62 more for smokers than for non-smokers.

Results like these have prompted some US employers to add a "surcharge" to their smoking employees' share of group health insurance premiums to cover the higher claims payments associated with this population. The Resinoid Engineering Corporation stopped hiring smokers in its Ohio plant because their health care claims were $6,000 higher per employee per year for smokers than for non-smokers; a similar move by a Chicago, Illinois company was barred because the state law prohibits discriminatory hiring on the basis of lifestyle.

Other employers, using the "carrot" rather than the "stick" approach, have offered inducements such as monetary or other types of awards to employees who successfully quit smoking. A popular approach is to refund the tuition required for participating in a smoking cessation programme to those who complete the course or, more strictly, to those who remain abstinent for a defined period following the completion of the course.

In addition to increased health care costs and costs associated with lost productivity due to sickness among smokers, there are other increased costs associated with smoking, namely those arising from lost productivity during smoking breaks, higher fire and life insurance costs, and higher general cleaning costs related to smoking. For example, Air Canada identified savings of about US$700,000 per year by not having to clean ashtrays and being able to extend the frequency of deep cleaning of its planes from six to nine months after implementing its tobacco-free policy (WHO 1992). A study by Kristein (1983) designed to take into account all of the increased costs due to smoking estimated the total to be $1,300 per smoker per year (adjusted to 1993 dollars). He also discussed other areas of excess cost, including, in particular, the costs of higher levels of maintenance for computers and other sensitive equipment, and for installing and maintaining ventilation systems. Furthermore, he added that other costs result from the "inefficiency and errors based on the established literature as to the effects of higher carbon monoxide levels in smokers, eye irritation, measured lower attentiveness, cognitive and exercise capacity function".

Smoking Policies and Regulations

In the 1980s, laws and voluntary policies to restrict smoking at the workplace increased in number and strength. Some pertain only to government worksites which, together with places of work where children are present, have often taken the lead. Others affect both government and private worksites. They are characterized by banning smoking altogether ("smoke-free" worksites); restricting smoking in common areas such as cafeterias and meeting rooms; allowing smoking only in special smoking areas; and requiring accommodation of the interests of smokers and non-smokers, with primacy given to the wishes of the latter.

Some programmes regulate smoking in worksites where certain hazardous materials are present. For example, in 1976 Norway issued rules prohibiting the assignment of persons who smoke to areas where they may be exposed to asbestos. In 1988, Spain prohibited smoking in any place where the combination of smoking and occupational hazards results in greater risk to the health of workers. Spain also prohibits smoking in any worksite where pregnant women work. Other countries that have taken legislative measures to restrict smoking in the workplace include Costa Rica, Cuba, Denmark, Iceland and Israel (WHO 1992).

Increasingly, legislation restricting smoking at the worksite is part of a broader regulation covering public places. New Zealand, Norway and Sweden have enacted such legislation while Belgium, the Netherlands and Ireland have passed laws prohibiting smoking in most public places. The 1991 French law prohibits smoking in all places designed for collective use, notably schools and public transportation (WHO 1992).

In the United States and Canada, although federal agencies have adopted smoking control policies, legislation has been limited to states and provinces and to municipalities. By 1989, 45 US states had enacted laws restricting smoking in public places, while 19 states and the District of Columbia had adopted ordinances restricting smoking in private workplaces (Bureau of National Affairs 1989). The state of California has a bill pending that would totally ban smoking in all indoor employment areas and would also obligate an employer to take reasonable steps to prevent visitors from smoking (Maskin, Connelly and Noonan 1993). For some time, the Occupational Safety and Health Administration (OSHA) in the US Department of Labor has been considering the regulation of ETS in the workplace both as an independent toxicant and as a component of indoor air (Corporate Health Policies Group 1993).

Another incentive for employers to reduce smoking in the workplace comes from cases of disability stemming from exposure to ETS that have won worker's compensation awards. In 1982, a federal appellate court found an employee eligible for disability retirement because she had been forced to work in a smoke-filled environment (Parodi vs. Veterans Administration 1982). Similarly, employees have been awarded worker's compensation payments because of adverse reactions to tobacco smoke on the job. Indeed, William Reilly, the former administrator of the US Environmental Protection Agency (EPA) has expressed the hope that the threat of employer liability raised by the recent release of the EPA's designation of EST as a significant health hazard would obviate the necessity of additional federal government regulations (Noah 1993).

Another factor favouring the establishment of policies curbing workplace smoking is the change in public attitudes reflecting (1) recognition of the mounting scientific evidence of the risks of cigarette smoke to smokers and non-smokers alike, (2) a decline in the prevalence of smoking, (3) a decline in the social acceptability of smoking and (4) a heightened awareness of the rights of non-smokers. The American Lung Association (1992) reported consistent increases in the overall percentage of adults who favour workplace smoking restrictions, from 81% in 1983 to 94% in 1992, while in the same period, those favouring a total ban increased from 17% to 30% and those favouring no restrictions fell from 15% to 5%.

Labour unions are also increasingly supportive of non-smoking policies (Corporate Health Policies Group 1993).

Recent US surveys have shown a marked trend towards not only increased adoption of smoking restrictions but also their increasing stringency (Bureau of National Affairs 1986, 1991). The percentage of companies with such policies rose from 36% in 1986 to 85% in 1991 while, in the same period, there was a sixteen-fold increase in the percentage with total bans or "smoke-free" policies (Bureau of National Affairs 1991; Coalition on Smoking and Health 1992).

Smoking Cessation Programmes

Worksites are becoming increasingly common settings for health education and promotion efforts. Of several cited studies (Coalition on Smoking and Health 1992), one survey indicates that 35.6% of companies offer some kind of smoking cessation assistance. Another study shows that non-smoking policies may also provide environmental support to individuals attempting to quit smoking. Thus, a non-smoking policy may also be considered an important element in a smoking cessation programme.

Smoking cessation methods are divided into two categories:

·     Unassisted methods, which include going "cold turkey" (i.e., just stopping without recourse to any special techniques); gradually reducing the number of cigarettes smoked per day; using low-tar or low-nicotine cigarettes; quitting with friends, relatives or acquaintances; using special cigarette filters or holders; using other nonprescription products; or substituting another tobacco product for cigarettes (snuff, chewing tobacco, pipes or cigars).

·     Assisted methods, which include attending a programme or a course with or without a fee; consulting a mental health professional; hypnosis; acupuncture; and using nicotine gum or nicotine skin patches.

The efficacy of these various methods is the subject of much controversy largely due to the difficulties and costs associated with long-term follow-up and the obvious self-interest of the vendors of programmes and products. Another serious limitation relates to the ability to verify the smoking status of programme participants (Elixhauser 1990). Saliva tests measuring cotinine, a metabolite of nicotine, are an effective objective indicator of whether an individual has recently been smoking, but they are moderately complicated and expensive and, thus. not widely used. Accordingly, one is forced to depend on the questionable reliability of the individual's self-reports of success in either quitting or cutting down on the amount smoked. These problems make it extremely difficult to compare various methods to one another or even to make proper use of a control group.

Despite these encumbrances, two general conclusions can be drawn. First, those individuals most successful in permanently quitting do so largely on their own, often after numerous attempts to do so. Secondly, barring the individual "cold turkey" approach, multiple interventions in combination appear to enhance the effectiveness of efforts to quit, especially when accompanied by support in maintaining abstinence and reinforcement of the quit-smoking message (Bureau of National Affairs 1991). The importance of the latter is confirmed by a study (Sorenson, Lando and Pechacek 1993) which found that the highest overall cessation rate was achieved by smokers who worked among a high proportion of non-smokers and who were frequently asked not to smoke. Still, the six-month quitting rate was only 12%, compared to a rate of 9% among the control group. Obviously, cessation programmes in general must not be expected to produce dramatic positive results but, instead, must be viewed as requiring a persistent, patient effort towards the goal of quitting smoking.

Some workplace smoking cessation programmes have been overly simple or naive in their approach, while others have lacked long-term determination and commitment. Companies have tried everything from simply restricting smoking to specified areas of the worksite or autocratically making a sudden announcement banning all smoking, to providing expensive and intensive (but often short-lived) programmes offered by outside consultants. The problem and the challenge is to successfully accomplish the transition to a smoke-free workplace without sacrificing worker morale or productivity.

The following section will present an approach that incorporates our present knowledge of the difficulties individuals face in quitting and the employer attitude necessary to best achieve the goal of non-smoking in the workplace.

An Alternative Approach to Achieving a Smoke-free Workplace

Past experience has shown that simply offering smoking cessation programmes to volunteers does not advance the goal of a smoke-free workplace because the majority of smokers will not participate in them. At any given time, only about 20% of smokers are ready to quit and only a minority of this group will sign up for a cessation programme. For the other 80% of smokers who don't want to quit or who don't believe they can quit when the enterprise goes smoke-free, instituting a ban on smoking in the workplace will just tend to cause them to move their smoking during working hours "out the door" to a designated smoking area or somewhere outside the building. This "80% problem"-the problem that 80% of the smokers are not going to be helped or even consider participating in the programme if only smoking cessation programmes are offered-has numerous consequent negative effects on employee relations, productivity, operating costs and health-related costs.

An alternative, and successful, approach has been developed by Addiction Management Systems, an organization based in Toronto, Canada. This approach is based on the knowledge that change and the modification of behaviour is a process which can be planned and managed using organizational and behavioural techniques. It involves dealing with control of smoking in the workplace in the same way as any other major policy or procedural change for the company, with informed decisions made by management after input from representative employee groups. A controlled change is made by supporting those managers responsible for overseeing the change and making all smokers positive participants in the change by providing them with the "tools" to accommodate to the new non-smoking environment without requiring them to quit smoking. The focus is on communications and team-building by involving and educating all of those affected by the policy change.

The actual process of the transition to a smoke-free workplace begins with the announcement of the policy change and the start of a transition period of several months' duration before the policy goes into effect. In behavioural terms, the upcoming policy change to becoming smoke-free acts as a "stimulus to change" and creates a new environment in which it is in the interest of all smokers to seek a means of successfully adapting to the new environment.

The announcement of this policy change is followed by a communication programme aimed at all employees, but focussed on two important groups: the supervisors who must implement and oversee the new non-smoking policy, and the smokers who need to learn to adapt to the new environment. An important part of the communication programme is making smokers aware that, while they will not be required to quit smoking unless they so choose, they must nonetheless adhere to the new policy forbidding smoking in the workplace during the workday. All employees receive the communications about the policy and upcoming changes.

During the transition period, supervisors are provided with communications materials and a training programme to enable them to understand the policy change and to anticipate questions, problems or other concerns which may come up during or after the change. As the group most directly affected when the policy goes into effect, smokers are consulted about their specific needs and also receive their own training programme. The special focus of the latter is to acquaint them with a voluntary self-help "smoking control" programme that contains a number of options and choices which allow the smokers to understand the programme and to learn to modify their smoking behaviour in order to refrain from smoking during the workday as required once the new policy goes into effect. This allows each smoker to personalize his or her own programme, with "success" defined by the individual, whether it be quitting altogether or just learning how not to smoke during the workday. Accordingly, resentment is neutralized and the change to the smoke-free workplace becomes a positive motivating factor for the smoker.

The end result of this approach is that when the effective date of the policy arrives, the transition to a smoke-free workplace becomes a "non-event"-it simply happens, and it is successful. The reason this occurs is that the groundwork has been laid, the communications have been carried out, and all of those persons involved understand what needs to happen and have the means to make a successful transition.

What is important from an organizational standpoint is that the change is one which tends to be self-maintaining, with only minimal ongoing input from management. Also important is the effect that once successful in learning to "manage" their smoking problem, the smokers in the "80% group" tend to build on their success and to progress towards quitting completely. Finally, in addition to the beneficial effect on the well-being and morale of employees who are positively involved in the transition to a smoke-free environment, the organization accrues over time benefits in terms of higher productivity and reduced costs related to health care.

Evaluation of Effectiveness

In evaluating the effectiveness of the programme, there are two separate criteria that must be considered. The first is whether the workplace truly becomes a smoke-free environment. Success with respect to this goal is relatively easy to measure: it is based on regular supervisors' reports on violations of the policy within their work areas; monitoring complaints from other employees; and the results of unannounced spot checks of the workplace to reveal the presence or absence of cigarette butts, ashes and smoke-laden air.

The second measure of success, and more difficult to determine, is the number of employees who actually quit smoking and maintain their smoke-free status. While perhaps the most practical position to take is to be concerned only with worksite smoking, such a limited success will bring about fewer long-term benefits, especially with respect to decreasing illness and health care costs. While periodic mandatory saliva tests for cotinine to identify those who continue to smoke would be the best and most objective method for evaluating long-term programme success, this is not only complicated and expensive but also is fraught with numerous legal and ethical questions regarding employee privacy. A compromise is the use of annual or semi-annual anonymous questionnaires that ask how individuals' smoking habits have changed and how long abstinence from smoking has been maintained and that, at the same time, probe changes in employees' attitudes toward the policy and the programme. Such questionnaires have the added advantage of being a means of reinforcing the non-smoking message and of keeping the door open for those still smoking to reconsider dropping the habit.

A final long-term outcome evaluation involves monitoring employee absenteeism, illnesses and health care costs. Any changes would at first be subtle, but over a number of years they should be cumulatively significant. Death benefits paid prior to normal retirement age could be another long-term reflection of the success of the program. Of course, it is important to adjust such data for such factors as changes in the work force, employee characteristics such as age and sex, and other factors affecting the organization. Analysis of these data is manifestly subject to the rules of statistics and would probably be valid only in organizations with a large and stable workforce and adequate data collection, storage and analysis capabilities.

Smoking Control Worldwide

There is a growing worldwide unwillingness to continue to bear the burdens of cigarette smoking and nicotine addiction in terms of their effects on human well-being and productivity, on health and health care costs, and on the economic health of work organizations and nations. This is exemplified by the expanding participation in World No-Tobacco Day that has been spearheaded by the World Health Organization in May of each year since 1987 (WHO 1992).

The aim of this event is not only to ask people to stop smoking for one day but also to trigger interest in controlling smoking among public and private organizations and to promote pressure for the passage of laws, by-laws or regulations advancing the cause of tobacco-free societies. It is also hoped that the relevant agencies will be stimulated to initiate research on specific themes, publish information or initiate action. To this end, each World No-Tobacco Day is assigned a specific theme (table 15.3); of particular interest to readers of this article is the 1992 Day which addressed "Tobacco-free workplaces: safer and healthier".

Table 15.3 Themes of "World No-Tobacco Days"

1992     Tobacco Free Workplaces: safer and healthier

1993     Health Services: our window to a tobacco-free world

1994     The Media and Tobacco: getting the health message across

1995     The Economics of Tobacco: tobacco costs more than you think

1996     Sports and the Arts

1997     United Nations and Specialized Agencies against Tobacco

A problem beginning to be recognized is the increase in cigarette smoking in developing countries where, prompted by the marketing blandishments of the tobacco industry, populations are being encouraged to view smoking as a hallmark of social advancement and sophistication.

Conclusion

The adverse effects of cigarette smoking on individuals and societies are increasingly being recognized and understood (except by the tobacco industry). Nevertheless, smoking continues to enjoy social acceptability and widespread use. A special problem is that many young people become addicted to nicotine years before they are old enough to work.

The workplace is an exceptionally useful arena for combatting this health hazard. Workplace policies and programmes can have a strong positive influence over the behaviour of employees who smoke, abetted by peer pressure from non-smoking coworkers. The wise organization will not only appreciate that control of workplace smoking is something that serves its own self-interest in terms of legal liabilities, absenteeism, production and health-related costs, but will also recognize that it can be a matter of life and death for its employees.

SMOKING CONTROL PROGRAMMES AT MERRILL LYNCH AND COMPANY, INC.:  A CASE STUDY

Kristan D. Goldfein

In 1990, the US Government demonstrated strong support for workplace health promotion programmes with the publication of Healthy People 2000, setting forth the National Health Promotion and Disease Prevention Objectives for the Year 2000 (US Public Health Service 1991). One of these objectives calls for an increase in the percentage of worksites offering health promotion activities for their employees by the year 2000, "preferably as part of a comprehensive employee health promotion program" (Objective 8.6). Two objectives specifically include efforts to prohibit or severely restrict smoking at work by increasing the percentage of worksites with a formal smoking policy (Objective 3.11) and by enacting comprehensive state laws on clean indoor air (Objective 3.12).

In response to these objectives and employee interest, Merrill Lynch and Company, Inc. (hereafter called Merrill Lynch) launched the Wellness and You programme for employees at headquarters locations in New York City and in the state of New Jersey. Merrill Lynch is a US-based, global financial management and advisory company, with a leadership position in businesses serving individuals as well as corporate and institutional clients. Merrill Lynch's 42,000 employees in more than 30 countries provide services including securities underwriting, trading and brokering; investment banking; trading of foreign exchange, commodities and derivatives; banking and lending; and insurance sales and underwriting services. The employee population is diverse in terms of ethnicity, nationality, educational achievement and salary level. Nearly half of the employee population is headquartered in the New York City metropolitan area (includes part of New Jersey) and in two service centres in Florida and Colorado.

Merrill Lynch's Wellness and You Programme

The Wellness and You programme is based in the Health Care Services Department and is managed by a doctorate-level health educator who reports to the medical director. The core wellness staff consists of the manager and a full-time assistant, and is supplemented by staff physicians, nurses and employee assistance counsellors as well as outside consultants as needed.

In 1993, its initial year, over 9,000 employees representing approximately 25% of the workforce participated in a variety of Wellness and You activities, including the following:

·     self-help and written information programmes, including the distribution of pamphlets on a diversity of health topics and a Merrill Lynch personal health guide designed to encourage employees to get the tests, immunizations, and guidance they need to stay healthy

·     educational seminars and workshops on topics of broad interest such as smoking cessation, stress management, AIDS, and Lyme disease

·     comprehensive screening programmes to identify employees at risk for cardiovascular disease, skin cancer, and breast cancer. These programmes were provided by outside contractors on company premises either in health services clinics or mobile van units

·     ongoing programmes, including aerobic exercise in the company cafeteria and personal weight management classes in company conference rooms

·     clinical care, including influenza immunizations, dermatology services, periodic health examinations and nutritional counselling in the employee health services clinics.

In 1994, the programme expanded to include an onsite gynaecology screening programme comprising of Pap smears and pelvic and breast examinations; and a worldwide emergency medical assistance programme to help American employees locate an English-speaking doctor anywhere in the world. In 1995, wellness programmes will be extended to service offices in Florida and Colorado and will reach approximately half of the entire workforce. Most services are offered to employees free of charge or at nominal cost.

Smoking Control Programmes at Merrill Lynch

Anti-smoking programmes have gained a prominent place in the workplace wellness arena in recent years. In 1964, the US Surgeon General identified smoking as the single cause of the greater part of preventable disease and premature death (US Department of Health, Education, and Welfare 1964). Since then, research has demonstrated that the health risk from inhaling tobacco smoke is not limited to the smoker, but includes those who inhale second-hand smoke (US Department of Health and Human Services 1991). Consequently, many employers are taking steps to limit or curtail smoking by employees out of concern for employee health as well as their own "bottom lines". At Merrill Lynch, Wellness and You includes three types of smoking cessation effort: (1) the distribution of written material, (2) smoking cessation programmes, and (3) restrictive smoking policies.

Written materials

The wellness programme maintains a wide selection of quality educational materials to provide information, assistance and encouragement to employees to improve their health. Self-help materials such as pamphlets and audiotapes designed to educate employees about the harmful effects of smoking and about the benefits of quitting are available in the health care clinic waiting rooms and through interoffice mail by request.

Written materials also are distributed at health fairs. Often these health fairs are sponsored in conjunction with national health initiatives so as to capitalize on existing media attention. For example, on the third Thursday of each November, the American Cancer Society sponsors the Great American Smokeout. This national campaign, designed to encourage smokers to give up cigarettes for 24 hours, is well publicized throughout the United States by television, radio and newspapers. The idea is that if smokers can prove to themselves that they can quit for the day, they might quit for good. In 1993's Smokeout, 20.5% of smokers in the United States (9.4 million) stopped smoking or reduced the number of cigarettes they smoked for the day; 8 million of them reported continuing not to smoke or reducing their smoking one to ten days later.

Each year, members of Merrill Lynch's medical department set up quit-smoking booths on the day of the Great American Smokeout at home office locations. Booths are stationed in high-traffic locations (lobbies and cafeterias) and provide literature, "survival kits" (containing chewing gum, cinnamon sticks, and self-help materials), and quit-smoking pledge cards to encourage smokers to quit smoking at least for the day.

Smoking cessation programmes

Since no single smoking cessation programme works for everyone, employees at Merrill Lynch are offered a variety of options. These include self-help written materials ("quit kits"), group programmes, audiotapes, individual counselling and physician intervention. Interventions range from education and classic behaviour modification to hypnosis, nicotine replacement therapy (e.g., "the patch" and nicotine chewing gum), or a combination. Most of these services are available to employees free of charge and some programmes, such as group interventions, have been subsidized by the firm's benefits department.

Non-smoking policies

In addition to smoking cessation efforts aimed at individuals, smoking restrictions are becoming increasingly common in the workplace. Many jurisdictions in the United States, including the states of New York and New Jersey, have enacted strict workplace smoking laws that, for the most part, limit smoking to private offices. Smoking in common work areas and conference rooms is permitted, but only if each and every person present agrees to allow it. The statutes typically mandate that non-smokers' preferences receive priority even to the point of banning smoking entirely. Figure 15.15  summarizes the city and state regulations applicable in New York City.

Figure 15.15 Summary of city and state restrictions on smoking in New York

In many offices, Merrill Lynch has implemented smoking policies which extend beyond the legal requirements. Most headquarters cafeterias in New York City and in New Jersey have gone smoke-free. In addition, total smoking bans have been implemented in some office buildings in New Jersey and Florida, and in certain work areas in New York City.

There seems to be little debate about the adverse health effects of tobacco exposure. However, other issues should be considered in developing a corporate smoking policy. Figure 15.16 outlines many of the reasons why a company may or may not elect to restrict smoking beyond the legal requirements.

Figure 15.16 Reasons for and against restricting smoking in the workplace

Evaluation of Smoking Cessation Programmes and Policies

Given the relative youth of the Wellness and You programme, no formal evaluation has yet been conducted to determine the effect of these efforts on employee morale or smoking habits. However, some studies suggest that worksite smoking restrictions are favoured by a majority of employees (Stave and Jackson 1991),result in decreased cigarette consumption (Brigham et al. 1994; Baile et al. 1991; Woodruff et al. 1993), and effectively increase smoking cessation rates (Sorensen et al. 1991).

CANCER PREVENTION AND CONTROL

Peter Greenwald and Leon J. Warshaw

Within the next decade, it is predicted, cancer will become the leading cause of death in many developed countries. This reflects not so much an increase in the incidence of cancer but rather a decrease in mortality due to cardiovascular disease, currently topping the mortality tables. Equally with its high mortality rate, we are disturbed by the spectre of cancer as a "dread" disease: one associated with a more or less rapid course of disability and a high degree of suffering. This somewhat fearsome picture is being made easier to contemplate by our growing knowledge of how to reduce risk, by techniques permitting early detection and by new and powerful achievements in the field of therapy. However, the latter may be associated with physical, emotional and economic costs for both the patients and those concerned about them. According to the US National Cancer Institute (NCI), a significant reduction in cancer morbidity and mortality rates is possible if current recommendations relating to use of tobacco, dietary changes, environmental controls, screening and state-of-the-art treatment are effectively applied.

To the employer, cancer presents significant problems entirely apart from the responsibility for possible occupational cancer. Workers with cancer may have impaired productivity and recurrent absenteeism due both to the cancer itself and the side effects of its treatment. Valuable employees will be lost through prolonged periods of disability and premature death, leading to the considerable cost of recruiting and training replacements.

There is a cost to the employer even when it is a spouse or other dependant rather than the healthy employee who develops the cancer. The caregiving burden may lead to distraction, fatigue and absenteeism which tax that employee's productivity, and the often considerable medical expenses increase the cost of employer-sponsored health insurance. It is entirely appropriate, therefore, that cancer prevention should be a major focus of worksite wellness programmes.

Primary Prevention

Primary prevention involves avoidance of smoking and modifying other host factors that may influence the development of cancer, and identifying potential carcinogens in the work environment and eliminating or at least limiting workers' exposure to them.

Controlling exposures

Potential as well as proven carcinogens are identified through basic scientific research and by epidemiological studies of exposed populations. The latter involves industrial hygiene measurements of the frequency, magnitude and duration of the exposures, coupled with comprehensive medical surveillance of the exposed workers, including analysis of causes of disability and death. Controlling exposures involves the elimination of these potential carcinogens from the workplace or, when that is not possible, minimizing exposure to them. It also involves the proper labelling of such hazardous materials and continuing education of workers with respect to their handling, containment and disposal.

Smoking and cancer risk

Approximately one-third of all cancer deaths and 87% of all lung cancers in the US are attributable to smoking. Tobacco use is also the principal cause of cancers of the larynx, oral cavity and oesophagus and it contributes to the development of cancers of the bladder, pancreas, kidney, and uterine cervix. There is a clear dose-response relationship between lung cancer risk and daily cigarette consumption: those who smoke more than 25 cigarettes a day have a risk that is about 20 times greater than that of non-smokers.

Experts believe that the involuntary intake of the tobacco smoke emitted by smokers ("environmental tobacco smoke") is a significant risk factor for lung cancer in non-smokers. In January 1993, the US Environmental Protection Agency (EPA) classified environmental tobacco smoke as a known human carcinogen which, it estimated, is responsible for approximately 3,000 lung cancer deaths annually among US non-smokers.

The 1990 US Surgeon General's report on the health benefits of smoking cessation provides clear evidence that quitting smoking at any age is beneficial to one's health. For example, five years after quitting, former smokers experience a diminished risk for lung cancer; their risk, however, remains higher than that of non-smokers for as long as 25 years.

The elimination of tobacco exposure by employer-sponsored/ labour union-sponsored smoking cessation programmes and worksite policies enforcing a smoke-free working environment represent a major element in most worksite wellness programmes.

Modifying host factors

Cancer is an aberration of normal cell division and growth in which certain cells divide at abnormal rates and grow abnormally, sometimes migrating to other parts of the body, affecting the form and function of involved organs, and ultimately causing death of the organism. Recent, continuing biomedical advances are providing increasing knowledge of the carcinogenesis process and are beginning to identify the genetic, humoral, hormonal, dietary and other factors that may accelerate or inhibit it-thus leading to research on interventions that have the potential to identify the early, precancerous process and so to help restore the normal cellular growth patterns.

Genetic factors

Epidemiologists continue to accumulate evidence of familial variations in the frequency of particular types of cancer. These data have been bolstered by molecular biologists who have already identified genes that appear to control steps in cellular division and growth. When these "tumour suppressor" genes are damaged by naturally-occurring mutations or the effects of an environmental carcinogen, the process may go out of control and a cancer is initiated.

Heritable genes have been found in patients with cancer and members of their immediate families. One gene has been associated with a high risk of colon cancer and endometrial or ovarian cancer in women; another with a high risk of breast and ovarian cancer; and a third with a form of malignant melanoma. These discoveries led to a debate about the ethical and sociological issues surrounding DNA testing to identify individuals carrying these genes with the implication that they then might be excluded from jobs involving possible exposure to potential or actual carcinogens. After studying this question, the National Advisory Council for Human Genome Research (1994), raising issues to do with the reliability of the testing, the present effectiveness of potential therapeutic interventions, and the likelihood of genetic discrimination against those found to be at high risk, concluded that "it is premature to offer DNA testing or screening for cancer predisposition outside a carefully monitored research environment".

Humoral factors

The value of the prostate specific antigen (PSA) test as a routine screening test for prostatic cancer in older men has not been scientifically demonstrated in a clinical trial. However, in some instances, it is being offered to male workers, sometimes as a token of gender equity to balance the offering of mammography and cervical Pap smears to female workers. Clinics providing routine periodic examinations are offering the PSA test as a supplement to and, sometimes, even as a replacement for the traditional digital rectal examination as well as the recently introduced rectal ultrasound examination. Although its use appears to be valid in men with prostatic abnormalities or symptoms, a recent multinational review concludes that measurement of PSA should not be a routine procedure in screening healthy male populations (Adami, Baron and Rothman 1994).

Hormonal factors

Research has implicated hormones in the genesis of some cancers and they have been used in the treatment of others. Hormones, however, do not appear to be an appropriate item to emphasize in workplace health promotion programmes. A possible exception would be warnings of their potential carcinogenic hazard in certain cases when recommending hormones for the treatment of menopausal symptoms and the prevention of osteoporosis.

Dietary factors

Researchers have estimated that approximately 35% of all cancer mortality in the US may be related to diet. In 1988, the US Surgeon General's Report on Nutrition and Health indicated that cancers of the lung, colon-rectum, breast, prostate, stomach, ovary and bladder may be associated with diet. Research indicates that certain dietary factors-fat, fibre, and micronutrients such as beta-carotene, vitamin A, vitamin C, vitamin E and selenium-may influence cancer risk. Epidemiological and experimental evidence indicates that modulation of these factors in the diet can reduce the occurrence of some types of cancer.

Dietary fat

Associations between excess intake of dietary fat and the risk of various cancers, particularly cancers of the breast, colon and prostate, have been demonstrated in both epidemiological and laboratory studies. International correlational studies have shown a strong association between the incidence of cancers at these sites and total dietary fat intake, even after adjusting for total caloric intake.

In addition to the amount of fat, the type of fat consumed may be an important risk factor in cancer development. Different fatty acids may have various site-specific tumour-promoting or tumour-inhibiting properties. Intake of total fat and saturated fat has been strongly and positively associated with colon, prostate, and post-menopausal breast cancers; intake of polyunsaturated vegetable oil has been positively associated with post-menopausal breast and prostate cancers, but not with colon cancer. Conversely, consumption of highly polyunsaturated omega-3 fatty acids found in certain fish oils may not affect or may even decrease the risk of breast and colon cancers.

Dietary fibre

Epidemiological evidence suggests that the risk of certain cancers, particularly colon and breast cancers, may be lowered by increased intake of dietary fibre and other dietary constituents associated with high intakes of vegetables, fruits, and whole grains.

Micronutrients

Epidemiological studies generally show an inverse relationship between cancer incidence and intake of foods high in several nutrients having antioxidant properties, such as beta-carotene, vitamin C (ascorbic acid), and vitamin E (alpha-tocopherol). A number of studies have shown that low intakes of fruits and vegetables are associated with increased risk of lung cancer. Deficiencies of selenium and zinc have also been implicated in increased cancer risk.

In a number of studies in which the use of antioxidant supplements was shown to reduce the expected number of serious heart attacks and strokes, the data on cancer were less clear. However, results from the Alpha-Tocopherol, Beta-Carotene (ATBC) Lung Cancer Prevention clinical trial, conducted by the NCI in collaboration with the National Public Health Institute of Finland, indicated that vitamin E and beta-carotene supplements did not prevent lung cancer. Vitamin E supplementation also resulted in 34% fewer prostate cancers and 16% fewer colorectal cancers, but those subjects taking beta-carotene had 16% more lung cancers, which was statistically significant, and had slightly more cases of other cancers than those taking vitamin E or the placebo. There was no evidence that the combination of vitamin E and beta-carotene was better or worse than either supplement alone.

The researchers have not yet determined why those taking beta-carotene in the study were observed to have more lung cancers. These results suggest the possibility that a different compound or compounds in foods which have high levels of beta-carotene or vitamin E may be responsible for the protective effect observed in epidemiological studies. The researchers also speculated that the length of time of supplementation may have been too short to inhibit the development of cancers in long-term smokers. Further analyses of the ATBC study, as well as results from other trials in progress, will help resolve some of the questions that have arisen in this trial, particularly the question of whether large doses of beta-carotene may be harmful to smokers.

Alcohol

Excessive use of alcoholic beverages has been associated with cancer of the rectum, pancreas, breast and liver. There is also strong evidence supporting a synergistic association of alcohol consumption and tobacco use with increased risk of cancer of the mouth, pharynx, oesophagus and larynx.

Dietary recommendations

Based on the compelling evidence that diet is related to cancer risk, the NCI has developed dietary guidelines that include the following recommendations:

·     Reduce fat intake to 30% or less of calories.

·     Increase fibre intake to 20 to 30 grams per day, with an upper limit of 35 grams.

