OCCUP. MED. (1992) 42, 175-178
VIEWPOINT '92
Health promotion in the British workplace: a suitable case for treatment? Irene Menzies Hill Edinburgh, UK
INTRODUCTION In 1705, Bernardino Ramazzini the acclaimed father of occupational medicine stated that, "tis a sordid profit that is accompanied by the destruction of health'1, a statement which still has some relevance in the organization of work in modern Britain. Government policy on occupational health provision is in a state of flux. The growth of occupational health departments in the workplace has been haphazard and disorganized, with the decision to introduce such a service left to the individual employer. Existing workplace cover may consist of a doctor, nurse, safety officer, first-aider or occupational hygienist, working either singly or in a group, and providing a wide range of uncoordinated health/hazard-related services. Welldeveloped services are provided in previously nationalized industries and many of those with a perceived high risk of injury or occupational disease but, despite many recommendations, over 80 per cent of British worksites still have grossly inadequate provision. This voluntary approach would appear to have failed, with small workforces and those where females predominate, being particularly deficient2. As so few workers have access to an occupational health specialist, they present at local surgeries or hospitals, to be seen by doctors who may have no postgraduate experience of occupational health3. This Requests lor reprints should be addressed to: Irene Menzies Hill, 40 Cadogan Road, Edinburgh EH16 6LY, UK.
© 1992 Butterworth-Heinemann (or SOM 0962-7480/92/040175-04
means that the effects of work on health can go undetected and unrecorded. However, although postgraduate training for General Practitioners in occupational health has been advocated for many years, provision is still variable, and the recent inadequate funding of academic occupational health departments4, is threatening the future training of both undergraduates and postgraduate physicians in this field. Traditionally, occupational health services have been concerned mainly with pre-employment screening, accident prevention, or health surveillance of those working in hazardous areas. With the exception of a limited number offirmswith enthusiastic and experienced occupational health nurses and physicians, little attention has been given to the promotion of health in the workplace. Indeed, the current syllabus of the Faculty of Occupational Medicine5, pays scant attention to the teaching of health education to its trainees, so there is every reason to suppose that the medical model will continue to dominate occupational health practice in the future. Clearly, the majority of health promotion activities extend beyond the boundaries of most traditional British occupational health departments. Currently, British occupational health physicians and nurses are employed in an advisory capacity only and, although they can recommend changes in damaging work practices to management, they have no executive power. The power of enforcement is held by both local authority environmental health departments and the
Downloaded from http://occmed.oxfordjournals.org/ at Indiana University Library on July 12, 2015
Over the years, the British workplace has provided a fertile bed for the growth of health-related surveillance, research and intervention. A brief review of the literature on this topic, highlights the plethora of different groups involved, and their differing agenda in relation to the health of the workforce. Key participants, including the workforce, have different perceptions of, and commitment to, the promotion of health. Health promotion should be concerned with reducing inequalities in health experience and opportunity but, because the large majority of British workplaces have no access to appropriate occupational health services, most health promotion activity is concentrated in large profit-making concerns with suitable existing facilities. In this article, the background to health-related initiatives in the British workplace is given, and the various contributions to workplace health promoting activities are noted. Their potential for mis-use is discussed and the. need for a more comprehensive and integrated approach to primary care, including health promotion, is suggested. In the present economic climate in Britain there is a need to create a comprehensive database of all health promotion activities so that, with collaboration, integration and coordination of all initiatives, regardless of venue, we can put our present meagre resources to best use.
