Boosting health promotion

The leading causes of death in the developed world are ischaemic heart disease, stroke and cancer. The known links between these conditions and poor diet, smoking and alcohol use highlight the health promotion role OH professionals can play. They can contribute to the public health agenda by offering information to the workforce on lifestyle issues.

It seems, however, that few services in the UK routinely offer lifestyle screening, which could identify people likely to benefit from health-related information.


Smoking causes one in 10 adult deaths worldwide. According to Ash, a campaigning public health charity working to eliminate the harm caused by tobacco, 114,000 smokers die every year from smoking-related diseases in the UK.

A survey of 200 workplaces found that absence rates were higher among smokers, with an estimated cost of £40m per year, and annual productivity losses of about £450m. The study also found that the workplace also bore the cost of smoking-related fire damage.


In Scotland, it has long been recognised that poor diet is a major cause of poor health, the main identified problems being the high intake of saturated fats, and low intake of fruit and vegetables. In adults, obesity increases the risk of heart disease, hypertension, diabetes mellitus and osteoarthritis. According to the National Audit Office, it is estimated that by 2010, obesity will cost the UK economy £3.6bn per year.


The World Health Organization (WHO) has classified levels of risk associated with alcohol consumption as ‘low risk’, ‘hazardous’, and ‘harmful’, while the Department of Health advises that there is no significant health risk for men who drink up to three or four units of alcohol a day. The equivalent advice for women is no more than two or three units per day.

Hazardous drinking is defined as a pattern of drinking that carries a high risk of harm, whereas harmful drinkers are already experiencing harm. A general guideline based on the WHO classification and information from the UK Alcohol Forum regarding the level at which hazardous and harmful drinking occurs is provided in Table 1 (see below).

The cost of alcohol misuse in lost productivity in England is estimated to be £6.4bn, and 77% of UK employers have alcohol policies. However, as a consequence of employers’ legal responsibilities, it may be that the prevention of industrial injury and occupation-related morbidity are prioritised over health promotion activities.

The study

There is therefore a clear need for screening and interventions on a range of lifestyle issues. The importance of primary prevention by OH services is highlighted by the UK health departments. However, a literature search identified no report of lifestyle screening in any UK workplace.We therefore conducted a postal survey with the aim of exploring the prevalence of lifestyle factors associated with ill health in the Scottish working population.

It also seems that few studies have investigated employees’ views of work-based lifestyle screening and OH interventions, so the study also aimed to assess participants’ views on the issue.


Data collection

A questionnaire on participants’ demographic characteristics, smoking habits, diet, and alcohol consumption was used. The section on smoking used the Fagerström Test for Nicotine Dependence. Seven items associated with the most common diet-related health risks were selected from the European Health and Behaviour Survey questionnaire, developed and validated by Wardle and Steptoe (1991).

Finally, the Alcohol Use Disorders Identification Test (AUDIT) was used to detect individuals whose levels of consumption placed them at risk of developing alcohol-related health and/or social problems. As indicated in Table 1, a score of 0-7 for men, or 0-5 for women, is indicative of low-risk drinking; 8-15 for men and 6-15 for women indicates hazardous drinking; and between 16 and the maximum score of 40 suggests harmful drinking.

A short questionnaire was designed to elicit respondents’ views on the acceptability of the process.

Population and sample

In the UK, local authority employees cover a range of occupations and socio-economic groups, and can therefore be considered representative of the working population. Permission was granted to conduct the study in a local authority council, which serves a mixed urban and rural population in Scotland.

In liaison with the council’s personnel officer, workers were categorised as manual, clerical or professional, and stratified so that proportionate numbers were selected for screening.

The gender distribution of the council workforce as a whole comprises 71% females and 29% males. Computer-generated random numbers were used to identify 900 potential participants, 270 male (30%) and 630 female   (70%).

These employees were sent information regarding the purpose of the study, along with a copy of the questionnaire and a stamped-addressed envelope for its return. Consent to participate was assumed by the return of completed questionnaires. Staff were assured of confidentiality and the voluntary nature of participation. Employers had no knowledge of their participation and no access to the data.

Questionnaires to assess the acceptability of the screening process were sent to a random sub-sample of the 900 potential participants (25%).