·     Include a variety of vegetables and fruits in the daily diet.

·     Avoid obesity.

·     Consume alcoholic beverages in moderation, if at all.

·     Minimize consumption of salt-cured (packed in salt), salt-pickled (soaked in brine), or smoked foods (associated with increased incidence of stomach and oesophageal cancer).

These guidelines are intended to be incorporated into a general dietary regimen that can be recommended for the entire population.

Infectious diseases

There is increasing knowledge of the association of certain infectious agents with several types of cancer: for example, the hepatitis B virus with liver cancer, the human papillomavirus with cervical cancer, and the Epstein-Barr virus with Burkitt's lymphoma. (The frequency of cancer among patients with AIDS is attributable to the patient's immunodeficiency and is not a direct carcinogenic effect of the HIV agent.) A vaccine for hepatitis B is now available that, when given to children, ultimately will reduce their risk for liver cancer.

Worksite Cancer Prevention

To explore the potential of the workplace as an arena for the promotion of a broad set of cancer prevention and control behaviours, the NCI is sponsoring the Working Well Project. This project is designed to determine whether worksite-based interventions to reduce tobacco use, achieve cancer preventive dietary modifications, increase screening prevalence and reduce occupational exposure can be developed and implemented in a cost-effective way. It was initiated in September 1989 at the following four research centres in the United States.

·     M.D. Anderson Cancer Center, Houston, Texas

·     University of Florida, Gainesville, Florida

·     Dana Farber Cancer Institute, Boston, Massachusetts

·     Miriam Hospital/Brown University, Providence, Rhode Island

The project involves approximately 21,000 employees at 114 different worksites around the United States. Most of the selected worksites are involved predominantly in manufacturing; other types of worksites in the project included fire stations and newspaper printers. Tobacco reduction and dietary modification were areas of intervention included in all of the worksites; however, each site maximized or minimized particular intervention programmes or included additional options to meet the climatic and socioeconomic conditions of the geographic area. The centres in Florida and Texas, for example, included and emphasized skin cancer screening and the use of sun screens because of increased exposure to the sun in those geographic regions. The centres in Boston and Texas offered programmes that emphasized the relationship between cancer and tobacco use. The Florida centre enhanced the diet modification intervention with supplies of fresh citrus fruits, readily available from the state's farming and fruit industry. Management-employee consumer boards also were established at the worksites of the Florida centre to work with the food service to ensure that the cafeterias offered fresh vegetable and fruit selections. Several of the worksites participating in the project offered small prizes-gift certificates or cafeteria lunches-for continued participation in the project or for achievement of a desired goal, such as smoking cessation. Reduction of exposure to occupational hazards was of special interest at those worksites where diesel exhaust, solvent use or radiation equipment were prevalent. The worksite-based programmes included:

·     group activities to generate interest, such as taste testing of various foods

·     directed group activities, such as quit-smoking contests

·     medical/scientific-based demonstrations, such as CO2 testing, to verify the effect of smoking on the respiratory system

·     seminars on business practices and policy development aimed at significantly reducing or eliminating occupational exposure to potentially or actually dangerous or toxic materials

·     computer-based self-help and self-assessment programmes on cancer risk and prevention

·     manuals and self-help classes to help reduce or eliminate tobacco use, achieve dietary modifications, and increase cancer screening.

Cancer education

Worksite health education programmes should include information about signs and symptoms that are suggestive of early cancer-for example, lumps, bleeding from the rectum and other orifices, skin lesions that do not appear to heal-coupled with advice to seek evaluation by a physician promptly. These programmes might also offer instruction, preferably with supervised practice, in self-examination of the breast.

Cancer screening

Screening for precancerous lesions or early cancer is carried out with a view to their earliest possible detection and removal. Educating individuals about the early signs and symptoms of cancer so that they may seek the attention of a physician is an important part of screening.

A search for early cancer should be included in every routine or periodic medical examination. In addition, mass screenings for particular types of cancer may be carried out in the workplace or in a community facility near the worksite. Any acceptable and justifiable screening of an asymptomatic population for cancer should meet the following criteria:

·     The disease in question should represent a substantial burden at the public health level and should have a prevalent, asymptomatic, nonmetastatic phase.

·     The asymptomatic, nonmetastatic phase should be recognizable.

·     The screening procedure should have reasonable specificity, sensitivity and predictive values; it should be of low risk and low cost, and be acceptable to both the screener and the person being screened.

·     Early detection followed by appropriate treatment should offer a substantially greater potential for cure than exists in cases in which discovery was delayed.

·     Treatment of lesions detected by screening should offer improved outcomes as measured in cause-specific morbidity and mortality.

The following additional criteria are particularly relevant in the workplace:

·     Employees (and their dependants, when involved in the programme) should be informed of the purpose, nature and potential results of the screening, and a formal "informed consent" should be obtained.

·     The screening programme should be conducted with due consideration for the comfort, dignity and privacy of the individuals consenting to be screened and should involve minimal interference with working arrangements and production schedules.

·     Screening results should be conveyed promptly and privately, with copies forwarded to personal physicians designated by the workers. Counselling by trained health professionals should be available to those seeking clarification of the screening report.

·     The individuals screened should be informed of the possibility of false negatives and warned to seek medical evaluation of any signs or symptoms developing soon after the screening exercise.

·     A prearranged referral network should be in place to which those with positive results who are not able or do not wish to consult their personal physicians may be referred.

·     The costs of the necessary confirmatory examinations and the costs of treatment should be covered by health insurance or otherwise be affordable.

·     A prearranged follow-up system should be in place to be sure that positive reports have been promptly confirmed and proper interventions arranged.

A further final criterion is of fundamental importance: the screening exercise should be conducted by properly skilled and accredited health professionals using state-of-the-art equipment and interpretation and analysis of the results should be of the highest possible quality and accuracy.

In 1989 the US Preventive Services Task Force, a panel of 20 experts from medicine and other related fields drawing upon hundreds of "advisors" and others from the United States, Canada and the United Kingdom, assessed the effectiveness of some 169 preventive interventions. Its recommendations with respect to screening for cancer are summarized in table 15.4 . Reflecting the Task Force's somewhat conservative attitude and rigorously applied criteria, these recommendations may differ from those advanced by other groups.

Table 15.4 Screening for neoplastic diseases

Types of cancer

Recommendations of the US Preventive Services Task Force*

Breast

All women over age 40 should receive an annual clinical breast examination. Mammography every one to two years is recommended for all women beginning at age 50 and continuing until age 75 unless pathology has been detected. It may be prudent to begin mammography at an earlier age for women at high risk for breast cancer. Although the teaching of breast self-examination is not specifically recommended at this time, there is insufficient evidence to recommend any change in current breast self- examination practices (i.e., those who are now teaching it should continue the practice).

Colorectal

There is insufficient evidence to recommend for or against faecal occult blood testing or sigmoidoscopy as effective screening tests for colorectal cancer in asymptomatic individuals. There are also insufficient grounds for discontinuing this form of screening where it is currently practised or for withholding it from persons who request it. It may be clinically prudent to offer screening to persons aged 50 or older with known risk factors for colorectal cancer.

Cervical

Regular Papanicolaou (Pap) testing is recommended for all women who are or have been sexually active. Pap smears should begin with the onset of sexual activity and should be repeated every one to three years at the physician's discretion. They may be discontinued at age 65 if previous smears have been consistently normal.

Prostate

There is insufficient evidence to recommend for or against routine digital rectal examination as an effective screening test for prostate cancer in asymptomatic men. Transrectal ultrasound and serum tumour markers are not recommended for routine screening in asymptomatic men.

Lung

Screening asymptomatic persons for lung cancer by performing routine chest radiography or sputum cytology is not recommended.

Skin

Routine screening for skin cancer is recommended for persons at high risk. Clinicians should advise all patients with increased outdoor exposure to use sunscreen preparations and other measures to protect from ultraviolet rays. Currently there is no evidence for or against advising patients to perform skin self-examination.

Testicular

Periodic screening for testicular cancer by testicular examination is recommended for men with a history of cryptorchidism, orchiopexy, or testicular atrophy. There is no evidence of clinical benefit or harm to recommend for or against routine screening of other men for testicular cancer. Currently there is insufficient evidence for or against counselling patients to perform periodic self-examination of the testicles.

Ovarian

Screening of asymptomatic women for ovarian cancer is not recommended. It is prudent to examine the adnexa when performing gynecologic examinations for other reasons.

Pancreatic

Routine screening for pancreatic cancer in asymptomatic persons is not recommended.

Oral

Routine screening of asymptomatic persons for oral cancer by primary care clinicians is not recommended. All patients should be counselled to receive regular dental examinations,  to discontinue the use of all forms of tobacco,  and to limit consumption of alcohol.

Source: Preventive Services Task Force 1989.

Screening for breast cancer

There is a general consensus among experts that screening with mammography combined with clinical breast examination every one to two years will save lives among women aged 50 to 69, reducing breast cancer deaths in this age group by up to 30%. Experts have not reached agreement, however, on the value of breast cancer screening with mammography for asymptomatic women aged 40 to 49. The NCI recommends that women in this age group should be screened every one to two years and that women at increased risk for breast cancer should seek medical advice about whether to begin screening before age 40.

The female population in most organizations may be too small to warrant the installation of mammography equipment onsite. Accordingly, most programmes sponsored by employers or labour unions (or both) rely on contracts with providers who bring mobile units to the workplace or on providers in the community to whom participating female employees are referred either during working hours or on their own time. In making such arrangements, it is essential to be sure that the equipment meets standards for x-ray exposure and safety such as those promulgated by the American College of Radiology, and that the quality of the films and their interpretation is satisfactory. Further, it is imperative that a referral resource be prearranged for those women who will require a small needle aspiration or other confirmatory diagnostic procedures.

Screening for cervical cancer

Scientific evidence strongly suggests that regular screening with Pap tests will significantly decrease mortality from cervical cancer among women who are sexually active or who have reached the age of 18. Survival appears to be directly related to the stage of the disease at diagnosis. Early detection, using cervical cytology, is currently the only practical means of detecting cervical cancer in localized or premalignant stages. The risk of developing invasive cervical cancer is three to ten times greater in women who have never been screened than in those who have had Pap tests every two or three years.

Of particular relevance to the cost of workplace screening programmes is the fact that cervical cytology smears can be obtained quite efficiently by properly trained nurses and do not require the involvement of a physician. Perhaps of even greater importance is the quality of the laboratory to which they are sent for interpretation.

Screening for colorectal cancer

It is generally agreed that early detection of precancerous colorectal polyps and cancers by periodic tests for faecal blood, as well as digital rectal and sigmoidoscopic examinations, and their timely removal, will reduce mortality from colorectal cancer among individuals aged 50 and over. The examination has been made less uncomfortable and more reliable with the replacement of the rigid sigmoidoscope by the longer, flexible fibreoptic instrument. There remains, however, some disagreement as to which tests should be relied upon and how often they should be applied.

Pros and cons of screening

There is general agreement about the value of cancer screening in individuals at risk because of family history, prior occurrence of cancer, or known exposure to potential carcinogens. But there appear to be justifiable concerns about the mass screening of healthy populations.

Advocates of mass screening for the detection of cancer are guided by the premise that early detection will be followed by improvements in morbidity and mortality. This has been demonstrated in some instances, but is not always the case. For example, although it is possible to detect lung cancer earlier by use of chest x rays and sputum cytology, this has not led to any improvement in treatment outcomes. Similarly, concern has been expressed that increasing the lead time for treatment of early prostatic cancers may not only be without benefit but may, in fact, be counterproductive in view of the longer period of well-being enjoyed by patients whose treatment is delayed.

In planning mass screening programmes, consideration must also be given to the impact on the well-being and pocketbooks of patients with false positives. For example, in several series of cases, 3 to 8% of women with positive breast screenings had unnecessary biopsies for benign tumours; and in one experience with the faecal blood test for colorectal cancer, nearly one-third of those screened were referred for diagnostic colonoscopy, and most of them showed negative results.

It is clear that additional research is needed. To assess the efficacy of screening, the NCI has launched a major study, the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trials (PLCO) to evaluate early detection techniques for these four cancer sites. Enrolment for the PLCO began in November 1993, and will involve 148,000 men and women, aged 60 to 74 years, randomized to either the intervention or the control group. In the intervention group, men will be screened for lung, colorectal and prostatic cancer while women will be screened for lung, colorectal and ovarian cancer; those assigned to the control group will receive their usual medical care. For lung cancer, the value of an annual single-view chest x ray will be studied; for colorectal cancer, annual fibreoptic sigmoidoscopy will be performed; for prostate cancer, digital rectal examination and a blood test for PSA will be done; and for ovarian cancer, yearly physical and transvaginal ultrasound examinations will be supplemented by an annual blood test for the tumour marker known as CA-125. At the end of 16 years and the expenditure of US$ 87.8 million, it is hoped that solid data will be obtained about how screening may be used to obtain early diagnoses that may extend lives and reduce mortality.

Treatment and Continuing Care

Treatment and continuing care comprise efforts to enhance the quality of life for those in whom a cancer has taken hold and for those involved with them. Occupational health services and employee assistance programmes sponsored by employers and unions can provide useful counsel and support to workers being treated for cancer or who have a dependant receiving treatment. This support can include explanations of what is going on and what to expect, information that is sometimes not provided by oncologists and surgeons; guidance in referrals for second opinions; and consultations and assistance with regard to access to centres of highly specialized care. Leaves of absence and modified work arrangements may make it possible for workers to remain productive while in treatment and to return to work earlier when a remission is achieved. In some workplaces, peer support groups have been formed to provide an exchange of experiences and mutual support for workers facing similar problems.

Conclusion

Programmes for the prevention and detection of cancer can make a meaningful contribution to the well-being of the workers involved and their dependants and yield a significant return to the employers and labour unions that sponsor them. As with other preventive interventions, it is necessary that these programmes be properly designed and carefully implemented and, since their benefits will accrue over many years, they should be continued on a steady basis.

WOMEN'S HEALTH

Patricia A. Last

There is a common misperception that, outside of reproductive differences, female and male workers will be similarly affected by workplace health hazards and attempts to control them. While women and men do suffer from many of the same disorders, they differ physically, metabolically, hormonally, physiologically and psychologically. For example, women's smaller average size and muscle mass dictate special attention to the fitting of protective clothing and devices and the availability of properly designed hand tools, while the fact that their body mass is usually smaller than that of men makes them more susceptible, on average, to the effects of alcohol abuse on the liver and the central nervous system.

They also differ in the types of job they hold, in the social and economic circumstances that influence their lifestyles, and in their participation in and response to health promotion activities. Although there have been some recent changes, women are still more likely to be found in jobs that are stultifyingly routine and in which they are exposed to repetitive injury. They suffer from pay inequity and are much more likely than men to be burdened with homemaking responsibilities and the care of children and elderly dependants.

In industrialized countries women have a longer life expectancy than men; this applies to every age group. At age 45, a Japanese woman may expect to live on average another 37.5 years, and a 45-year-old Scottish woman another 32.8 years, with women from most of the other countries of the developed world falling between these limits. These facts lead to an assumption that women are, therefore, healthy. There is a lack of awareness that these "extra" years are frequently marred by chronic illness and disability much of which is preventable. Many women know far too little about the health risks they face and, therefore, about the measures they can take to control those risks and protect themselves against serious disease and injury. For example, many women are rightfully concerned about breast cancer but ignore the fact that heart disease is by far the major cause of death in women and that, owing primarily to the increase in their cigarette smoking-which is also a major risk factor for coronary artery disease-the incidence of lung cancer among women is increasing.

In the United States, a 1993 national survey (Harris et al. 1993), involving interviews of more than 2,500 adult women and 1,000 adult men, confirmed that women suffer from serious health problems and that many do not receive the care they need. Between three and four out of ten women, the survey found, are at risk for undetected treatable disease because they are not receiving appropriate clinical preventive services, largely because they lack health care insurance or because their doctors never suggested that appropriate tests were available and should be sought. Furthermore, a substantial number of the American women surveyed were not happy with their personal physicians: four out of ten (twice the proportion of men) said their physicians "spoke down" to them and 17% (compared to 10% of men) had been told that their symptoms were "all in the head".

While overall rates of mental illness are roughly the same for men and women, the patterns are different: women suffer more from depression and anxiety disorders while drug and alcohol abuse and antisocial personality disorders are more common among men (Glied and Kofman 1995). Men are more likely to seek and receive care from mental health specialists while women are more often treated by primary care physicians, many of whom lack the interest if not the expertise to treat mental health problems. Women, especially older women, receive a disproportionate share of the prescriptions for psychotropic drugs, so that concern has arisen that these drugs are possibly being overutilized. All too often, difficulties stemming from inordinate levels of stress or from problems that are preventable and treatable are explained away by health professionals, family members, supervisors and co-workers, and even by women themselves, as being reflective of the "time of the month" or "change of life", and, therefore, go untreated.

These circumstances are compounded by the assumption that women-young and old alike-know all there is to know about their bodies and how they function. This is far from the truth. There exists widespread ignorance and uncritically accepted misinformation. Many women feel ashamed to reveal their lack of knowledge and are being needlessly worried by symptoms that are in fact either "normal" or simply explained.

As women constitute some 50% of the workforce in a large section of the employment arena, and considerably more in some service industries, the consequences of their preventable and correctable health problems levy a significant and avoidable toll on their well-being and productivity and on the organization as well. That toll may be considerably reduced by a worksite health promotion programme designed for women.

Worksite Health Promotion for Women

A good deal of health information is provided by newspapers and magazines and on television but much of that is incomplete, sensationalized or geared to the promotion of particular products or services. Too often, in reporting on current medical and scientific advances, the media raise more questions than they answer and even cause needless anxiety. Health care professionals in hospitals, clinics and private offices often fail to make sure that their patients are properly educated about the problems they present, to say nothing of taking the time to inform them about important health issues unrelated to their symptoms.

A properly designed and administered worksite health promotion programme should provide accurate and complete information, opportunities to ask questions either in group or individual sessions, clinical preventive services, access to a variety of health promotion activities and counselling about adjustments that may prevent or minimize distress and disability. The worksite offers an ideal venue for the sharing of health experiences and information, particularly when they are relevant to circumstances encountered on the job. One can also take advantage of the peer pressure that is present in the workplace to provide workers with additional motivation for participating and persisting in health promoting activities and in maintaining a healthful lifestyle.

There is a variety of approaches to programming for women. Ernst and Young, the large accounting firm, offered its London employees a series of Health Seminars for Women conducted by an outside consultant. They were attended by all grades of staff and were well received. The women who attended were secure in the format of the presentations. As an outsider, the consultant posed no threat to their employment status, and together they cleared up many areas of confusion about women's health.

Marks and Spencer, a major retailer in the United Kingdom, conducts a programme through its in-house medical department using outside resources to provide services to employees in their many regional worksites. They offer screening examinations and individual advice to all their staff, together with an extensive range of health literature and videotapes, many of which are produced in-house.

Many companies use independent health advisers outside the company. An example in the United Kingdom is the service provided by the BUPA (British United Provident Association) Medical Centres, who see many thousands of women through their network of 35 integrated but geographically scattered units, supplemented by their mobile units. Most of these women are referred through their employers' health promotion programmes; the remainder come independently.

BUPA was probably the first, at least in the United Kingdom, to establish a women's health centre dedicated to preventive services exclusively for women. Hospital-based and free-standing women's health centres are becoming more common and are proving attractive to women who have not been well served by the prevailing health care system. In addition to providing prenatal and obstetrical care, they tend to offer broad-ranging primary care, with most placing particular emphasis on preventive services.

The National Survey of Women's Health Centers, conducted in 1994 by researchers from the Johns Hopkins School of Hygiene and Public Health with support from the Commonwealth Foundation (Weisman 1995), estimated that there are 3,600 women's health centres in the United States, of which 71% are reproductive health centres providing primarily routine outpatient gynaecological examinations, Pap tests and family planning services. They also provide pregnancy tests, abortion counselling (82%) and abortions (50%), screening and treatment for sexually transmitted diseases, breast examinations and blood pressure checks.

Twelve per cent are primary care centres (these include women's college health services) which provide basic well-woman and preventive care including periodic physical examinations, routine gynaecological examinations and Pap tests, diagnosis and treatment of menstrual problems, menopausal counselling and hormone replacement therapy, and mental health services, including drug and alcohol abuse counselling and treatment.

Breast centres constitute 6% of the total (see below), while the remainder are centres providing various combinations of services. Many of these centres have demonstrated interest in contracting to provide services to female employees of nearby organizations as part of their worksite health promotion programmes.

Regardless of the venue, the success of worksite health promotion programming for women hinges not only on the reliability of the information and services offered but, more important, on the manner in which they are presented. The programmes must be sensitized to women's attitudes and aspirations as well as to their concerns and, while being supportive, they should be free of the condescension with which these problems are so often addressed.

The remainder of this article will focus on three categories of problems regarded as particularly important health concerns for women-menstrual disorders, cervical and breast cancer and osteoporosis. However, in addressing other health categories, the worksite health promotion programme should ensure that any other problems of particular relevance for women will not be overlooked.

Menstrual Disorders

For the great majority of women, menstruation is a "natural" process that presents few difficulties. The menstrual cycle may be disturbed by a variety of conditions which may cause discomfort or concern for the employee. These may lead her to take sick absence on a regular basis, often reporting a "cold" or "sore throat" rather than a menstrual problem, especially if the absence certificate is to be submitted to a male manager. However, the absence pattern is obvious and referral to a qualified health professional may resolve the problem rapidly. Menstrual problems that may affect the workplace include amenorrhoea, menorrhagia, dysmenorrhoea, the premenstrual syndrome (PMS) and menopause.

Amenorrhoea

While amenorrhoea may create concern, it does not ordinarily affect work performance. The most common cause of amenorrhoea in younger women is pregnancy and in older women it is menopause or a hysterectomy. However, it may also be attributable to the following circumstances:

·     Poor nutrition or underweight. The reason for poor nutrition may be socioeconomic in that little food is available or affordable, but it may also be the result of self-starvation related to eating disorders such as anorexia nervosa or bulimia.

·     Excessive exercise. In many developed countries. women train excessively in physical fitness or sports programmes. Even though their food intake may be adequate, they may have amenorrhoea.

·     Medical conditions. Problems arising from hypothyroidism or other endocrine disorders, tuberculosis, anaemia from any cause and certain serious, life-threatening diseases can all cause amenorrhoea.

·     Contraceptive measures. Medications containing progesterone only will commonly lead to amenorrhoea. It should be noted that sterilization without öphorectomy does not cause a woman's periods to stop.

Menorrhagia

In the absence of any objective measure of menstrual flow, it is commonly accepted that any flow of menses which is heavy enough to interfere with a woman's normal day-to-day activities, or which leads to anaemia, is excessive. When the flow is heavy enough to overwhelm the normal circulating anti-clotting factor, the woman with "heavy periods" may complain of passing clots. Inability to control the blood flow by any normal sanitary protection can lead to considerable embarrassment in the workplace and may lead to a pattern of regular, monthly one- or two-day absences.

Menorrhagia may be caused by uterine fibroids or polyps. It can also be caused by an intrauterine contraceptive device (IUD) and, rarely, it may be the first indication of a severe anaemia or other serious blood disorder such as leukaemia.

Dysmenorrhoea

Although the vast majority of menstruating women experience some discomfort at the time of menstruation, only a few have pain sufficient to interfere with normal activity and, thus, require referral for medical attention. Again, this problem may be suggested by a pattern of regular monthly absences. Such difficulties associated with menstruation may for certain practical purposes be classified thus:

1.     Primary dysmenorrhoea. Young women with no evidence of disease may suffer pain on the day before or on the first day of their period that is serious enough to induce them to take time off from work. Although no cause has been found, it is known to be associated with ovulation and, hence, can be prevented by the oral contraceptive pill or by other medication which prevents ovulation.

2.     Secondary dysmenorrhoea. The onset of painful periods in a woman in her middle thirties or later suggests pelvic pathology and should be fully investigated by a gynaecologist.

It should be noted that some over-the-counter or prescribed analgesics taken for dysmenorrhoea may cause drowsiness and can present a problem for women working in jobs that require alertness to occupational hazards.

Premenstrual syndrome

Premenstrual syndrome (PMS), a combination of physical and psychological symptoms experienced by a relatively small percentage of women during the seven or ten days prior to menstruation, has developed its own mythology. It has falsely been credited as the cause of women's so-called emotionalism and "flightiness". According to some men, all women suffer from it, while ardent feminists claim that no women have it. In the workplace, it has improperly been cited as a rationale for keeping women out of positions requiring decision making and the exercise of judgement, and it has served as a convenient excuse for denying women promotion to managerial and executive levels. It has been blamed for women's problems with interpersonal relations and, indeed, in England it has provided the grounds for pleas of temporary insanity that enabled two separate female defendants to escape charges of murder.

The physical symptoms of PMS may include abdominal distention, breast tenderness, constipation, sleeplessness, weight gain due to increased appetite or to sodium and fluid retention, fine-movement clumsiness and inaccuracy in judgement. The emotional symptoms include excessive crying, temper tantrums, depression, difficulty in making decisions, an inability to cope in general and a lack of confidence. They always occur in the premenstrual days, and are always relieved by the onset of the period. Women taking the combined oral contraceptive pill and those who have had oophorectomies rarely get PMS.

The diagnosis of PMS is based on the history of its temporal relationship to menstrual periods; in the absence of definitive causes, there are no diagnostic tests. Its treatment, the intensity of which is determined by the intensity of the symptoms and their effect on normal activities, is empirical. Most cases respond to simple self-help measures which include abolishing caffeine from the diet (tea, coffee, chocolate and most cola soft drinks all contain significant amounts of caffeine), frequent small feedings to minimize any tendency to hypoglycaemia, restricting sodium intake to minimize fluid retention and weight gain, and regular moderate exercise. When these fail to control the symptoms, physicians may prescribe mild diuretics (for two to three days only) that control sodium and fluid retention and/or oral hormones that modify ovulation and the menstrual cycle. In general, PMS is treatable and should not represent a significant problem to women in the workplace.

Menopause

Menopause reflecting ovarian failure may occur in women in their thirties or may be postponed to well beyond the age of 50; by the age of 48, about half of all women will have experienced it. The actual time of the menopause is influenced by general health, nutrition and familial factors.

The symptoms of the menopause are diminished frequency of periods usually coupled with scanty menstrual flow, hot flushes with or without night sweats, and a diminution in vaginal secretions, which may cause pain during sexual intercourse. Other symptoms frequently attributed to the menopause include depression, anxiety, tearfulness, lack of confidence, headaches, changes in skin texture, loss of sexual interest, urinary difficulties and sleeplessness. Interestingly, a controlled study involving a symptom questionnaire administered to both men and women showed that a significant portion of these complaints were shared by men of the same age (Bungay, Vessey and McPherson 1980).

The menopause, coming as it does at about the age of 50, may coincide with what has been called the "mid-life transition" or the "mid-life crisis", terms coined to denote collectively the experiences which seem to be shared by both men and women in their middle years (if anything, they appear to be more common among men). These include loss of purpose, dissatisfaction with one's job and with life in general, depression, waning interest in sexual activity and a tendency to diminished social contacts. It may be precipitated by the loss of spouse or partner through separation or death or, as regards one's job, by failure to win an expected promotion or by separation, whether by termination or voluntary retirement. In contrast to menopause, there is no known hormonal basis for the mid-life transition.

Particularly in women, this period may be associated with the "empty nest syndrome," the sense of purposelessness that may be felt when, their children having left the home, their whole perceived raison d'être seems to have been lost. In such cases, the job and the social contacts in the workplace often provide a stabilizing, therapeutic influence.

Like many of the other "female problems," menopause has developed its own mythology. Preparatory education debunking these myths supplemented by sensitive supportive counselling will go far to preventing significant dislocations. Continuing to work and maintaining her satisfactory performance on the job may be of crucial value in sustaining a woman's well-being at this time.

It is at this point that the advisability of hormone replacement therapy (HRT) needs to be considered. Currently the subject of some controversy, HRT was originally prescribed to control menopausal symptoms if they became excessively severe. While usually effective, the hormones commonly used often precipitated vaginal bleeding and, more important, they were suspected of being carcinogenic. As a result, they were prescribed only for limited periods of time, just long enough to control the troublesome menopausal symptoms.

HRT has no effect on the symptoms of the mid-life transition. However, if a woman's flushes are controlled and she can get a good night's sleep because her night sweats are prevented, or if she can respond to lovemaking more enthusiastically because it is no longer painful, then some of her other problems may be resolved.

Today, the value of long-term HRT is increasingly being recognized in maintaining the integrity of bone in women with osteoporosis (see below) and in reducing the risk of coronary heart disease, now the highest-ranking cause of death among women in industrialized countries. Newer hormones, combinations and sequences of administration may eliminate the occurrence of planned vaginal bleeding and there appears to be little or no risk of carcinogenesis, even among women with a history of cancer. However, because many physicians are strongly biased for or against HRT, women need to be educated about its benefits and disadvantages so that they can participate confidently in the decision about whether to use it or not.

Recently, calling to mind the millions of women "baby boomers" (children born after the Second World War) who will be reaching the age of menopause within the next decade, the American College of Obstetricians and Gynecologists (ACOG) warned that staggering increases in osteoporosis and heart disease could result unless women are better educated about menopause and the interventions designed to prevent disease and disability and to prolong and enhance their lives after menopause (Voelker 1995). ACOG president William C. Andrews, MD, has proposed a three-pronged programme that includes a massive campaign to educate physicians about the menopause, a "perimenopausal visit" to a physician by all women over the age of 45 for a personal risk assessment and in-depth counselling, and involvement of the news media in educating women and their families about the symptoms of menopause and the benefits and risks of treatments like HRT before women reach menopause. The worksite health promotion programme can make a major contribution to such an educational effort.

Screening for Cervical and Breast Disease

With regard to women's needs, a health promotion programme should either provide or, at least, recommend periodic screening for cervical and breast cancer.

Cervical disease

Regular screening for precancerous cervical changes by means of the Pap test is a well-established practice. In many organizations, it is made available in the workplace or in a mobile unit brought to it, eliminating the need for female employees to spend time travelling to a facility in the community or visiting their personal physicians. The services of a physician are not required in the administration of this procedure: satisfactory smears may be taken by a well-trained nurse or technician. More important is the quality of the reading of the smears and the integrity of the procedures for record-keeping and reporting of the results.

Breast cancer

Although breast screening by mammography is widely practised in almost all developed countries, it has been established on a national basis only within the United Kingdom. Currently, over a million women in the United Kingdom are screened, with each woman aged 50 to 64 having a mammogram every three years. All the examinations, including any further diagnostic studies needed to clarify abnormalities in the initial films, are free of charge to the participants. The response to the offer of this three-year cycle of mammography has been over 70%. Reports for the 1993-1994 period (Patnick 1995) show a rate of 5.5% for referral to further assessment; 5.5 women per 1,000 women screened were discovered to have breast cancer. The positive predictive value for surgical biopsy was 70% in this programme, compared to some 10% in programmes reported elsewhere in the world.

The critical issues in mammography are the quality of the procedure, with particular emphasis on minimizing radiation exposure, and the accuracy of the interpretation of the films. In the United States, the Food and Drug Administration (FDA) has promulgated a set of quality regulations proposed by the American College of Radiology that, commencing October 1, 1994, must be observed by the more than 10,000 medical units taking or interpreting mammograms around the country (Charafin 1994). In accordance with the national Mammography Standards Act (enacted in 1992), all mammography facilities in the United States (except those operated by the Department of Veterans Affairs, which is developing its own standards) had to be certified by the FDA as of this date. These regulations are summarized in figure 15.17 .

Figure 15.17 Mammography quality standards in the United States

A recent phenomenon in the United States is the increase in the number of breast or breast health centres, 76% of which have appeared since 1985 (Weisman 1995). They are predominantly hospital-affiliated (82%); the others are primarily profit-making enterprises owned by physician groups. About a fifth maintain mobile units. They provide outpatient screening and diagnostic services including physical breast examinations, screening and diagnostic mammography, breast ultrasound, fine-needle biopsy and instruction in breast self-examination. Slightly more than one-third also offer treatment for breast cancer. While primarily focussed on attracting self-referrals and referrals by community physicians, many of these centres are making an effort to contract with employer- or labour union-sponsored health promotion programmes to provide breast screening services to their female participants.