176
Occup. Med. 1992, Vol. 42, No 4
THE STATE OF THE ART In 1984, a former employee of the Health Education Council considered that, 'health education in the workplace consists largely of 'ad hoc' initiatives resulting from individual enthusiasm, they are poorly supported, unrelated to need, use inappropriate methods and have made little impact'10. As yet there has been no national survey of worksite health promotion initiatives in Britain, so it is impossible to assess whether any real progress has been made, though there is evidence of an increased awareness of the workplace as a venue for health promoting activities. A few of the country's main employers, in consultation
with the trade unions, have been instrumental in the setting up of the worksite health promotion programmes11. Similarly, national health promotion projects such as the 'Look After Yourself (LAY) programme, 'Heartbeat Wales'12, and smaller projects such as the use of mobile screening units13, have also been taken up by industry. These programmes have been directed at a wide range of health issues including smoking, cervical and breast screening, stress, nutrition, blood cholesterol, diet and exercise; as well as at traditional occupational health concerns such as noise, dusts and hazardous substances. In general, the combination of 'lifestyle' and environmental factors is sound practice as, in some hazardous work environments, only when these issues have been raised, will wider campaigns on the hazards of smoking and diet seem credible and relevant to many workers. Meanwhile, the toll from work-related diseases and injuries is still large, and few workers are fully informed about the health hazards they face in the workplace. Since the demise of the Industrial Health Education Society in 1944, education of the shopfloor worker on occupational health, as opposed to safety, has been sadly neglected14. In an attempt to redress the balance, some individual occupational health projects have been set up in major industrial towns in England, which attempt to facilitate the flow of information on occupational health and hazards to both workers and their general practitioners. The schemes operate mainly for small workplaces with no occupational health provision, and GPs are provided with record cards detailing the work histories and identifying possible hazard exposures of consulting workers15'16. The researchers emphasize the benefits of siting such occupational health care in the GP surgery but, as these initiatives are independent of the workplace, they may tend to promote the individualistic view of becoming a 'safe worker' rather than also attempting to establish a safe workplace by measuring exposures, quantifying risks and implementing controls. Generally speaking it is environmental factors which determine the risk of a given occupation or activity, and all reasonably practicable means should be implemented to control these, before emphasis is placed on behaviour modification of workers. Freedom from hazards to health is, however, dependent upon the active cooperation of the employees. Bamford17 suggests that the 'occupational health team is in a privileged position to undertake health promotion activities in the workplace, as they have the know-how of medical practice, are respected and trusted by workers and have unique employee contact. They move with ease among the whole range of employees and can relate to workers'. However, as this same team must constantly walk the tightrope between the implementation of company policy and care of the individual worker, the workforce may well be suspicious of a crusading health promotion initiative perceived as a management 'weeding-out' exercise. Although based on the North American experience, Gordon18 argues persuasively against the use of the workplace for health promotion activities, as she sees
Downloaded from http://occmed.oxfordjournals.org/ at Indiana University Library on July 12, 2015
Health and Safety Executive, who are charged with taking appropriate steps to secure the health, safety and welfare of people at work. However, although tighter controls have been introduced recently, notably on the use of hazardous substances6, with the imposition of a statutory obligation on employers to provide information, instruction and training for those likely to be exposed, the system of inspecting worksites has been undermined by a declining health and safety inspectorate. The problem is compounded by the practice of subcontracting, an increase in the number of small firms, and the proportion of the British workforce who are now self-employed7. Unfortunately, these are the areas which have been found to perform badly in health and safety terms, as the employees lack the protection of union representation, and also have inadequate occupational health service provision8. In general however, state provision of health and safety information to small businesses has also been minimal and, as small firms and workplaces are rarely inspected, many owners know little about the legislative and technical requirements necessary to protect their workforces. The fragmentation of health promoting services in the British workplace has been further complicated by the recent imposition of elements of preventative medicine on general practitioners, by the implementation of new GP contracts with the National Health Service. These place specific requirements on GPs to undertake health screening, and to reach targets for vaccination and cervical cytology. A recent survey has found that general practitioners are less than happy for workplace provision of those services which would normally attract an item-of-service fee in general practice, though they are happy for health-affecting 'lifestyle' factors to be tackled in this setting9. As some general practitioners already feel that occupational health physicians and nurses 'meddle' in primary care, and occupational health teams feel that the health of the workforce is their remit, this could beg the question of what health promoting work should be carried out in the British workplace, and who the main actors should be. These questions are however irrelevant for the large majority of workplaces which have no access to health care of any kind.