Response rate

Four hundred and twenty-five questionnaires were returned, giving a 47% response rate. Table 3 (see below) shows the age and gender distributions. The majority (37%) of female employees are clerical workers, while 33% are manual workers and 29% are professionals. Of the men, more than half (56%) are professionals, 32% are manual workers, and 10% are clerical workers. Four female workers (1%) and two males (2%) did not give their job titles.


Of the 424 respondents who completed the smoking section of the questionnaire, (19%) were smokers. Of these, (21%) smoked fewer than one cigarette per day. The results of the Fagerström test for nicotine dependence showed that the majority of daily smokers have ‘low’ or ‘very low’ nicotine dependence. The majority of smokers indicated that they would like to stop, or would consider stopping in the future. Only four respondents indicated that they had no intention of stopping.

The majority of female smokers are 46 to 55 years old, whereas most male smokers are 56 to 65. Of those in the professional category, 15% smoke. Twenty-five of the clerical workers smoke (20%), and 22% of those in the manual category are smokers, indicating that smoking behaviour seems similar across the employment categories.


None of the participants complied with guidelines in all areas of healthy eating. Only 4% reported eating fried foods more than once or twice a week. However, 39% do not appear to eat fruit or vegetables more than once a day. Most reported that they would consider changing their diet now (30%), or in the future (27%).


All 425 respondents answered this section of the questionnaire, although 3% did not answer the question regarding the number of units consumed on a typical day. Of those who did complete this question, 58 men and 195 women reported drinking within the guideline daily limits. Sixty women and 40 men reported drinking more than the recommended number of units, with 6% of women and 5% of men reporting binge-level drinking (ie, more than twice the daily benchmark for their gender).

Fifty-nine respondents abstain from alcohol completely, while 293 drink in the ‘low-risk’ category. A further 111 drink at hazardous levels, and 10 drink at harmful levels. For the remaining 12, an AUDIT score could not be calculated due to missing responses.

The findings showed that males are more prevalent in the harmful drinking category. Of those employees in the professional category, 43 were classed as high-risk drinkers. High-risk drinkers also made up 28% of clerical workers, and 29% of manual workers.


Sixty-three of the 225 questionnaires were returned, giving a response rate of 28%.

The majority indicated that they had been happy to take part, compared with 18% who reported reluctance to give personal details. Nobody said they were suspicious that the information might be disclosed to their employer, and only one found the questions intrusive. Fifty (81%) said they would prefer to receive such questionnaires at their home addresses, compared with seven (11%) whose preference was to receive it at work. Five (8%) indicated no preference.

Twenty-eight (44%) said that they would be more likely to take part in this kind of survey if it were conducted by the council’s OH department, compared with 20 (33%) who would prefer it to be undertaken by an external organisation. Fifteen (23%) had no preference.


The study was conducted to test the feasibility of using a postal survey to screen the workforce for lifestyle factors that are associated with ischaemic heart disease, stroke and cancer. The response rate of 47% was achieved, which is higher than usual for postal surveys.

However, since it is not possible to know how representative of the population the findings are, some caution should be exercised in interpreting the results. Despite this, they suggest that there is scope within the workplace for the delivery of health-promoting initiatives in relation to smoking cessation, healthy eating, and low-risk levels of alcohol consumption.


The results show that 19% of respondents smoke. Thirty-three per cent of those aged 16 to 25 are smokers. The fact that a higher proportion of men than women smoke reflects the national pattern. The gender distribution and levels of dependence as measured by the Fagerström Test are similar to those reported for UK smokers in an international study on nicotine dependence.

The prevalence of smoking in our sample, and the fact that more than two-thirds of the sub-sample were in favour of smoking-related health promotion activities, highlights the need for action in this area, which occupational health nurses are well placed to address.


It could be argued that, compared with the environmental effects of second-hand tobacco, or the risks to colleagues of employees who are intoxicated, the health risks associated with poor diet relate only to the employee as an individual. Screening in relation to diet could therefore be viewed as less appropriate for OH practitioners.

However, given the rise in diet-related diseases such as hypertension and diabetes mellitus, and the increased focus of the public health dimension of OH service delivery, we support claims that opportunities to promote and sustain dietary change should be maximised.