Introducing such screening programmes into the workplace can generate considerable anxiety among some women, particularly those with personal or family histories of cancer and those found to have "abnormal" (or inconclusive) results. The possibility of such non-negative results should be carefully explained in presenting the programme, along with the assurance that arrangements are in place for the additional examinations needed to explain and to act upon them. Supervisors should be educated to sanction absences by these women when the necessary follow-up procedures cannot be expeditiously arranged outside of working hours.

Osteoporosis

Osteoporosis is a metabolic bone disorder, much more prevalent in women than in men, that is characterized by a gradual decline in bone mass leading to susceptibility to fractures which may result from seemingly innocuous movements and accidents. It represents an important public health problem in most developed countries.

The most common sites for fractures are the vertebrae, the distal portion of the radius and the upper portion of the femur. All fractures at these sites in older individuals should cause one to suspect osteoporosis as a contributing cause.

While such fractures usually occur later in life, after the individual has left the workforce, osteoporosis is a desirable target for worksite health promotion programmes for a number of reasons: (1) the fractures may involve retirees and add significantly to their medical care costs, for which the employer may be responsible; (2) the fractures may involve the elderly parents or in-laws of current employees, creating a dependant-care burden that can compromise their attendance and work performance; and (3) the workplace presents an opportunity to educate younger people about the eventual danger of osteoporosis and to urge them to initiate the lifestyle changes that can slow its progress.

There are two types of primary osteoporosis:

·     Post-menopausal, which is related to loss of oestrogens and, hence, is more prevalent in women than in men (ratio = 6:1). It is commonly found in the 50-to-70 age group and is associated with vertebral fractures and Colles fractures (of the wrist).

·     Involutional, which occurs mainly in those over the age of 70 and is only twice as common among women than in men. It is thought to be due to age-related changes in vitamin D synthesis and is associated chiefly with vertebral and femoral fractures.

Both types may be present simultaneously in women. In addition, in a small percentage of cases, osteoporosis has been attributed to a variety of secondary causes including: hyperparathyroidism; the use of corticosteroids, L-thyroxine, aluminium-containing antacids and other drugs; prolonged bed rest; diabetes mellitus; the use of alcohol and tobacco; and rheumatoid arthritis.

Osteoporosis may be present for years and even decades before fractures result. It can be detected by well-standardized x-ray measurements of bone density, calibrated for age and sex, and supplemented by laboratory evaluation of calcium and phosphorus metabolism. Unusual radiolucency of bone in conventional x rays may be suggestive, but such osteopenia usually cannot be reliably detected until more than 30% of the bone is lost.

It is generally agreed that screening asymptomatic individuals for osteoporosis should not be employed as a routine procedure, especially in worksite health promotion programmes. It is costly, not very reliable except in the most well-staffed facilities, involves exposure to radiation and, most important, does not identify those women with osteoporosis who are most likely to have fractures.

Accordingly, although everyone is subject to some degree of bone loss, the prevention programme for osteoporosis is focussed on those individuals who are at higher risk for its more rapid progression and who are therefore more susceptible to fractures. A special problem is that although the earlier in life the preventive measures are started, the more effective they are, it is nonetheless difficult to motivate younger people to adopt lifestyle changes in the hope of avoiding a health problem that may develop at what many of them consider to be a very remote age of life. A saving grace is that many of the recommended changes are also useful in the prevention of other problems as well as in promoting general health and well-being.

Some risk factors for osteoporosis cannot be changed. They include:

·     Race. On average, Whites and Orientals have lower bone density than Blacks matched age for age and are therefore at greater risk.

·     Sex. Women have less dense bones than men when matched for age and race and therefore are at greater risk.

·     Age. All people lose bone mass with age. The stronger the bones are in youth, the less likely is it that the loss will reach potentially dangerous levels in old age.

·     Family history. There is some evidence of a genetic component in the attainment of peak bone mass and the rate of subsequent bone loss; thus, a family history of suggestive fractures in family members may represent an important risk factor.

The fact that these risk factors cannot be altered makes it important to give attention to those that can be modified. Among the measures that may be taken to delay the onset of osteoporosis or to diminish its severity, the following may be mentioned:

·     Diet. If adequate amounts of calcium and vitamin D are not present in the diet, supplementation is recommended. This is particularly important for people with lactose intolerance who tend to avoid milk and milk products, the major sources of dietary calcium, and is most effective if maintained from childhood until the thirties as peak bone density is being achieved. Calcium carbonate, the most commonly used form of calcium supplementation, frequently causes side effects such as constipation, rebound hyperacidity, abdominal bloating and other gastrointestinal symptoms. Accordingly, many people substitute preparations of calcium citrate which, despite a significantly lower content of elemental calcium, is better absorbed and has fewer side-effects. The amounts of vitamin D present in the usual multivitamin preparation suffice for slowing the bone loss of osteoporosis. Women should be cautioned against excessive doses, which may lead to hypervitaminosis D, a syndrome that includes acute renal failure and increased resorption of bone.

·     Exercise. Regular moderate weight-bearing exercise-for example, 45 to 60 minutes of walking at least three times a week-is advisable.

·     Smoking. Women who smoke have their menopause on average two years earlier than non-smokers. Without hormone replacement, the earlier menopause will accelerate post-menopausal bone loss. This is another important reason to counter the current trend to increased cigarette smoking among women.

·     Hormone replacement therapy. If oestrogen replacement is undertaken, it should be started early in the progress of the menopausal changes since the rate of bone loss is greatest during the first few years after menopause. Because bone loss is resumed after the discontinuation of oestrogen therapy, it should be maintained indefinitely.

Once osteoporosis is diagnosed, treatment is aimed at circumventing further bone loss by following all of the above recommendations. Some recommend using calcitonin, which has been shown to increase total body calcium. However, it must be given parenterally; it is expensive; and there is yet no evidence that it retards or reverses the loss of calcium in the bone or reduces the occurrence of fractures. Biphosphonates are gaining ground as anti-resorptive agents.

It must be remembered that osteoporosis sets the stage for fractures but it does not cause them. Fractures are caused by falls or sudden injudicious movements. While the prevention of falls should be an integral part of every worksite safety programme, it is particularly important for individuals who may have osteoporosis. Thus, the health promotion programme should include education about safeguarding the environment in both the workplace and in the home (e.g., eliminating or taping down trailing electrical wires, painting the edges of steps or irregularities in the floor, tacking down slippery rugs and promptly drying up any wet spots) as well as sensitizing individuals to such hazards as insecure footwear and seats that are difficult to get out of because they are too low or too soft.

Women's Health and Their Work

Women are in the paid workforce to stay. In fact, they are the mainstay of many industries. They should be treated as equal to men in every respect; only some aspects of their health experience are different. The health promotion programme should inform women about these differences and empower them to seek the kind and quality of health care they need and deserve. Organizations and those who manage them should be educated to understand that most women do not suffer from the problems described in this article, and that, for the small proportion of women who do, prevention or control is possible. Except in rare instances, no more frequent than among men with similar health problems, these problems do not constitute barriers to good attendance and effective work performance.

Many women managers get to their high positions not only because their work is excellent, but because they experience none of the problems of female health that have been outlined above. This can make some of them intolerant and unsupportive of other women who do have such difficulties. One major area of resistance to women's status in the workplace, it appears, can be women themselves.

A worksite health promotion programme that embodies a focus on women's health issues and problems and addresses them with appropriate sensitivity and integrity can have an important positive impact for good, not only for the women in the workforce, but also for their families, the community and, most important, the organization.

MAMMOGRAPHY PROGRAMME AT MARKS AND SPENCER:  A CASE STUDY

Jillian Haslehurst

This case study describes the mammography programme at Marks and Spencer, the first to be offered by an employer on a nationwide scale. Marks and Spencer is an international retail operation with 612 stores worldwide, the majority being in the United Kingdom, Europe and Canada. In addition to a number of international franchise operations, the company owns Brooks Brothers and Kings Super Markets in the United States and D'Allaird's in Canada and pursues extensive financial activities.

The company employs 62,000 people, the majority of whom work in 285 stores in the United Kingdom and the Republic of Ireland. The company's reputation as a good employer is legendary and its policy of good human relations with staff has included the provision of comprehensive, high-quality health and welfare programmes.

Although a treatment service is provided at some work locations, this need is largely met by community-based primary care physicians. The company health policy emphasises the early detection and prevention of disease. A number of innovative screening programmes have consequently been developed over the past 20 years, many of which have predated similar projects in the National Health Service (NHS). Over 80% of the workforce is female, a fact that has influenced the choice of screening programmes, which include cervical cytology, ovarian cancer screening and mammography.

Breast Cancer Screening

In the mid-1970s the New York HIP study (Shapiro 1977) proved that mammography was capable of detecting impalpable breast cancers with the expectation that earlier detection would reduce mortality. To an employer of large numbers of middle-aged women, the appeal of mammography was obvious and a screening programme was introduced in 1976 (Hutchinson and Tucker 1984; Haslehurst 1986). At that time there was virtually no access to reliable high-quality mammography in the public sector and that available in private health care organizations was of variable quality and expensive. The first task therefore was to ensure access to a uniformly high quality and this challenge was met by using mobile screening units, each equipped with a waiting area, examination cubicle and mammography equipment.

Centralized administration and film processing allowed continuous checks on all aspects of quality and allowed film interpretation to be undertaken by an experienced group of mammographers. There was, however, a disadvantage in that the radiographer was not able to immediately examine the developed film to verify that there were no technical errors so that if there had been any, the employee could be recalled or other arrangements made for the necessary repeat examination.

Compliance has always been exceptionally high and has remained over 80% for all age groups. Doubtless this is due peer group pressure, the easy availability of the service at or near the worksite and, until recently, a lack of mammography facilities in the NHS.

Women are invited to join the screening programme and attendance is entirely voluntary. Prior to screening, short educational sessions are carried out by the company doctor or nurse, both of whom are available to answer queries and give explanations. Common anxieties include concern about radiation dosage and worry that the compression of the breast may cause pain. Women who are recalled for further tests are seen during working hours and fully recompensed for travel expenses for themselves and a companion.

Three modalities were used for the first five years of the programme: clinical examination by a highly trained nurse-practitioner, thermography and mammography. Thermography was a time-consuming examination with a high rate of false positives and made no contribution to the cancer detection rate; accordingly it was discontinued in 1981. Although of limited value in cancer detection, clinical examination, which includes a detailed review of personal and family history, provides invaluable information to the radiologist and allows the client time to discuss her fears and other health issues with a sympathetic health professional. Mammography is the most sensitive of the three tests. Cranio-caudal and lateral oblique views are taken at the initial examination with single views only at the interval check. Single reading of films is the norm, though double reading is used for difficult cases and as a random quality check. Figure 15.18 shows the contribution of clinical examination and mammography to the total cancer detection rate. Of the 492 cases of cancer found, 10% were detected by clinical examination alone, 54% by mammography alone, and 36% were noted by clinical examination and mammography.

Figure 15.18 Screening for breast cancer. Contribution of clinical examination and mammography  to cancer detection, by age group

Women aged 35 to 70 were offered screening when the programme was first introduced but the low cancer detection rate and high incidence of benign breast disease among those in the 35 to 39 age group led to withdrawal of the service in 1987 from these women. Figure 15.19 shows the numbers of screen-detected cancers by age group.

Figure 15.19 Age distribution of screen-detected cancers

Similarly, the screening interval has changed from a yearly interval (reflecting initial enthusiasm) to a two-year gap. Figure 15.20 shows the number of screen-detected cancers by age group with the corresponding numbers of interval tumours and missed tumours. Interval cases are defined as those occurring after a truly negative screen during the time between routine tests. Missed cases are defined as those cancers which can be seen retrospectively on the films but were not identified at the time of the screening test.

Figure 15.20 Number of screen-detected cancers, interval cancers and missed cancers,  by age group

Among the screened population, 76% of breast cancers were detected at screening with a further 14% of cases occurring during the interval between examinations. The interval cancer rate will be carefully monitored to ensure that it does not rise to an unacceptably high level.

The survival benefit of screening women under the age of 50 remains unproven although it is agreed that smaller cancers are detected and this allows some women to choose between mastectomy or breast conservation therapy-a choice valued highly by many. Figure 15.21 shows the sizes of screen-detected cancers, the majority being under two centimetres in size and node negative.

Figure 15.21 Sizes of screen-detected cancers

Impact of the Forrest Report

In the late 1980s, Professor Sir Patrick Forrest recommended that regular breast screening be made available to women over the age of 50 via the NHS (i.e., with no charge at the point of delivery of the service) (Forrest 1987). His most important recommendation was that the service should not start until specialist staff had been fully trained in the multidisciplinary approach to breast care diagnosis. Such staff was to include radiologists, nurse counsellors and breast physicians. Since 1990, the United Kingdom has had an outstanding breast screening and assessment service for women over 50.

Coincidentally with this national development, Marks and Spencer reviewed its data and a major flaw in the programme became apparent. The recall rate following routine screening was in excess of 8% for women over fifty and 12% for younger women. Analysis of the data showed that common reasons for recall were technical problems, such as malpositioning, processing errors, difficulties with grid lines or a need for further views. Additionally, it was clear that the use of ultrasonography, specialized mammography and fine needle aspiration cytology could cut the recall and referral rate even further. An initial study confirmed these impressions, and it was decided to redefine the screening protocol so that clients who needed further tests were not referred back to their family practitioners, but were retained within the screening programme until a definitive diagnosis was made. Most of these women were returned to a schedule of routine recall after the further investigations and this reduced the formal surgical referral rate to a minimum.

Instead of duplicating the service provided by the National Health Service, a policy of partnership was developed which allowed Marks and Spencer to draw upon the expertise of the public sector while company funding is used to improve service for all. The breast screening programme is now delivered by a number of providers: about half the requirement is met by the original mobile service but employees at the larger city stores now receive routine screening at specialist centres, which may either be in the private or public sectors. This cooperation with the National Health Service has been an exciting and challenging development and has helped to improve the overall standards of breast diagnosis and care for the entire population. By marrying together both private worksite and public sector programmes it is possible to deliver an exceptionally high quality service to a widely distributed population.

WORKSITE STRATEGIES TO IMPROVE MATERNAL AND INFANT HEALTH:  EXPERIENCES OF US EMPLOYERS

Maureen P. Corry and Ellen Cutler

There is a growing awareness among public and private sector employers in the United States that healthy birth outcomes, productivity and the organization's economic status are connected. Concurrently, there is heightened concern about occupational reproductive health hazards. Never before have employers had better reasons to improve maternal and infant health among employees and their families. Rising health care costs, changing workforce demographics, and increasing evidence that healthy employees lead to productivity gains, are compelling reasons to make maternal and infant health an addition to their health education and promotion programmes.

A maternal and infant health strategy is a term broadly used to define any thoughtfully planned employer-sponsored or union-sponsored initiative that promotes the health and well-being of women, before, during, and after pregnancy, and supports the health of infants during the first year of life as well. There is no single solution or approach to improving maternal and infant health. Rather, for most employers, the effort is a combination of the following activities, custom-fit to meet the environment that makes their workplace unique.

Health Care Benefits

It is helpful to view maternal and infant health care benefits as a continuum of care that provides reproductive health awareness and family planning counselling and services throughout the reproductive life span. The benefits listed in table 15.5  represent those a health insurance plan should cover because of their significance in improving maternal and infant health.

Table 15.5 Health insurance benefits

Pre-pregnancy

Pregnancy

Post-pregnancy

Infancy

Annual preconception or interconception care visit (includes family planning services)

Genetic counselling and testing

Postpartum care

Normal newborn nursery care

Genetic counselling and testing

Prenatal care-should be offered with no deductibles or copayments

Prescription drug plan

Neonatal intensive care-no pre-existing conditions exclusions for newborns

Prescription drug plan

Labour and delivery at a hospital or birthing centre should be offered with no deductibles or copayments

Home health care services

Prescription drug plan

Substance abuse treatment

·     Room and board at a hospital or birthing centre

Substance abuse treatment

Home health care services

 

·     Anaesthesia services

   
 

·     Prescription drug plan (including prenatal vitamins)

   
 

·     Home health care services

   
 

·     Substance abuse treatment

   

Source: March of Dimes Birth Defects Foundation 1994.

Benefits design

While many American health care plans provide coverage for preconception and prenatal care, there are a number of reasons why it may be difficult for some women to obtain high quality, affordable care. For example, some providers require payment in advance for prenatal care and delivery services, yet most insurers will not make payment until after delivery. Other barriers to accessing proper care include high deductible fees or copayments, inconvenient office hours, lack of coverage for dependants, and geographic inaccessibility. Employers cannot eliminate all of these barriers, but it would represent an excellent beginning to help remove the burdens of upfront payments and high deductible fees and to offer assistance to the employee in finding acceptance by a suitable provider of prenatal care.

At Texas Instruments (TI), the goal is to make prenatal care affordable regardless of an employee's income level or health care provider. Mothers seeking prenatal care inside the TI network pay only 10% of an upfront negotiated fee, a single charge that covers prenatal care services and both uncomplicated deliveries and Caesarean sections.

The Haggar Apparel Company pays 100% of the cost of prenatal care upfront if an employee or dependant accesses prenatal care in the first trimester of pregnancy. The Home Depot (a retailer of builder's wares and related merchandise) waives the expectant mother's hospital deductible fee if prenatal care visits begin in the first trimester.

While many plans provide for adequate care for a newborn's first few days of life, coverage for the infant's ongoing preventive care after leaving the hospital, frequently referred to as well-baby care, is often inadequate or nonexistent.

At the First National Bank of Chicago, expectant mothers who are enrolled in the indemnity plan and who complete a prenatal education programme by the end of their fourth month of pregnancy have the $400 deductible charge waived from their newborn's first year health insurance coverage. The Monfort Company, a beef packing plant in Greeley, Colorado, totally covers well-baby care up to age three.

Benefits-related Services and Employee Programmes

Table 15.6 lists benefits-related services and programmes that are considered important supportive features to a maternal and infant health strategy. These services and programmes may be provided directly by the employer, either in the workplace or a nearby location, or under a contract with an outside agency or vendor, depending on the structure, location and size of the organization and may be administered by the benefits, employee health, health promotion or employee assistance department, for example.

Table 15.6 Other benefits-related services provided by the employer

SERVICES

Pre-pregnancy

Pregnancy

Post-pregnancy

Infancy

 

  • Maternity management  programme
  • Maternity high-risk case  management (may be part of a  maternity management  programme)
  • Maternity disability benefits
  • Case management services for high-risk newborns
  • Dependant care reimbursement accounts

PROGRAMMES

Pre-pregnancy

Pregnancy

Post-pregnancy

Infancy

  • Preconception health promotion
  • Smoking cessation programmes
  • Prenatal health promotion
  • Sensitivity training for managers
  • Parenting classes on infant care  and development
  • Smoking cessation programme
  • Lactation programme
  • On-site child care facility
  • Referrals to child care services

Source: March of Dimes Birth Defects Foundation 1994.

Few companies can offer all of these components; however, the more complete and comprehensive the strategy, the better the chance of improving the health of mothers and babies.

Pre-pregnancy and pregnancy period

Maternity management programmes are gaining popularity because they offer attractive features to both the expectant parents and the employer. While not designed to replace prenatal care delivered by a health care professional, maternity management is a benefit-related service that provides personalized advice and support customized to a mother's needs and risk levels.

Levi Strauss & Company, one of the nation's largest clothing and apparel producers, offers a maternity management programme administered by an insurance company. Employees are encouraged to access the programme as soon as they are pregnant and they will receive $100 cash for calling the toll-free maternity management number. In 1992, costs for newborns whose mothers participated in the programme were nearly 50% lower than for those whose mothers who did not.

The First National Bank of Chicago offers the March of Dimes Babies and You prenatal health promotion programme as part of its maternal and infant health strategy. This programme is described below and in the case study above.

Babies and You: A prenatal health promotion programme

The March of Dimes' Babies and You prenatal health promotion programme was developed in 1982 in partnership with maternal and infant health care specialists throughout the country. Extensively field-tested by March of Dimes chapters and worksites, the programme is continuously updated and enhanced.

Babies and You educates adults about how to practise healthy lifestyle behaviours before and during pregnancy, motivates women to get early and regular prenatal care, and influences employers to implement strategies that support healthy pregnancy outcomes.

Prenatal health promotion activities should be reaching male as well as female employees, partners, other family members and friends. Babies and You is adaptable to the unique needs of any given workforce. Consideration is given to the educational level, culture and language of prospective participants, as well as to any worksite restrictions and available community resources.

Because employers are at different stages in their health promotion activities, Babies and You offers three levels of implementation: an information campaign, educational seminars, and training of health professionals (see box.). The most popular topics for informational materials and educational seminars are preconception and prenatal care, foetal development, genetics, the male role in pregnancy, nutrition during pregnancy, and parenting. The topics covered in the prenatal programmes of 31 companies surveyed by the New York Business Group on Health found the dominant themes to be understanding what goes on during pregnancy and delivery; timely care by qualified health professionals; practicing healthy behaviours related to pregnancy and avoidance of hazards that might affect mother and/or foetus; care of the newborn; and maintaining satisfactory family and work relationships (Duncan, Barr and Warshaw 1992).

BABIES AND YOU: LEVELS OF IMPLEMENTATION

Level I Informational Campaign is designed to create awareness at the worksite about the importance of early and regular prenatal care. To sustain this level of implementation, a variety of print and audiovisual materials is available from the March of Dimes.

Level II Educational Seminars are delivered at the worksite by March of Dimes volunteer health professionals. Fourteen different seminar topics are available to choose from, including: preconception care, prenatal care, nutrition, exercise and pregnancy, pregnancy after 35, stress and pregnancy, pregnancy complications, well-baby care, male role in pregnancy, and breastfeeding.

Level III Training of Health Professionals allows a worksite to establish Babies and You as an on-going component of its wellness activities. The March of Dimes provides a one-day training on programme delivery and implementation to on-site health professionals such as occupational health nurses, benefits managers, medical directors and health promotion specialists.

But no matter what level of Babies and You a worksite chooses to implement, there are eight goals of a successful prenatal health promotion effort that this programme strives to achieve:

·     Management commitment

·     Inter-departmental programme planning

·     Employee input

·     The offering of incentives

·     Supportive benefits and policies

·     Establishment of communications channels

·     Access to community resources

·     Evaluation

Post-pregnancy and infancy period

In addition to implementing health promotion programmes and other services that focus on a mother's health before and during pregnancy, many employers also offer programmes that support parents and infants after pregnancy, during the critical first twelve months and beyond. Maternity disability benefits, lactation programmes, dependant care reimbursement accounts (e.g., pre-tax set-asides of earnings that employees may draw on to pay for dependant care expenses), parenting classes and onsite child care are just a few of the benefits and programmes now offered.

For example, to maintain goodwill with its employees, Lancaster Laboratories, based in Lancaster, Pennsylvania, and providing contract laboratory research and consulting to the environmental, food and pharmaceutical industries, continues to provide health care insurance benefits during both maternity disability leave and unpaid parental leave whether or not the employee plans to return to work after having given birth. This family-supportive management approach has gotten results: in an industry where a 27% turnover rate is the norm, the rate at Lancaster is only 8% (March of Dimes 1994).

Lactation programmes also are easy and beneficial for employers to implement. The health benefits of breastfeeding extend beyond the child's own. A recent study shows that improving an infant's health through breastfeeding has a direct effect on employee productivity. Healthier infants mean mothers and fathers miss significantly fewer days of work to care for a sick child (Ryan and Martinez 1989). Offering a lactation programme simply requires providing onsite space and equipment for pumping and storing breast milk.

The Los Angeles Department of Water and Power was able to quantify some benefits of its lactation programme: for example, 86% of participants state that the programme eased their transition back to work; 71% report taking less time off since participating; and programme participants have a 2% turnover rate (March of Dimes 1994).

Employer Policies

There are many workplace policies that employers can initiate to create a maternal and infant-health supportive culture. Instituting new policies and changing old ones can send an important message to employees about the company's corporate culture.

Some policies affect the health of all workers, like creating a smoke-free environment. Others focus on selected groups, such as those that address occupational reproductive health hazards and which are targeted to meet the needs of men and women who are planning to have a child. Still more, including flexible work policies, support pregnant women in scheduling prenatal visits and ease the burden of parents with infants and small children. Finally, policies relating to modifying work assignments when needed during pregnancy and resolving questions of disability and its duration help to protect the health of the pregnant worker while minimizing interference with her work assignments.

When the Warner-Lambert Company, a leader in the pharmaceutical, consumer health care and confectionary products industries, initiated its maternity management and prenatal education programmes, the company also introduced comprehensive guidelines for managing reproductive health. The guidelines encourage employees to complete questionnaires assessing the potential of reproductive health hazards in their jobs or worksites. If necessary, a Warner-Lambert safety engineer will conduct an assessment to determine what, if any, control of workplace hazards or job restrictions may be necessary.

In addition to reproductive health hazards policies, a number of employers offer flexible family leave policies. For example, at AT&T, the communications giant, employees can take up to 12 months of unpaid leave to care for a newborn or adopted child. More than 50% of the employees who have taken advantage of this leave policy since 1990 returned to work within three months. Within six months, 82% of the employees were back at work (March of Dimes 1994).

And at PepsiCo Inc., the large beverage and food conglomerate based in Purchase, New York, fathers of newborns can take up to eight weeks of paid leave and an additional eight weeks of unpaid leave with a guarantee of the same or a comparable job when they return (March of Dimes 1994).

Designing a Maternal and Infant Health Strategy to Meet Business Needs

Any sustainable employer-based maternal and infant health strategy, in addition to being acceptable to employees, must meet sound business objectives. Depending on a company's objectives, different benefits, employee programmes, or policies may take priority. The following steps are useful in developing a preliminary strategy:

1.     Document existing benefits, programmes, and policies that support maternal and infant health in order to create the foundation of a formal strategy.

2.     Find out about community resources available to assist the company's efforts.

3.     Prepare a prioritized list of preliminary maternal and infant health initiatives which includes changes or introductions in benefits, programmes, or policies.

4.     Gain preliminary support from top management before taking the next step.

5.     Assess perceived needs and test proposed strategies with employees to validate preliminary recommendations.

6.     Develop a formal maternal and infant health strategy by articulating a mission, outlining objectives, allocating the resources needed, identifying potential obstacles and key players, preparing an implementation timetable and gaining necessary support at all levels of the company.

Implementing maternal and infant health initiatives

The next step is to implement the benefits, programmes and policies that are part of the strategy. The implementation process typically includes the following steps:

1.     Assign responsibility for implementation.

2.     Select quality measurements by which to manage the programme.

3.     Evaluate and select vendors.

4.     Review incentives and other methods to increase employee participation.

5.     Communicate initiatives to employees and family members.

Managing the success of a maternal and infant health strategy

After implementation, an employer's maternal and infant health strategy should be reviewed for effectiveness in meeting original objectives and business needs. Evaluation and feedback are essential and help to ensure that the maternal and infant health initiatives are meeting both the employer's and employees' needs.

Mother and Child Health in France

Shortly after World War II, France instituted Protection maternelle et infantile (PMI), a nationwide system through which public and private health professionals, in collaboration with social services, provide basic preventive health, medical, social and educational services to pregnant women, infants and children through to the age of six.

For the most part, families and private physicians arrange individually for preconception counselling, family planning, early and regular prenatal care and preventive health examinations and vaccinations for children up to the age of six. Participation in the programme is encouraged through 100% reimbursement by national health insurance (in order to qualify for this coverage, women must register their pregnancies by the 15th week of gestation), monthly (family) allowance payments from a woman’s fourth month of gestation through to the child’s third month of life as an incentive for compliance with the national guidelines for preventive care, and a continuing programme of information and education.

Women not able to participate in care via the private sector are covered by 96 locally controlled PMI centres, one in each French département. In addition to providing free neighbourhood health clinics, these centres identify and target for intervention pregnant women and children at risk, conduct home visits and monitor the progress of all women and infants to ensure that the preventive services called for in the national guidelines are received.

The employers’ role in this system is regulated by law. They provide pregnant women with:

·     Job changes; flexible hours to ease commuting burdens and rest periods in order to reduce the stress and fatigue that may lead to premature delivery

·     Maternity leave with job security for mothers who bear or adopt children to promote bonding and healthy child development (a maternity benefit amounting to 84% of the salary, is paid by social security up to a ceiling)

·     Part-time work arrangements and unpaid parental leave with job security to enable parents to balance child care and work responsibilities (a national parental allowance helps to offset the cost of the unpaid leave) (Richardson 1994)

Conclusion

The need to address maternal and infant health in the American workplace will increase as more and more women enter the labour force and as family and workplace issues become inseparable. Forward-thinking companies have already recognized this and are developing innovative approaches. Employers are in a unique and powerful position to influence change and become leaders in promoting healthy mothers and babies.

HIV/AIDS EDUCATION

B.J. Stiles

As the epidemic of HIV infection worsens and spreads, increasing numbers of workplaces, labour unions, employers and employees are being affected by the threat of HIV infection and AIDS (collectively to be termed HIV/AIDS). The effects are often particular and highly visible; they can also be insidious and somewhat hidden. Over the relatively brief lifetime of the HIV epidemic, the direct and indirect consequences of AIDS for the business sector and for the workplace in general (as distinguished from its health care aspect), remain for the most part a peripherally acknowledged component of the severity and magnitude of AIDS.

The attitudes and opinions of employees about AIDS are of pivotal importance, and must be assessed if a workplace programme is to be planned and managed effectively. Employee ignorance and misinformation can represent major obstacles to an educational programme, and if misjudged or handled poorly, can lead to distrust and disruption, and can aggravate already-prevalent biases and fears about AIDS.

In the United States, "AIDS has generated more individual lawsuits across a broad range of health issues than any other disease in history", notes Lawrence Gostin of the HIV Litigation Project. A 1993 national survey of employee attitudes about AIDS by the National Leadership Coalition on AIDS reports that many working Americans continue to hold negative and potentially discriminatory attitudes toward HIV-infected co-workers, and the survey finds that most employees either don't know how their employers would react to HIV- or AIDS-related situations in their workplaces, or they think that their employer would dismiss an employee with HIV infection at the first sign of illness. Discriminating against employees based solely on disability is expressly forbidden in the United States by the Americans with Disabilities Act (ADA), which includes under its protection people with HIV infection and AIDS. The Americans with Disabilities Act requires employers of more than 15 people to make "reasonable accommodations", or adjustments in the job for their employees with disabilities, including HIV infection and AIDS.

For example, 32% of working Americans in the survey thought an employee with HIV infection would be fired or placed on disability leave at the first sign of illness. Clearly, if an employer moved to dismiss an employee with HIV infection solely on the basis of the diagnosis alone, that employer would be breaking the law. Such widespread employee ignorance of an employer's legal responsibilities clearly makes employers-and by extension, their managers and employees-vulnerable to potentially costly discrimination lawsuits, work disruptions and employee morale and productivity problems.

Misperceptions about the epidemic can also fuel discriminatory attitudes and behaviour among managers and employees and can place an employer at risk. For example, 67% of workers surveyed thought that their colleagues would be uncomfortable working with someone with HIV infection. Left unchecked, such attitudes and the sorts of behaviour consistent with them can place an employer at considerable risk. Managers may erroneously assume that discriminatory treatment against those with HIV infection or AIDS, or those perceived as being infected, is acceptable.

HIV/AIDS Management Challenges

The medical, legal, financial, and workplace developments arising from the epidemic pose a host of challenges for people with HIV infection and AIDS, their families, their unions and their employers. Labour leaders, business executives, human resource professionals and front-line managers face increasingly complicated duties, including controlling costs, protecting the confidentiality of employees' medical information and providing "reasonable accommodations" to their employees with HIV infection and AIDS, in addition to protecting people with HIV infection and AIDS and those perceived as having the illness from discrimination in hiring and promotion. People infected with HIV are remaining at work longer, so that employers need to plan how best to manage HIV-infected employees fairly and effectively over a longer period of time, and often with little or no training or guidance.

Effectively managing employees with AIDS requires keeping abreast of emerging health care options, health insurance and health care costs, and legal and regulatory requirements, shaping effective "reasonable accommodations", and managing concerns about confidentiality and privacy, discrimination issues, employee fears, harassment of infected workers, customer concerns, work disruptions, lawsuits, declines in worker productivity and morale-all the while maintaining a productive and profitable workplace and meeting business goals.

