In the UK some three-and-a-half million adults of working age suffer from asthma. Through analysis of the intervention to support one worker, Barbra Grohs and Professor Anne Harriss show the important role that occupational health can play in helping to manage and risk manage this condition, especially when it is being exacerbated by the workplace.
The aim of this article is to present the occupational health (OH) care of Mali (a pseudonym), a soldering technician, who had been referred to OH by his manager following seven episodes of short-term absence related to asthma.
These absences had resulted from exacerbations of his existing asthma and had arisen since commencing his role. There were concerns these absences could be associated with the work processes he performed.
About the authors
Barbra Grohs is a specialist occupational health adviser and Professor Anne Harris is emeritus professor in occupational health
When undertaking a management referral, the OH nurse/client interaction is associated with professional responsibilities. This includes the OH nurse having a duty to ensure from the outset that the employee has been properly informed of the purpose of the consultation and ensuring they have consented to the process and the preparation and release of an OH report.
Written consent to proceed with the consultation was therefore obtained. The role of the advisor and of the OH service in ensuring employees are not harmed by the work they perform was explained and the OH role in promoting the health and wellbeing of the workforce was highlighted (Thornbory, 2014).
To establish transparency, the reason for the referral was discussed. The questions raised by his manager and sickness absence dates were confirmed. The consequences of Mali not consenting to either the referral or release of the report were clearly explained.
The nature of the report to be sent to his manager following the consultation was clarified and he was told he could have sight of it before it was sent to the referring manager to correct any factual inaccuracies.
The confidential nature of the consultation was explained, as was how any health information would be used. Personal information must be kept confidential and information disclosed with the employee’s consent and only when justified. Once this had been established the consultation was undertaken.
Characteristics of asthma
Asthma is a common respiratory condition affecting people of all ethnicities, genders and across the age spectrum. It is characterised by airway inflammation, bronchial hyper-reactivity and bronchospasm leading to symptoms of recurring chest tightness, wheezing coughing and breathlessness. It is one of the major non-communicable diseases with more than 235 million people living with this condition (World Health Organization (WHO) 2017).
In the UK three-and-a-half million adults of working age suffer from asthma (Asthma UK, 2019) with a significant national impact, as the NHS spends £1bn per annum on treating this condition (Lofts & Wong 2018).
Mali disclosed having suffered with asthma since childhood, explaining that strong smells, exercise and stress triggered attacks.
He had observed an association between a recent exacerbation of his symptoms and his work as a welder. Such an association has also been noted by the Health and Safety Executive (2019).
Recognising trigger factors is important, as avoiding triggers can improve their symptoms reducing the likelihood of an acute exacerbation of their condition.
Mali’s condition was controlled using Symbicort and Ventolin inhalers. He was a non-smoker and, other than long-standing seasonal rhinitis, had no other long-term conditions. His asthma had been well controlled until commencing his current post as a full-time soldering technician six months previously.
He disclosed having been admitted to hospital for treatment for asthma two years ago, but since that point he had generally been symptom-free, rarely needing to use his Ventolin inhaler.
Over the last few months however, and since taking up his current post, he was now having three to four asthma attacks each week. The effectiveness of his medication had last been reviewed by his general practitioner three months previously.
Mali’s work tasks involved melting and applying solder using colophony, a rosin-based solder flux. Colophony, a known asthmagen (Health and Safety Executive 2015) is a common cause of occupational sensitisation.
It has been identified as one of the top five causes of occupational asthma and in the top ten for causing allergic alveolitis, eye irritation and rhinitis (Burge, 2000). Since starting this job, his use of inhalers had increased and his hayfever symptoms, which included rhinitis and eye irritation, had worsened.
Asthma control test
An indication of the level of symptom control can be assessed using the asthma control test (Nathan et al 2004). This incorporates five multi-choice questions producing an overall score of between 5-25, with a score below 19 indicating sub-optimal control. Mali scored within in this category.
A purely biomedical model could have been used to identify and document health issues. Such an approach has its limitations as it focuses on biological pathology but fails to take into account subjective experiences and human qualities (Palmer et al, 2013). The biopsychosocial model (BPSM) proposed by Engel (1980) incorporates a more holistic approach than the pure medical model incorporating additional psychosocial facets.