Health promotion in the British workplace: I. M. Hill
in the British workplace is not known, of those which have been reported, very few have been sited in the food industry or in the traditionally male-orientated workplaces such as mining, steel or car manufacturing. An excellent reason for using the workplace for health promotion therefore, is in its ability to target a captive audience of male workers, who would normally fall through the health care/health promotion net. Despite the fact that the male unskilled worker enters employment earlier than his skilled counterpart, usually works in a noisier, dirtier, more physically demanding job, is subject to shift-work and longer hours, and generally has a shorter holiday entitlement than a professional worker, promotion of his health has been largely ignored. Certainly in Britain, women and children are the main recipients of the majority of screening activities, immunization programmes, community developments, self-help groups and health education activities. Paradoxically, women have also been found to be the main participants in worksite health promotion programmes21.
CONCLUSION It can be seen that a large number of factors inhibit a more comprehensive approach to health promotion in the British workplace, and the recommendation of a remedy, pre-supposes that the worksite is a suitable venue for such activity. This has yet to be proved. Ethical problems and ironies exist which must be identified and remedied, and existing inequalities in workplace health care provision must be tackled. Until every worker has access to even basic occupational health services, including adequate health education directly relevant to occupational health risks, then the benefits of health promoting activities will continue to be enjoyed only by those employed in the larger companies which have the resources to provide such programmes. Thus, legislation is required to influence the development of occupational health departments and services for all, and small companies should be encouraged to make collective arrangements with local, suitably qualified, occupational health physicians. Because of the proposed changes in the administration of the National Health Service, new self-governing hospitals could be in a position to sell occupational health services to localfirms,in order to raise additional income. As this would be dependent on the continuous employment of suitably trained practitioners, adequate funding of academic occupational health departments would be essential. By offering financial incentives to GPs who undertake 'health promotion work', the British government has identified the importance of the Primary Care team in this field. Although it is the policy of most occupational health departments to share the results of workplace screening with local GPs, the subject of item-of-service fees, and the conflicting agenda of key actors in workplace health promotion activity, must be resolved. Finally, there is a need for all health-promoting activity to be centrally registered so that an holistic
Downloaded from http://occmed.oxfordjournals.org/ at Indiana University Library on July 12, 2015
that it is not necessarily a neutral ground, and feels that 'voluntary' programme participation can sometimes obscure subtle coercion. Occupational physicians who. are 'company' men may make clinical decisions which allow the personnel department to screen out workers with existing conditions and, by focusing on the hazards of smoking to individual workers for example, they may shield the company from litigation over hazardous, dusty work practices. Gordon also questions whether confidentiality can be maintained under these conditions. A company without a well established alcohol policy for example, may deter an employee from seeking advice and counselling concerning a drink problem and, if the alcohol problem affects the safety of the workforce, then the company doctor cannot remain neutral and maintain confidentiality. As the large majority of well organised health promotion activities in Britain are based in large companies which follow the North American lead, these comments will have some relevance to any workplace health promotion activity run by occupational health departments, and are therefore worthy of consideration. Health promotion activity should aim to make 'healthy choices easy choices', and consequently, the implementation of workplace smoking, alcohol and food policies are high on most agenda. Thankfully, because of the collective nature of these worksite campaigns, concentration on 'lifestyle' factors should not be perceived as 'victim blaming'. However, it is still necessary to recognise the limitations of the concept of 'free choice' if it is assumed that the word on healthy 'lifestyles' will spread from the workplace into the community19. Women, for example, are traditionally thought to be in control of family eating habits but, research has shown that the food choices of a family have more to do with the preferences of the male partner20. Concentration on promoting healthy eating patterns in women in the workplace therefore, may only serve to increase their burden of guilt if they are forced to continue feeding their family on an 'unhealthy' diet at home. In the large housing estate which provides workers for a local factory for example, food choices are dependent on the local traders, rather than under the control of the consumer. Similar dilemmas occur with the large numbers of the British workforce employed in the manufacturing and retail side of the food industry which produces instant, highly processed, high fat, high salt and high sugar convenience foods for the modern market. An accepted bonus in these areas consists of a workers allowance of the company's products, either free or at vastly reduced prices. Thus, free biscuits, cakes and pastries, free or reduced-price pies, sausages or other reconstituted meat and fish products are made available to a grateful workforce. A health promotion message in these workplaces, on either dental health or healthy eating, might seem unrealistic to a workforce which needs the cheap foods to stretch their limited financial resources, though it could provide a unique chance for an enthusiastic occupational health team to educate the manufacturer in the production of a more healthy product. Although the full extent of health promotion activities
177
178
Occup. Med. 1992, Vol. 42, No 4
approach to health, safety and welfare can emerge encompassing, not only the workplace, but the community in which it is situated.