That is a large and somewhat complex set of expectations, a fact that underscores one of the essential needs in setting about to provide workplace education, namely, to start with managers and to train and motivate them to view AIDS in the workplace as part of long-term strategies and goals.

Amid the barrage of questions and concerns about the epidemic and how to manage its impact on the workplace, employers can take cost-effective steps to minimize risk, cut health care costs, protect their company's future and, most important, save lives.

Step one: Establish a workplace HIV/AIDS policy

The first step toward effectively managing the workplace issues arising from the HIV epidemic is to put in place a sound workplace policy. Such a policy must set forth clearly the ways a business will deal with the host of complex but manageable challenges generated by HIV/AIDS. ("A sound workplace policy that accounts for an employer's responsibilities to infected and affected workers will help keep a business from becoming a test case," says Peter Petesch, a Washington, DC-based labour lawyer interested in the issue of AIDS and its workplace ramifications.)

Of course, a workplace policy itself will not remove the difficulties inherent in managing an employee with a fatal and often stigmatized illness. Nonetheless, a written workplace policy goes a long way towards preparing a company for its efforts to manage AIDS by minimizing risks and protecting its workforce. An effective written policy will include among its aims the need to

·     Set a consistent internal standard for a company's entire HIV/AIDS programme.

·     Standardize a company's position and communications about HIV/AIDS.

·     Establish a precedent and standards for employee behaviour.

·     Inform all employees where they can go for information and assistance.

·     Instruct supervisors how to manage AIDS in their work groups.

Effective HIV/AIDS policies should cover and provide guidance on compliance with the law, nondiscrimination, confidentiality and privacy, safety, performance standards, reasonable accommodation, co-worker concerns and employee education. In order to be effective, a policy must be communicated to employees at every level of the company. Moreover, it is crucial to have the outspoken, highly visible support of upper-level management and executives, including the chief executive, in reinforcing the urgency and importance of the messages outlined above. Without this level of commitment, a policy that exists just "on paper" runs the risk of being simply a lion with no teeth.

There are two general approaches to developing HIV/AIDS policies:

1.     The life-threatening illness approach. Some employers choose to develop their HIV/AIDS policy as part of the continuum of all life-threatening illnesses or disabilities. These policies usually state that HIV/AIDS will be handled as are all other long-term illnesses-compassionately, sensibly and without discrimination.

2.     The HIV/AIDS-specific approach. This approach to policy development specifically acknowledges and addresses HIV/AIDS as a major health issue with potential impact on the workplace. In addition to the policy statement itself, this approach often includes an educational component asserting that HIV/AIDS is not transmitted through casual workplace contact, and that employees with HIV infection or AIDS do not pose a health risk to co-workers or customers.

Step two: Train managers and supervisors

Managers and supervisors should be thoroughly familiarized with the employer's workplace HIV/AIDS policy guidelines. One should ensure that every level of management is supplied with clear and consistent guidance on the medical facts and the minimal risk of transmission in the general workplace. In countries with anti-discrimination laws, managers must also be thoroughly familiar with their requirements (e.g., the Americans with Disabilities Act and its reasonable accommodation requirements, nondiscrimination, confidentiality and privacy, workplace safety and employee performance standards in the United States).

Also, all managers must be prepared to field questions and concerns from employees about HIV/AIDS and the workplace. Often the front-line managers are the first ones called on to provide information and referrals to other sources of information and to provide in-depth answers to employee questions about why they should be concerned about HIV infection and AIDS and about how they are expected to behave. Managers should be educated and prepared before employee education programmes are instituted.

Step three: Educate employees

Workplace-based education programmes are inexpensive and cost-effective ways to minimize risk, protect workers' lives, save money on health care costs and save lives. MacAllister Booth, CEO of the Polaroid Corporation, recently said that the AIDS education and training for all Polaroid employees cost less than the treatment costs of one case of AIDS.

Workplace wellness programmes and health promotion are already an established part of the world of work for more and more workers, particularly among labour organizations and larger businesses. Campaigns to reduce medical costs and days missed due to preventable illnesses have focussed on the importance of stopping smoking and of exercising and following a healthier diet. Building on efforts to increase the safety of workplaces and the health of the workforce, workplace wellness programmes are already established as cost-effective and appropriate venues for health information for employees. HIV/AIDS education programmes can be integrated into these ongoing health promotion efforts.

Further, studies have shown that many employees trust their employers to provide accurate information about a broad range of topics, including health education. Working people are concerned about AIDS, many lack understanding of the medical and legal facts about the epidemic, and they want to learn more about it.

According to a study by the New York Business Group on Health (Barr, Waring and Warshaw 1991), employees generally have a positive opinion of employers who provide information about AIDS and-depending on the type of programme offered-found the employer to be a more credible source of information than either the media or the government. Further, according to the National Leadership Coalition on AIDS' survey of working American's attitudes about AIDS, 96% of employees who received AIDS education at work supported workplace-based HIV/AIDS education.

Ideally, attendance at employee education sessions should be mandatory, and the programme should last at least one and a half hours. The session should be conducted by a trained educator, and should present materials in an objective and nonjudgemental way. The programme should also allow for a question-and-answer period and provide referrals for confidential assistance. Initiatives taken with regard to AIDS in the workplace should be ongoing, not one-shot events, and are more effective when linked with such public acknowledgements of the importance of the problem as World AIDS Day observances. Finally, one of the most effective methods for discussing AIDS with employees is to invite a person living with HIV infection or AIDS to address the session. Hearing first-hand how someone lives and works with HIV infection or AIDS has been shown to have a positive impact on the effectiveness of the session.

A thorough workplace AIDS education programme should include a presentation of these matters:

·     the medical facts- how HIV is and is not transmitted, emphasizing that it cannot be spread through casual contact and is virtually impossible to contract in the workplace

·     the legal facts, including employer responsibilities, especially the importance of confidentiality and privacy and of providing reasonable accommodations

·     the psychosocial issues, including how to respond to a co-worker with HIV/AIDS, and what it is like to live and work with HIV/AIDS

·     guidelines on company policies, benefits and information

·     information for employees to take home to their families to teach them how to protect themselves

·     information on community resources and places to go for anonymous testing.

Studies caution that attitudes about AIDS can be negatively reinforced if an education or training session is too brief and not sufficiently thorough and interactive. Similarly, simply handing out a brochure has been shown to increase anxiety about AIDS. In a brief, cursory session, attendees have been found to absorb some of the facts, but to leave with unresolved anxieties about the transmission of HIV, anxieties which have, in fact, been aroused by the introduction of the subject. Thus it is important to allow sufficient time in a training session for in-depth discussion, questions and answers, and referrals to other sources of confidential information. Optimally, a training session should be compulsory because the stigma still associated with HIV infection and AIDS will prevent many from attending a voluntary session.

Some Union Responses to HIV/AIDS

Some leading examples of union HIV/AIDS education and policy initiatives include the following:

1.     The Seafarers International Union established an HIV/AIDS education programme as a mandatory component of the curriculum for merchant marine students at its Lundeberg School of Seamanship in Piney Point, Maryland. Individuals wishing to enter the industry may attend a 14-week training course at the school, and those already working in the industry attend no-cost classes to upgrade their skills and to obtain high-school equivalency diplomas or associate degrees. The Seafarers educational seminars about HIV/AIDS last two hours, and this comprehensive approach is based on the recognition that a thorough training is necessary to meet the needs of a workforce which travels abroad and operates in a self-contained environment. The HIV prevention course is part of a programme that covers employment practices, workplace health and safety, and the containment of health care costs. The education is supplemented by the showing of a variety of AIDS videotapes in the closed circuit television system in the Lundeberg school, publication of articles in the school newspaper and the distribution of brochures at Union Halls in each port. Free condoms are also made available.

2.     The Service Employees International Union (SEIU) became involved in AIDS-related activities in 1984 when fear of AIDS transmission first arose among its members working at San Francisco General Hospital. To assure that health care workers would be able to continue to provide compassionate care to their patients, it was critically important that irrational fear be confronted with factual information and that adequate safety precautions be implemented at the same time. This crisis led to the establishment of the SEIU's AIDS Program, a model for peer-oriented efforts, in which members work with each other to resolve educational and emotional support needs. The programme includes monitoring infection control procedures in hospitals, responding to individual requests from union members to design and conduct AIDS training programmes and encouraging hospital management coordination with the SEIU on AIDS-related concerns.

3.     A significant benefit of the SEIU approach to HIV/AIDS has been the development of scientifically-based policies and member education programmes that demonstrate genuine concern for all involved in the epidemic, including the health care worker, the patient and the public. The union actively promotes AIDS awareness on the national and international levels at conferences and meetings, a focus which has positioned the SEIU at the forefront of educating newly arrived immigrant workers about HIV prevention and about workplace safety with respect to all blood-borne pathogens. This educational effort takes into account the primary or preferred languages and cultural differences among its target audience.

Conclusion

Although the unions and companies responding constructively to the day-to-day workplace challenges of HIV/AIDS are in the minority, many have provided the models and a growing body of knowledge that is readily available to help others effectively address HIV as a workplace concern. The insight and experience gained over the past ten years demonstrate that well-planned AIDS policies, workplace standards and practices, leadership and ongoing labour, management and employee education are effective methods for addressing these challenges.

As trade unionists, industry groups and business associations recognize the growing consequences of AIDS for their sectors, new groups are forming to address the particular relevance of AIDS to their interests. The Thai Business Coalition on AIDS was launched in 1993, and appears likely to stimulate similar developments in other Pacific Rim countries. Several business and trade groups in Central and Southern Africa are taking the initiative in providing workplace education, and similar undertakings have become visible in Brazil and in the Caribbean.

The World Development Report (1993) was devoted to "Investing in Health" and examined the interplay between human health, health policy and economic development. The report provided a number of examples of the threat which AIDS poses to development strategies and accomplishments. This report indicates that there is a growing opportunity to utilize the skills and resources of global finance and development, working in closer harmony with public health leaders around the world, to form more effective action plans for confronting the economic and business challenges stemming from AIDS (Hammer 1994).

Unions and employers find that implementing AIDS policies and employee education programmes before confronting a case of HIV helps reduce workplace disruptions, saves money by protecting the health of the workforce, averts costly legal battles, and prepares managers and employees to respond constructively to the challenges of AIDS in the workplace. The tools needed to manage the multiple and complex day-to-day issues associated with the disease are readily accessible and inexpensive. Finally, they can save lives and money.

HEALTH PROTECTION AND PROMOTION: INFECTIOUS DISEASES

William J. Schneider

Prevention and control of infectious diseases is a central responsibility of the employee health service in areas where they are endemic, where work entails exposure to particular infectious agents to which the population may be singularly susceptible, and where community health services are deficient. In such circumstances, the medical director must act as the public health officer for the workforce, a duty that requires attention to sanitation, potable food and water, potential vectors of infection, appropriate immunization when available, as well as early detection and prompt treatment of infections when they occur.

In well-developed urban areas where employees are relatively healthy, concern over infectious diseases is usually eclipsed by other problems, but prevention and control of infectious diseases remain, nonetheless, important responsibilities of the employee health service. By virtue of their prevalence among all age groups (obviously including those most likely to be employed) and because of their fundamental capacity to be spread through the close contacts characteristic of the typical work environment, infectious diseases are an appropriate target for any employee health promotion programme. However, the efforts of employee health units to respond to the problem they pose are not often discussed. In part, this lack of attention may be attributed to the view that such efforts are a matter of routine, taking the form, say, of seasonal influenza immunization programmes. Additionally, they may be overlooked because they are activities not necessarily associated with broad health promotion initiatives but, instead, are woven into the fabric of the comprehensive employee health programme. For example, the individual counselling and treatment of employees undergoing periodic health evaluation often includes ad hoc health promotion interventions directed at infectious illnesses. Nonetheless, all these represent meaningful activities which, with or without formal designation as a "programme", may be combined into a cohesive strategy for the prevention and control of infectious diseases.

These activities may be divided among a number of components: dissemination of information and employee education; immunizations; response to outbreaks of infection; protecting the health of travellers; reaching family members; and keeping up-to-date. To illustrate how these may be integrated into a comprehensive employee health programme serving a large urban, largely white-collar workforce, this article will describe the programme at J.P. Morgan and Company, Inc., based in New York City. While it has unique features, it is not dissimilar from those maintained by many large organizations.

J.P. Morgan & Company, Inc.

J.P. Morgan & Company, Inc., is a corporation providing diverse financial services throughout the world. Headquartered in New York City, where approximately 7,500 of its 16,500 employees are based, it maintains offices of various sizes elsewhere in the United States and Canada and in major cities of Europe, Asia, Latin America and Australia.

In-house medical departments were present in each of its immediate parent organizations from the early part of this century and, following the amalgamation of J.P. Morgan with Guaranty Trust Company, the employee health unit has evolved to provide not only standard occupational medical activities but a broad range of free services to employees, including periodic health evaluations, immunizations, outpatient primary care, health education and promotion and an employee assistance programme. The effectiveness of the medical department, which is based in New York City, is enhanced by the concentration of the bulk of Morgan's workforce in a limited number of centrally located facilities.

Dissemination of Information

Dissemination of relevant information is usually the cornerstone of a health promotion programme and it is arguably the simplest approach whether resources are limited or abundant. Providing accurate, meaningful, and understandable information-modified as needed according to employees' age, language, ethnicity and educational level-serves not only to educate but also to correct misconceptions, inculcate effective prevention strategies and direct employees to appropriate resources within or outside the worksite.

This information can take many forms. Written communications can be directed to employees at their workstations or to their homes, or can be distributed at central worksite locations. These may consist of bulletins or publications obtained from government or voluntary health agencies, pharmaceutical companies or commercial sources, among others or, if resources permit, they can be developed in-house.

Lectures and seminars can be even more effective particularly when they allow employees to pose questions about their individual concerns. On the other hand, they present the drawback of requiring accessibility and a greater time commitment on the part of both employer and staff; they also breach anonymity, which sometimes may be an issue.

HIV/AIDS

Our own experience with the dissemination of health information on HIV infection can be viewed as an example of this activity. The first cases of the illness were reported in 1981 and we first became aware of cases among our employees in 1985. In 1986, in large measure because of local media attention to the problem, the employees in one of our European offices (where no cases of the illness had yet surfaced) requested a programme on AIDS. The speakers included the corporate medical director and an expert on infectious diseases from a local university hospital. The audience consisted of almost 10% of that unit's entire workforce of whom 80% were women. The emphasis of these and subsequent presentations was on transmission of the virus and on strategies for prevention. As one might assume from the composition of the audience, there was considerable concern about heterosexual spread.

The success of that presentation facilitated the development of a far more ambitious programme at the New York headquarters the following year. A newsletter and brochure anticipated the events with a brief discussion of the illness, posters and other advertisements were utilized to remind employees of the times and places of presentations, and managers strongly encouraged attendance. Because of the commitment of management and general concerns about the illness in the community, we were able to reach between 25 and 30% of the local workforce in the multiple presentations.

These sessions included a discussion by the corporate medical director, who acknowledged the presence of the illness among employees and noted that the corporation was committed to their continuing employment as long as they remained well enough to work effectively. He reviewed the corporation's policy on life-threatening illnesses and noted the availability of confidential HIV testing through the medical department. An educational videotape on the illness was shown, followed by an expert speaker from the local municipal health department. A period of questions and answers followed and, at the close of the session, everyone was given a packet of information materials on HIV infection and prevention strategies.

The response to these sessions was very positive. At a time when other corporations were experiencing workplace disruptions over employees with HIV infections, Morgan had none. An independent survey of employees (and those of several other corporations with similar programmes) found that programme participants thoroughly appreciated the opportunity to attend such sessions and found the information provided was more helpful than that available to them from other sources (Barr, Waring and Warshaw 1991).

We held similar sessions on HIV infection in 1989 and 1991, but found that attendance diminished with time. We attributed this, in part, to perceived saturation with the subject and, in part, to the illness shifting its impact to the chronically unemployed (in our area); indeed, the number of employees newly infected with HIV who came to our attention dramatically declined after 1991.

Lyme disease

Meanwhile, Lyme disease, a bacterial illness transmitted by the bite of the deer tick in suburban and local vacation environments has become increasingly prevalent among our employees. A lecture on this subject supplemented by printed information attracted considerable attention when it was given in 1993. Points emphasized in this presentation included recognition of the illness, testing, treatment and, most important, prevention.

In general, programmes designed to disseminate information whether written or in lecture form, should be credible, easily understandable, practical and relevant. They should serve to elevate awareness, especially with regard to personal prevention and when and how to obtain professional attention. At the same time, they should serve to dissipate any inappropriate anxieties.

Immunization Programmes

Immunizations at the worksite address an important public health need and are likely to provide tangible benefits, not only to the individual recipients but to the organization as well. Many employers in the developed world who do not have an employee health service arrange for outside contractors to come to the worksite to provide a mass immunization programme.

Influenza.

While most immunizations provide protection for many years, influenza vaccine must be administered annually because of continuing changes in the virus and, to a lesser extent, waning patient immunity. Since influenza is a seasonal illness whose infectiousness is typically widespread in the winter months, the vaccine should be administered in the autumn. Those most in need of immunization are older employees and those with underlying illnesses or immune deficiencies, including diabetes and chronic lung, heart and kidney problems. Employees in health care institutions should be encouraged to be immunized not only because they are more likely to be exposed to persons with the infection, but also because their continuing ability to work is critical in the event of a serious outbreak of the illness. A recent study has shown that vaccination against influenza offers substantial health-related and economic benefits for healthy, working adults also. Since the morbidity associated with the illness can typically result in a week or more of disability, often involving multiple employees in the same unit at the same time, there is sufficient incentive for employers to prevent the resultant impact on productivity by offering this relatively innocuous and inexpensive form of immunization. This becomes especially important when public health authorities anticipate major changes in the virus and predict a major epidemic for a given season.

Probably, the main barrier to the success of influenza (or any other) immunization programmes is the reluctance of individuals to participate. To minimize their hesitation, it is important to educate employees on the need for and availability of the vaccine and to make the immunization readily accessible. Notices should go out through all available means, generically identifying all those in special need of immunization emphasizing the relative safety of the vaccine, and explaining the procedure through which it can be obtained.

Time and the inconvenience of travel to visit a personal physician are potent disincentives for many individuals; the most effective programmes will be those that provide immunizations at the worksite during working hours with minimum delays. Finally, cost, a major barrier, should either be held to a minimum or absorbed entirely by the employer or the group health insurance programme.

Contributing to employee acceptance of immunizations are such additional factors as community publicity and incentive programmes. We have found that media reports of a threatening influenza epidemic will regularly increase employee acceptance of the vaccine. In 1993, to encourage all employees to have their vaccination status evaluated and to receive needed immunizations, the medical department at Morgan offered those who accepted these services participation in a lottery in which company stock was the prize. The number of employees seeking immunization in this year was half again as great as the number seen during the same period in the prior year.

Diphtheria-tetanus.

Other immunizations advised for healthy adults of typical employment age are diphtheria-tetanus and, possibly measles, mumps, and rubella. Diphtheria-tetanus immunization is recommended every ten years throughout life, assuming that one has had a primary series of immunizations. With this interval, we find immune status most easily confirmed and the vaccine most easily administered during our employees' periodic health evaluations (see below), although this can also be accomplished in a company-wide immunization campaign such as the one used in the incentive programme mentioned above.

Measles.

Public health authorities recommend measles vaccine for everyone born after 1956 who does not have documentation of two doses of measles vaccine on or after the first birthday, a history of measles confirmed by a physician, or laboratory evidence of measles immunity. This immunization can readily be administered during a pre-employment or pre-placement health evaluation or in a company-wide immunization campaign.

Rubella.

Public health authorities recommend that everyone have medical documentation of having received rubella vaccine or laboratory evidence of immunity to this illness. Adequate rubella immunization is especially important for health care workers, for whom it is likely to be mandated.

Again, adequate rubella immunity should be ascertained at the time of employment or, absent this possibility, through periodic immunization campaigns or during periodic health evaluations. Effective immunity can be conferred on persons in need of rubella or rubeola vaccine by administration of MMR (measles-mumps-rubella) vaccine. Serologic testing for immunity can be undertaken to identify the immune status of an individual prior to immunization, but this is not likely to be cost-effective.

Hepatitis B.

In so far as hepatitis B is transmitted through sexual intimacy and by direct contact with blood and other body fluids, initial immunization efforts were directed at populations with elevated risks, such as health professionals and those with multiple sexual partners. Additionally, the increased prevalence of the illness and carrier state in certain geographic areas such as the Far East and sub-Saharan Africa has given priority to immunization of all newborns there and of those who frequently travel to, or remain for extended periods in, those regions. More recently, universal immunization of all newborns in the United States and elsewhere has been proposed as a more effective strategy for reaching vulnerable individuals.

In the work environment, the focus of hepatitis B immunization has been on health care workers because of the risk of their exposure to blood. Indeed, in the United States, government regulation requires informing such personnel and other likely responders to health care emergencies of the advisability of being immunized against hepatitis B, in the context of a general discussion of universal precautions; immunization must then be provided.

Thus, in our setting at Morgan, information about hepatitis B immunization is conveyed in three contexts: in discussions on sexually transmitted diseases such as AIDS, in presentations to health care and emergency service personnel on the risks and precautions relevant to their health care work, and in interventions with individual employees and their families anticipating assignments in areas of the world where hepatitis B is most prevalent. The immunization is provided in conjunction with these programmes.

Hepatitis A.

This illness, typically transmitted by contaminated food or water, is much more prevalent in developing nations than in industrialized countries. Thus, protection efforts have been directed at travellers to areas of risk or those who have household contact or other very close contact with those newly diagnosed with the illness.

Now that a vaccine to protect against hepatitis A has become available, it is administered to travellers to developing countries and to close contacts of newly diagnosed, documented cases of hepatitis A. If there is insufficient time for antibody levels to develop prior to the departure of travellers, serum immune globulin may be administered simultaneously.

As an effective, safe hepatitis A vaccine is available, immunization efforts can be directed to a significantly larger target group. At a minimum, frequent travellers to and residents in endemic areas should receive this immunization, and food handlers should also be considered for immunization because of the risk of their transmitting the illness to large numbers of people.

Prior to any immunization, careful attention should be paid to possible contraindications, such as hypersensitivity to any vaccine component or, in the case of live vaccines such as measles, mumps, and rubella, immune deficiency or pregnancy, whether present or soon anticipated. Appropriate information on possible vaccine risks should be conveyed to the employee and signed consent forms obtained. The limited possibility of immunization-related reactions should be anticipated in any programme.

Those organizations with existing medical staffs can obviously utilize their own personnel to implement an immunization programme. Those without such personnel may arrange for immunizations to be provided by community physicians or nurses, hospitals or health agencies or by government health agencies.

Response to Outbreaks

Few events arouse as much interest and concern among employees in a particular work unit or an entire organization as awareness that a co-worker has a contagious illness. The essential response of the employee health service to such news is to identify and appropriately isolate those who are ill, both the source case and any secondary cases, while disseminating information about the illness that will allay the anxiety of those who believe that they may have been exposed. Some organizations, hoping to minimize potential anxiety, may limit this dissemination to possible contacts. Others, recognizing that the "grapevine" (informal communication among employees) will not only spread the news but will probably also convey misinformation that could unleash latent anxiety, will seize the event as a unique opportunity to educate the entire workforce about the potential for spread of the disease and how to prevent it. At Morgan, there have been several episodes of this type involving three different diseases: tuberculosis, rubella, and food-borne gastroenteritis.

Tuberculosis.

Tuberculosis is justifiably feared because of the potentially significant morbidity of the illness, especially with the increasing prevalence of multiple drug resistant bacteria. In our experience, the illness has been brought to our attention by news of the hospitalization and definitive diagnosis of the index cases; fortunately at Morgan, secondary cases have been rare and have been limited to skin test conversions only.

Typically with such cases, public health authorities are notified, following which contacts are encouraged to undergo baseline tuberculin skin testing or chest x-rays; the skin tests are repeated ten to twelve weeks later. For those whose skin tests convert from negative to positive in the follow-up testing, chest x-rays are obtained. If the x-ray is positive, employees are referred for definitive treatment; if negative, isoniazid prophylaxis is prescribed.

During each stage of the process, informational sessions are held on both a group and individual basis. Anxiety is typically disproportionate to risk, and reassurance, as well as the need for prudent follow-up, are the primary targets of the counselling.

Rubella.

Morgan's cases of rubella have been identified on visits to the employee health unit. To avoid further contact, the employees are sent home even if there is only a clinical suspicion of the illness. Following serologic confirmation, usually within 48 hours, epidemiological surveys are conducted to identify other cases while information about the occurrence is disseminated. Although the major targets of these programmes are female employees who may be pregnant and who might have been exposed, the outbreaks have served as an opportunity to verify the immune status of all employees and to offer vaccine to all those who might need it. Again, local public health authorities are advised of these occurrences and their expertise and assistance are utilized in addressing organizational needs.

Food-borne infection.

A single experience with a food-related illness outbreak occurred at Morgan several years ago. It was due to staphylococcal food poisoning which was traced to a food handler with a skin lesion on one of his hands. Over fifty employees who utilized the in-house dining facilities developed a self-limited illness which was characterized by nausea, vomiting and diarrhoea, appearing approximately six hours after ingesting the offending cold duck salad, and resolving within 24 hours.

In this instance, the thrust of our health education efforts was to sensitize the food handlers themselves to the signs and symptoms of illness that should influence them to leave their work and seek medical attention. Certain managerial and procedural changes were also implemented:

·     making supervisors aware of their responsibility to assure that workers with signs of illness receive medical scrutiny

·     holding periodic educational sessions for all food service employees to remind them of appropriate precautions

·     assuring that disposable gloves are used.

Recently, two neighbouring organizations also experienced food-related illness outbreaks. In one, hepatitis A was transmitted to a number of employees by a food handler in the company dining room; in the other, a number of employees developed salmonella food poisoning after consuming a dessert prepared with raw eggs in a restaurant off the premises. In the first instance, the organization's educational efforts were directed at the food handlers themselves; in the second, information on various foods prepared from raw eggs-and the potential hazard that this entailed-was shared with the entire workforce.

Individual Interventions

While the three experiences described above follow the typical health promotion format of reaching out to the entire employee population or, at least, to a substantial subset, much of the health promotion activities of organizations like Morgan with respect to infectious diseases takes place on a one-on-one basis. These include interventions that are made possible by pre-placement, periodic, or retirement health evaluations, inquiries about international travel, and incidental visits to the employee health service.

Pre-placement examinations.

Individuals examined at the time of employment are typically young and healthy and are unlikely to have had recent medical attention. They are often in need of such immunizations as measles, rubella, or diphtheria-tetanus. Additionally, those scheduled to be placed in areas of potential disease transmission such as in health or food services receive appropriate counselling about the precautions that they should observe.

Periodic medical examinations.

Similarly, the periodic health evaluation provides the opportunity to review immunization status and to discuss the risks that may be associated with specific chronic illnesses and the precautions that should be undertaken. Examples of the latter include the need for annual influenza immunization for individuals with diabetes or asthma and instruction for diabetics on the appropriate care of the feet to avoid local infection.

Recently reported news about infectious diseases should be discussed, particularly with those with known health problems. For example, news of outbreaks of an E. coli infection attributed to eating inadequately cooked ground meat would be of importance to all, while the danger of contracting cryptosporidiosis from swimming in public pools would be especially relevant to those with HIV disease or other immune deficiencies.

Pre-retirement examinations.

Employees who are examined in relation to retirement should be urged to obtain pneumococcal immunization and advised about annual influenza immunization.

Pre-travel protection.

The increasing globalization of work assignments coupled with the heightened interest in international travel for pleasure have contributed to a continuing expansion of the population needing protection against infectious diseases not likely to be encountered at home. A pre-travel encounter should include a medical history to reveal any individual health vulnerabilities that may increase the risks associated with the anticipated travel or assignment. A good-and not uncommon-example of this is the pregnant woman considering travel to an environment with chloroquine-resistant malaria, since the alternative forms of malaria prophylaxis may be contraindicated during pregnancy.

Comprehensive information on the infectious illnesses prevalent in the areas to be visited should be provided. This should include methods of transmission of the relevant illnesses, avoidance and prophylactic techniques, and typical symptoms and strategies for obtaining medical attention if they develop. And, of course, indicated immunizations should be provided.

Visits to the employee health service.

In most occupational health settings, employees may receive first aid and treatment for symptoms of illness; in some, as at Morgan, a broad range of primary care services is available. Each encounter offers an opportunity for preventive health interventions and counselling. This includes providing immunizations at appropriate intervals and alerting employee-patients about health precautions relative to any underlying illness or potential exposure. A particular advantage of this situation is that the very fact that the employee has sought this attention suggests that he or she may be more receptive to the advice given than may be the case when the same information is received in a broad educational campaign. The health professional should capitalize on this opportunity by ensuring that appropriate information and necessary immunizations or prophylactic medications are provided.

Reaching family members.

Although the main thrust of occupational health is to assure the health and well-being of the employee, there are many reasons to see that effective health promotion efforts are conveyed to the employee's family as well. Obviously, most of the objectives noted earlier are equally applicable to other adult members of the household and, while the direct services of the occupational health unit are generally not available to family members, the information can be conveyed home through newsletters and brochures and by word of mouth.

An additional consideration is the health of children, especially in view of the importance of early childhood immunizations. It has been recognized that these immunizations are often overlooked, at least in part, not only by the economically disadvantaged, but even by the children of more affluent US corporate employees. Seminars on well-baby care and printed information on this subject, provided either by the employer or by the employer's health insurance carrier may serve to minimize this deficiency. Additionally, modifying health insurance coverage to include such "preventive" measures as immunizations should also serve to encourage appropriate attention to this matter.

Keeping Abreast

Although the introduction of antibiotics in the middle of the twentieth century led some to believe that infectious diseases would soon be eliminated, actual experience has been very different. Not only have new infectious diseases appeared (e.g., HIV and Lyme disease), but more infectious agents are developing resistance to formerly effective medications (e.g., malaria and tuberculosis). It is imperative, therefore, that occupational health professionals keep their knowledge of developments in the field of infectious diseases and their prevention current. Although there are many ways of doing this, periodic reports and bulletins emanating from the World Health Organization and national health agencies such as the US Centers for Disease Control and Prevention are particularly useful.

Conclusion

High among employers' responsibilities for the health of the workforce is the prevention and control of infectious diseases among employees. This includes identification, isolation and appropriate treatment of individuals with infections together with prevention of their spread to co-workers and dependants and allaying the anxieties of those concerned about potential contact. It also involves education and appropriate protection of employees who may encounter infectious diseases while at work or in the community. The employee health service, as illustrated by the above description of activities of the medical department at J.P. Morgan and Company, Inc., in New York City, may play a central role in meeting this responsibility, resulting in benefit to individual employees, the organization as a whole and the community.

PROTECTING THE HEALTH OF THE TRAVELLER

Craig Karpilow

In this era of multinational organizations and ever-expanding international trade, employees are being increasingly called upon to undertake travel for business reasons. At the same time, more employees and their families are spending their holidays in travel to distant places around the world. While for most people such travel is usually exciting and enjoyable, it is often burdensome and debilitating and, especially for those who are not properly prepared, it can be hazardous. Although life-threatening situations may conceivably be encountered, most of the problems associated with travel are not serious. For the holiday traveller, they bring anxiety, discomfort and inconvenience along with the disappointment and added expense involved in shortening a trip and making new travel arrangements. For the business person, travel difficulties may ultimately affect the organization adversely on account of the impairment of his or her work performance in negotiations and other dealings, to say nothing of the cost of having to abort the mission and sending someone else to complete it.

This article will outline a comprehensive travel protection programme for individuals making short-term business trips and it will briefly describe steps that may be taken to circumvent the more frequently encountered travel hazards. (The reader may consult other sources-e.g., Karpilow 1991-for information on programmes for individuals on long-term expatriate assignments and on programmes for whole units or groups of employees dispatched to workstations in distant locales).