The majority of respondents deviated from health guidelines in one or two of the key areas used in the questionnaire. The most common deviation related to fruit and vegetable consumption, with 39% of respondents eating fruit and vegetables less than daily.

A recent review indicated that since 1996, there has been no significant change in consumption of saturated fat, fruit and vegetables, bread, oil-rich fish or breakfast cereal in the UK. In our sample, 7% of manual workers consume fried foods more than once or twice a week. In both the clerical and professional categories, however, only 3% did.

These findings have obvious implications for OH services. There may be scope for local activities to be delivered in parallel with population-wide campaigns, or for collaborative projects with catering staff to provide information on healthy eating and awareness raising initiatives.


The results show that 39% of men and 25% of women consume alcohol at hazardous or harmful levels. High-risk drinking seems to be equally spread between employment categories, but proportionately more men than women reported drinking at harmful levels, which reflects UK drinking patterns.

Twenty-six per cent of respondents were found to be hazardous drinkers, compared with 2% who were drinking at harmful levels. This suggests that a much higher proportion of the workforce is at risk of developing alcohol-related health problems compared with those who are already experiencing serious consequences of their drinking, such as alcohol dependence.

There is convincing evidence of the effectiveness of brief intervention for people whose consumption places them at risk of developing alcohol. Such interventions have been shown to be cost-effective when delivered in primary healthcare, but no study of their use in occupational settings in the UK has been reported.

The findings suggest that there may be a prevention role for OH services in the delivery of interventions. Indeed, the implementation of health promotion in the workplace and reduction in hazardous drinking are key objectives of a range of national and international public health policy documents.


The majority of the employees who took part in the acceptability survey appeared to welcome the opportunity for health promotion advice and information.


In addition to the limitations associated with the relatively low response rate, the self-report nature of the data raises questions about its reliability. However, validated questionnaires were used in an attempt to reduce the risk of response bias as a consequence of such factors as memory distortion or social desirability.

In addition, when embedded within a general lifestyle questionnaire, the AUDIT tool has been shown to be highly reliable. Despite this, 3% of respondents did not provide answers to the question relating to number of units consumed on a typical day. This could reflect confusion over the number of units per standard drink.

Question 2 of the AUDIT questionnaire asks respondents to calculate the number of drinks consumed on a typical drinking day. We briefly outlined the number of units contained various drinks. This calculation becomes more complicated when respondents do not use standard measures – for instance, when drinking at home.

This confusion could mean that those who did answer the question under-reported the number of units consumed, producing misleading results on rates of harmful and binge drinking. Since this study was undertaken, a pictorial version of this part of the AUDIT tool has become available, which may facilitate understanding of the concept of a standard drink or unit.

The study was conducted in one local authority in Scotland, limiting the ability to generalise from the findings. It is not known how participants from the private sector, for example, would have responded.


The findings from this study suggest that, despite these limitations, there is scope within the workplace for the delivery of health-promoting initiatives in relation to smoking, diet, and alcohol consumption. Furthermore, they suggest that the workforce is amenable to the assessment of lifestyle issues and the receipt of information and advice aimed at promoting health.


The authors of this paper wish to thank the council employees who, by completing questionnaires, provided the information on which this paper is based. Acknowledgement is also due to the Alcohol Education and Research Council for funding the study.

This article was written by Hazel Watson, professor of nursing; Katherine McArthur, research assistant; and Rosemary Whyte, research fellow, all from the Caledonian Nursing and Midwifery Centre, Glasgow Caledonian University; and Marisa Stevenson, OH adviser, Axa PPP OH Services


  • Lopez AD, Mathers CD, Ezzati M, Jamison D, Murray CJL: The Global and Regional Burden of Disease and Risk Factors, 2001: Systematic analysis of population health data, Lancet, 367 (9524): 1747-1757 (2006).

  • Scottish Executive, Improving Scotland’s Health, the Challenge. Edinburgh, the Stationery Office (2003)

  • Department of Health (2003) Taking a public health approach in the workplace

  • World Health Organisation (2006) Declaration on Workers Health

  • WHO (2005) Tobacco Free Initiative (TFI)
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  • Department of Health (2006) How Much is Too Much? Drinking and You

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