REFERENCES
Downloaded from http://occmed.oxfordjournals.org/ at Indiana University Library on July 12, 2015
1. Ramazzini B. Diseases of Workers. (De Morbis Artificum Diatriba, 1713). Translated from the Latin text. New York: Hafner, 1964. 2. Webb T, Schilling R. Health at Work? London: Health Education Authority, 1988. 3. Harrington JM, Philipp R, Seaton A. Undergraduate Occupational Health Teaching in British Medical Schools. J R Coll Phys 1989; 1: 24-7. 4. British Medical Association. News item. Br MedJ 1988; 297: 1050-1. 5. Royal College of Physicians. Syllabus of the Faculty of Occupational Medicine 1985. 6. Health and Safety Commission. Control of Substances Hazardous to Health Regulations. London: HMSO, 1988. 7. Harvey S. Just an occupational hazard? Policies for Health at Work. London: Kings Fund, 1989. 8. Lee WR. Health and Safety in Small Businesses. Br Med J 1987; 295: 230. 9. Parker G. Attitudes of General Practitioners to Occupational Health Services. J Soc Occup Med 1991; 41: 34-6. 10. McEwan J. Health Education in the Workplace. In:
Harrington JM. (ed) Recent Advances in Occupational Health. Edinburgh: Churchill Livingstone, 1984; 211-21. 11. Scottish Health Education Group. Health Promotion in the Workplace. Edinburgh: SHEG, 1987. 12. Langley A, Lewis S, Harries M. Health promotion in the Workplace. Occup Health 1988;December: 724-5. 13. Thornton J, Chamberlain J. Cervical screening in the workplace. Community Med 1989; 11: 290-8. 14. Watterson A. Occupational Healdi Education in die United Kingdom workplace: looking backwards and going forwards? Br J Ind Med 1990; 47: 366-71. 15. Camden Occupational Health Project. Occupational Health Workers, new members of the Primary Care Team. London: C.O.H.P. 1988. 16. Bedale C. Work and Health Project. North Manchester Health Promotion Unit, Manchester M9 1XS, 1990. 17. Bamford T. Healdi Education. In: Dixon WW, Price SM. (eds.) Aspects of Occupational Health. London: Faber & Faber, 1984; 73-92. 18. Gordon J. Workplace Health Promotion: the right idea in the wrong place. Health Education Research 1987; 2: 69-71. 19. Baric L. A healthy enterprise in a healthy environment. Journal of the Institute of Health Education 1990; 28: 84-91. 20. '• Charles N, Kerr M. Issues of responsibility and control in the feeding of families. In: Rodmell S, Watt A. (eds.) The Politics of Health Education. London: Routledge & Kegan Paul, 1986; 57-75. 21. Sloan RP, Gruman J. Participation in workplace health promotion programmes: the contribution of health and organisational factors. Health Educ Q 1988; 15:269-88.