A Comprehensive Travel Protection Programme

Occasional seminars on managing the hazards of travel are a feature of many worksite health promotion programmes, especially in organizations where a sizeable proportion of employees travels extensively. In such organizations, there often is an in-house travel department which may be given the responsibility of arranging the sessions and procuring the pamphlets and other literature that may be distributed. For the most part, however, educating the prospective traveller and providing any services that may be needed are conducted on an individual rather than a group basis

Ideally, this task is assigned to the medical department or employees' health unit, where, it is to be hoped, a knowledgeable medical director or other health professional will be available. The advantages of maintaining in-house medical unit staff, apart from convenience, is their knowledge of the organization, its policies and its people; the opportunity for close collaboration with other departments that may be involved (personnel and travel, for example); access to medical records containing health histories of those assigned to travel assignments, including details of any prior travel misadventures; and, at least, a general knowledge of the kind and intensity of work to be accomplished during the trip.

Where such an in-house unit is lacking, the travelling individual may be referred to one of the "travel clinics" that are maintained by many hospitals and private medical groups in the community. The advantages of such clinics include medical staff specializing in the prevention and treatment of the diseases of travellers, current information about conditions in the areas to be visited and fresh supplies of any vaccines that may be indicated.

A number of elements should be included if the travel protection programme is to be truly comprehensive. These are considered under the following heads.

An established policy

Too often, even when a trip has been scheduled for some time, the desired steps to protect the traveller are taken on an ad hoc, last-minute basis or, sometimes, neglected entirely. Accordingly, an established written policy is a key element in any travel protection programme. Since many business travellers are high-level executives, this policy should be promulgated and supported by the chief executive of the organization so that its provisions can be enforced by all of the departments involved in travel assignments and arrangements, which may be headed by managers of lower rank. In some organizations, the policy expressly prohibits any business trip if the traveler has not received a medical "clearance". Some policies are so detailed that they designate minimal height and weight criteria for authorizing the booking of more expensive business-class seating instead of the much more crowded seats in the economy or tourist sections of commercial aircraft, and specify the circumstances under which a spouse or family members may accompany the traveller.

Planning the trip

The medical director or responsible health professional should be involved in planning the itinerary in conjunction with the travel agent and the individual to whom the traveller reports. The considerations to be addressed include (1) the importance of the mission and its ramifications (including obligatory social activities), (2) the exigencies of travel and conditions in the parts of the world to be visited, and (3) the physical and mental condition of the traveller along with his or her capacity to withstand the rigours of the experience and continue to perform adequately. Ideally, the traveller will also be involved in such decisions as to whether the trip should be postponed or cancelled, whether the itinerary should be shortened or otherwise modified, whether the mission (i.e., with respect to number of people visited or number or duration of meetings, etc.) should be modified, whether the traveller should be accompanied by an aide or assistant, and whether periods of rest and relaxation should be built into the itinerary.

Pre-travel medical consultation

If a routine periodic medical examination has not been performed recently, a general physical examination and routine laboratory tests, including an electrocardiogram, should be performed. The purpose is to ensure that the employee's health will not be adversely affected either by the rigours of transit per se or by other circumstances encountered during the trip. The status of any chronic diseases needs to be determined and modifications advised for those with such conditions as diabetes, autoimmune diseases or pregnancy. A written report of the findings and recommendations should be prepared to be made available to any physicians consulted for problems arising en route. This examination also provides a baseline for evaluating potential illness when the traveller returns.

The consultation should include a discussion of the desirability of immunizations, including a review of their potential side-effects and the differences between those that are required and those that are only recommended. An inoculation schedule individualized for the traveler's needs and departure date should be developed and the necessary vaccines administered.

Any medications being taken by the traveller should be reviewed and prescriptions provided for adequate supplies, including allowances for spoilage or loss. Modifications of timing and dosage must be prepared for travellers crossing several time zones (e.g., for those with insulin-dependent diabetes). Based on the work assignment and mode of transport, medications should be prescribed for the prevention of certain specific diseases, including (but not limited to) malaria, traveller's diarrhoea, jet lag and high altitude sickness. In addition, medications should be prescribed or supplied for on-the-trip treatment of minor illnesses such as upper respiratory infections (particularly nasal congestion and sinusitis), bronchitis, motion sickness, dermatitis and other conditions that may be reasonably anticipated.

Medical kits

For the traveller who does not wish to spend valuable time searching for a pharmacy in case of need, a kit of medications and supplies may be invaluable. Even if the traveller may be able to find a pharmacy, the pharmacist's knowledge of the traveller's special condition may be limited, and any language barrier may result in serious lapses in communication. Further, the medication offerred may not be safe and effective. Many countries do not have strict drug labelling laws and quality assurance regulations are sometimes non-existent. The expiration dates of medications are often ignored by small pharmacies and the high temperatures in tropical climates may inactivate certain medications that are stored on shelves in hot shops.

While commercial kits stocked with routine medications are available, the contents of any such kit should be customized to meet the traveller's specific needs. Among those most likely to be needed, in addition to medications prescribed for specific health problems, are drugs for motion sickness, nasal congestion, allergies, insomnia and anxiety; analgesics, antacids and laxatives, as well as medication for haemorrhoids, menstrual discomfort and nocturnal muscle cramps. The kit may furthermore contain antiseptics, bandages and other surgical supplies.

Travellers should carry either letters signed by a physician on letterhead stationery or else prescription blanks listing the medications being carried and indicating the conditions for which they have been prescribed. This may save the traveller from embarrassing and potentially long delays at international ports of entry where customs agents are especially diligent in looking for illicit drugs.

The traveller should also carry either an extra pair of eyeglasses or contact lenses with adequate supplies of cleansing solutions and other necessary appurtenances. (Those going to excessively dirty or dusty areas should be encouraged to wear eyeglasses rather than contact lenses). A copy of the user's lens prescription will facilitate the procurement of replacement glasses should the traveller's pair be lost or damaged.

Those who travel frequently should have their kits checked before each trip to make sure that the contents have been adjusted to the particular itinerary and are not outdated.

Medical records

In addition to notes confirming the appropriateness of the medications being carried, the traveller should carry a card or letter summarizing any significant medical history, findings on his or her pre-travel health assessment and copies of a recent electrocardiogram and any relevant laboratory data. A record of the traveller's most recent immunizations may obviate the necessity of submitting to mandatory inoculation at the port of entry. The record should also contain the name, address, telephone and fax numbers of a physician who can supply additional information about the traveller should it be required (a Medic-Alert type of badge or bracelet can be useful in this regard).

A number of vendors can supply medical record cards with microfilm chips containing travellers' complete medical files. While often convenient, the foreign physician may lack access to the microfilm viewer or a hand lens powerful enough to read them. There is also the problem of making sure that the information is up-to-date.

Immunizations

Some countries require all arriving travellers to be vaccinated for certain diseases, such as cholera, yellow fever or plague. While the World Health Organization has recommended that only vaccination for yellow fever be required, a number of countries still require cholera immunization. In addition to protecting travellers, the required immunizations are also intended to protect their citizens from diseases that may be carried by travellers.

Recommended immunizations are intended to prevent travellers from contracting endemic diseases. This list is much longer than the "required" list and is enlarging annually as new vaccines are developed to combat new and rapidly advancing diseases. The desirability of a specific vaccine also changes frequently in accord with the amount and virulence of the disease in the particular area. For this reason, current information is essential. This may be obtained from the World Health Organization; from government agencies such as the US Centers for Disease Control and Prevention; the Canada Health and Welfare Department; or from the Commonwealth Department of Health in Sydney, Australia. Similar information, usually derived from such sources, may be obtained from local voluntary and commercial organizations; it is also available in periodically updated computer software.

Immunizations recommended for all travellers include diphtheria-tetanus, polio, measles (for those born after 1956 and without a physician-documented episode of measles), influenza and hepatitis B (particularly if the work assignment may involve exposure to this hazard).

The amount of time available for departure may influence the immunization schedule and dosage. For example, for the individual who has never been immunized against typhoid, two injections, four weeks apart, should produce the highest antibody titre. If there is not enough time, those who have not been previously inoculated may be given four pills of the newly developed oral vaccine on alternate days; this will be considerably more effective than a single dose of the injected vaccine. The oral vaccine regimen may also be used as a booster for individuals who have previously received the injections.

Health Insurance and Repatriation Coverage

Many national and private health insurance programmes do not cover individuals who receive health services while outside of the specified area. This can cause embarrassment, delays in receiving needed care and high out-of-pocket expenses for individuals who incur injuries or acute illnesses while on a trip. It is prudent, therefore, to verify that the traveller's current health insurance will cover him or her throughout the trip. If not, procurement of temporary health insurance covering the entire period of the trip should be advised.

Under certain circumstances, particularly in undeveloped areas, lack of adequate modern facilities and concern over the quality of the available care may dictate medical evacuation. The traveller may be returned to his or her home city or, when the distance is too great, to an acceptable urban medical centre en route. A number of companies provide emergency evacuation services around the world; some, however, are available only in more limited areas. Since such situations are usually quite urgent and stressful for all those involved, it is wise to make preliminary stand-by arrangements with a company that serves the areas to be visited and, since such services may be quite expensive, to confirm that they are covered by the traveller's health insurance programme.

Post-travel Debriefing

A medical consultation soon after return is a desirable follow-up to the trip. It provides for a review of any health problems that may have arisen and the proper treatment of any that may not have entirely cleared up. It also provides for a debriefing on the circumstances encountered en route that can lead to more appropriate recommendations and arrangements if the trip is to be repeated or undertaken by others.

Coping with the Hazards of Travel

Travel almost always entails exposure to health hazards that, at the least, present inconvenience and annoyance and can lead to serious and disabling illnesses or worse. For the most part, they can be circumvented or controlled, but this usually requires a special effort on the part of the traveller. Sensitizing the traveller to recognize them and providing the information and training required to cope with them is the major thrust of the travel protection programme. The following represent some of the hazards most commonly encountered during travel.

Jet lag.

Rapid passage across time zones can disrupt the physiological and psychological rhythms-the circadian rhythms-that regulate the organism's functions. Known as "jet lag" because it occurs almost exclusively during air travel, it can cause sleep disturbances, malaise, irritability, reduced mental and physical performance, apathy, depression, fatigue, loss of appetite, gastric distress and altered bowel habits. As a rule, it takes several days before a traveller's rhythms adapt to the new location. Consequently, it is prudent for travellers to book long-distance flights several days prior to the start of important business or social engagements so as to allow themselves a period during which they can recover their energy, alertness and work capacities (this also applies to the return flight). This is particularly important for older travellers, since the effects of jet lag seem to increase with age.

A number of approaches to minimizing jet lag have been employed. Some advocate the "jet lag diet," alternating feasting and fasting of carbohydrates or high protein foods for three days prior to departure. Others suggest eating a high carbohydrate dinner prior to departure, limiting food intake during the flight to salads, fruit plates and other light dishes, drinking a good deal of fluids before and during the trip (enough on the plane to require the hourly use of the rest room) and avoidance of all alcoholic beverages. Others recommend the use of a head-mounted light that suppresses the secretion of melatonin by the pineal gland, the excess of which has been linked to some of the symptoms of jet lag. More recently, small doses of melatonin in tablet form (1 mg or less-larger doses, popular for other purposes, produce drowsiness) taken on a prescibed schedule several days before and after the trip, have been found useful in minimizing jet lag. While these may be helpful, adequate rest and a relaxed schedule until the readjustment has been completed are most reliable.

Air travel.

In addition to jet lag, travel by air can be difficult for other reasons. Getting to and through the airport can be a source of anxiety and irritation, especially when one has to cope with traffic congestion, heavy or bulky luggage, delayed or cancelled flights and dashing through terminals to make connecting flights. Long periods of confinement in narrow seats with insufficient leg room are not only uncomfortable but may precipitate attacks of phlebitis in the legs. Most passengers in well-maintained modern aircraft will have no difficulty breathing since cabins are pressurized to maintain a simulated altitude below that of 8,000 feet above sea level. Cigarette smoke may be annoying for those seated in or near the smoking sections of planes that have not been designated as smoke-free.

These problems can be minimized by such steps as prearranging transfers to and from the airports and assistance with baggage, providing electric carts or wheel chairs for those for whom the long walk between the terminal entrance and the gate may be troublesome, eating lightly and avoiding alcoholic beverages during the flight, drinking plenty of fluids to combat the tendency toward dehydration and getting out of one's seat and walking about the cabin frequently. When the lattermost alternative is not feasible, performing stretching and relaxing exercises like those demonstrated in figure 15.22  is essential. Eye shades may be helpful in trying to sleep during the flight, while wearing ear plugs throughout the flight has been shown to decrease stress and fatigue.

Figure 15.22 Exercises to be performed during long airplane trips

In some 25 countries, including Argentina, Australia, India, Kenya, Mexico, Mozambique and New Zealand, arriving aircraft cabins are required to be sprayed with insecticides before passengers are allowed to leave the plane The purpose is to prevent disease-bearing insects from being brought into the country. Sometimes, the spraying is cursory but often it is quite thorough, taking in the entire cabin, including the seated passengers and crew. Travellers who find the hydrocarbons in the spray annoying or irritating should cover their faces with a damp cloth and practice relaxation breathing exercises.

The United States objects to this practice. Transportation Secretary Federico F. Peña has proposed that all airlines and travel agencies be required to notify passengers when they will be sprayed, and the Transportation Department plans to bring this controversial issue before the International Civil Aviation Association and to cosponsor a World Health Organization symposium on this question (Fiorino 1994).

Mosquitoes and other biting pests.

Malaria and other arthropod-borne diseases (e.g., yellow fever, viral encephalitis, dengue fever, filariasis, leishmaniasis, onchocercosis, trypanosomiasis and Lyme disease) are endemic in many parts of the world. Keeping from getting bitten is the first line of defence against these diseases.

Insect repellents containing "DEET" (N,N-diethyl-meta-toluamide) may be used on the skin and/or clothing. Because DEET can be absorbed through the skin and may cause neurological symptoms, preparations with a DEET concentration over 35% are not recommended, especially for infants. Hexanediol is a useful alternative for those who may be sensitive to DEET. Skin-So-Soft®, the commercially available moisturizer, needs to be reapplied every twenty minutes or so to be an effective repellent.

All persons travelling in areas where insect-borne diseases are endemic should wear long-sleeve shirts and long trousers, especially after dusk. In hot climates, wearing loose-fitting thin cotton or linen garments is actually cooler than leaving the skin exposed. Perfumes and scented cosmetics, soaps and lotions that may attract insects should be avoided. Lightweight mesh jackets, hoods and face guards are particularly helpful in highly infested areas. Mosquito bed netting and window screens are important adjuncts. (Before retiring, it is important to spray the inside of the bednetting in case undesirable insects have become trapped in it.)

Protective clothing and nets may be treated with a DEET-containing repellent or with permethrin, an insecticide available in both spray and liquid formulations.

Malaria.

Despite decades of mosquito eradication efforts, malaria remains endemic in most tropical and subtropical regions of the world. Because it is so dangerous and debilitating, the mosquito control efforts described above should be supplemented by prophylactic use of one or more antimalarial drugs. While a number of fairly effective antimalarials have been developed, some strains of the malaria parasite have become highly resistant to some if not all of the currently used drugs. For example, chloroquine, traditionally the most popular, is still effective against strains of malaria in certain parts of the world but is useless in many other areas. Proguanil, mefloquine and doxycycline are currently most commonly used for chloroquine-resistant strains of malaria. Maloprim, fansidar and sulfisoxazole are also used in certain areas. A prophylactic regimen is started prior to entering the malarious area and continued for some time after leaving it.

The choice of the drug is based on "up to the minute" recommendations for the particular areas to be visited by the traveller. The potential side-effects should also be considered: for example, fansidar is contraindicated during pregnancy and lactation, while mefloquine should not be used by airline pilots or others in whom central nervous system side-effects could impair performance and affect the safety of others, nor by those taking beta-blockers or calcium-channel blockers or other drugs that alter cardiac conduction.

Contaminated water.

Contaminated tap water may be a problem all over the world. Even in modern urban centers, defective pipes and faulty connections in older or poorly maintained buildings may allow the spread of infection. Even bottled water may not be safe, particularly if the plastic seal on the cap is not intact. Carbonated beverages are generally safe to drink provided they have not been allowed to go flat.

Water can be disinfected by heating it to 62ºC for 10 minutes or by adding iodine or chlorine after filtering to remove parasites and worm larvae and then allowing it to stand for 30 minutes.

Water filtration units sold for camping trips are usually not appropriate for areas where the water is suspect since they do not inactivate bacteria and viruses. So-called "Katadyn" filters are available in individual units and filter out organisms larger than 0.2 microns but must be followed by iodine or chlorine treatment to remove viruses. The more recently developed "PUR" filters combine 1.0 micron filters with exposure to a tri-iodine resin matrix that eliminates bacteria, parasites and viruses in a single process.

In areas where the water may be suspect, the traveller should be advised not to use ice or iced drinks and to avoid brushing the teeth with water that has not been purified.

Another important precaution is to avoid swimming or dangling limbs in fresh-water lakes or streams harboring the snails carrying the parasites that cause schistosomiasis (bilharzia).

Contaminated food.

Food may be contaminated at the source by the use of "night soil" (human body wastes) as a fertilizer, in passage by a lack of refrigeration and exposure to flies and other insects, and in preparation by poor hygiene on the part of cooks and food handlers. In this respect, the food prepared by a street vendor where one can see what is being cooked and how it is being prepared may be safer than the "four star" restaurant where the posh ambience and clean uniforms worn by the staff may hide lapses in the storage, preparation and serving of the food. The old adage, "If you can't boil it or peel it yourself, don't eat it" is probably the best advice one can give the traveller.

Traveller's diarrhoea.

Travellers' diarrhoea is encountered worldwide in modern urban centres as well as in undeveloped areas. While most cases are attributed to organisms in food and drink, many are simply the result of strange foods and food preparation, dietary indiscretions and fatigue. Some cases may also follow bathing or showering in unsafe water or swimming in contaminated lakes, streams and pools.

Most cases are self-limited and respond promptly to such simple measures as maintaining an adequate fluid intake, a light bland diet and rest. Simple medications such as attapulgite (a clay product that acts as an absorbent), bismuth subsalicylate and anti-motility agents such as loperamide or reglan may help to control the diarrhoea. However, when the diarrhoea is unusually severe, lasts more than three days, or is accompanied by repeated vomiting or fever, medical attention and the use of appropriate antibiotics are advisable. Selection of the antibiotic of choice is guided by laboratory identification of the offending organism or, if that is not feasible, by an analysis of the symptoms and epidemiological information about the prevalence of particular infections in the areas visited. The traveller should be provided with a pamphlet such as the one developed by the World Health Organization (figure 15.23) that explains what to do in simple, non-alarming language.

Figure 15.23 A sample of a World Health Organization educational pamphlet on traveller's diarrhoea

Prophylactic use of antibiotics has been suggested before one enters an area where water and food are suspect, but this is generally frowned upon since the antibiotics themselves may cause symptoms and taking them in advance may lead the traveller to ignore or become lax towards the precautions that have been advised.

In some cases, the onset of the diarrhoea may not occur until after the return home. This is particularly suggestive of parasitic disease and is an indication that the appropriate laboratory tests be made to determine whether such an infection exists.

Altitude sickness.

Travellers to mountainous regions such as Aspen, Colorado, Mexico City or La Paz, Bolivia, may have difficulty with the altitude, particularly those with coronary artery disease, congestive heart failure or lung diseases such as emphysema, chronic bronchitis or asthma. When mild, altitude sickness may cause fatigue, headache, exertional dyspnoea, insomnia or nausea. These symptoms generally subside after a few days of diminished physical activity and rest.

When more severe, these symptoms may progress to respiratory distress, vomiting and blurred vision. When this occurs, the traveller should seek medical attention and get to a lower altitude as quickly as possible, perhaps meanwhile even inhaling supplementary oxygen.

Crime and civil unrest.

Most travellers will have the sense to avoid war zones and areas of civil unrest. However, while in strange cities, they may unwittingly stray into neighbourhoods where violent crime is prevalent and where tourists are popular targets. Instructions on safeguarding jewelry and other valuables, and maps showing safe routes from the airport to the centre of the city and which areas to shun, may be helpful in avoiding being victimized.

Fatigue.

Simple fatigue is a frequent cause of discomfort and impaired performance. A good deal of the difficulty attributed to jet lag is often the result of the rigours of travel in planes, buses and automobiles, poor sleep in strange beds and strange surroundings, overeating and alcohol consumption, and schedules of business and social engagements that are too full and demanding.

The business traveller is often bedevilled by the volume of work to clear up prior to departure as well as in preparing for the trip, to say nothing of catching up after the return home. Teaching the traveller to prevent the accumulation of undue fatigue while educating the executive to whom he or she reports to consider this ubiquitous hazard in laying out the assignment is often a key element in the travel protection programme.

Conclusion

With the increase in travel to strange and distant places for business and for pleasure, protecting the health of the traveller has become an important element in the worksite health promotion programme. It involves sensitizing the traveller to the hazards that will be encountered and providing the information and the tools needed to circumvent them. It includes medical services such as the pre-travel consultations, immunizations and provisions of medications that are likely to be needed en route. Participation by the organization's management is also important in developing reasonable expectations for the mission, and making suitable travel and living arrangements for the trip. The goal is successful completion of the mission and the safe return of a healthy, travelling employee.

STRESS MANAGEMENT PROGRAMMES

Leon J. Warshaw

The essential mission of occupational health and safety is to protect and enhance the health, well-being and productivity of workers, individually and collectively. That mission cannot be accomplished without an understanding of stress and the mechanisms through which it affects individuals and organizations, and without a well-planned programme that will both alleviate its deleterious effects and, more important, prevent them.

Stress is an inescapable ingredient of the lives of all people everywhere. It stems from-and simultaneously affects-individuals' inner sense of well-being; their relationships with family, friends, co-workers and strangers; and their capacity to function in the home, the workplace and the community. When excessive, it leads to physical or psychological symptoms and, when prolonged, it may lead to disability and disease. It modifies individuals' perceptions, feelings, attitudes and behaviour and affects the organizations whose activities they direct or carry out. The subject of stress is covered extensively elsewhere in this Encyclopaedia.

Designing a Stress Management Programme

The effective workplace stress management programme will contain a number of overlapping elements operating concurrently. Some are formalized under the designation of a stress management programme while others are simply part of general organizational management even when they are explicitly aimed at controlling stress. Some of these are aimed at employees individually and in groups; others are aimed at stressors arising in the workplace; and still others address the stressors impinging on the organization as an entity in itself which inevitably filter down to affect some or all of the employees. The elements of a workplace stress management programme will be examined under the following headings.

1.     Managing stress-related symptoms. This element deals with individuals already suffering from the effects of stress. Labelled the "medical model," it attempts to identify individuals with signs and symptoms and to persuade them to come forward voluntarily or accept referral to professionals able to evaluate their problems, diagnose the causes and offer appropriate treatment. It may be based in the employee health service or in the employee assistance programme, or it may be associated with any other counselling services provided by the organization. The services may cover a broad range extending from one-on-one interviews and examinations to telephone "hot-lines" for emergency situations to comprehensive centres with multidisciplinary staffs of qualified professionals. It may be served by full- or part-time professionals or by contractual or casual referral arrangements with professionals who come to the worksite or are based in nearby facilities in the community. Some units deal with any and all problems, while others may more or less focus on such specific stress-related syndromes as hypertension, backache, alcoholism, drug abuse or family problems. The contributions of these service elements to the stress management programme are based on the following capabilities:

·     An awareness that many recurrent or persistent somatic complaints such as muscular aches and pains, backache, headache, gastrointestinal upsets, and so on, are attributable to stress. Instead of simply providing palliative medications and advice, the alert health professional or counsellor will recognize the pattern and direct attention to the stressors that are actually responsible.

·     Recognition that when a number of employees in a particular unit or area of the workplace present such functional complaints, a search should be initiated for a causative factor in the work environment which may prove to be a controllable stressor.

·     Reaching out to individuals involved in or witnessing a cataclysmic occurrence such as a fatal accident, or an episode of violence.

·     Seizing the opportunity to stay a disciplinary action faced by an employee because of inadequate performance or aberrant behaviour pending an opportunity to lower the stress level and restore his or her normal equanimity and work capacity.

2.     Reducing individual vulnerability. The most common elements in stress management programmes are those that help individuals to cope with stress by reducing their vulnerability. These include series of seminars and workshops, supplemented by audiotapes or videotapes and pamphlets or other publications that educate employees to cope with stress more effectively. Their common denominators are these:

·     Training in self-awareness and problem analysis to detect signs of increasing stress and identify the stressors that are responsible

·     Assertiveness training enabling workers to become more dynamic in dealing with them

·     Techniques that will reduce stress to more tolerable levels

Some of the tools they employ are listed in figure 15.24 . For those not familiar with the term, "rap sessions" are meetings of groups of employees, with or without supervisors being present, in which experiences and problems are discussed and complaints freely ventilated. They are analogous to the shop meetings held under union auspices.

Figure 15.24 Some approaches to reducing vulnerability

3.     Interpersonal relations in the workplace. Organizations are being increasingly made aware of stressors emanating from the diversity of the workforce and the interpersonal problems they often present. Prejudice and bigotry do not stop at the gates of the worksite and are often compounded by insensitive or discriminatory behaviour on the part of managers and supervisors. Sexual and racial bias may take the form of harassment and may even be expressed in or evoke acts of violence. When rampant, such attitudes demand prompt correction through enunciation of an explicit policy that includes disciplinary actions against those who are guilty, coupled with protecting victims emboldened to complain against reprisals.

4.     Managing job-related stressors. It is the organization's responsibility to minimize job-related stressors that may have an adverse effect on employees' capacity to function effectively. It is most important to ensure that supervisors and managers on all levels receive appropriate training to recognize and to deal promptly and effectively with the "people problems" that will inevitably arise in the workplace.

5.     Managing the organization's stress. The organization as an entity is exposed to stressors which, if not properly managed, filter down through the workforce, inevitably impinging on employees on all levels. This state of affairs requires the establishment of challenging but attainable goals and objectives, early identification and assessment of potential stressors that may thwart those plans, coordination of the organization's capacities to deal with them and the communication of the results of those efforts to the workforce. The last-mentioned need is particularly critical at times of economic stringency, when employee collaboration and optimal productivity are especially important in dealing with such crises as changes in top management, threatened mergers and takeovers, plant closings or relocations. and downsizing.

6.     Helping to manage personal stressors. While the management of stressors arising in the home and in the community is fundamentally a problem for the individual, employers are discovering that the stress they generate is inevitably brought into the workplace where, either on their own or in conjunction with job-related stressors, they often affect employees' well-being and compromise their work performance. Accordingly, employers are finding it expedient (and in some instances, necessary) to establish programmes designed to assist employees to cope with stressors of this sort. A list of the most common personal stressors and workplace programmes aimed at them is presented in figure 15.25 .

Figure 15.25 Stressors in the workplace and workplace programmes to help with them

Basic Principles of the Programme

In establishing a worksite stress management programme, some basis principles must be emphasized.

First, it must be remembered that there are no boundaries between stress arising in the workplace, in the home and in the community. Each individual presents a unique composite of all of the factors which are carried wherever he or she may go. This means that while the programme must focus on those problems arising in the workplace, it must recognize that these continue to affect the worker's outside life, nor can it ignore those originating off the job. Indeed, it has been shown that work itself and the support derived from co-workers and the organization may have a therapeutic value in dealing with personal and family problems. In fact, the loss of this support probably accounts for much of the disability associated with retirement, even when it is voluntary.

Second, stress is highly "contagious". It not only affects particular individuals but also those about them with whom they must relate and collaborate. Thus, dealing with stress is simultaneously therapeutic and preventive.

Third, coping with stress is inherently an individual responsibility. Troubled employees can be identified and offered counselling and guidance. They can be given support and encouragement and taught to improve their coping skills. When necessary, they can be referred to qualified health professionals in the community for more intensive or prolonged therapy. But, in the last analysis, all this requires the consent and participation of the individual which, in turn, depends on the structure of the programme, its status in the organization, the competence of its staff and the reputations they earn, and its accessibility. Perhaps the most important determinant of programme success is the establishment of and strict adherence to a policy of observing the confidentiality of personal information.

Fourth, control of workplace stress is fundamentally a managerial responsibility. The programme must be based on an explicit organizational policy that places high value on employee's health and well-being. And that policy must be reflected in the day-to-day operations by the attitudes and behaviour of managers on all levels,

Fifth, employee involvement in the programme's design and operation and, particularly, in identifying stressors and devising ways to control them is an important ingredient of programme success. This is facilitated in many workplaces where safety and health joint labour-management committees function or where worker participation in managerial decision-making is encouraged.

Finally, a successful stress management programme requires an intimate understanding of the employees and the environment in which they work. It is most successful when stress-related problems are identified and resolved before any damage is done.

Conclusion

The essential mission of occupational health and safety is to protect and enhance the health, well-being and productivity of workers, individually and collectively. That mission cannot be accomplished without an understanding of stress and the mechanisms through which it affects individuals and organizations, and a well-planned programme that will both alleviate its deleterious effects and, more important, prevent them.

ALCOHOL AND DRUG ABUSE

Sheila B. Blume

Introduction

Throughout history human beings have sought to alter their thoughts, feelings and perceptions of reality. Mind-altering techniques, including reduction of sensory input, repetitive dancing, sleep deprivation, fasting and prolonged meditation have been employed in many cultures. However, the most popular method for producing mood and perception changes has been the use of mind-altering drugs. Of the 800,000 species of plants on earth, about 4,000 are known to produce psychoactive substances. Approximately 60 of these have been used consistently as stimulants or intoxicants (Malcolm 1971). Examples are coffee, tea, the opium poppy, coca leaf, tobacco and Indian hemp, as well as those plants from which beverage alcohol is fermented. In addition to naturally occurring substances, modern pharmaceutical research has produced a range of synthetic sedatives, opiates and tranquillizers. Both plant-derived and synthetic psychoactive drugs are commonly used for medical purposes. Several traditional substances are also employed in religious rites and as part of socialization and recreation. In addition, some cultures have incorporated drug use into customary workplace practices. Examples include the chewing of coca leaves by Peruvian Indians in the Andes and the smoking of cannabis by Jamaican sugar cane workers. The use of moderate amounts of alcohol during farm labour was an accepted practice in the past in some Western societies, for example in the United States in the eighteenth century and the early nineteenth century. More recently, it was customary (and even required by some unions) for employers of battery burners (workers who incinerate discarded storage batteries to salvage their lead content) and house painters using lead-based paints to provide each worker with a daily bottle of whisky to be sipped during the work day in the belief-an erroneous one-that it would prevent lead poisoning. In addition, drinking has been a traditional part of certain occupations, as, for example, among brewery and distillery salespeople. These sales representatives are expected to accept the hospitality of the tavern owner on completing their order-taking.

Customs that dictate alcohol use persist in other work too, such as the "three martini" business lunch, and the expectation that groups of workers will stop at the neighbourhood pub or tavern for a few convivial rounds of drinks at the end of the work day. This latter practice poses a particular hazard for those who then drive home.

Mild stimulants also remain in use in contemporary industrial settings, institutionalized as coffee and tea breaks. However, several historical factors have combined to make the use of psychoactive substances at the workplace a major social and economic problem in contemporary life. The first of these is the trend towards employing increasingly sophisticated technology in today's workplace. Modern industry requires alertness, unimpaired reflexes and accurate perception on the part of workers. Impairments in these areas can cause serious accidents on one hand and can interfere with the accuracy and efficiency of work on the other. A second important trend is the development of more powerful psychoactive drugs and more rapid means of drug administration. Examples are the intranasal or intravenous administration of cocaine and the smoking of purified cocaine ("freebase" or "crack" cocaine). These methods, delivering much more powerful cocaine effects than the traditional chewing of coca leaves, have greatly increased the dangers of cocaine use on the job.

Effects of Alcohol and Other Drug Use in the Workplace

Figure 15.26 summarizes the various ways in which the use of psychoactive substances can influence the functioning of employees in the workplace. Intoxication (the acute effects of drug ingestion) is the most obvious hazard, accounting for a wide variety of industrial accidents, for example vehicle crashes due to alcohol-impaired driving. In addition, the impaired judgement, inattention and dulled reflexes produced by alcohol and other drugs also interferes with productivity at every level, from the board room to the production line. Furthermore, workplace impairment due to drug and alcohol use often lasts beyond the period of intoxication. The alcohol-related hangover may produce headache, nausea and photophobia (light sensitivity) for 24 to 48 hours after the last drink. Workers suffering from alcohol dependence may also undergo alcohol withdrawal symptoms on the job, with shaking, sweating and gastrointestinal disturbances. Heavy cocaine use is characteristically followed by a withdrawal period of depressed mood, low energy and apathy, all of which interfere with work. Both intoxication and the after-effects of drug and alcohol use also characteristically lead to lateness and absenteeism. In addition, the chronic use of psychoactive substances is implicated in a wide range of health problems that increase society's medical costs and time lost from work. Cirrhosis of the liver, hepatitis, AIDS and clinical depression are examples of such problems.

