Professional Documents
Culture Documents
Framework and Model:
Background and Supporting Literature and Practices
by Joan Burton
Readers’ comments:
Kazutaka Kogi, President, International Commission on Occupational Health:
“The draft Framework is well framed and excellently prepared. The document will
be a solid basis for future developments in promoting healthy workplaces
internationally.”
Tom Shakespeare, World Health Organization, Headquarters:
“Excellent review of evidence; good, clear, workable conclusions and
recommendations.”
Marilyn Fingerhut, National Institute for Occupational Safety and Health, USA
“This is a great document! Enjoyed reading it!”
Wolf Kirsten, International Health Consulting:
“Well done on the comprehensive approach covering the key areas and at the same
time keeping it simple and avoiding long and complex scientific constructs.”
Teri Palermo, National Institute for Occupational Safety and Health, USA:
“Congratulations on an impressive and useful document. The attention to
psychosocial issues, work-life balance, mental health issues and their impact on the
safety and health of the workforce is important and not always recognized. I also
liked your discussion of the need and challenges regarding rigorous evaluation of
interventions including cost-effectiveness. The framework is comprehensive and
provides a useful guidance for program development.”
Fintan Hurley and Joanne Crawford, Institute of Occupational Medicine, Edinburgh, Scotland, UK
“We found this a very interesting, well-informed, wide-ranging and useful report. It
includes a great deal of useful information. It is written in an accessible style, which
we both liked.”
Wendy Macdonald, Centre for Ergonomics & Human Factors, La Trobe University, Victoria, Australia
“I think this is an outstandingly good document that will be extremely useful, and
for the most part is beautifully written. Congratulations to the author and the others
who have contributed… It’s a pleasure to see so many important issues linked
together and discussed (very usefully) in the one document – a real tour de force.”
Rob Gründemann, TNO, The Netherlands:
“I have read the document with great pleasure. It gives a good and comprehensive
overview of the state of the art on actions directed at workplace health and the
research on the effectiveness of workplace health interventions.”
February 2010
Submitted to Evelyn Kortum
WHO Headquarters, Geneva, Switzerland
Table of Contents
Page
Acknowledgements ……………………………………………………………………………………….. iv
i
Chapter 7: The Process: How To Create a Healthy Workplace …………………………………........ 59
A. Continual Improvement Process Models ………………………………………….…. 59
B. Are Continual Improvement/OSH Management Systems Effective? ………….….. 61
C. Key Features of the Continual Improvement Process in Health & Safety………… 62
1. Leadership Engagement based on Core Values ……………………………….. 62
2. Involve Workers and their Representatives……………………………………… 62
3. Gap Analysis………………………………………………………………….…….. 63
4. Learn from Others………………………………………………………………….. 64
5. Sustainability………………………………………………………………….…….. 64
D. The Importance of Integration ………………………………………………………… 65
ii
Tables and Figures
List of Figures Page
Figure ES1 WHO Healthy Workplace Model: Avenues of Influence, Process and Core Principles ……………. 3
Figure 9.2 WHO Model of Healthy Workplace Continual Improvement Process ……………............................. 89
Figure 9.4 WHO Healthy Workplace Model: Avenues of Influence, Process and Core Principles……………… 97
Table 4.2 Work-Family Conflict Effects On Worker Health, the Enterprise and Society ……………….………... 39
Table 6.1 Evidence for Effectiveness of Occupational Health & Safety Interventions …………………………… 48
Table 6.3 Evidence for Effectiveness of Personal Health Resource Interventions in the Workplace …………... 52
Box 7.1 Learn from Others: WISE, WIND and WISH …………………………………………………….…………. 65
Table 8.1 Countries Classified By National Economic Level And Labour Market Policies …………………….… 70
Table 8.2 Percent of Countries in WHO Regions That Have Ratified Selected ILO Conventions …………….… 71
Table 8.4 Comparison of Selected Workers’ Compensation Features in USA, Canada, Australia ……............. 75
Table 8.5 Work and the Protection of Workers’ Health in Wealthy and Poor Countries, 1880-2007. …............ 77
Table 9.1 Application of WHO Continual Improvement Process in Large and Small Enterprises ….…………… 95
iii
Acknowledgements
This document was written by Joan Burton, Canada, as result of Agreement for Performance of Work
No. 2009/26011-0. Joan Burton, BSc, RN, MEd, is a Temporary Advisor to WHO, and the Senior
Strategy Advisor, Healthy Workplaces, for the Industrial Accident Prevention Association (IAPA) (retired).