Although preferable to a purely medical model, the shortfall is that it lacks sufficient focus on factors within the workplace. The seminal Hanasaari (1988) model takes workplace issues into consideration. Consequently, the assessment process was guided by both the Hanasaari (1988) model and the BPSM, as this provided a systematic approach to taking a medical, psychological and social history and considers the client within the context of the workplace.
How these approaches were applied is discussed below. The Hanasaari (1988) model was selected to guide the consultation, as it incorporates a global view on assessing the relationship between the employee (man), health and work represented by the central triad (Federation of Occupational Health Nursing in the European Union (FOHNEU), 1998).
An outer circle acknowledges global effects, includes the economic, political, social, ecological and organisational factors. Within these global concepts lie organisational policies and procedures and the legal aspects discussed above, such as the requirements of Section 2 of the Health and Safety at Work Act 1974, the Control of Substances Hazardous to Health (COSHH) Regulations 2002.
With regards to COSHH, regulations six and 11 are particularly relevant, as the former requires risk assessments and the latter requires health surveillance to be offered to employees working with hazardous materials.
The Equality Act 2010 is also pertinent as asthma is a long-term condition, and was significantly impacting on Mali’s quality of life. The decision regarding whether the Equality Act 2010 applies is a legal one, however, and can only be made by a judge or an employment tribunal judge.
Under the Hanasaari model, occupational health is presented as a flexible, proactive influence that improves the health of employees, with the potential to affect communities outside the workplace and influencing the total environment.
The level of its impact is influenced by: the global environment, teamwork, research and professional and personal values of the nurse (FOHNEU, 1998). Engel’s BPSM incorporates coloured flags representing medical, psychological and social elements that may be barriers to continuing in post.
The referral information provided by Mali’s manager was important in relation to the man, work and health triad that is central to the Hanasaari (1988) model. Mali’s manager had provided data-sheets for all the materials to which Mali was exposed in the workplace, including those for solvents and cleaning agents.
The data-sheets for these materials included the hazard statements H334 and H335 and risk phrases R42 and R43, indicating their association with respiratory irritation and sensitisation from inhalation and skin contact. Four of the eight chemicals he used could have been aggravating Mali’s asthma and, it was concluded, could be associated with worsening his rhinitis and his increased use of inhalers.
Pathophysiological changes associated with asthma
Asthma is a heightened auto-immune response associated with environmental and genetic factors resulting from immune responses elicited by antigens and characterised by raised IgE antibody levels (Spickett, 2013).
The IgE antibody is specific to one allergen, triggering the release of histamine and heparin granules from the mast cess into the interstitial tissue, resulting in oedematous and restricted airways (West and Harriss 2016).
Lofts and Wong (2018) note two types of occupational asthma: irritant-induced and allergic asthma. In Mali’s case, the material data-sheets confirmed that materials he used at work included both respiratory irritants and sensitisers. Although Mali stated that his asthma attacks could also be triggered by exercise, his symptoms worsened significantly when performing soldering activities.
Cullinan (2011) highlights the two broad categories of work-related asthma, the first a newly induced exposure to airborne sensitiser or irritant at work and the second a pre-existing asthma provoked by workplace exposure to aggravating agents, including exercise, fumes and dusts. Welding and soldering are high risk with regards to exacerbation of asthma and the development of occupational asthma.
People with asthma have very sensitive airways, triggers causing the muscles around the airways to tighten, restricting their lumen. The lining becomes inflamed with increased sputum further narrowing them, resulting in increasing breathing difficulties (British Lung Foundation (BLF), 2019).
Spirometry is the lung function test used in the assessment of people with respiratory illnesses. Three spirometry measurements, the FVC, FEV1 and FEV1/FVC ratio, are compared to predicted values based on healthy individuals with normal lung function of the same sex, age, height and ethnicity of the person being assessed.
Interpretation of spirometry results involves comparing measured values to predicted values. If the FVC and the FEV1 are within 80% of the predicted value, the results are considered to be normal. The normal value for the FEV1/FVC ratio is 70% (65% in those aged over 65). The lower the measured value compared to the reference value corresponds to increasingly severe lung abnormality, as shown below.