Figure 15.26 Ways in which alcohol/drug use can cause problems in the workplace

Workers who become heavy, frequent users of alcohol or other drugs (or both) may develop a dependency syndrome, which characteristically includes a preoccupation with obtaining the drug or the money needed to buy it. Even before other drug or alcohol-induced symptoms begin to interfere with work, this preoccupation may already have started to impair productivity. Furthermore, as a result of the need for money, the employee may resort to stealing items from the workplace or selling drugs on the job, creating another set of serious problems. Finally, the close friends and family members of drug and alcohol abusers (often referred to as "significant others") are also affected in their ability to work by anxiety, depression and a variety of stress-related symptoms. These effects may even carry over into later generations in the form of residual work problems in adults whose parents suffered from alcoholism (Woodside 1992). Health expenditures for employees with serious alcohol problems are about twice as high as health costs for other employees (Institute for Health Policy 1993). Health costs for members of their families are also increased (Children of Alcoholics Foundation 1990).

Costs to Society

For the above reasons and others, drug and alcohol use and abuse have created a major economic burden on many societies. For the United States, the societal cost estimated for the year 1985 was US$70.3 billion (thousand millions) of for alcohol and $44 billion for other drugs. Of the total alcohol-related costs, $27.4 billion (about 39% of the total) was attributed to lost productivity. The corresponding figure for other drugs was $6 billion (about 14% of the total) (US Department of Health and Human Services 1990). The remainder of the cost accruing to society as a result of drug and alcohol abuse includes the costs for the treatment of medical problems (including AIDS and alcohol-related birth defects), vehicle crashes and other accidents, crime, property destruction, incarceration and the social welfare costs of family support. Although some of these costs may be attributed to the socially acceptable use of psychoactive substances, the vast majority are associated with drug and alcohol abuse and dependence.

Drug and Alcohol Use, Abuse and Dependence

A simple way to categorize the patterns of use of psychoactive substances is to distinguish among non-hazardous use (use in socially accepted patterns that neither create harm nor involve a high risk of harm), drug and alcohol abuse (use in high risk or harm-producing ways) and drug and alcohol dependence (use in a pattern characterized by signs and symptoms of the dependence syndrome).

Both the International Classification of Diseases, 10th edition (ICD-10) and the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th edition (DSM-IV) specify diagnostic criteria for drug and alcohol-related disorders. The DSM-IV uses the term abuse to describe patterns of drug and alcohol use that cause impairment or distress, including interference with work, school, home or recreational activities. This definition of the term is also meant to imply recurrent use in physically hazardous situations, such as repeatedly driving while impaired by drugs or alcohol, even if no accident has yet occurred. The ICD-10 uses the term harmful use instead of abuse and defines it as any pattern of drug or alcohol use that has caused actual physical or psychological harm in an individual who does not meet the diagnostic criteria for drug or alcohol dependence. In some cases drug and alcohol abuse is an early or prodromal stage of dependence. In others, it constitutes an independent pattern of pathological behaviour.

Both the ICD-10 and the DSM-IV use the term psychoactive substance dependence to describe a group of disorders in which there is both interference with functioning (in job, family and social arenas) and an impairment in the individual's ability to control the use of the drug. With some substances, a physiological dependence develops, with increased tolerance to the drug (higher and higher doses required to obtain the same effects) and a characteristic withdrawal syndrome when use of the drug is abruptly discontinued.

A definition recently prepared by the American Society of Addiction Medicine and the National Council on Alcoholism and Drug Dependence of the United States describes the features of alcoholism (a term usually employed as a synonym for alcohol dependence) as follows:

Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic. (Morse and Flavin 1992)

The definition then goes on to explain the terms used, for example, that the qualification "primary" implies that alcoholism is a discrete disease rather than a symptom of some other disorder, and that "impaired control" means that the affected person cannot consistently limit the duration of a drinking episode, the amount consumed or the resulting behaviour. "Denial" is described as referring to a complex of physiological, psychological and culturally-influenced manoeuvres that decrease the recognition of alcohol-related problems by the affected individual. Thus, it is common for persons suffering from alcoholism to regard alcohol as a solution to their problems rather than as a cause.

Drugs capable of producing dependence are commonly divided into several categories, as listed in table 15.7 . Each category has both a specific syndrome of acute intoxication and a characteristic combination of destructive effects related to long-term heavy use. Although individuals often suffer from dependency syndromes relating to a single substance (e.g., heroin), patterns of multiple drug abuse and dependence are also common.

Table 15.7 Substances capable of producing dependence

Category of drug

Examples of general effects

Comments

Alcohol (e.g., beer, wine, spirits)

Impaired judgement, slowed reflexes, impaired motor function, somnolence, coma-overdose may be fatal

Withdrawal may be severe; danger to foetus if used excessively in pregnancy

Depressants (e.g., sleeping medicines, sedatives, some tranquillizers)

Inattention, slowed reflexes, depression, impaired balance, drowsiness, coma-overdose may be fatal

Withdrawal may be severe

Opiates (e.g., morphine, heroin, codeine, some prescription pain medications)

Loss of interest, "nodding"-overdose may be fatal. Subcutaneous or intravenous abuse may spread Hepatitis B, C and HIV/AIDS via needle-sharing

 

Stimulants (e.g., cocaine, amphetamines)

Elevated mood, overactivity, tension/anxiety, rapid heartbeat, constriction of blood vessels

Chronic heavy use may lead to paranoid psychosis. Use by injection may spread Hepatitis B, C and HIV/AIDS via needle-sharing

Cannabis (e.g., marijuana, hashish)

Distorted time sense, impaired memory, impaired coordination

 

Hallucinogens (e.g., LSD (lysergic acid diethylamide), PCP (phencyclidine), mescaline)

Inattention, sensory illusions, hallucinations, disorientation, psychosis

Does not produce withdrawal symptoms but users may experience "flashbacks"

Inhalants (e.g., hydrocarbons, solvents, gasoline)

Intoxication similar to alcohol, dizziness, headache

May cause long- term organ damage (brain, liver, kidney)

Nicotine (e.g., cigarettes, chewing tobacco, snuff)

Initial stimulant, later depressant effects

May produce withdrawal symptoms. Implicated in causing a variety of cancers, cardiac and pulmonary diseases

Drug and alcohol-related disorders often affect the employee's family relationships, interpersonal functioning and health before obvious work impairments are noticed. Therefore, effective workplace programmes cannot be limited to efforts at achieving drug and alcohol abuse prevention on the job. These programmes must combine employee health education and prevention with adequate provisions for intervention, diagnosis and rehabilitation as well as long-term follow-up of affected employees after their reintegration into the workforce.

Women and Substance Abuse

While social changes in some areas have narrowed the differences between men and women, substance abuse has traditionally been seen as a man’s problem. Substance abuse was felt to be incompatible with women’s role in society. Consequently, while men’s abuse ot substances could be excused, or even condoned, as an acceptable part of manhood, women’s abuse of substances attracted a negative stigma. While this latter fact may be claimed to have prevented many women from abusing drugs, it has also made it extremely difficult for substance-dependent women to seek assistance for their dependence in many societies.

Negative attitudes to women’s substance abuse, coupled with the reluctance of women to admit their abuse and dependence have resulted in scanty data being available specifically on women. Even in countries with considerable information about drug abuse and dependence, it is often hard to find data relating directly to women. In cases where studies have examined women’s role in substance abuse the approach has by no means been gender-specific, so that conclusions may have been clouded by viewing women’s involvement from a male perspective.

Another factor related to the concept of substance abuse as a male problem is the lack of services for women substance abusers. ... Where services, such as treatment and rehabilitation services, do exist, they frequently have an approach based on male role models of drug dependence. Where services are provided for women, it is clear that they must be accessible. This is not always easy when women’s drug dependence is stigmatized and when cost of treatment is beyond the means of the majority of women.

Quoted from: World Health Organization 1993.

Approaches to Drug and Alcohol-related Problems in the Workplace

Concern over the serious productivity losses caused by drug and alcohol abuse and dependence have led to several related approaches on the part of governments, labour and industries. These approaches include so-called "drug-free workplace policies" (including chemical testing for drugs) and employee assistance programmes.

One example is the approach taken by the United States Military Services. In the early 1980s successful anti-drug policies and drug testing programmes were established in each branch of the US military. As a result of its programme, the US Navy reported a dramatic fall in the proportion of random urine tests of its personnel that were positive for illicit drugs. The positive test rates for those under age 25 fell from 47% in 1982, to 22% in 1984, to 4% in 1986 (DeCresce et al. 1989). In 1986 the President of the United States issued an executive order requiring that all federal government employees refrain from illegal drug use, whether on or off the job. As the largest single employer in the United States, with over two million civilian employees, the federal government thereby assumed the lead in developing a national drug-free workplace movement.

In 1987, following a fatal railway accident linked to marijuana abuse, the US Department of Transportation ordered a drug and alcohol testing programme for all transportation workers, including those in private industry. Managements in other work settings have followed suit, establishing a combination of supervision, testing, rehabilitation and follow-up in the workplace that has shown consistently successful results.

The case-finding, referral and follow-up component of this combination, the employee assistance programme (EAP), has become an increasingly common feature of employee health programmes. Historically, EAPs evolved from more narrowly-focused employee alcoholism programmes that had been pioneered in the United States during the 1920s and expanded more rapidly in the 1940s during and after the Second World War. Current EAPs are customarily established on the basis of a clearly enunciated company policy, often developed by joint agreement between management and labour. This policy includes rules of acceptable workplace behaviour (e.g., no alcohol or illicit drugs) and a statement that alcoholism and other drug and alcohol dependence are considered treatable diseases. It also includes a statement of confidentiality, guaranteeing the privacy of sensitive personal employee information. The programme itself conducts preventive education for all employees and special training for supervisory personnel in identifying job performance problems. Supervisors are not expected to learn to diagnose drug and alcohol-related problems. Rather, they are trained to refer employees who show problematic job performance to the EAP, where an assessment is made and a plan of treatment and follow-up is formulated, as appropriate. Treatment is usually provided by community resources outside the workplace. EAP records are kept confidentially as a matter of company policy, with reports relating only to the subject's degree of cooperation and general progress released to management except in cases of imminent danger. Disciplinary action is usually suspended as long as the employee cooperates with treatment. Self-referrals to the EAP are also encouraged. EAPs that help employees with a wide range of social, mental health and drug and alcohol-related problems are known as "broad-brush" programmes to distinguish them from programmes that focus only on drug and alcohol abuse.

There is no question of the appropriateness of employers' prohibiting the use of alcohol and other drugs during working hours or in the workplace. However, the right of the employer to prohibit the use of such substances away from the workplace during off hours has been disputed. Some employers have said, "I don't care what employees do off the job as long as they report on time and are able to perform adequately," and some labour representatives have opposed such a prohibition as an intrusion on the worker's privacy. Yet, as noted above, excess use of drugs or alcohol during off-hours can affect work performance. This is recognized by airlines when they prohibit all use of alcohol by air crews during a specified number of hours prior to flight time. Although the prohibitions of alcohol use by an employee before flying or driving a vehicle are generally accepted, blanket prohibitions of tobacco, alcohol or other drug use outside of the workplace have been more controversial.

Workplace drug testing programmes

Along with EAPs, increasing numbers of employers have also instituted workplace drug testing programmes. Some of these programmes test only for illicit drugs, while others include breath or urine testing for alcohol. Testing programmes may involve any of the following components:

·     pre-employment testing

·     random testing of employees in sensitive positions (e.g., nuclear reactor operators, pilots, drivers, operators of heavy machinery)

·     testing "for cause" (e.g., after an accident or if a supervisor has good reason to suspect that the employee is intoxicated)

·     testing as part of the follow-up plan for an employee returning to work after treatment for drug or alcohol abuse or dependence.

Drug testing programmes create special responsibilities for those employers who undertake them (New York Academy of Medicine 1989). This is discussed more fully under "Ethical Issues" in the Encyclopaedia. If employers rely on urine tests in making employment and disciplinary decisions in drug-related cases, the legal rights of both employers and employees must be protected by meticulous attention to collection and analysis procedures and to the interpretation of laboratory results. Specimens must be collected carefully and labelled immediately. Because drug users may attempt to evade detection by substituting a sample of drug-free urine for their own or by diluting their urine with water, the employer may require that the specimen be collected under direct observation. Because this procedure adds time and expense to the procedure it may be required only in special circumstances rather than for all tests. Once the specimen is collected, a chain-of-custody procedure is followed, documenting each movement of the specimen to protect it from loss or misidentification. Laboratory standards must ensure specimen integrity, with an effective programme of quality control in place, and staff qualifications and training must be adequate. The test used must employ a cut-off level for the determination of a positive result that minimizes the possibility of a false positive. Finally, positive results found by screening methods (e.g., thin-layer chromatography or immunological techniques) should be confirmed to eliminate false results, preferably by the techniques of gas chromatography or mass spectrometry, or both (DeCresce et al. 1989). Once a positive test is reported, a trained occupational physician (known in the United States as a medical review officer) is responsible for its interpretation, for example, ruling out prescribed medication as a possible reason for the test results. Performed and interpreted properly, urine testing is accurate and may be useful. However, industries must calculate the benefit of such testing in relationship to its cost. Considerations include the prevalence of drug and alcohol abuse and dependence in the prospective workforce, which will influence the value of pre-employment testing, and the proportion of the industry's accidents, productivity losses and medical benefit costs related to the abuse of psychoactive substances.

Other methods of detecting drug and alcohol-related problems

Although urine testing is an established screening method for detecting drugs of abuse, there are other methods available to EAPs, occupational physicians and other health professionals. Blood alcohol levels may be estimated by means of breath testing. However, a negative chemical test of any kind does not rule out a drug or alcohol problem. Alcohol and some other drugs are metabolized rapidly and their aftereffects may continue to impair work performance even when the drugs are no longer detectable on a test. On the other hand, the metabolites produced by the human body after the ingestion of certain drugs may remain in the blood and urine for many hours after the drug's effects and aftereffects have subsided. A positive urine test for drug metabolites therefore does not necessarily prove that the employee's work is drug-impaired.

In making an assessment of employee drug and alcohol-related problems a variety of clinical screening instruments are used (Tramm and Warshaw 1989). These include pencil-and-paper tests, such as the Michigan Alcohol Screening Test (MAST) (Selzer 1971), the Alcohol Use Disorders Identification Test (AUDIT) developed for international use by the World Health Organization (Saunders et al. 1993), and the Drug Abuse Screening Test (DAST) (Skinner 1982). In addition, there are simple sets of questions that can be incorporated into history-taking, for example the four CAGE questions (Ewing 1984) illustrated in figure 15.27 . All of these methods are used by EAPs to evaluate employees referred to them. Employees referred for job performance problems such as absences, lateness and decreased productivity on the job should additionally be evaluated for other mental health problems such as depression or compulsive gambling, which may also produce impairments in job performance and are often associated with drug and alcohol-related disorders (Lesieur, Blume and Zoppa 1986). With respect to pathological gambling, a paper-and-pencil screening test, the South Oaks Gambling Screen (SOGS) is available (Lesieur and Blume 1987).

Figure 15.27 The CAGE questions

Treatment of Disorders Related to the Use of Drugs and Alcohol

Although each employee presents a unique combination of problems to the addiction treatment professional, the treatment of disorders related to drug and alcohol use usually consists of four overlapping phases: (1) identification of the problem and (as necessary) intervention, (2) detoxification and general health assessment, (3) rehabilitation, and (4) long-term follow-up.

Identification and intervention

The first phase of treatment involves confirming the presence of a problem caused by the use of drugs or alcohol (or both) and motivating the affected individual to enter treatment. The employee health programme or company EAP has the advantage of using the employee's concern both for health and job security as motivational factors. Workplace programmes are also likely to understand the employee's environment and his or her strengths and weaknesses, and can thus choose the most appropriate treatment facility for referral. An important consideration in making a referral for treatment is the nature and extent of workplace-based health insurance coverage for the treatment of drug and alcohol-induced disorders. Policies with coverage of the full range of inpatient and outpatient treatments offer the most flexible and effective options. In addition, the involvement of the employee's family at the intervention stage is often helpful.

Detoxification and general health assessment

The second stage combines the appropriate treatment needed to help the employee attain a drug and alcohol-free state with a thorough evaluation of the patient's physical, psychological, family, interpersonal and work-related problems. Detoxification involves a short period-several days to several weeks-of observation and treatment for the elimination of the drug of abuse, recovery from its acute effects, and control of any symptoms of withdrawal. While detoxification and the assessment activities are progressing, the patient and "significant others" are educated about the nature of drug and alcohol dependence and recovery. They and the patient are also introduced to the principles of self-help groups, where this modality is available, and the patient is motivated to continue in treatment. Detoxification may be carried out in an inpatient or outpatient setting, depending on the needs of the individual. Treatment techniques found useful include a variety of medications, augmented by counselling, relaxation training and other behavioural techniques. Pharmacological agents used in detoxification include drugs which can substitute for the drug of abuse to relieve withdrawal symptoms and then be gradually reduced in dosage until the patient is drug-free. Phenobarbital and the longer-acting benzodiazepines are often used this way to achieve detoxification in the case of alcohol and sedative drugs. Other medicines are used to relieve withdrawal symptoms without substituting a similarly-acting drug of abuse. For example, clonidine is sometimes used in the treatment of opiate withdrawal symptoms. Acupuncture has also been used as an aid in detoxification, with some positive results (Margolin et al. 1993).

Rehabilitation

The third phase of treatment combines helping the patient establish a stable state of ongoing abstinence from all substances of abuse (including those prescription drugs which may cause dependence) and treating whatever associated physical and psychological conditions accompany the drug-related disorder. Treatment may begin on an inpatient or intensive outpatient basis, but characteristically continues in an outpatient setting for a number of months. Group, individual and family counselling and behavioural techniques may be combined with psychiatric management, which may include medication. The goals include helping patients understand their patterns of drug or alcohol use, identifying triggers for relapse after past efforts at recovery, helping them to develop drug-free coping patterns in dealing with life problems, and helping them integrate into a clean and sober social support network in the community. In some cases of opiate dependence, long-term maintenance on a long-acting synthetic opiate (methadone) or an opiate receptor blocking drug (naltrexone) is the treatment of choice. Maintenance on a daily dose of methadone, a long-acting opiate, is recommended by some practitioners for individuals with long-term opiate addiction who are unwilling or unable to achieve drug-free status. Patients stably maintained on methadone over long periods are able to function successfully in the workforce. In many cases, such patients are eventually able to detoxify and become drug free. In these cases, maintenance is combined with counselling, social services and other rehabilitative treatment. Recovery is defined in terms of stable abstinence from all drugs other than the drug of maintenance.

Long-term follow-up

The final phase of treatment continues on an outpatient basis for a year or more after a stable remission is attained. The goal of long-term follow-up is preventing relapse and helping the patient internalize new patterns of coping with life problems. The EAP or employee health service can be a great help during the rehabilitation and follow-up phases by monitoring cooperation in treatment, encouraging the recovering employee to maintain abstinence and assisting him/her in readjusting to the workplace. Where self-help or peer assistance groups are available (for example, Alcoholics Anonymous or Narcotics Anonymous), these groups provide a life-long supportive programme for sustained recovery. Since drug or alcohol dependence is a chronic disorder in which there may be relapses, company policies often require follow-up and monitoring by the EAP for a year or more after abstinence is established. If an employee relapses the EAP usually re-evaluates the situation and a change in treatment plan may be instituted. Such relapses, if brief and followed by a return to abstinence, usually do not signal overall treatment failure. Employees who do not cooperate with treatment, deny their relapses in face of clear evidence or cannot maintain stable abstinence will continue to show poor work performance and may be terminated from employment on that basis.

Effectiveness of Workplace-based Programmes

An investment in workplace programmes to deal with drug and alcohol problems has been profitable in many industries. An example is a study of 227 employees of a large US manufacturing company who were referred for the treatment of alcoholism by the company's EAP. Employees were randomly assigned to three treatment approaches: (1) mandatory inpatient care, (2) mandatory attendance at Alcoholics Anonymous (AA) or, (3) a choice of inpatient care, outpatient care or AA. At follow-up, two years later, only 13% of the employees had been discharged. Of the remainder, less than 15% had job problems and 76% were rated "good" or "excellent" by their supervisors. Time absent from work fell by more than a third. Although some differences were found between initial treatment approaches the two-year job outcomes were similar for all three (Walsh et al. 1991).

The US Navy has calculated that its inpatient drug and alcohol rehabilitation programmes have produced an overall ratio of financial benefit to cost of 12.9 to 1. This figure was calculated by comparing the cost of the programme with the costs that would have been incurred in replacing the successfully rehabilitated programme participants with new personnel (Caliber Associates 1989). The Navy found that the benefit to cost ratio was highest for those over 26 years of age (17.8 to 1) as compared to younger personnel (8.2 to 1) and found the greatest benefit for alcoholism treatment (13.8 to 1), versus other drug (10.3 to 1) or polydrug dependence treatment (6.8 to 1). Nevertheless, the programme produced financial savings in all categories.

In general, workplace-based programmes for the identification and rehabilitation of employees who suffer from alcohol and other drug problems have been found to benefit both employers and workers. Modified versions of EAP programmes have also been adopted by professional organizations, such as the medical societies, nursing associations and bar associations (associations of lawyers). These programmes receive confidential reports about possible signs of impairment in a professional from colleagues, families, clients or employers. Face-to-face intervention is performed by peers, and if treatment is required the programme makes the appropriate referral. It then monitors the recovery of the individual and helps the recovering professional deal with practice and licensing problems (Meek 1992).

Conclusion

Alcohol and other psychoactive drugs are significant causes of problems in the workplace in many parts of the world. Although the type of drug used and the route of administration may vary from place to place and with the type of industry, the abuse of drugs and alcohol creates health and safety hazards for users, for their families, for other workers and, in many cases, for the public. An understanding of the types of drug and alcohol problems that exist within a given industry and the intervention and treatment resources available in the community will allow rehabilitative programmes to be developed. Such programmes bring benefits to employers, employees, their families and the larger society in which these problems arise.

EMPLOYEE ASSISTANCE PROGRAMMES

Sheila H. Akabas

Introduction

Employers may recruit workers and trade unions may enlist members, but both get human beings who bring to the workplace all the concerns, problems and dreams characteristic of the human condition. As the world of work has become increasingly conscious that the competitive edge in a global economy depends on the productivity of its work force, the key agents in the workplace-management and labour unions-have devoted significant attention to meeting the needs of those human beings. Employee Assistance Programmes (EAPs), and their parallel in unions, Membership Assistance Programmes (MAPs) (hereafter referred to jointly as EAPs), have developed in workplaces around the world. They constitute a strategic response to meeting the diverse needs of a working population and, more recently, to meeting the humanist agenda of organizations of which they are a part. This article will describe the origins, functions and organization of EAPs. It is written from the point of view of the social worker's profession, which is the major profession driving this development in the United States and one which, because of its worldwide interconnections, appears to be playing a major role in establishing EAPs worldwide.

The extent of development of employee assistance programmes varies from country to country, reflecting, as David Bargal has pointed out (Bargal 1993), the differences in degree of industrialization, state of the professional training available for appropriate personnel, degree of unionization in the employment sector and societal commitment to social issues, among other variables. His comparison of EAP development in Australia, the Netherlands, Germany and Israel leads him to suggest that although industrialization may be a necessary condition to achieve a high rate of EAPs and MAPs in a country's workplaces, it may not be sufficient. The existence of these programmes also is characteristic of a society with significant unionization, labour/management cooperation and a well-developed social service sector in which government plays a major role. Further, there is need for a professional culture, supported by an academic specialization that promotes and disseminates social services at the workplace. Bargal concludes that the greater the aggregate of these characteristics in a given nation, the more likely that there will be extensive availability of EAP services in its workplaces.

Diversity is also apparent among programmes within individual countries in relation to structure, staffing, focus and scope of programme. All EAP efforts, however, reflect a common theme. The parties in the workplace seek to provide services to remediate the problems that employees experience, often without causal relationship to their work, that interfere with employees' productivity on the job and sometimes with their general well-being as well. Observers have noted an evolution in EAP activities. Although the initial impetus may be the control of alcoholism or drug abuse among workers, nevertheless, over time, interest in individual workers becomes more broadly based, and the workers themselves become only one element in a dual focus that embraces the organization as well.

This organizational focus reflects an understanding that many workers are "at risk" of being unable to maintain their work roles and that the "risk" is as much a function of the way the work world is organized as it is a reflection of the individual characteristics of any particular worker. For example, ageing workers are "at risk" if the workplace technology changes and they are denied retraining because of their age. Single parents and caretakers of the elderly are "at risk" if their work environment is so rigid that it does not provide time flexibility in the face of the illness of a dependant. A person with a disability is "at risk" when a job changes and accommodations are not offered to enable the individual to perform in keeping with the new requirements. Many other examples will occur to the reader. What is significant is that, in the matrix of being able to change the individual, the environment, or some combination thereof, it has become increasingly clear that a productive, economically successful work organization cannot be achieved without consideration of the interaction between organization and individual at a policy level.

Social work rests on a model of individual in environment. The evolving definition of "at risk" has enhanced the potential contribution of its practitioners. As Googins and Davidson have noted, the EAP is exposed to a range of problems and issues affecting not only individuals, but also families, the corporation and the communities in which they are located (Googins and Davidson 1993). When a social worker with an organizational and environmental outlook functions in the EAP, that professional is in a unique position to conceptualize interventions that promote not only the EAP's role in delivery of individual service but in advising on organizational policy in the workplace as well.

History of EAP Development

The origin of social service delivery at the workplace dates back to the time of industrialization. In the craft workshops that marked an earlier period, work groups were small. Intimate relationships existed between the master craftsman and his journeymen and apprentices. The first factories introduced larger work groups and impersonal relationships between employer and employee. As problems that interfered with the workers' performance became apparent, employers began to provide helping individuals, often called social or welfare secretaries, to assist workers recruited from rural settings, and sometimes new immigrants, with the process of adjusting to formalized workplaces.

This focus on using social workers and other human service providers to achieve acculturation of new populations to the demands of factory labour continues internationally to this day. Several nations, for example Peru and India, legally require that work settings that exceed a particular employment level provide a human service worker to be available to replace the traditional support structure that was left behind in the home or rural environment. These professionals are expected to respond to the needs presented by the newly recruited, largely displaced rural residents in relation to concerns of everyday living such as housing and nutrition as well as those involving illness, industrial accidents, death and burial.

As the challenges involved in maintaining a productive work force evolved, a different set of issues asserted itself, warranting a somewhat different approach. EAPs probably represent a discontinuity from the earlier welfare secretary model in that they are more clearly a programmatic response to the problems of alcoholism. Pressed by the need to maximize productivity during the Second World War, employers "attacked" the losses resulting from alcohol abuse among workers by establishing occupational alcoholism programmes in the major production centres of the Western Allies. The lessons learned from the effective efforts at containing alcoholism, and the concomitant improvement in the productivity of the workers involved, received recognition after the War. Since that time, there has been a slow but steady increase in service delivery programmes worldwide that make use of the employment site as an appropriate location and centre of support for remediating problems that are identified as causes of major drains in productivity.

This trend has been aided by the development of multinational corporations that tend to replicate an effective effort, or a legally required system, in all their corporate units. They have done so almost without regard to the programme's relevance or cultural appropriateness to the particular country in which the unit is located. For example, South African EAPs resemble those in the United States, a state of affairs accountable in part by the fact that the earliest EAPs were established in the local outposts of multinational corporations that are headquartered in the United States. This cultural crossover has been positive in that it has fostered replication of the best of each country on a worldwide scale. An example is the sort of preventive action, in relation to sexual harassment or labour force diversity issues that have come to prominence in the United States, that has become the standard to which American corporate units around the world are expected to adhere. These provide models for some local firms to establish comparable initiatives.

Rationale for EAPs

EAPs may be differentiated by their stage of development, programme philosophy or definition of what problems are appropriate to address and what services are acceptable responses. Most observers would agree, however, that these occupational interventions are expanding in scope in the countries that have already established such services, and are incipient in those nations that have yet to establish such initiatives. As already indicated, one reason for expansion can be traced to the widespread understanding that drug and alcohol abuse in the workplace is a significant problem, costing lost time and high medical care expenses and seriously interfering with productivity.

But EAPs have grown in response to a wide array of changing conditions that cross national boundaries. Unions, pressed to offer benefits to maintain the loyalty of their members, have viewed EAPs as a welcome service. Legislation on affirmative action, family leave, worker's compensation and welfare reform all involve the workplace in a human service outlook. The empowerment of working populations and the search for gender equity that are needed for employees to function effectively in the team environment of the modern production machine, are aims that are well served by the availability of destigmatized, universal social service delivery systems that can be established in the world of work. Such systems also help with the recruitment and retention of a quality labour force. EAPs have also filled the gap in community services that exists, and seems to be increasing, in many nations of the world. The spread of, and desire to contain HIV/AIDS, as well as the growing interest in prevention, wellness and safety in general, have each contributed support to the educational role of EAPs in the world's workplaces.

EAPs have proven a valuable resource in helping workplaces respond to the pressure of demographic trends. Such changes as the increase in single parenthood, in the employment of mothers (whether of infants or of young children), and in the number of two-worker families have required attention. The ageing of the population and the interest in reducing welfare dependency through maternal employment-facts that are apparent in most industrialized countries-have involved the workplace in roles that require assistance from human service providers. And, of course, the ongoing problem of drug and alcohol abuse that has reached epidemic proportions in many countries, has been a major concern of work organizations. A survey examining public perception of the drug crisis in 1994 as compared with five years earlier found that 50% of respondents felt it was much greater, an additional 20% felt it was somewhat greater, only 24% considered it the same and the remaining 6% felt it had declined. While each of these trends varies from country to country, all exist across countries. Most are characteristic of the industrialized world where EAPs have already developed. Many can be observed in the developing countries that are experiencing any significant degree of industrialization.

Functions of EAPs

The establishment of an EAP is an organizational decision that represents a challenge to the existing system. It suggests that the workplace has not attended adequately to the needs of individuals. It confirms the mandate for employers and trade unions, in their own organizational interest, to respond to the broad social forces at work in society. It is an opportunity for organizational change. Though resistance may occur, as it does in all situations where systemic change is attempted, the trends described earlier provide many reasons why EAPs can be successful in their quest for offering both counselling and advocacy services to individuals and policy advice to the organization.

The kinds of functions EAPs serve reflect the presenting issues to which they seek to respond. Probably every programme extant deals with drug and alcohol abuse. Interventions in this connection usually include assessment, referral, training for supervisors and operation of support groups to maintain employment and encourage abstinence. The service agenda of most EAPs, however, is more broadranging. Programmes offer counselling to those experiencing marital problems or difficulties with children, those needing help with finding day care or those making decisions concerning elder care for a family member. Some EAPs have been asked to deal with work environment issues. Their response is to give help to families adjusting to relocation, to bank employees who experience robberies and need trauma debriefing, to disaster crews, or to health care workers accidentally exposed to HIV infection. Assistance in coping with "downsizing" is supplied, too, to both those laid off and the survivors of such lay-offs. EAPs may be called on to assist with organizational change to meet affirmative action goals or to serve as case managers in achieving accommodation and return to work for employees who become disabled. EAPs have been enlisted in preventive activities as well, including good nutrition and smoking cessation programmes, encouraging participation in exercise regimes or other parts of health promotion efforts, and offering educational initiatives that can range from parenting programmes to preparation for retirement.

Although these EAP responses are multifaceted, they typify EAPs as widespread as Hong Kong and Ireland. Studying a non-random sample of American employers, trade unions and contractors who deliver EAP drug and alcohol abuse services, for example, Akabas and Hanson (1991) found that plans in a variety of industries, with different histories and under various auspices, all conform to each other in important ways. The researchers, expecting that there would be a wide variety of creative responses to dealing with workplace needs, identified, on the contrary, an astounding uniformity of programme and practice. At an International Labour Organization (ILO) international conference convoked in Washington, D.C. to compare national initiatives, a similar degree of uniformity was confirmed throughout western Europe (Akabas and Hanson 1991).