We would like to acknowledge the astute and helpful direction and input from the following individuals
who made up the Project Working Group:
• Evelyn Kortum, Global Project Coordinator, World Health Organization Headquarters,
Occupational Health, Switzerland
• PK Abeytunga, Canadian Centre for Occupational Health & Safety, Canada
• Fernando Coelho, Serviço Social da Indústria, Brazil
• Aditya Jain, Institute of Work, Health and Organisations, United Kingdom
• Marie Claude Lavoie, World Health Organization, AMRO, USA
• Stavroula Leka, Institute of Work, Health and Organisations, United Kingdom
• Manisha Pahwa, World Health Organization, AMRO, USA
Thanks are also due to the diligent and thoughtful comments provided by the Peer Reviewers:
iv
v
WHO Healthy Workplace Framework:
Background and Supporting Literature and Practices
Joan Burton
“It is unethical and short-sighted business practice to compromise the health of workers for the
wealth of enterprises.” Evelyn Kortum, WHO
Executive Summary
If you put the phrase, “healthy workplace” into four large “avenues of influence”, and also the
the Google search engine, you get about process – one of continual improvement – that
2,000,000 results. Clearly it’s a hot topic. And will ensure success and sustainability of healthy
just as clearly, once you follow some of the links, workplace initiatives. While the model can be
there are thousands of interpretations of what demonstrated graphically, as is done on page 3,
the phrase means; thousands of providers of the framework includes the description and
healthy workplace models, tools and information; explanation of what the model represents and
thousands of researchers looking into the how it works.
subject. The World Health Organization (WHO)
intends that this background document, the WHO intends that this document will be followed
framework and model of a healthy workplace, by practical Guidance documents tailored to
will help make some sense of this specific sectors and cultures, which will
overabundance of information, and provide summarize the framework and provide practical
some guidance to those stakeholders who are assistance to employers and workers and their
trying to make a difference in workplace health. representatives for implementing the healthy
workplace framework in an enterprise.
The background document is written primarily for
occupational health and/or safety professionals, The background document is organized into nine
scientists, and medical practitioners, to provide chapters, as follows:
the scientific basis for a healthy workplace
framework. It is intended to examine the Chapter 1 examines the question, “Why develop
literature related to healthy workplaces in some a framework for healthy workplaces? Indeed,
depth, and in the end, to suggest a flexible, why be concerned about healthy workplaces at
evidence-based framework for healthy all?” Some answers are provided from ethical,
workplaces that can be applied by employers business, and legal standpoints. A very brief
and workers in collaboration, regardless of the outline of recent WHO global directives is
sector or size of the enterprise, the degree of provided.
development of the country, or the regulatory or
cultural background in the country. The term Chapter 2 expands on the global picture and
“framework” is used to mean a description of key describes key declarations and documents
principles and an interpretive explanation of the agreed to by the world community through the
suggested model for healthy workplaces. The WHO and ILO over the past 60 years, looking at
phrase healthy workplace “model” is used to both occupational health and safety, and health
mean the abstract representation of the promotion efforts and initiatives.
structure, content, processes and system of the
healthy workplace concept. The model includes Chapter 3 looks at the question, “What is a
both the content of the issues that should be healthy workplace?” Some general definitions
addressed in a healthy workplace, grouped into are provided from the literature, as well as the
WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices
WHO definition developed for this document. Given the discussion about evaluation literature
Then perspectives and the work being done in in the previous chapter, this section provides
this area in each of the six WHO Regions are primarily evidence from systematic reviews of
summarized. the literature.
