Keeping health under surveillance

The objective of health surveillance is ultimately to improve the wellbeing of employees. OH professionals will need to be familiar with health theories and the associated ethical standards to understand the purpose behind surveillance procedures. But it is worth first considering what is actually meant by the term ‘health’.

The concept of health is interpreted differently by various groups. The International Labour Organisation suggests that employees’ health in the workplace should involve an enhancement of their mental and physical elements. When asked, employees have varying opinions on what health is, ranging from the medical models of the absence of disease and work-related stress, to achieving optimum physical fitness. The common denominator is the absence of an obstacle that otherwise prevents people from achieving a desired level of health.

Defining health
David Seedhouse, professor of healthcare analysis at the School of Health and Social Sciences, defines this subjective view of health as “the set of conditions which enable a person to work to fulfil [their] realistic chosen potential”.

Sociologists and epidemiologists, on the other hand, correlate health with a range of other factors, which have positive or negative influences. These include the person’s socio-economic status and personal circumstances, as well as the environment in which they live and work, and exposure to diseases and the political climate, among others.

Class considerations

A study by Kunst of 11 European countries concluded that there was a link between occupational class – meaning manual or non-manual work – and mortality. For example, smoking among lower occupational classes has contributed to higher levels of ischemic heart disease in that group.

The study also suggested that individuals of higher occupational class have the means (higher incomes, a sense of control, better education) to access the best available health strategies. If this presents a true picture of some degree of inequality of access to health services, then employers are in a good position to close the gap, provided that access to workplace health programmes are available to everyone, regardless of class.

Those responsible for workplace health regulations need a more specific definition of health to develop suitable policies. An example can be found in The Health of Canadians, The Lalonde Report: “Good health is the bedrock on which social progress is built. A nation of healthy people can do those things which make life worthwhile, and as the level of health increases, so does the potential for happiness.”

The current UK guideline, the government White Paper Saving Lives: Our Healthier Nation, takes more of a deontological approach to defining health, meaning that it is based on the ethical theory of duties and rights. It states: “We want to see healthier people in a healthy country, against a backdrop of action by government. We want to see everyone take the opportunity of better health.”

This system describes a ‘social contract’ between the duty of the government, the rights of the public to expect services and the responsibility of the individual to make use of the services offered.

This ethical standard has filtered down to occupational health strategies. Health and safety regulations dictate that it is the duty of the employer to offer health surveillance, and the right of the employee to expect this service. The employee also has a responsibility to participate.

The employee enters into the social contract by informed consent, meaning that they have full knowledge of what to expect. Although employees have the option to refuse, this is discouraged by OH as it conflicts with the social contract of health surveillance provision. OH professionals must establish an ethical standard to underpin the reason for any health surveillance activity, be it utility or deontology.

What is surveillance?

According to Teutsch, health surveillance is an outcome-orientated activity – the outcome being the data that the surveillance produces – and it mainly assesses the health status of a particular group or community. In an industrial setting, Harrington implies that health surveillance is a periodic medical or physiological assessment of workers exposed to particular hazards in the workplace.

The purpose of any surveillance programme should be to prevent and protect against occupationally related diseases. This can be achieved by monitoring exposure to specific risks in the workplace. Close examination of an individual’s health status over a period of time provides evidence of safe processes in work areas.

Current health surveillance guidelines for work environments indicate that systems ought to be set up to detect early signs of occupational health problems. However, this should only be one of the functions of any programme. Another to consider is the education of employees, as encouraging them to understand the nature and importance of health surveillance ensures their co-operation. Given adequate information, they are more likely to report health problems to their managers or OH departments. Any outcomes should be discussed with the employer to reduce or eliminate risks to employees’ health.

Designing a health surveillance programme follows a simple formula.

Knowledge of controllable risk factors is just one step towards managing better health at work. Related OH activities should also include appropriate education of employees about the impact of their personal health, and habits in the working environment.

Assuming that good health can be affected by certain obstacles in the workplace, it would be useful at this point to identify some of these potential problems.

Identifying risks

The most common obstacle to health is occupational disease, defined by Cherry as a disease caused by or made worse by workplace exposures to risk elements. These risks can include vapours, airborne particles and fumes that affect respiration, and exposure to contact with abrasive and sensitising agents, such as chemicals. If noise levels are excessive, hearing may also be affected, while long periods spent using vibrating tools without adequate breaks can also be detrimental.