Respondents in the surveyed work organizations in the United States agreed that legislation has had a significant impact on determining the components of their programmes and the rights and expectations of client populations. In general, programmes are staffed by professionals, more often social workers than professionals of any other discipline. They respond to a broad constituency of workers, and often their family members, with services that provide diverse care for a range of presenting problems in addition to their focus on rehabilitation of alcohol and drug abusers. Most programmes overcome general inattention by top management and inadequate training for and support from supervisors, to achieve penetration rates of between 3 and 5% of the total workers at the target site. The professionals who staff the EAP and MAP movements seem to agree that confidentiality and trust are the keys to effective service. They claim success in dealing with the problems of drug and alcohol abuse although they can point to few evaluative studies to confirm the efficacy of their intervention in relation to any aspect of service delivery.

Estimates suggest that there are as many as 10,000 EAPs now in operation in settings throughout the United States alone. Two main types of service delivery systems have evolved, the one directed by an inhouse staff and the other provided by an outside contractor that offers service to numerous work organizations (employers and trade unions) at the same time. There is a raging debate as to the relative merits of internal versus external programmes. Claims of increased protection of confidentiality, greater diversity of staff and clarity of role undiluted by other activities, are made for external programmes. Advocates of internal programmes point to the advantage conferred by their position within the organization with respect to effective intervention at the systems level and to the policy-making influence that they have gained as a result of their organizational knowledge and involvement. Since organization-wide initiatives are increasingly valued, internal programmes are probably better for those worksites that have sufficient demand (at least 1,000 employees) to warrant a full-time staffer. This arrangement allows, as Googins and Davidson (1993) point out, improved access to employees because of the varied services that can be offered and the opportunity it affords to exert influence on policymakers, and it facilitates collaboration and integration of the EAP function with others in the organization-all of these capabilities strengthen the authority and role of the EAP.

Work and Family Issues: A Case in Point

The interaction of EAPs, over time, with work and family issues provides an informative example of the evolution of EAPs and of their potential for individual and organizational impact. EAPs developed, historically speaking, parallel with the period during which women entered the labour market in increasing numbers, especially single mothers and mothers of infants and young children. These women often experienced tension between their family demands for dependant care-whether children or the elderly-and their job requirements in a work environment in which the roles of work and family were considered to be separate, and management was inhospitable to the need for flexibility with respect to work and family issues. Where there was an EAP, the women brought their problems to it. EAP staffers identified that women under stress became depressed and sometimes coped with this depression by drug and alcohol abuse. Early EAP responses involved counselling on drug and alcohol abuse, education about time management, and referral to child and elder care resources.

As the number of clients with similar presenting problems mounted, EAPs carried out needs assessments that pointed to the importance of moving from case to class, that is, they began to look for group rather than individual solutions, offering, for example, group sessions on coping with stress. But even this proved to be an inadequate approach to problem resolution. With an understanding that needs differ across the life cycle, EAPs began thinking about their client population in age-related cohorts that had different requirements. Young parents needed flexible leave to care for sick children and easy access to child care information. Those in their middle thirties to late forties were identified as the "sandwich generation"; at their time of life, the twofold demands of adolescent children and ageing relatives increased the need for an array of support services that included education, referral, leave, family counselling and abstinence assistance, among others. The mounting pressures experienced by ageing workers who face the onset of disability, the need to accommodate to a work world in which almost all one's associates, including one's supervisors, are younger than oneself, while planning for retirement and dealing with their frail elderly relatives (and sometimes with the parenting demands of the children of their children), create yet another set of burdens. The conclusion drawn from monitoring these individual needs and the service response to them was that what was required was a change in workplace culture that integrated the work and family lives of employees.

This evolution has led directly to the emergence of the EAP's current role with respect to organizational change. During the process of meeting individual needs, it is probable that any given EAP has built up credibility within the system and is regarded by the key people as the source of knowledge about work and family issues. Likely, it has served an educational and informational role in response to questions raised by managers in numerous departments affected by the problems that occur when these two aspects of human life are experienced in conflict with each other. The EAP has probably collaborated with many organizational actors, including affirmative action officers, industrial relations experts, union representatives, training specialists, safety and health personnel, the medical department staff, risk managers and other human resource personnel, and fiscal workers, and line managers and supervisors.

A force field analysis, a technique suggested in the 1950s by Kurt Lewin (1951), provides a framework for defining the activities necessary to undertake to produce organizational change. The occupational health professional should understand where there will be support within the organization to resolve work and family issues on a systemic basis, and where there might be opposition to such a policy approach. A force field analysis should identify the key actors in the corporation, union or government agency who will influence change, and the analysis will summarize the promoting and restraining forces that will influence these actors in relation to work and family policy.

A sophisticated outcome of an organizational approach to work and family issues will have the EAP participating in a policy committee that establishes a statement of purpose for the organization. The policy should recognize the dual interests of its employees in being both productive workers and effective family participants. Expressed policy should indicate the organization's commitment to establishing a flexible climate and work culture in which such dual roles can exist in harmony. Then an array of benefits and programmes may be specified to fulfil that commitment including, but not limited to, flexible work schedules, job sharing and part-time employment options, subsidized or onsite child care, an advice and referral service to assist with other child and eldercare needs, family leave with and without pay to cover demands deriving from illness of a relative, scholarships for children's education and for employees' own development, and individual counselling and group support systems for the variety of presenting problems experienced by family members. These manifold initiatives related to work and family issues would combine to allow a total individual and environmental response to the needs of workers and their work organizations.

Conclusions

There is ample experiential evidence to suggest that the provision of these benefits assists workers to their goal of productive employment. Yet these benefits have the potential to become costly programmes and they offer no guarantee that work will be performed in an effective and efficient manner as a result of their implementation. Like the EAPs that foster them, work and family benefits must be assessed for their contribution to the organization's effectiveness as well as to the well-being of its many constituencies. The uniformity of development, described earlier, can be interpreted as support for the fundamental value of EAP services across work places, employers and nations. As the world of work becomes increasingly demanding in the era of a competitive global economy, and as the knowledge and skill that workers bring to the job becomes more important than their mere presence or physical strength, it seems safe to predict that EAPs will be called upon increasingly to provide guidance to organizations in fulfilling their humanist responsibilities to their employees or members. In such an individual and environmental approach to problem solving, it seems equally safe to predict that social workers will play a key role in service delivery.

HEALTH IN THE THIRD AGE: PRE-RETIREMENT PROGRAMMES

H. Beric Wright

It is increasingly being recognized that the last third of life-the "third age"-requires as much thought and planning as do education and training (the "first age") and career development and retraining (the "second age"). About 30 years ago, when the movement to address the needs of the retired began, the average male employee in the United Kingdom, and in many other developed countries as well, retired at the age of 65 as a rather worn-out worker with a limited life expectancy and, especially if he was a blue collar worker or labourer, with an inadequate pension or none at all.

This scene has been changing dramatically. Many people are retiring younger, voluntarily or at ages other than those dictated by mandatory retirement regulations; for some, early retirement is being forced upon them by illness and disability and by redundancy. At the same time, many others are electing to continue to work long past the "normal" retirement age, in the same job or in another career.

By and large, today's retirees generally have better health and longer life expectancies. Indeed, in the United Kingdom, the over-80s are the fastest growing group in the population, while more and more people are living into their 90s. And with the surge of women into the workforce, a growing number of the retirees is female, many of whom, owing to longer life expectancies than their male counterparts, will be single or widowed.

For a time-two decades or longer for some-most retirees retain mobility, vigour and functional capacities honed by experience. Thanks to higher living standards and advances in medical care, this period continues to extend. Sadly, however, many live longer than their biological structures were designed for (i.e., some of their bodily systems give up efficient service while the rest struggle on), causing increasing medical and social dependency with ever fewer compensatory enjoyments. The goal of retirement planning is to enhance and extend enjoyment of the period of well-being and ensure to the extent possible the resources and support systems needed during the final decline. It goes beyond estate planning and the disposition of property and assets, although these are often important elements.

Thus, retirement today can offer immeasurable compensations and benefits. Those who retire in good health can expect to live another 20 to 30 years, enjoying potentially purposeful activity for at least two-thirds of this period. This is far too long to drift about doing nothing in particular or rotting away on some sunny "Costa Geriatrica". And their ranks are being swelled by those who retire early by choice or, sadly, because of redundancy, and by women, too, more of whom are retiring as adequately pensioned workers expecting to remain purposefully active rather than to live as dependants.

Fifty years ago, pensions were inadequate and economic survival was a struggle for most of the elderly. Now, employer-provided pensions and general welfare benefits supplied by government agencies, although still inadequate for many, do allow a not too unreasonable existence. And, because the skilled workforce is shrinking in many industries while employers are recognizing that older workers are productive and often more reliable employees, opportunities for third-agers to get part-time employment are improving.

Further, the "retired" now form about a third of the population. Being sound in mind and limb, they are an important and potentially contributory segment of society which, as they recognize their importance and potential, can organize themselves to pull much more weight. An example in the United States is the American Association of Retired Persons (AARP), which offers to its 33 million members (not all of whom are retired, since membership in the AARP is open to anyone aged 50 or over) a broad range of benefits and exercises considerable political influence. At the first Annual General Meeting of the United Kingdom's Pre-Retirement Association (PRA) in 1964, Lord Houghton, its president, a member of the Cabinet, said, "If only pensioners could get their act together, they could swing an election." This has not yet happened, and probably never will in these terms, but it is now accepted in most developed countries that there is a "third age", comprising a third of the population that has both expectations and needs along with an enormous potential for contributing to the benefit of its members and to the community as a whole.

And with this acceptance, there has been a growing realization that adequate provision and opportunity for this group is vital to social stability. Over the last few decades, politicians and governments have begun to respond through extension and improvement of the variety of "social security" and other welfare programmes. These responses have been handicapped both by fiscal exigencies and by bureaucratic rigidities.

Another, major, handicap has been the attitude of the pensioners themselves. Too many have accepted the stereotyped personal and social image of retirement as both the end of recognition as a useful or even deserving member of society and the expectation of being shunted into a backwater where one can be conveniently forgotten. Overcoming this negative image has been, and to a degree still is, the main objective of training for retirement.

As more and more retirees accomplished this transformation and looked to fulfil the needs that emerged, they became aware of the shortcomings of government programmes and began to look to employers to fill the gap. Thanks to accumulated savings and employer-provided pension programmes (many of which were shaped through collective bargaining with unions), they discovered financial resources that were often considerable. To enhance the value of their private pension schemes, employers and unions began to arrange for (and even offer) programmes providing advice and support in managing them.

In the United Kingdom, credit for this is largely due to the Pre-Retirement Association (PRA) which, with government support through the Department of Education (initially, this programme was shunted among the Departments of Health, Employment, and Education), is being accepted as the mainstream of retirement preparation.

And, as the thirst for such guidance and assistance has grown, a veritable industry of voluntary and for-profit organizations has come into existence to meet the demand. Some function quite altruistically; others are self-serving, and include insurance companies that wish to sell annuities and other insurance, investment firms that manage accumulated savings and pension income, real estate brokers selling retirement homes, operators of retirement communities seeking to sell memberships, charities that offer advice on the tax benefits of making contributions and bequests, and so on. These are supplemented by an army of publishers offering "how-to" books, magazines, audiotapes and videotapes, and by colleges and adult education organizations that offer seminars and courses on relevant topics.

While many of these providers focus primarily on coping with financial, social or family problems, recognition that well-being and productive living are dependent on being healthy has led to the increasing prominence of health education and health promotion programmes intended to avert, defer or minimize illness and disability. This is particularly the case in the United States, where employers' financial commitment for the escalating costs of health care for retirees and their dependants has not only become a very weighty burden but now must be projected as a liability on the balance sheets included in corporation annual reports.

Indeed, some of the categorical voluntary health organizations (e.g., heart, cancer, diabetes, arthritis) produce educational materials specifically designed for employees approaching retirement age.

In short, the third age has arrived. Pre-retirement and retirement programmes offer opportunities both for maximizing personal and social well-being and function and for providing the necessary understanding, training and support.

Role of the Employer

Although far from universal, the main support and funding for pre-retirement programmes has come from employers (including local and central governments and the armed forces). In the United Kingdom, this was in large part due to the efforts of the PRA, which, early on, initiated company membership through which employees are provided with encouragement, advice and in-house courses. It has, in fact, not been difficult to convince commerce and industry that they have a responsibility far beyond the mere provision of pensions. Even there, as pension schemes and their tax implications have become more complicated, detailed explanations and personalized advice have become more important.

The workplace provides a convenient captive audience, making the presentation of programmes more efficient and less costly, while peer pressure enhances employee participation. The benefits to the employees and their dependants are obvious. The benefits to the employers are substantial, albeit more subtle: improved morale, the enhancement of the company's image as a desirable employer, encouragement for retaining older employees with valuable experience, and retaining the good will of retirees, many of whom, thanks to profit-sharing and company-sponsored investment plans, are also shareholders. When workforce reductions are desired, employer-sponsored pre-retirement programmes are often presented to enhance the attractiveness of the "golden handshake," a package of inducements for those accepting early retirement.

Similar benefits accrue to trade unions who offer such programmes as an adjunct to union-sponsored pension programmes: making union membership more attractive and enhancing good will and esprit de corps among union members. It should be noted that interest among the trade unions in the United Kingdom is only beginning to develop, primarily among the smaller and professional unions, like that of the airline pilots.

The employer may contract for a complete, "pre-packaged" programme or assemble one from the list of individual elements offered by organizations like the PRA, assorted adult educational institutions and the many investment, pension and insurance firms that offer retirement training courses as a commercial venture. Although generally of a high standard, the latter have to be monitored to be sure that they provide straightforward, objective information rather than promotion of the provider's own products and services. The employer's departments of personnel, pension and, where there is one, education, should be involved in assembling and presenting the programme.

The programmes may be given entirely in-house or at a conveniently located facility in the community. Some employers offer them during working hours but, more often, they are made available during lunch periods or after hours. The latter are more popular because they minimize interference with work schedules and they facilitate the attendance of spouses.

Some employers cover the entire cost of participation; others share it with the employees while some rebate all or part of the employee's share on successful completion of the programme. While faculty should be available for answers to questions, participants are usually referred to appropriate experts when individualized personal consultations are needed. As a rule, these participants accept responsibility for any costs that may be required; sometimes, when the expert is affiliated with the programme, the employer may be able to negotiate reduced fees.

Pre-retirement Course

Philosophy

For many people, especially those who have been workaholics, separation from work is a wrenching experience. Work provides status, identity and association with other people. In many societies, we tend to be identified and to identify ourselves socially by the jobs we do. The work context that we are in, especially as we grow older, dominates our lives in terms of what we do, where we go and, particularly for professional people, our daily priorities. Separation from co-workers, and a sometimes unhealthy level of preoccupation with minor family and household affairs, indicate a need for developing a new frame of social reference.

Well-being and survival in retirement depend on understanding these changes and setting out to make the most of the opportunities they present. Central to such understanding is the concept of maintenance of health in the widest sense of the World Health Organization definition and a more modern acceptance of a holistic approach to medical problems. Establishment of and adherence to a healthful life style must be supplemented by properly managing finances, housing, activities and social relationships. Preserving financial resources for the time when increasing disability requires special care and assistance that may increase the cost of living is often more important than estate planning.

Organized courses which provide information and guidance may be considered the keystone of pre-retirement training. It is sensible for the course organizers to realize that the aim is not to provide all the answers but to delineate possible problem areas and point the way to the best solutions for each individual.

Topic areas

Pre-retirement programmes may include a variety of elements; the following briefly described topics are the most fundamental and should be assured a place among any programme's discussions:

Vital statistics and demography.

Life expectancies at relevant ages-women live longer than men-and trends in family composition and their implications.

Understanding retirement.

The lifestyle, motivational and opportunity-based changes to be required over the next 20 to 30 years.

Health maintenance.

Understanding the physical and mental aspects of ageing and elements of the lifestyle that will promote optimal well-being and functional capacity (e.g., physical activity, diet and weight control, coping with failing vision and hearing, increased sensitivity to cold and hot weather, and use of alcohol, tobacco and other drugs). Discussions of this topic should include dealing with doctors and the health care system, periodic health screening and preventive interventions, and attitudes toward illness and disability.

Financial planning.

Understanding the company's pension plan as well as potential social security and welfare benefits; managing investments to preserve resources and maximize income, including the investment of lump sum payments; managing home ownership and other properties, mortgages, and so on; continuation of employer/union-sponsored and other health insurance, including consideration of long-term care insurance, if available; how to select a financial advisor.

Domestic planning.

Estate planning and making a will; executing a living will (i.e., the setting forth of "medical directives" or naming a health care proxy) containing wishes about what treatments should or should not be administered in the event of potentially terminal illness and inability to participate in decision-making; relationships with spouse, children, grandchildren; coping with constriction of social contacts; role reversal in which the wife continues a career or outside activities while the husband takes more responsibility for cooking and homemaking.

Housing.

Home and garden may become too large, costly and burdensome as financial and physical resources shrink, or it may be too small as the retiree recreates an office or workshop in the home; with both spouses at home, it is helpful, if possible, to arrange for each to have his and her own territory to provide a modicum of privacy for activities and reflection; consideration of moving to another area or country or to a retirement community; availability of public transportation if automobile driving becomes imprudent or impossible; preparing for eventual frailty; assistance with homemaking and social contacts for the single person.

Possible activities.

How to find opportunities and training for new jobs, hobbies and volunteer activities; educational activities (e.g., completion of interrupted diploma and degree courses); travel (in the United States, Elderhostel, a voluntary organization, offers a large catalogue of year-round one-week or two-week adult education courses given at college campuses and vacation resorts throughout the United States and internationally).

Time management.

Developing a schedule of meaningful and enjoyable activities that balance individual and joint involvement; while new opportunities for "togetherness" are a benefit of retirement, it is important to realize the value of independent activities and to avoid "getting in each other's way"; group activities including clubs, church and community organizations; recognizing the motivational value of ongoing paid or voluntary work commitments.

Organizing the course

The type, content and length of the course are usually determined by the sponsor on the basis of the available resources and expected costs, as well as the level of commitment and the interests of employee participants. Few courses will be able to cover all of the above topic areas in exhaustive detail, but the course should include some discussion of most (and preferably all) of them.

The ideal course, educators tell us, is of the day-release type (employees attend the course on company time) with about ten sessions in which participants can get to know each other and instructors can explore individual needs and concerns. Few companies can afford this luxury, but Pre-Retirement Associations (of which the United Kingdom has a network) and adult education centres run them successfully. The course may be presented as a short-term entity-as a two-day course which allows participants more discussion and more time for guidance in activities is probably the best compromise, rather than as a one-day course in which condensation requires more didactic than participative presentations-or it may involve a series of more or less brief sessions.

Who attends?

It is prudent that the course be open to spouses and partners; this may influence its location and timing.

Clearly, every employee facing retirement should be given the opportunity to attend, but the problem is the mix. Senior executives have very different attitudes, aspirations, experiences and resources than relatively junior executives and line staff. Widely differing educational and social backgrounds may inhibit the free-wheeling exchanges that make the courses so valuable to participants, particularly with respect to finances and post-retirement activities. Very large classes dictate a more didactic approach; groups of 10 to 20 facilitate valuable exchanges of concerns and experiences.

Employees in large companies which emphasize corporate identity, like IBM in the United States and Marks & Spencer in the United Kingdom, often find it difficult to fit into the wide world without the "big brother" aura to support them. This is particularly true of the separate services in the armed forces, at least in the United Kingdom and the United States. At the same time in such tightly-knit groups, employees sometimes find it difficult to express concerns that might be construed as company disloyalty. This does not appear as much of a problem when courses are given off-site or include employees of number of companies, a necessity when smaller organizations are involved. These "mixed" groups are often less formal and more productive.

Who teaches?

It is essential that the instructors have the knowledge and, especially, the communication skills required to make the course a useful and pleasurable experience. While the company's personnel, medical and education departments may be involved, qualified consultants or academicians are often considered to be more objective. In some instances, qualified instructors recruited from among the company's retirees can combine greater objectivity with knowledge of the company environment and culture. Since it is rare for any one individual to be expert in all of the issues involved, a course director supplemented by several specialists is usually desirable.

Supplemental materials

The course sessions are usually supplemented by workbooks, videotapes and other publications. Many programmes include subscriptions to pertinent books, periodicals, and newsletters, which are most effective when addressed to the home, where they may be shared by spouses and family members. Membership in national organizations, like PRA and AARP or their local counterparts, provides access to useful meetings and publications.

When is the course given?

Pre-retirement programmes generally begin about five years before the scheduled retirement date (recall that AARP membership becomes available at age 50, regardless of planned retirement age). In some companies, the course is repeated every one or two years, with employees invited to take it as often as they wish; in others, the curriculum is divided into segments given in successive years to the same group of participants with content varying as the retirement date approaches.

Course evaluation

The number of eligible employees electing to participate and the rate of drop-out are perhaps the best indicators of the utility of the course. However, a mechanism should be introduced so that participants can feed back their impressions of the course content and the quality of the instructors as a basis for making changes.

Caveats

Courses with uninspired presentations of largely irrelevant material are not likely to be very successful. Some employers use questionnaire surveys or conduct focus groups to probe the interests of potential participants.

An important point in the decision-making process is the state of employer/employee relations. When hostility is overt or just beneath the surface, employees are not likely to assign great value to anything the employer offers, especially if it is labelled "for your own good". Employee acceptance can be enhanced by having one or more staff committees or union representatives involved in the design and planning.

Finally, as retirement approaches and becomes a way of life, circumstances change and new problems arise. Accordingly, periodic repetition of the course should be planned, both for those who might benefit from a rerun and those who are newly approaching the "third age".

Post-retirement Activities

Many companies continue contact with retirees throughout their lives, often together with their surviving spouses, especially when employer-sponsored health insurance is continued. Periodic health screenings and health education and promotion programmes designed for "seniors" are provided and, when needed, access to individual consultations on health, financial, domestic and social problems is made available. An increasing number of larger companies subsidize pensioner clubs which may have more or less autonomy in programming.

Some employers make a point of rehiring retirees on a temporary or part-time basis when extra help is needed. Other examples from New York City include: the Equitable Life Assurance Society of the United States, which encourages retirees to volunteer their services to non-profit-making community agencies and educational institutions, paying them a modest stipend to offset commuting and incidental out-of-pocket expenses; the National Executive Service Corps, which arranges to provide the expertise of retired executives to companies and government agencies around the world; the International Ladies Garment Workers Union (ILGWU), which has instituted the "Friendly Visiting Program," which trains retirees to provide companionship and useful services to members beset by problems of ageing. Similar activities are sponsored by pensioner clubs in the United Kingdom.

Except for employer/union-sponsored pensioner clubs, most post-retirement programmes are carried out by adult education organizations through their offerings of formal courses. In the United Kingdom, there are several nationwide pensioner groups like PROBUS which holds regular local meetings to provide information and social contacts to their members, and the PRA which offers individual and corporate membership for information, courses, tutors and general advice.

An interesting development in the United Kingdom, based on a similar organization in France, is the University of the Third Age, which is centrally coordinated with local groups in the larger towns. Its members, mostly professionals and academics, work to broaden their interests and extend their knowledge.

Through their regular intramural publications as well as in materials specifically prepared for retirees, many companies and unions provide information and advice, often spiced with anecdotes about retirees' activities and experiences. Most developed countries have at least one or two general circulation magazines aimed at retirees: France's Notre Temps has a large circulation among third agers and, in the United States, AARP's Modern Maturity goes to its more than 33 million members. In the UK there are two monthly publications for the retired: Choice and SAGA Magazine. The European Commission is currently sponsoring a multi-language retirement workbook, Making the Most of Your Retirement.

Eldercare

In the many developed countries, employers are becoming increasingly aware of the impact of the problems faced by employees with elderly or disabled parents, in-laws and grandparents. Although some of these may be pensioners of other companies, their needs for support, attention, and direct services may be significant burdens for the employees who must contend with their own jobs and personal affairs. To ease those burdens and reduce the consequent distraction, fatigue, absenteeism and lost productivity, employers are offering "eldercare programmes" to these caregivers (Barr, Johnson and Warshaw 1992; US General Accounting Office 1994). These provide various combinations of education, information and referral programmes, modified work schedules and respite leaves, social support, and financial aid.

Conclusion

It is abundantly clear that demographic and social workforce trends in the developed countries are producing increasing awareness of the need for information, training and advice across the whole spectrum of "third age" problems. This awareness is being appreciated by employers and labour unions-and by politicians, as well-and is being translated into pre-retirement programmes and post-retirement activities which offer potentially great benefits to the ageing, their employers and unions, and society at large.

OUTPLACEMENT

Saul G. Gruner and Leon J. Warshaw

Outplacement is a professional consulting service that helps organizations plan and implement individual terminations or reductions in their workforces so as to minimize disruptions and avoid legal liability, and counsels terminated employees in order to minimize the trauma of separation while orienting them towards seeking alternative employment or new careers.

The economic downturn of the 1980s, which continues in the 1990s, has been characterized by a virtual pandemic of job terminations reflecting the closing down of obsolescent or unprofitable units, plants and businesses, the elimination of redundancies created by mergers, takeovers, consolidations and reorganizations, and the trimming of staff to reduce operating costs and produce a "lean and mean" workforce. Although less striking than in private industry thanks to the protection of civil service regulations and political pressures, the same phenomenon has also been seen in government organizations struggling to cope with budget deficits and a philosophy that less government is desirable.

For the terminated employees, job loss is a potent stressor and source of trauma, especially when the manner of dismissal is sudden and brutal. It generates anger, anxiety and depression and may cause decompensation in persons with marginal adjustment to chronic mental illness. Rarely, the anger may express itself in sabotage or violence aimed at the supervisors and managers responsible for the termination. Sometimes, the violence is directed at spouses and family members.

The trauma of job loss has also been associated with physical ailments ranging from headaches, gastrointestinal disturbances and other functional complaints to stress-related disorders such as heart attacks, bleeding peptic ulcers and colitis.

In addition to the financial impact of loss of earnings and, in the United States, loss of employer-sponsored health insurance, job loss also affects the health and well-being of the families of the terminated employees.

Employees who are not terminated are also affected. Despite employers' reassurances, there often is concern over the possibility of additional layoffs (threatened job loss has been found to be an even more potent stressor than actual loss of the job). In addition, there is the stress of adjusting to changes in work load and job content as relationships with co-workers are reshuffled. "Downsizing", or reduction in the size of a workforce, may also be traumatic to the employer. It may take significant time and effort to smooth out the resultant organizational disruptions and achieve the desired productive efficiency. Valuable employees not scheduled for termination may leave for other, ostensibly more secure jobs and better-organized firms. There is also the potential of legal liability stemming from discharged employees' allegations of breach of contract or unlawful discrimination.

Outplacement-A Preventive Approach

Outplacement is a professional service offered to prevent, or at least minimize, the trauma of staff reduction for terminated employees, those who remain and the employer.

Not all discharged employees require assistance. For some, the termination precipitates an opportunity to seek new work that might provide welcome relief from a job that had become stultifying and offered little hope of advancement. For most, however, professional counselling in working through the almost inevitable disappointment and anger of dismissed employees and help in finding new jobs can facilitate the restoration of their sense of self-worth and their well-being. Even those who accept the lure of the "golden handshake" (a package of enhanced severance and retirement benefits) and leave voluntarily may benefit from help in making the necessary readjustments.

It is generally agreed that outplacement services are most inexpensively provided by in-house staff. However, even a large organization with a competent and well-functioning staff may not have had much experience with the sensitive work of downsizing and may be too busy planning the restructuring of the organization following the exodus to attend to the niceties that may be involved. Even hardened executives often find it difficult to deal with their erstwhile co-workers. Furthermore, the departing employees are more likely to give credibility to advice from a "neutral" resource.

Accordingly, the vast majority of organizations find it expedient to contract with an outplacement consultant or consulting firm. This neutrality is reinforced by having all possible outplacement contacts located offsite in separate quarters occupied even temporarily by the consultant(s).

Outplacement Process

The outplacement process for terminated employees needs to be individualized depending on their attitudes, capabilities and circumstances, and the nature of the job market locally or in other regions. For non-exempt production workers and first-line supervisors, it involves an inventory of the worker's skills and, where there is a market for them, assistance in placement. Where no suitable jobs exist, it involves assessment of the potential for retraining, referral for retraining, and assistance in marketing the new skills. An unfortunate complication that is difficult to overcome arises when the pay scales for the available new jobs do not measure up to the earnings of the former employment.

For employees in managerial and "creative" positions, the process generally involves a number of phases that are frequently overlapping. These phases are considered under the following heads.

Leaving the past employer. The object is to help the candidate through the stages of reaction, understanding and acceptance of his or her predicament. Occasionally, this may require the intervention of a mental health professional.

This usually involves a reevaluation of the termination event. To earn the candidate's confidence and assist in establishing a desirable rapport, the consultant generally reviews the circumstances of the termination and makes certain that the candidate understands them and, furthermore, has received all of the monetary and other benefits to which he or she may be entitled.

This phase concludes when the candidate is able to deal constructively with the immediate problems and responsibilities and is ready to start preparing for the future with a positive attitude. Ideally, some measure of reconciliation has been established with the past employer and the candidate is willing to accept whatever support may be offered. Such support may include temporary use of an office with a business address and telephone, supplemented by the services of a secretary who can provide typing and photocopying services, take messages, confirm appointments, etc. Most candidates function more effectively from an business-like office environment than from their own homes. Also, the consultant helps formulate a mutually satisfactory reason for the termination and arrange a mutually acceptable response to requests for references from potential employers.

Preparation for new employment. This phase is intended to provide the focus and structure for positive thinking and action. It involves a start of the recovery of self-confidence (which continues throughout the process) by building a personal data base of the candidate's skills, abilities, knowledge and experience, and learning to communicate it in clear, functional terms. Simultaneously, the candidate begins to identify and confirm suitable job objectives and to consider the nature of the jobs for which his or her background might be particularly suitable. Through it all, the candidate acquires the knack of accumulating and organizing information that will highlight the range and depth of his or her experience and level of competence.

Résumé writing. Here, the candidate learns to develop a flexible tool that will present his or her objectives, qualifications, and background, arouse the interest of potential employers, help obtain interviews, and serve as an aid during job interviews. Rather than being restricted to a fixed format, the résumé is varied to "package" skills and experiences to make them most attractive for particular job opportunities.

Assessing job opportunities. The consultant guides the candidate to an assessment of the availability of potential jobs that might be suitable. This includes a survey of different industries, the job market in different localities, opportunities for growth and advancement, and likely earning potential. Experience indicates that about 80% of job opportunities are "hidden," that is, they are not readily apparent on the basis of industry designation or job title. Where appropriate, the assessment also includes an appraisal of the potential of self-employment.

Job-hunting campaign. This involves identifying and exploring existing and potential opportunities through direct approaches to potential employers and developing and making use of contacts and intermediaries. The campaign entails obtaining interviews with the "right" people on a right basis, and using letters both to obtain interviews and as a follow-up to interviews.

The consultant will, as part of enhancing the candidate's job-hunting skills, improve his or her writing and interview techniques. Practice in letter writing is aimed at polishing a communication skill that is uniquely helpful in defining job opportunities, in identifying the "right" people and developing contacts with them, obtaining interviews with them and in following up on interviews. The candidate is further trained by interview coaching, which involves role playing and critiquing videotapes of practice interviews in order to maximize the effectiveness with which his or her personality, experience and desires are presented. The candidate's chances of coming away from an interview, with, at least, an appointment for the next interview, if not an actual job offer, are by this means enhanced.

Negotiating compensation. The consultant will help candidates overcome their dislike or even fear of discussing compensation in negotiating a potential position so that they can obtain the best compensation package possible under the existing circumstances, avoiding the possibility of over-selling or under-selling themselves or antagonizing the interviewer.

Control. Within the limits of the consulting contract, regular contact with the candidate is maintained until a new position is maintained. This involves gathering and organizing information to track how the campaign is progressing and to ensure optimal use of time and effort. It will help the candidate to avoid errors of omission and provide a signal to correct errors of commission.

Following through. When a new position is obtained, the candidate notifies the consultant and the old employer as well as other prospective employers with whom he or she may have been negotiating.