The WHO definition of a healthy workplace is as Chapter 7 discusses the “how to” of creating a
follows: healthy workplace, and introduces the concept
of continual improvement or OSH management
A healthy workplace is one in which workers and systems. It also includes a discussion of some
managers collaborate to use a continual of the key features of the many continual
improvement process to protect and promote the improvement models; and examines the
health, safety and well-being of workers and the importance of integration.
sustainability of the workplace by considering
the following, based on identified needs: Chapter 8 takes a step back from the framework
• health and safety concerns in the physical and looks at healthy workplace issues in the “big
work environment; picture” – the global legal and policy context.
• health, safety and well-being concerns in Clearly, while this document is focusing on
the psychosocial work environment things employers and workers can do, the
including organization of work and success of their efforts cannot help but be
workplace culture; influenced, for better or for worse, by the
• personal health resources in the workplace; external regulatory and cultural context of the
and country and society in which they operate. This
• ways of participating in the community to chapter discusses legislation and some of the
improve the health of workers, their families standards setting bodies and their work as they
and other members of the community. relate to workplace health, safety and well-being.
Chapter 4 examines the complex Chapter 9 is the chapter that presents the model
interrelationships between and among work, the and framework for a healthy workplace that
physical and mental health of workers, the WHO has developed. It is intended as a natural
community, and the health of the enterprise and outcome and conclusion to the synthesis of
society. This is a key chapter that supports with information and evidence presented in earlier
hard scientific evidence both the ethical case for chapters. Both the content of a healthy
a healthy workplace and the business case. It workplace programme in the form of four
begins to flesh out the details of which factors avenues of influence, and the suggested
under the control of employers and workers continual improvement process are discussed.
affect the health, safety and well-being of The four avenues are represented by the four
workers and the success of an enterprise. bullets in the proposed WHO definition of a
These factors provide the primary basis for the healthy workplace, above. The eight steps in
framework. the continual improvement process are
summarized as Mobilize, Assemble, Assess,
Chapter 5 discusses the issue of evaluation. Prioritize, Plan, Do, Evaluate, Improve. Both the
While there are many things employers and content and the process, as well as core
workers can do, how do they know which ones principles, are represented graphically in the
will be the most effective and cost-effective? model illustrated below.
This chapter looks at some of the issues related
to the quality of published studies and evidence. In addition to the nine chapters, there are two
annexes that include a list of acronyms and a
Chapter 6 then examines the scientific evidence glossary of terms.
for interventions that work and those that do not.
2 Executive Summary
WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices
Executive Summary 3
WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices
4 Executive Summary
WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices
Chapter 1:
Why Develop a Healthy Workplace Framework?
To answer this question, perhaps another standards, the environment, and anti-corruption.
question should be answered first: why bother At present there are over 7700 businesses from
with healthy workplaces at all? While it may be over 130 countries that have participated, to
obvious self-interest for workers and their advance their commitment to sustainability and
representatives to want a healthy workplace, corporate citizenship.i
why should employers care? There are several
answers to that. At the XVIII World Congress on Safety and
Health at Work held in Seoul, Korea in 2008,
A. It is the Right Thing to Do: Business participants signed the Seoul Declaration on
Ethics Safety and Health at Work, which specifically
Every major religion and philosophy since the asserts that entitlement to a safe and healthy
beginning of time has stressed the importance of work environment is a fundamental human
a personal moral code to define interactions with right.ii
others. The most basic of ethical principles
deals with avoiding doing harm to others. Clearly, creating a healthy workplace that does
Beyond that, in different cultures or different no harm to the mental or physical health, safety
times, there have been, and continue to be or well-being of workers is a moral imperative.