VIEWPOINT '92
Health promotion in the British workplace: a suitable case for treatment? Irene Menzies Hill Edinburgh, UK
INTRODUCTION In 1705, Bernardino Ramazzini the acclaimed father of occupational medicine stated that, "tis a sordid profit that is accompanied by the destruction of health'1, a statement which still has some relevance in the organization of work in modern Britain. Government policy on occupational health provision is in a state of flux. The growth of occupational health departments in the workplace has been haphazard and disorganized, with the decision to introduce such a service left to the individual employer. Existing workplace cover may consist of a doctor, nurse, safety officer, first-aider or occupational hygienist, working either singly or in a group, and providing a wide range of uncoordinated health/hazard-related services. Welldeveloped services are provided in previously nationalized industries and many of those with a perceived high risk of injury or occupational disease but, despite many recommendations, over 80 per cent of British worksites still have grossly inadequate provision. This voluntary approach would appear to have failed, with small workforces and those where females predominate, being particularly deficient2. As so few workers have access to an occupational health specialist, they present at local surgeries or hospitals, to be seen by doctors who may have no postgraduate experience of occupational health3. This Requests lor reprints should be addressed to: Irene Menzies Hill, 40 Cadogan Road, Edinburgh EH16 6LY, UK.
© 1992 Butterworth-Heinemann (or SOM 0962-7480/92/040175-04
means that the effects of work on health can go undetected and unrecorded. However, although postgraduate training for General Practitioners in occupational health has been advocated for many years, provision is still variable, and the recent inadequate funding of academic occupational health departments4, is threatening the future training of both undergraduates and postgraduate physicians in this field. Traditionally, occupational health services have been concerned mainly with pre-employment screening, accident prevention, or health surveillance of those working in hazardous areas. With the exception of a limited number offirmswith enthusiastic and experienced occupational health nurses and physicians, little attention has been given to the promotion of health in the workplace. Indeed, the current syllabus of the Faculty of Occupational Medicine5, pays scant attention to the teaching of health education to its trainees, so there is every reason to suppose that the medical model will continue to dominate occupational health practice in the future. Clearly, the majority of health promotion activities extend beyond the boundaries of most traditional British occupational health departments. Currently, British occupational health physicians and nurses are employed in an advisory capacity only and, although they can recommend changes in damaging work practices to management, they have no executive power. The power of enforcement is held by both local authority environmental health departments and the
Downloaded from http://occmed.oxfordjournals.org/ at Indiana University Library on July 12, 2015
Over the years, the British workplace has provided a fertile bed for the growth of health-related surveillance, research and intervention. A brief review of the literature on this topic, highlights the plethora of different groups involved, and their differing agenda in relation to the health of the workforce. Key participants, including the workforce, have different perceptions of, and commitment to, the promotion of health. Health promotion should be concerned with reducing inequalities in health experience and opportunity but, because the large majority of British workplaces have no access to appropriate occupational health services, most health promotion activity is concentrated in large profit-making concerns with suitable existing facilities. In this article, the background to health-related initiatives in the British workplace is given, and the various contributions to workplace health promoting activities are noted. Their potential for mis-use is discussed and the. need for a more comprehensive and integrated approach to primary care, including health promotion, is suggested. In the present economic climate in Britain there is a need to create a comprehensive database of all health promotion activities so that, with collaboration, integration and coordination of all initiatives, regardless of venue, we can put our present meagre resources to best use.