Spirometry test FVC and FEV1
- Normal: equal to or greater than 80%
- Abnormal: 70-79% (mild); 60-69% (moderate); less than 60% (severe)
Spirometry test FEV1/FVC
- Normal: equal to or greater than 70%
- Abnormal: 60-69% (mild); 50-59% (moderate); less than 50% (severe)
Mali’s FEV1 was 70% of the predicted value based on his height and ethnicity and an FEV1/FVC ratio of 69% indicating a moderate abnormality and an obstructive pattern. Mali gave positive answers for asthmatic symptoms, and when spirometry was undertaken an FEV1/FVC ratio of 69% was recorded.
In order to gain a better insight into the timing and severity of his symptoms, Mali was asked to participate in serial peak expiratory flow measurements. These were performed two-hourly during waking hours on both work and non-workdays and over a four-week period.
The aim was to identify any patterns which might indicate work exacerbated asthma (Moore, 2012). This term describes the worsening of asthma related to work but the patient’s asthma is not caused by work.
Engel’s (1980) BPSM provides a holistic understanding of health and as a function of the relationship between biological, psychological and social elements (Lunt et al, 2007) explaining biopsychosocial interrelations, coping mechanisms, personality, social support, organisational culture, and socio-economic elements.
In Mali’s case, using this model for a comprehensive assessment provided reliable information for quality clinical records and reports. Central to this model is that healthcare must take account of the influence of psychosocial factors on the course of illness shifting the focus from disease and recognising that illness starts with a health problem, is subjective and has a personal, psychological dimension which is ultimately expressed in a social context (Palmer et al 2013).
Cognisance of the clinical effects of asthma is referred to as red flags, (Watson, 2012) and formed one element of the consultation. The second facet of the BPSM is a range psychosocial flags.
Watson (2012) observes that yellow flags consider how feelings and behaviours affect the way an employee manages a situation, black flags relate to the environment within which the employee functions whilst blue flags cover workplace concerns and the client’s perceptions regarding their work and health (Watson, 2012).
Mali was keen to continue to undertake his existing work responsibilities, so there were no concerns regarding blue flags. He was aware his manager was keen to ensure that none of his team should be exposed to hazardous materials and therefore black flags were not a concern.
The only other significant applicable flag was a blue flag and related to Mali’s perception that his colleagues were unsupportive. He reported they made fun of him during exacerbations of his asthma, telling him to calm down as they thought he was having a panic attack. This experience was explored with Mali, along with strategies which could be utilised to address this.
Referral to an occupational physician
As a deterioration in his lung function was noted and associated with his work with colophony he was referred to the occupational physician (OP) for a further opinion.
A diagnosis of work-exacerbated asthma resulted. This condition is generally manageable provided there is careful attention to the control of workplace exposures. Elimination of causative materials, substituting these with other reagents, engineering and administrative controls are first-line control strategies.
Personal protective equipment (PPE) should only be considered as the last resort once all other available control measures have been tried and deemed inadequate. This advice was incorporated in the response from the OH nurse to Mali’s manager.
A further recommendation was that the efficacy of control measures should be checked and an occupational hygienist would be able to give advice on whether current control measures were both sufficient and effective.
Cullinan (2011) notes that such workplace controls should be supplemented with appropriate pharmacological treatment of the underlying disease.
Effective collaboration with an OH multi-professional team including an OH nurse, physician and hygienist helped Mali returned to work safely. This supported the employer to meet its business needs and its legal obligation to ensure the safety at work of its employees.
As a result of a risk assessment and a further assessment undertaken by an occupational hygienist it was decided that improvements could be made with regards to local exhaust ventilation.
The specification of an extracted booth with air speed between 0.5m and 1m per second at the face of the booth and tip extraction on the soldering iron would reduce exposure to hazardous substances during soldering.
Effective local exhaust ventilation or dust/fume extraction can carry away airborne contaminants before they can be inhaled.
In conclusion, considering the effect of work processes on health and health on work and viewing these through the lens of the Hanasaari (1988) model focused the approach of the OH adviser when considering the effect of work processes on health and health on work.
It acted as a reminder that the role of the OH adviser is to consider how work-exacerbated ill health can be addressed.
The multi-disciplinary team approach involved further advice from an occupational physician and an occupational hygienist. The BPSM guided the consultation by the OH nurse and ensured psychosocial elements were acknowledged.
Recommending strategies that supported Mali to remain at work and avoid unemployment was an important public health initiative, as unemployment and financial deprivation is associated with deteriorating health (Black, 2008).
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