many differences in what is considered moral From an ethical perspective, if it is considered
behaviour. One clear example is the attitudes wrong to expose workers to asbestos in an
towards and treatment of women in different industrialized nation, then it should be wrong to
times and cultures. Nevertheless, within any do so in a developing nation. If it is considered
one culture there are underlying beliefs about wrong to expose men to toxic chemicals and
what kind of behaviour is considered good and other risk factors, then it should be considered
right, and what is considered wrong. It has been wrong to expose women and children. Yet many
an unfortunate but common occurrence multinationals manage to compartmentalize their
however, for these moral codes to be kept in the ethical codes to allow export of the most
realm of “personal” codes, and not always dangerous conditions or processes to
applied to business dealings. developing countries where attitudes towards
human rights, discrimination or gender issues
In recent years, more attention has been paid to may put workers at increased risk.iii,iv,v In this
business ethics, in the wake of Enron, way they are able to take advantage of lax or
WorldCom, Parmalat, and other accounting non-existent health, safety and environmental
scandals. These highly publicized events laws or lax enforcement of the laws, to save
highlighted the harmful impact on people and money in the short term, in what has been
their families, and have caused a general outcry dubbed “the race to the bottom.”vi
for a higher ethical standard of conduct for
businesses. Trade unions have done their best On the other hand, many employers have
for decades to point out the weaknesses in the recognized the moral imperative and have gone
moral codes of many employers, by linking above and beyond legislated minimum
business behaviours to the real-life suffering and standards, in what is sometimes called
pain of workers and their families. Corporate Social Responsibility. Many case
studies exist that provide excellent examples of
The United Nations Global Compact is an enterprises that have exceeded legal
international leadership platform for businesses requirements, to ensure that workers have not
that recognizes the existence of universal only a safe and healthy work environment, but a
principles related to human rights, labour sustainable community as well.
demonstrating that in the long term, the most impact on the economy. The enormous
successful and competitive companies are those economic cost of problems associated with
that have the best health and safety records, health and safety at work inhibits economic
and the most physically and mentally healthy growth and affects the competitiveness of
and satisfied workers.viii businesses.x
C. It is the Legal Thing to Do: The Law The ILO estimates that two million women and
If sections A and B above represent the “carrot” men die each year as a result of occupational
for creating a healthy workplace, this is the accidents and work-related illnesses.xi WHO
“stick.” Most countries have some legislation estimates that 160 million new cases of work-
requiring, at a minimum, that employers protect related illnesses occur every year, and stipulates
workers from hazards in the workplace that that workplace conditions account for over a
could cause injury or illness. Many have much third of back pain, 16% of hearing loss, nearly
more extensive and sophisticated regulations. 10% of lung cancer; and that 8% of the burden
So complying with the law, and thus avoiding of depression can be attributed to workplace
fines or imprisonment for employers, directors risk.xii Every three-and-a-half minutes,
and sometimes even workers, is another reason somebody in the European Union (EU) dies from
for paying attention to the health, safety and work-related causes. This means almost
well-being of workers. The legislative framework 167,000 deaths a year in Europe alone, as a
varies tremendously from country to country, result of either work-related accidents (7,500) or
however. This aspect will be discussed at some occupational diseases (159,500). Every four-
length in Chapter 8. and-a-half seconds, a worker in the EU is
involved in an accident that forces him/her to
D. Why a Global Framework? stay at home for at least three working days.
Given the ethical, business and legal reasons for The number of accidents at work causing three
creating healthy workplaces, why then is a or more days of absence is huge, with over 7
global framework and guidance required? A million every year.xiii
look at the global situation reveals that many,
possibly most, enterprises/organizations and Furthermore, these are only aggregate figures,
governments have not understood the with no breakdown by sex, age, ethnicity,
advantages of healthy workplaces, or do not immigrant status or other demographics.