176
Occup. Med. 1992, Vol. 42, No 4
THE STATE OF THE ART In 1984, a former employee of the Health Education Council considered that, 'health education in the workplace consists largely of 'ad hoc' initiatives resulting from individual enthusiasm, they are poorly supported, unrelated to need, use inappropriate methods and have made little impact'10. As yet there has been no national survey of worksite health promotion initiatives in Britain, so it is impossible to assess whether any real progress has been made, though there is evidence of an increased awareness of the workplace as a venue for health promoting activities. A few of the country's main employers, in consultation
with the trade unions, have been instrumental in the setting up of the worksite health promotion programmes11. Similarly, national health promotion projects such as the 'Look After Yourself (LAY) programme, 'Heartbeat Wales'12, and smaller projects such as the use of mobile screening units13, have also been taken up by industry. These programmes have been directed at a wide range of health issues including smoking, cervical and breast screening, stress, nutrition, blood cholesterol, diet and exercise; as well as at traditional occupational health concerns such as noise, dusts and hazardous substances. In general, the combination of 'lifestyle' and environmental factors is sound practice as, in some hazardous work environments, only when these issues have been raised, will wider campaigns on the hazards of smoking and diet seem credible and relevant to many workers. Meanwhile, the toll from work-related diseases and injuries is still large, and few workers are fully informed about the health hazards they face in the workplace. Since the demise of the Industrial Health Education Society in 1944, education of the shopfloor worker on occupational health, as opposed to safety, has been sadly neglected14. In an attempt to redress the balance, some individual occupational health projects have been set up in major industrial towns in England, which attempt to facilitate the flow of information on occupational health and hazards to both workers and their general practitioners. The schemes operate mainly for small workplaces with no occupational health provision, and GPs are provided with record cards detailing the work histories and identifying possible hazard exposures of consulting workers15'16. The researchers emphasize the benefits of siting such occupational health care in the GP surgery but, as these initiatives are independent of the workplace, they may tend to promote the individualistic view of becoming a 'safe worker' rather than also attempting to establish a safe workplace by measuring exposures, quantifying risks and implementing controls. Generally speaking it is environmental factors which determine the risk of a given occupation or activity, and all reasonably practicable means should be implemented to control these, before emphasis is placed on behaviour modification of workers. Freedom from hazards to health is, however, dependent upon the active cooperation of the employees. Bamford17 suggests that the 'occupational health team is in a privileged position to undertake health promotion activities in the workplace, as they have the know-how of medical practice, are respected and trusted by workers and have unique employee contact. They move with ease among the whole range of employees and can relate to workers'. However, as this same team must constantly walk the tightrope between the implementation of company policy and care of the individual worker, the workforce may well be suspicious of a crusading health promotion initiative perceived as a management 'weeding-out' exercise. Although based on the North American experience, Gordon18 argues persuasively against the use of the workplace for health promotion activities, as she sees
Downloaded from http://occmed.oxfordjournals.org/ at Indiana University Library on July 12, 2015
Health and Safety Executive, who are charged with taking appropriate steps to secure the health, safety and welfare of people at work. However, although tighter controls have been introduced recently, notably on the use of hazardous substances6, with the imposition of a statutory obligation on employers to provide information, instruction and training for those likely to be exposed, the system of inspecting worksites has been undermined by a declining health and safety inspectorate. The problem is compounded by the practice of subcontracting, an increase in the number of small firms, and the proportion of the British workforce who are now self-employed7. Unfortunately, these are the areas which have been found to perform badly in health and safety terms, as the employees lack the protection of union representation, and also have inadequate occupational health service provision8. In general however, state provision of health and safety information to small businesses has also been minimal and, as small firms and workplaces are rarely inspected, many owners know little about the legislative and technical requirements necessary to protect their workforces. The fragmentation of health promoting services in the British workplace has been further complicated by the recent imposition of elements of preventative medicine on general practitioners, by the implementation of new GP contracts with the National Health Service. These place specific requirements on GPs to undertake health screening, and to reach targets for vaccination and cervical cytology. A recent survey has found that general practitioners are less than happy for workplace provision of those services which would normally attract an item-of-service fee in general practice, though they are happy for health-affecting 'lifestyle' factors to be tackled in this setting9. As some general practitioners already feel that occupational health physicians and nurses 'meddle' in primary care, and occupational health teams feel that the health of the workforce is their remit, this could beg the question of what health promoting work should be carried out in the British workplace, and who the main actors should be. These questions are however irrelevant for the large majority of workplaces which have no access to health care of any kind.