Follow-up. Again, within the limits of the contract, the consultant maintains contact to assist the candidate's adjustment to the new position to aid in overcoming any adverse factors and to encourage continuing career growth and development. Finally, at the close of the programme, the consultant provides the employer with an aggregate report of the results (personal and/or sensitive information is usually held confidential).

The organization

It is rare for the outplacement consultant to be involved in designating specifically which employees are to be separated and which will remain - that is a decision usually made by the organization's top management, often in consultation with department heads and line supervisors and in the light of the structure envisioned for the revised organization. The consultant, however, does provide guidance on the planning, timing and staging of the downsizing process and on the communications with both those who will leave and those who will remain. Since the "grapevine" (i.e., rumors circulating in the workforce) is usually active, it is imperative that these communications be timely, complete and accurate. Proper communications will also help address potential allegations of discrimination. The consultant also often assists with public relations communications to the industry, customers and the community.

Caveats

The extent of downsizing during the last decade, at least in the United States, has given impetus to development of a veritable industry of outplacement consultants and firms. A number of search firms devoted to identifying candidates for job vacancies have taken up outplacement as a side-line. A variety of semiprofessionals, including former personnel directors, have become outplacement counsellors.

Until recently, there was no formally adopted code of practice and ethical standards. However, in 1992, the International Association of Outplacement Professionals (IAOP) sponsored the creation of the Outplacement Institute, membership in which requires meeting a set of criteria based on educational background and personal experience, evidence of continuing participation in programs of personal and professional development, and a commitment to uphold and observe the published IAOP Standards for Ethical Practice.

Conclusion

Reduction in the size of a workforce is, at best, a trying experience for the employees being terminated or forced into retirement, and for those remaining and for the organization as a whole. It is invariably traumatic. Outplacement is a professional consulting service designed to prevent or minimize the potential adverse effects and promote the health and well-being of those involved.

REFERENCES

Adami, HG, JA Baron, and KJ Rothman. 1994. Ethics of a prostate cancer screening trial. Lancet (343):958-960.

Akabas, SH and M Hanson. 1991. Workplace drug and alcohol programmes in the United States. Working paper given at Proceedings of the Washington Tripartite Symposium on Drug and Alcohol Prevention and Assistance Programmes at the Workplace. Geneva: ILO.

American College of Obstetricians and Gynecologists (ACOG). 1994. Exercise during Pregnancy and the Postpartum Period. Vol. 189. Technical Bulletin. Washington, DC: DCL.

American Dietetic Association (ADA) and Office of Disease Prevention and Health Promotion. 1994. Worksite Nutrition: A Guide to Planning, Implementation, and Evaluation. Chicago: ADA.

American Lung Association. 1992. Survey of the public's attitudes toward smoking. Prepared for the Gallup Organization by the American Lung Association.

Anderson, DR and MP O'Donnell. 1994. Toward a health promotion research agenda: "State of the Science" reviews. Am J Health Promot (8):482-495.

Anderson, JJB. 1992. The role of nutrition in the functioning of skeletal tissue. Nutr Rev (50):388-394.

Article 13-E of the New York State Public Health Law. 

Baile, WF, M Gilbertini, F Ulschak, S Snow-Antle, and D Hann. 1991. Impact of a hospital smoking ban: Changes in tobacco use and employee attitudes. Addict Behav 16(6):419-426.

Bargal, D. 1993. An international perspective on the development of social work in the workplace. In Work and Well-Being, the Occupational Social Work Advantage, edited by P Kurzman and SH Akabas. Washington, DC: NASW Press.

Barr, JK, KW Johnson, and LJ Warshaw. 1992. Supporting the elderly: Workplace programs for employed caregivers. Milbank Q (70):509-533.

Barr, JK, JM Waring, and LJ Warshaw. 1991. Employees' sources of AIDS information: The workplace as a promising educational setting. J Occup Med (33):143-147.

Barr, JK and LJ Warshaw. 1993. Stress among Working Women: Report of a National Survey. New York: New York Business Group on Health.

Beery, W, VJ Schoenbach, EH Wagner, et al. 1986. Health Risk Appraisal: Methods and Programs, with Annotated Bibliography. Rockville, Md: National Center for Health Services Research and Health Care Technology Assessment.

Bertera, RL. 1991. The effects of behavioral risks on absenteeism and healthcare costs in the workplace. J Occup Med (33):1119-1124.

Bray, GA. 1989. Classification and evaluation of the obesities. Med Clin North Am 73(1):161-192.

Brigham, J, J Gross, ML Stitzer, and LJ Felch. 1994. Effects of a restricted worksite smoking policy on employees who smoke. Am J Public Health 84(5):773-778.

Bungay, GT, MP Vessey, and CK McPherson. 1980. Study of symptoms of middle life with special reference to the menopause. Brit Med J 308(1):79.

Bureau of National Affairs (BNA). 1986. Where There's Smoke: Problems and Policies Concerning Smoking in the Workplace. Rockville, Md: BNA.

-. 1989. Workplace smoking, corporate practices and developments. BNA's Employee Relations Weekly 7(42): 5-38.

-. 1991. Smoking in the workplace, SHRM-BNA survey no. 55. BNA Bulletin to Management.

Burton, WN and DJ Conti. 1991. Value-managed mental health benefits. J Occup Med (33):311-313.

Burton, WN, D Erickson, and J Briones. 1991. Women's health programs at the workplace. J Occup Med (33):349-350.

Burton, WN and DA Hoy. 1991. A computer-assisted health care cost management system. J Occup Med (33):268-271.

Burton, WN, DA Hoy, RL Bonin, and L Gladstone. 1989. Quality and cost effective management of mental health care. J Occup Med (31):363-367.

Caliber Associates. 1989. Cost-Benefit Study of the Navy's Level III Alcohol Rehabilitation Programme Phase Two: Rehabilitation vs Replacement Costs. Fairfax, Va: Caliber Associates.

Charafin, FB. 1994. US sets standards for mammography. Brit Med J (218):181-183.

Children of Alcoholics Foundation. 1990. Children of Alcoholics in the Medical System: Hidden Problems, Hidden Costs. New York: Children of Alcoholics Foundation.

The City of New York. Title 17, chapter 5 of the Administration Code of the City of New York.

Coalition on Smoking and Health. 1992. State Legislated Actions On Tobacco Issues. Washington, DC: Coalition on Smoking and Health.

Corporate Health Policies Group. 1993. Issues of Environmental Tobacco Smoke in the Workplace. Washington, DC: National Advisory Committee of the Interagency Committee on Smoking and Health.

Cowell, JWF. 1986. Guidelines for fitness-to-work examinations. CMAJ 135 (1 November):985-987.

Daniel, WW. 1987. Workplace Industrial Relations and Technical Change. London: Policy Studies Institute.

Davis, RM. 1987. Current trends in cigarette advertising and marketing. New Engl J Med 316:725-732.

DeCresce, R, A Mazura, M Lifshitz, and J Tilson. 1989. Drug Testing in the Workplace. Chicago: ASCP Press.

DeFriese, GH and JE Fielding. 1990. Health risk appraisal in the 1990s: Opportunities, challenges, and expectations. Annual Revue of Public Health (11):401-418.

Dishman, RH. 1988. Exercise Adherence: Its Impact On Public Health. Champaign, Ill: Kinetics Books.

Duncan, MM, JK Barr, and LJ Warshaw. 1992. Employer-Sponsored Prenatal Education Programs: A Survey Conducted By the New York Business Group On Health. Montvale, NJ: Business and Health Publishers.

Elixhauser, A. 1990. The costs of smoking and the effectiveness of smoking-cessation programs. J Publ Health Policy (11):218-235.

European Foundation for the Improvement of Living and Working Conditions.1991. Overview of innovative action for workplace health in the UK. Working paper no. WP/91/03/EN.

Ewing, JA. 1984. Detecting alcoholism: The CAGE questionnaire. JAMA 252(14):1905-1907.

Fielding, JE. 1989. Frequency of health risk assessment activities at US worksites. Am J Prev Med 5:73-81.

Fielding, JE and PV Piserchia. 1989. Frequency of worksite health promotion activities. Am J Prev Med 79:16-20.

Fielding, JE, KK Knight, RZ Goetzel, and M Laouri. 1991. Utilization of preventive health services by an employed population. J Occup Med 33:985-990.

Fiorino, F. 1994. Airline outlook. Aviat week space technol (1 August):19.

Fishbeck, W. 1979. Internal Report and Letter. Midland, Michigan: Dow Chemical Company, Corporate Medical Dept.

Food and Agriculture Organization of the United Nations (FAO) and World Health Organization (WHO). 1992. International Conference on Nutrition: Major Issues for Nutrition Strategies. Geneva: WHO.

Forrest, P. 1987. Breast Cancer Screening 1987. Report to the Health Ministers of England, Wales, Scotland, and Ireland. London: HMSO.

Freis, JF, CE Koop, PP Cooper, MJ England, RF Greaves, JJ Sokolov, D Wright, and Health Project Consortium. 1993. Reducing health care costs by reducing the need and demand for health services. New Engl J Med 329:321-325.

Glanz, K and RN Mullis. 1988. Environmental interventions to promote healthy eating: A review of models, programs, and evidence. Health Educ Q 15:395-415.

Glanz, K and T Rogers. 1994. Worksite nutrition programs in health promotion in the workplace. In Health Promotion in the Workplace, edited by MP O'Donnell and J Harris. Albany, NY: Delmar.

Glied, S and S Kofman. 1995. Women and Mental Health: Issues for Health Reform. New York: The Commonwealth Fund.

Googins, B and B Davidson. 1993. The organization as client: Broadening the concept of employee assistance programs. Social Work 28:477-484.

Guidotti, TL, JWF Cowell, and GG Jamieson. 1989. Occupational Health Services: A Practical Approach. Chicago: American Medical Association.

Hammer, L. 1994. Equity and gender issues in health care provision: The 1993 World Bank Development Report and its implications for health service recipients. Working Paper Series, no.172. The Hague: Institute of Social Studies.

Harris, L et al. 1993. The Health of American Women. New York: The Commonwealth Fund.

Haselhurst, J. 1986. Mammographic screening. In Complications in the Management of Breast Disease, edited by RW Blamey. London: Balliere Tindall.

Henderson, BE, RK Ross, and MC Pike. 1991. Toward the primary prevention of cancer. Science 254:1131-1138.

Hutchison, J and A Tucker. 1984. Breast screening results from a healthy, working population. Clin Oncol 10:123-128.

Institute for Health Policy. October, 1993. Substance Abuse: The Nation's Number One Health Problem. Princeton: Robert Wood Johnson Foundation.

Kaplan, GD and VL Brinkman-Kaplan. 1994. Worksite weight management in health promotion in the workplace. In Health Promotion in the Workplace, edited by MP O'Donnell and J Harris. Albany, NY: Delmar.

Karpilow, C. 1991. Occupational Medicine in the Industrial Workplace. Florence, Ky: Van Nostrand Reinhold.

Kohler, S and J Kamp. 1992. American Workers under Pressure: Technical Report. St. Paul, Minn.: St. Paul Fire and Marine Insurance Company.

Kristein, M. 1983. How much can business expect to profit from smoking cessation? Prevent Med 12:358-381.

Lesieur, HR and SB Blume. 1987. The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers. Am J Psychiatr 144(9):1184-1188.

Lesieur, HR, SB Blume, and RM Zoppa. 1986. Alcoholism, drug abuse and gambling. Alcohol, Clin Exp Res 10(1):33-38.

Lesmes, G. 1993. Getting employees to say no to smoking. Bus Health (March):42-46.

Lew, EA and L Garfinkel. 1979. Variations in mortality by weight among 750,000 men and women. J Chron Dis 32:563-576.

Lewin, K. [1951] 1975. Field Theory in Social Science: Selected Theoretical Papers by Kurt Lewin, edited by D Cartwright. Westport: Greenwood Press.

Malcolm, AI. 1971. The Pursuit of Intoxication. Toronto: ARF Books.

Mandelker, J. 1994. A wellness program or a bitter pill. Bus Health (March):36-39.

March of Dimes Birth Defects Foundation. 1992. Lessons Learned from the Babies and You Program. White Plains, NY: March of Dimes Birth Defects Foundation.

-. 1994. Healthy Babies, Healthy Business: An Employer's Guidebook on Improving Maternal and Infant Health. White Plains, NY: March of Dimes Birth Defects Foundation.

Margolin, A, SK Avants, P Chang, and TR Kosten. 1993. Acupuncture for the treatment of cocaine dependence in methadone-maintained patients. Am J Addict 2(3):194-201.

Maskin, A, A Connelly, and EA Noonan. 1993. Environmental tobacco smoke: Implications for the workplace. Occ Saf Health Rep (2 February).

Meek, DC. 1992. The impaired physician programme of the Medical Society of the District of Columbia. Maryland Med J 41(4):321-323.

Morse, RM and DK Flavin. 1992. The definition of alcoholism. JAMA 268(8):1012-1014.

Muchnick-Baku, S and S Orrick. 1992. Working for Good Health: Health Promotion and Small Business. Washington, DC: Washington Business Group on Health.

National Advisory Council for Human Genome Research. 1994. Statement on use of DNA testing for presymptomatic identification of cancer risk. JAMA 271:785.

National Council on Compensation Insurance (NCCI). 1985. Emotional Stress in the Workplace-New Legal Rights in the Eighties. New York: NCCI.

National Institute for Occupational Safety and Health (NIOSH). 1991. Current Intelligence Bulletin 54. Bethesda, Md: NIOSH.

National Institutes of Health (NIH). 1993a. National High Blood Pressure Education Program Working Group Report on Primary Prevention of Hypertension. National High Blood Pressure Education Program, National Heart, Lung, and Blood Institute. NIH publication No. 93-2669. Bethesda, Md: NIH.

-. 1993b. Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP II). National Cholesterol Education Program, National Institutes of Health, National Heart, Lung, and Blood Institute. NIH publication no. 93-3095. Bethesda, Md: NIH.

National Research Council. 1989. Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, DC: National Academy Press.

New York Academy of Medicine. 1989. Drugs in the workplace: Proceedings of a symposium. B NY Acad Med 65(2).

Noah, T. 1993. EPA declares passive smoke a human carcinogen. Wall Street J, 6 January.

Ornish, D, SE Brown, LW Scherwitz, JH Billings, WT Armstrong, TA Ports, SM McLanahan, RL Kirkeeide, RJ Brand, and KL Gould. 1990. Can lifestyle changes reverse coronary heart disease? The lifestyle heart trial. Lancet 336:129-133.

Parodi vs. Veterans Administration. 1982. 540 F. Suppl. 85 WD. Washington, DC.

Patnick, J. 1995. NHS Breast Screening Programmes: Review 1995. Sheffield: Clear Communications.

Pelletier, KR. 1991. A review and analysis of the cost effective outcome studies of comprehensive health promotion and disease prevention programs. Am J Health Promot 5:311-315.

-. 1993. A review and analysis of the health and cost-effective outcome studies of comprehensive health promotion and disease prevention programs. Am J Health Promot 8:50-62.

-. 1994. Getting your money's worth: The strategic planning programme of the Stanford Corporate Health Programme. Am J Health Promot 8:323-7,376.

Penner, M and S Penner. 1990. Excess insured health costs from tobacco-using employees in a large group plan. J Occup Med 32:521-523.

Preventive Services Task Force. 1989. Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. Baltimore: Williams & Wilkins.

Richardson, G. 1994. A Welcome for Every Child: How France Protects Maternal and Child Health-A New Frame of Reference for the United States. Arlington, Va: National Center for Education in Maternal and Child Health.

Richmond, K. 1986. Introducing heart healthy foods in a company cafeteria. J Nutr Educ 18:S63-S65.

Robbins, LC and JH Hall. 1970. How to Practice Prospective Medicine. Indianapolis, Ind: Methodist Hospital of Indiana.

Rodale, R, ST Belden, T Dybdahl, and M Schwartz. 1989. The Promotion Index: A Report Card on the Nation's Health. Emmaus, Penn: Rodale Press.

Ryan, AS and GA Martinez. 1989. Breastfeeding and the working mother: A profile. Pediatrics 82:524-531.

Saunders, JB, OG Aasland, A Amundsen, and M Grant. 1993. Alcohol consumption and related problems among primary health care patients: WHO collaborative project on early detection of persons with harmful alcohol consumption-I. Addiction 88:349-362.

Schneider, WJ, SC Stewart, and MA Haughey. 1989. Health promotion in a scheduled cyclical format. J Occup Med 31:482-485.

Schoenbach, VJ. 1987. Appraising health risk appraisal. Am J Public Health 77:409-411. 

Seidell, JC. 1992. Regional obesity and health. Int J Obesity 16:S31-S34.

Selzer, ML. 1971. The Michigan alcoholism screening test: The quest for a new diagnostic instrument. Am J Psychiatr 127(12):89-94.

Serdula, MK, DE Williamson, RF Anda, A Levy, A Heaton and T Byers. 1994. Weight control practices in adults: Results of a multistate survey. Am J Publ Health 81:1821-24.

Shapiro, S. 1977. Evidence of screening for breast cancer from a randomised trial. Cancer:2772-2792.

Skinner, HA. 1982. The drug abuse screening test (DAST). Addict Behav 7:363-371.

Smith-Schneider, LM, MJ Sigman-Grant, and PM Kris-Etherton. 1992. Dietary fat reduction strategies. J Am Diet Assoc 92:34-38.

Sorensen, G, H Lando, and TF Pechacek. 1993. Promoting smoking cessation at the workplace. J Occup Med 35(2):121-126.

Sorensen, G, N Rigotti, A Rosen, J Pinney, and R Prible. 1991. Effects of a worksite smoking policy: Evidence for increased cessation. Am J Public Health 81(2):202-204.

Stave, GM and GW Jackson. 1991. Effect of total work-site smoking ban on employee smoking and attitudes. J Occup Med 33(8):884-890.

Thériault, G. 1994. Cancer risks associated with occupational exposure to magnetic fields among electric utility workers in Ontario and Quebec, Canada, and France. Am J Epidemiol 139(6):550-572.

Tramm, ML and LJ Warshaw. 1989. Screening for Alcohol Problems: A Guide for Hospitals, Clinics, and Other Health Care Facilities. New York: New York Business Group on Health.

US Department of Agriculture: Human Nutrition Information Service. 1990. Report of the Dietary Guidelines Advisory Committee On Dietary Guidelines for Americans. Publication no. 261-495/20/24. Hyattsville, Md: US Government Printing Office.

US Department of Health, Education and Welfare. 1964. Smoking and Health Report of the Advisory Committee to the Surgeon General of the Public Health Service. PHS Publication No. 1103. Rockville, Md: US Department of Health, Education, and Welfare.

US Department of Health and Human Services (USDHHS). 1989. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. USDHHS publication no.10 89-8411.Washington, DC: US Government Printing Office.

-. 1990. Economic Costs of Alcohol and Drug Abuse and Mental Illness. DHHS publication no. (ADM) 90-1694. Washington, DC: Alcohol, Drug Abuse, and Mental Health Administration.

-. 1991. Environmental Tobacco Smoke in the Workplace: Lung Cancer and Other Effects. USDHHS (NIOSH) publication No. 91-108. Washington, DC: USDHHS.

US Food and Drug Administration (FDA). 1995. Mammography quality deadline. FDA Med Bull 23: 3-4.

US General Accounting Office. 1994. Long-Term Care: Support for Elder Care Could Benefit the Government Workplace and the Elderly. GAO/HEHS-94-64. Washington, DC: US General Accounting Office.

US Office of Disease Prevention and Health Promotion. 1992. 1992 National Survey of Worksite Health Promotion Activities: Summary Report. Washington, DC: Department of Health and Human Services, Public Health Service.

US Public Health Service. 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives-Full Report With Commentary. DHHS publication No. (PHS) 91-50212. Washington, DC: US Department of Health and Human Services.

Voelker, R. 1995. Preparing patients for menopause. JAMA 273:278.

Wagner, EH, WL Beery, VJ Schoenbach, and RM Graham. 1982. An assessment of health hazard/health risk appraisal. Am J Public Health 72:347-352.

Walsh, DC, RW Hingson, DM Merrigan, SM Levenson, LA Cupples, T Heeren, GA Coffman, CA Becker, TA Barker, SK Hamilton, TG McGuire, and CA Kelly. 1991. A randomized trial of treatment options for alcohol-abusing workers. New Engl J Med 325(11):775-782.

Warshaw, LJ. 1989. Stress, Anxiety, and Depression in the Workplace: Report of the NYGBH/Gallup Survey. New York: The New York Business Group on Health.

Weisman, CS. 1995. National Survey of Women's Health Centers: Preliminary Report for Respondents. New York: Commonwealth Fund.

Wilber, CS. 1983. The Johnson and Johnson Program. Prevent Med 12:672-681.

Woodruff, TJ, B Rosbrook, J Pierce, and SA Glantz. 1993. Lower levels of cigarette consumption found in smoke-free workplaces in California. Arch Int Med 153(12):1485-1493.

Woodside, M. 1992. Children of Alcoholics At Work: The Need to Know More. New York: Children of Alcoholics Foundation.

World Bank. 1993. World Development Report: Investing in Health. New York: 1993.

World Health Organization (WHO). 1988. Health promotion for working populations: Report of a WHO expert committee. Technical Report Series, No.765. Geneva: WHO.

-. 1992. World No-Tobacco Day Advisory Kit 1992. Geneva: WHO.

-. 1993. Women and Substance Abuse: 1993 Country Assessment Report. Document No. WHO/PSA/93.13. Geneva: WHO.

-. 1994. A Guide On Safe Food for Travellers. Geneva: WHO. 

Yen, LT, DW Edington, and P Witting. 1991. Prediction of prospective medical claims and absenteeism for 1,285 hourly workers from a manufacturing company, 1992. J Occup Med 34:428-435.

OTHER RELEVANT READINGS

Akabas, SH and PA Kurzman. 1982. Work, Workers and Work Organizations: A View from Social Work. Englewood Cliffs, NJ: Prentice Hall.

American College of Sports Medicine. 1992. ACSM Fitness Book. Champaign, Ill: Leisure Press.

American Heart Association, NYCA. 1993. Annotated Bibliography of Educational Materials Related to Cardiovascular Health for Patients and Families. New York: American Heart Association, New York City Affiliate.

Ashton, D. 1994. Exercise: Health benefits and risks. European Occupational Health Series, No. 7. Copenhagen: WHO Regional Office for Europe.

Barlow, DH. 1994. Advisory Group On Osteoporosis - Report. UK: Department of Health.

Blum, A. 1983. Curtailing the tobacco pandemic. In Cancer: Principles and Practice of Oncology, edited by VTJ DeVita, S Hellman, and SA Rosenberg. Philadelphia: JB Lippincott.

Bowden, KM and MA McDiarmid. 1994. Occupationally acquired tuberculosis: What's known. J Occup Med 36(3):320-325.

Bureau of National Affairs (BNA). 1988. Cost of Cesarean Deliveries. Washington, DC: Benefits Today.

Buring, JE and CH Hennekens. 1993. Retinoids and carotenoids. In Cancer: Principles and Practice of Oncology, edited by VTJ DeVita, S Hellman, and SA Rosenberg. Philadelphia: JB Lippincott.

Center for Corporate Public Involvement. 1994. 1994 Social Report. Washington, DC: American Council of Life Insurance and Health Insurance Association of America.

Centers for Disease Control (CDC). 1990. Public health burden of vaccine-preventable diseases among adults: Standards for adult immunization practice. Morb Mortal Weekly Rep 39:725-729.

-. 1991. Successful strategies in adult immunization. Morb Mortal Weekly Rep 40:700-3;709.

CIGNA Corporation. 1992. Infant Health in America: Everybody's Business (a Report). Columbia, Md: The Center for Risk Management and Insurance Research, Georgia State Univ. and the Center for Health Policy Studies.

Committee on Diet and Health Food and Nutrition Board, C of LS, National Research Council. 1989. Diet and Health: Implications for Reducing Chronic Disease Risk. Washington, DC: National Academy Press.

Consult America, I. 1989. Outplacement Consulting in the United States: Issues, Marketing and Trends. Maynard, Mass: Consult America.

Cooper, CL and R Payne. 1988. Causes, Coping, and Consequences of Stress At Work. New York: Wiley.

DeJoy, DM and MG Wilson. 1994. Critical Issues in Worksite Health Promotion. Needham Heights, Mass: Allyn & Bacon.

Denning, J. 1984. Women's Work and Health Hazards. London: Department of Occupational Health, School of Hygiene and Tropical Medicine.

Eckenrode, J and S Gore. 1990. Stress Between Work and Family. New York: Plenum Press.

Fauske, S. 1995. Model Programmes for Drug and Alcohol Abuse Prevention Among Workers and Their Families. Geneva: ILO.

Fielding, JE. 1989. Work site stress management: National survey results. J Occup Med 31:990-995.

-. 1990. Worksite health promotion in the US: Progress, lessons and challenges. Health Promot Int 5:75-84.

-. 1991. Occupational health physicians and prevention. J Occup Med 33:314-326.

Fowinkle, FJ. 1987. Healthier People. Atlanta: The Carter Center of Emory Univ. 

Fulwood, R, S Abraham, and E Johnson. 1981. Height and weight of adults ages 18-74 years by socioeconomic and geographic variables, United States. Vital Health Stat 11(224).

Googins, B and J Godfrey. 1987. Occupational Social Work. Englewood Cliffs, NJ: Prentice Hall.

Gould, GM and ML Smith. 1988. Social Work in the Workplace. New York: Springer Press.

Greenwald, P. 1993. Dietary fiber and cancer. In Cancer: Principles and Practice of Oncology, edited by VTJ DeVita, S Hellman, and SA Rosenberg. Philadelphia: JB Lippincott.

Greenwald, P and C Clifford. 1993. Dietary fat and cancer. In Cancer: Principles and Practice of Oncology, edited by VTJ DeVita, S Hellman, and SA Rosenberg. Philadelphia: JB Lippincott.

Guerrant, RL and DA Bobak. 1991. Bacterial and protozoal gastroenteritis. New Engl J Med 325(5):327-340.

Guthrie, HA and MF Picciano. 1995. Human Nutrition. St. Louis: Mosby.

Henderson, BE, L Bernstein, and R Ross. 1993. Hormones. In Cancer: Principles and Practice of Oncology, edited by VTJ DeVita, S Hellman, and SA Rosenberg. Philadelphia: JB Lippincott.

House, J. 1981. Work Stress and Social Support. Reading, Mass: Addison-Wesley.

Hudson Institute. 1987. Workforce 2000: Work and workers for the twenty-first century. Exec Summ June 1987:85.

Jamison, DT, WH Mosely, AR Measham, and JL Bobadilla. 1993. Disease Control Priorities in Developing Countries. Washington, DC: Oxford Univ. Press. (The International Bank for Reconstruction and Development/The World Bank.)

Kammerman, S and A Kahn. 1987. The Responsive Workplace. New York: Columbia Univ. Press.

Keita, GP and SL Sauter. 1992. Work and Well-Being: An Agenda for the 1990's. Washington, DC: American Psychological Association.

Kurzman, PA and SH Akabas. 1993. Work and Well-Being: The Occupational Social Work Advantage. Washington, DC: National Association of Social Workers Press.

Lalonde, M. 1975. A new perspective on the health of Canadians: A working document. Inform Canada.

Lechner, VM and MA Creedon. 1994. Managing Work and Family Life. New York: Springer.

Levi, L. 1981. Preventing Work Stress. Reading, Mass: Addison-Wesley.

McLean, AA. 1979. Work Stress. Reading, Mass: Addison-Wesley. 

McPherson, A. 1993. Women's Problems in General Practice. Washington, DC: Oxford Univ. Press.

Minor, AF. 1991. Source Book of Health Insurance Data. Unpublished Tabulations. Washington, DC: Health Insurance Association of America.

Muchnick-Baku, S. 1994. Conference Board Report. Washington, DC: Washington Business Group on Health.

National Coordinating Committee on Worksite Health Promotion. 1993. Health Promotion Goes to Work: Programs With an Impact. Washington, DC: US Government Printing Office.

New York Business Group on Health. 1990. Risk-Rated Health Insurance: Incentives for Healthy Lifestyles. Discussion paper, vol. 10(1). New York Business Group on Health.

Nichol, KL, A Kind, KL Margolis, et al. 1995. The effectiveness of vaccination against influenza in healthy, working adults. New Engl J Med 333:889-893.

Nutrition recommendations and principles for people with diabetes mellitus. 1994. . J Am Diet Assoc 94:504-506.

O'Donnell, MP and JS Harris. 1994. Health Promotion in the Workplace. New York: Delmar.

Paton, E. 1993. European Alcohol Action Plan. Copenhagen: Alcohol, Drugs and Tobacco Unit, Lifestyles and Health Department, WHO Regional Office for Europe.

Pecina, MM and I Bojanic. 1993. Overuse Injuries of the Musculoskeletal System. Boca Raton: CRC Press.

Peterson, KW and SB Hilles. 1992. Directory of Health Risk Appraisals. Indianapolis: Society for Prospective Medicine.

Ramanathan, CS. 1991. Occupational social work and multinational corporations. J Sociol Soc Welfare XVII(3):135-147.

Ramirez, S. 1994. Health Promotion for All: Strategies for Reaching Diverse Populations in the Workplace. Omaha, Nebr: Wellness Councils of America.

Reynolds, B. 1951. Social Work and Social Living. New York: Citadel.

Schneider, WJ. 1989. AIDS in the Workplace. J Occup Med 31:839-841. 

Scofield, ME. 1990. Worksite Health Promotion. Occup Med: State Art Rev 5(4) (October-December).

Silverman, B, B Simon, and R Woodrow. 1991. Workers in job jeapordy. In Handbook of Social Practice in Vulnerable Populations, edited by A Gitterman. New York: Columbia Univ. Press.

Sloan, RP, JC Gruman, and JP Allegrante. 1987. Investing in Employee Health: A Guide to Effective Health Promotion in the Workplace. San Francisco: Jossey-Bass.

Society for Nutrition Education. 1986. Nutrition at the worksite. J Nutr Educ 18(2).

Society for Prospective Medicine. 1981. Guidelines for Health Risk Appraisal/Reduction Systems. Bethesda, Md: Society for Prospective Medicine.

Swaim, M and R Swaim. 1988. Out the Organization. New York: Master Media.

Tabar, L and G Fagergberg. 1985. Reduction in mortality from breast cancer after mass screening with mammography. Lancet 1:829-832.

Task Force on Adult Immunization. 1994. Guide for Adult Immunization. Philadelphia: The American College of Physicians.

US Centers for Disease Control (CDC). 1993. International Infant Mortality Database. Atlanta: CDC.

US Department of Agriculture. 1990. Cross-Cultural Counselling. A Guide for Nutrition and Health Counselors. Washington, DC: United States Department of Health and Human Services.

US Department of Commerce, B of C. 1992. Employment Status of Mothers By Single Year Age of Youngest Child. Washington, DC: US Department of Commerce.

US Office of Disease Prevention and Health Promotion. 1994. Put Prevention into Practice Education and Action Kit (Includes Clinician's Handbook of Clinical Preventive Services As Well As Personal Health Guide). Washington, DC: US Government Printing Office.

-. 1991. Federal Employee Worksite Health Promotion Case Study Project: Summary Report. Washington, DC: Office of Labor Relations and Workforce Performance, Office of Personnel Management.

US Department of Labor Statistics. 1993. Employment and Earnings. Vol. 40, no. 1, table 3. Washington, DC: US Department of Labor Statistics.

-. 1992. Employment status of mothers by single year of age of youngest child. In Current Population Survey. Washington, DC: US Department of Labor Statistics

US Public Health Service. 1988. USDHHS: The Surgeon General's Report On Nutrition and Health. Summary and Recommendations. Washington, DC: US Government Printing Office.

US Small Business Administration. 1993. The State of Small Business. Washington, DC: US Government Printing Office.

Vanchieri, C. 1988. Breast cancer screening, the evidence of benefit for women 40-49. J Natl Cancer Inst 80:1090-1092.

Wark, TEE. 1987. Shopping for health risk appraisals. Health Act Manage 10 Oct:1,6-9.

Warshaw, LJ. 1979. Managing Stress. Reading, Mass: Addison-Wesley. 

Williams, WW, MA Hickson, MA Kane, et al. 1988. Immunization policies and vaccine coverage among adults. The risk for missed opportunities. Ann Intern Med 108:616-625.