have the knowledge, skills or tools to improve However, studies conducted at other scales
things. indicate that work-related risks and health
problems are not evenly distributed among all
There is widespread agreement among global groups.xiv,xv,xvi WHO recognizes this, stating in
agencies, including the World Health the Global Plan of Action on Workers Health (to
Organization (WHO) and the International be discussed later), “Measures need to be taken
Labour Organization (ILO) that the health, safety to minimize the gaps between different groups of
and well-being of workers, who make up nearly workers in terms of levels of risk.… Particular
half the global population, is of paramount attention needs to be paid to…the vulnerable
importance. It is important not only to individual working populations, such as younger and older
workers and their families, but also to the workers, persons with disabilities and migrant
productivity, competitiveness and sustainability workers, taking account of gender aspects.”xvii
of enterprises/ organizations, and thus to the
national economy of countries and ultimately to The ILO notes that, “Women’s safety and health
the global economy.ix The European Union problems are frequently ignored or not
stresses that the lack of effective health and accurately reflected in research and data
safety at work not only has a considerable collection. OSH inquiries seem to pay more
human dimension but also has a major negative attention to problems relating to male-dominated
work, and the data collected by OSH institutions other meetings on occupational health that are
and research often fail to reflect adequately the outlined in Chapter 2.
illnesses and injuries that women experience. In
addition, precarious work is often excluded from The GPA takes a public health perspective in
data collection. Since much of women’s work is addressing the different aspects of workers’
unpaid, or in self-employment or in the informal health, including primary prevention of
economy, many accidents are simply not occupational risks, protection and promotion of
recorded.”xviii The ILO states on its website that health at work, work-related social determinants
at present, only about 40% of countries report of health, and improving the performance of
data on occupational injuries by sex.xix health systems. In particular, it set out five
objectives: xxii
In recent years, globalization has played a major Objective 1: To devise and implement policy
role in workplace conditions. While international instruments on workers’ health
expansion provides an opportunity for Objective 2: To protect and promote health at
multinational corporations to export their good the workplace
practices from the developed world into Objective 3: To promote the performance of
developing nations, all too often the reverse is and access to occupational health
true. As mentioned above, short term financial services
gains often motivate multinationals to export the Objective 4: To provide and communicate evidence
worst of their working conditions, putting for action and practice
countless numbers of children, women and men Objective 5: To incorporate workers’ health into
at risk in developing nations.xx other policies.
While these data are distressing enough, they It is clear that all of these objectives are linked
only reflect the injuries and illnesses that occur and overlap, as they should. For example, in
in formal, registered workplaces. In many order to “protect and promote health at work”
countries, a majority of workers are in the (Objective 2) it is necessary to have policy
informal sector, and there is no record of their instruments on workers’ health at the national
work-related injuries or illnesses.xxi and enterprise level (Objective 1) and for
workers to have access to occupational health
In 1995, the World Health Assembly of the services (Objective 3), and for all this to be
World Health Organization endorsed the Global backed up by the best scientific evidence
Strategy on Occupational Health for All. The (Objective 4). In addition, workers’ health must
strategy emphasized the importance of primary be integrated into educational, trade,
prevention and encouraged countries with employment, economic development and other
guidance and support from WHO and ILO to policies (Objective 5) in order to truly protect and
establish national policies and programmes with promote workers’ health (Objective 2).
the required infrastructures and resources for
occupational health. Ten years later, a country The GPA provides a political framework for the
survey revealed that improvements in healthy development of policies, infrastructure,
workplace approaches were minimal and further technologies and partnerships for linking
improvement was required. In May 2007, the occupational health with public health to achieve
World Health Assembly endorsed the Global a basic level of health for all workers.xxiii It calls
Plan of Action on Workers Health (GPA) for the on all countries to develop national plans and
period 2008-2017 with the aim to move from strategies for its implementation. As such,
strategy to action and to provide new impetus for nations and enterprises look to WHO for some
action by Member States. This watershed guidance in wading through the overabundance
document was the culmination of numerous of information and recommendations referred to
above. Therefore, under Objective 2, WHO has
∗
WHO intends to publish additional materials in the future
that will provide enterprises with practical guidance specific
to sector, enterprise size, country and culture.