The main types of occupational disease linked to respiratory risk elements are occupational asthma, chronic obstructive pulmonary disease and interstitial lung disease, arising from exposure to agents such as isocyanates, coal dust and asbestos respectively. The effects of respiratory risk elements can be compounded by smoking habits and living and working in poorly ventilated areas. Where there is reason to believe that respiratory risk elements are present in the work environment, periodic lung function screening (spirometry) is one of the recommended assessment tools. Where compounding habits such as smoking exist, personal advice and health promotion is required as part of the health surveillance programme.

Skin diseases linked to exposure to foreign substances are mainly contact dermatitis, contact urticaria and occupational dermatoses. Health-surveillance programmes for contact risk elements require a review of skin hygiene practices both in and outside of work, as domestic habits can contribute to skin problems and compound the exposure effects in the workplace. Simple household chores such as using paint strippers, bleach or oven cleaners without reasonable care, can compromise skin integrity.

Workplace health surveillance for occupational disease is therefore carried out to ensure that individuals are protected from harmful elements. If the job requires that staff need to be protected, this should be contained within regulatory limits. For example, the limits of exposures to chemicals (solid, liquid or gas) as set out in Workplace Exposure Limits under Health and Safety Guidance Note EH40, covering substances that have a maximum exposure limit or are subject to an occupational exposure standard.

Occupational injuries

Health surveillance programmes are also set up to deal with another obstacle to good health – occupational injuries. To prevent this, OH practitioners must consider fitness- to-work issues and ask questions about whether an individual is capable or adequately trained to carry out a particular role.

For example, in a safety critical industry such as rail, track workers must pass a stringent medical examination. These workers are responsible for their own safety when working on or near tracks. Apart from falling within a desired range of physical capabilities, they are also expected to be free from personal habits of alcohol and drug abuse.

In less safety critical industries, good physical and mental capabilities among workers are expected. A fork-lift truck driver’s weight is not governed by legislation, however someone with a large frame may have difficulty fitting into the small space of a cab, as well as having reduced manoeuvrability and less room to carry out visual peripheral safety checks while driving. This could become a danger to others and would need to be addressed.

Workplace health surveillance in these two examples is based on ensuring safe work practices irrespective of whether it benefits the worker themselves or the people around them.

The absence of occupational mortality is perhaps the most desirable target of health surveillance programmes, and of particular relevance to this category are those who work in extreme temperatures, hostile environments and highly hazardous or safety critical jobs. For someone working in a cold store environment, for example, it is expected that they should have regular breaks, and that they be closely monitored for adverse effects of low temperatures, including poor circulation. They should also be monitored for pre-existing medical conditions such as musculoskeletal problems that would be aggravated by working in cold environments.

Cold conditions coupled with a hostile environment – for instance, a geologist working in Antarctica – requires close and frequent monitoring not only for adverse physical health effects, but also possibly for the isolation of being away from home. Psychological assessments could also be considered.

Workplace health surveillance is carried out at different levels depending on the risks and hazards of the occupations involved, ranging from basic respiratory function and audiometric testing, to more complex assessments on physical and mental capabilities. The most important overriding concern is finding ways to preserve the health of individuals and to remove obstacles that may be in conflict with this. The principles behind workplace surveillance have been tried and tested, and the results so far have been favourable.

Cherry, C (1999) Occupational Disease British Medical Journal, 318 p.1397-1399
Cox, R A F et al (2000) Fitness For Work. The Medical Aspects, 3rd Edition, Oxford University Press, Oxford
Department of Health (2000) Saving Lives: Our Healthier Nation
Harrington, J, Gill, F, Gardiner, K. (1998) Occupational Health, 4th Edition, Blackwell Science, Oxford
HSE (1999) Health Surveillance at Work, HSG61, HSE Books, Sudbury
ILO (1985) Occupational Health Services: An Overview, WHO Regional Publications, No.26 (1990) edited by Rantanen, J, Copenhagen
Kunst et al (1998) Occupational Class and Cause Specific Mortality in Middle-aged Men in 11 European Countries: Comparison of Population-based Studies, British Medical Journal, 316 (7145) p.1636-1642
Ministry of National Health and Welfare (Canada) (1974) A New Perspective on the Health of Canadians (chairman Lalonde, M), Ottawa
Rosseau, J J, translated by Cole, G D H (1762) Du Contrat Social Ou Principes Du Droit Politique, Archives de la Societe Jean-Jacques Rousseau, Geneva
Seedhouse, D. (1986) Health: The Foundations for Achievement, John Wiley & Sons, Chichester
Teutsch, S (2000) Evaluating Public Health Surveillance, Oxford University Press, New York

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