Health promotion in the British workplace: I. M. Hill
in the British workplace is not known, of those which have been reported, very few have been sited in the food industry or in the traditionally male-orientated workplaces such as mining, steel or car manufacturing. An excellent reason for using the workplace for health promotion therefore, is in its ability to target a captive audience of male workers, who would normally fall through the health care/health promotion net. Despite the fact that the male unskilled worker enters employment earlier than his skilled counterpart, usually works in a noisier, dirtier, more physically demanding job, is subject to shift-work and longer hours, and generally has a shorter holiday entitlement than a professional worker, promotion of his health has been largely ignored. Certainly in Britain, women and children are the main recipients of the majority of screening activities, immunization programmes, community developments, self-help groups and health education activities. Paradoxically, women have also been found to be the main participants in worksite health promotion programmes21.
CONCLUSION It can be seen that a large number of factors inhibit a more comprehensive approach to health promotion in the British workplace, and the recommendation of a remedy, pre-supposes that the worksite is a suitable venue for such activity. This has yet to be proved. Ethical problems and ironies exist which must be identified and remedied, and existing inequalities in workplace health care provision must be tackled. Until every worker has access to even basic occupational health services, including adequate health education directly relevant to occupational health risks, then the benefits of health promoting activities will continue to be enjoyed only by those employed in the larger companies which have the resources to provide such programmes. Thus, legislation is required to influence the development of occupational health departments and services for all, and small companies should be encouraged to make collective arrangements with local, suitably qualified, occupational health physicians. Because of the proposed changes in the administration of the National Health Service, new self-governing hospitals could be in a position to sell occupational health services to localfirms,in order to raise additional income. As this would be dependent on the continuous employment of suitably trained practitioners, adequate funding of academic occupational health departments would be essential. By offering financial incentives to GPs who undertake 'health promotion work', the British government has identified the importance of the Primary Care team in this field. Although it is the policy of most occupational health departments to share the results of workplace screening with local GPs, the subject of item-of-service fees, and the conflicting agenda of key actors in workplace health promotion activity, must be resolved. Finally, there is a need for all health-promoting activity to be centrally registered so that an holistic
Downloaded from http://occmed.oxfordjournals.org/ at Indiana University Library on July 12, 2015
that it is not necessarily a neutral ground, and feels that 'voluntary' programme participation can sometimes obscure subtle coercion. Occupational physicians who. are 'company' men may make clinical decisions which allow the personnel department to screen out workers with existing conditions and, by focusing on the hazards of smoking to individual workers for example, they may shield the company from litigation over hazardous, dusty work practices. Gordon also questions whether confidentiality can be maintained under these conditions. A company without a well established alcohol policy for example, may deter an employee from seeking advice and counselling concerning a drink problem and, if the alcohol problem affects the safety of the workforce, then the company doctor cannot remain neutral and maintain confidentiality. As the large majority of well organised health promotion activities in Britain are based in large companies which follow the North American lead, these comments will have some relevance to any workplace health promotion activity run by occupational health departments, and are therefore worthy of consideration. Health promotion activity should aim to make 'healthy choices easy choices', and consequently, the implementation of workplace smoking, alcohol and food policies are high on most agenda. Thankfully, because of the collective nature of these worksite campaigns, concentration on 'lifestyle' factors should not be perceived as 'victim blaming'. However, it is still necessary to recognise the limitations of the concept of 'free choice' if it is assumed that the word on healthy 'lifestyles' will spread from the workplace into the community19. Women, for example, are traditionally thought to be in control of family eating habits but, research has shown that the food choices of a family have more to do with the preferences of the male partner20. Concentration on promoting healthy eating patterns in women in the workplace therefore, may only serve to increase their burden of guilt if they are forced to continue feeding their family on an 'unhealthy' diet at home. In the large housing estate which provides workers for a local factory for example, food choices are dependent on the local traders, rather than under the control of the consumer. Similar dilemmas occur with the large numbers of the British workforce employed in the manufacturing and retail side of the food industry which produces instant, highly processed, high fat, high salt and high sugar convenience foods for the modern market. An accepted bonus in these areas consists of a workers allowance of the company's products, either free or at vastly reduced prices. Thus, free biscuits, cakes and pastries, free or reduced-price pies, sausages or other reconstituted meat and fish products are made available to a grateful workforce. A health promotion message in these workplaces, on either dental health or healthy eating, might seem unrealistic to a workforce which needs the cheap foods to stretch their limited financial resources, though it could provide a unique chance for an enthusiastic occupational health team to educate the manufacturer in the production of a more healthy product. Although the full extent of health promotion activities
177
178
Occup. Med. 1992, Vol. 42, No 4
approach to health, safety and welfare can emerge encompassing, not only the workplace, but the community in which it is situated.
REFERENCES
Downloaded from http://occmed.oxfordjournals.org/ at Indiana University Library on July 12, 2015
1. Ramazzini B. Diseases of Workers. (De Morbis Artificum Diatriba, 1713). Translated from the Latin text. New York: Hafner, 1964. 2. Webb T, Schilling R. Health at Work? London: Health Education Authority, 1988. 3. Harrington JM, Philipp R, Seaton A. Undergraduate Occupational Health Teaching in British Medical Schools. J R Coll Phys 1989; 1: 24-7. 4. British Medical Association. News item. Br MedJ 1988; 297: 1050-1. 5. Royal College of Physicians. Syllabus of the Faculty of Occupational Medicine 1985. 6. Health and Safety Commission. Control of Substances Hazardous to Health Regulations. London: HMSO, 1988. 7. Harvey S. Just an occupational hazard? Policies for Health at Work. London: Kings Fund, 1989. 8. Lee WR. Health and Safety in Small Businesses. Br Med J 1987; 295: 230. 9. Parker G. Attitudes of General Practitioners to Occupational Health Services. J Soc Occup Med 1991; 41: 34-6. 10. McEwan J. Health Education in the Workplace. In:
Harrington JM. (ed) Recent Advances in Occupational Health. Edinburgh: Churchill Livingstone, 1984; 211-21. 11. Scottish Health Education Group. Health Promotion in the Workplace. Edinburgh: SHEG, 1987. 12. Langley A, Lewis S, Harries M. Health promotion in the Workplace. Occup Health 1988;December: 724-5. 13. Thornton J, Chamberlain J. Cervical screening in the workplace. Community Med 1989; 11: 290-8. 14. Watterson A. Occupational Healdi Education in die United Kingdom workplace: looking backwards and going forwards? Br J Ind Med 1990; 47: 366-71. 15. Camden Occupational Health Project. Occupational Health Workers, new members of the Primary Care Team. London: C.O.H.P. 1988. 16. Bedale C. Work and Health Project. North Manchester Health Promotion Unit, Manchester M9 1XS, 1990. 17. Bamford T. Healdi Education. In: Dixon WW, Price SM. (eds.) Aspects of Occupational Health. London: Faber & Faber, 1984; 73-92. 18. Gordon J. Workplace Health Promotion: the right idea in the wrong place. Health Education Research 1987; 2: 69-71. 19. Baric L. A healthy enterprise in a healthy environment. Journal of the Institute of Health Education 1990; 28: 84-91. 20. '• Charles N, Kerr M. Issues of responsibility and control in the feeding of families. In: Rodmell S, Watt A. (eds.) The Politics of Health Education. London: Routledge & Kegan Paul, 1986; 57-75. 21. Sloan RP, Gruman J. Participation in workplace health promotion programmes: the contribution of health and organisational factors. Health Educ Q 1988; 15:269-88.