Chapter 2:
History of Global Efforts
To Improve Worker Health
The origin and evolution of efforts to improve and safety, dealing primarily with the physical
worker health, safety and well-being are complex, work environment, and to establish legislative
as ideas about how best to achieve the WHO’s and infrastructure support to enforce health
and ILO’s goals for workers have evolved over and safety in workplaces. The aim of the
time. WHO and ILO joined forces very soon after suggested policy is to prevent accidents and
WHO’s formation, in the Joint ILO/WHO injury to health arising out of work, by
Committee on Occupational Health, recognizing minimizing the causes of hazards inherent in
the importance of these issues. It is relatively the working environment. To date 56 nations
recently, however, that health promotion has have ratified it.
specifically been linked to the workplace. For
several decades, health promotion activities and 1985 – ILO Convention 161.29 Four years
occupational health activities operated in two later at the 71st session of the ILO, this
somewhat separate streams. In recent years the Occupational Health Services Convention was
streams have converged, and the linkages have approved. This resolution calls on employers
become stronger, both within WHO and between in Member States to establish occupational
WHO and ILO. health services for all workers in the private
and public sectors. These services would
A brief chronology and description of key events include surveillance of hazardous situations in
and declarations is as follows: the environment, surveillance of worker health,
advice and promotion related to worker health
1950 – Joint ILO/WHO Committee on including occupational hygiene and
Occupational Health. Soon after the formation of ergonomics, first aid and emergency health
the World Health Organization, this joint services, and vocational rehabilitation. This
committee initiated collaboration between the two Convention has been ratified by 28 countries
organizations, which has continued to the present to date.
day.
1986 – Ottawa Charter.30 This key document,
25
1978 – Declaration of Alma-Ata. After the generated at WHO’s First International
International Conference on Primary Health Care Conference on Health Promotion, in Ottawa,
held in Alma Ata in the former Soviet Union, this Canada, is generally credited with introducing
Declaration was signed by all participants. It the concept of health promotion as it is used
“heralded a shift in power from the providers of today: “the process of enabling people to
health services to the consumers of those increase control over, and to improve, their
services and the wider community”26 and in noting health.” It further legitimized the need for
that primary health care brought national health intersectoral collaboration, and introduced the
care “as close as possible to where people live “settings approach.” This included the
and work”27 rather than only in hospitals, provided workplace as one of the key settings for health
the right environment for the concepts of health promotion, as well as suggesting the
promotion and occupational health and safety to workplace as one area where a supportive
develop and grow. environment for health must be created.
1981 – ILO Convention 155.28 Passed at the 67th 1994 – Global Declaration of Occupational
ILO session in 1981, this Occupational Health and Health for All.31 Over the years, a network of
Safety convention requires Member States to over 60 WHO Collaborating Centres in
establish national policies on occupational health Occupational Health has developed. These
Chapter 3:
What is a Healthy Workplace?
A. General Definitions sees the term healthy workplace as emphasizing
Any definition of a healthy workplace should more the physical and mental well-being of
encompass WHO’s definition of health: “A state employees, whereas a healthy organization has
of complete physical, mental and social well- “…embedded employee health and well-being
being, and not merely the absence of disease.”xlii into how the organization operates and goes
Definitions of a healthy workplace have evolved about achieving its strategic goals.”xlv
greatly over the past several decades. From an
almost exclusive focus on the physical work Grawitch et al. have noted that the definition of a
environment (the realm of traditional healthy workplace depends on the messenger.
occupational health and safety, dealing with They state that the Families and Work Institute
physical, chemical, biological and ergonomic believes that the key to a healthy workplace
hazards), the definition has broadened to depends on the introduction of effective work-life
include health practice factors (lifestyle); balance interventions; the Institute for Health
psychosocial factors (work organization and and Productivity Management emphasizes the
workplace culture); and a link to the community; role of health and wellness programmes
all of which can have a profound effect on targeted at specific physical health risks of
employee health. employees; and Fortune Magazine, with its 100
Best Places to Work list emphasizes the role of
The WHO Regional Office for the Western organizational culture, and uses company
Pacific defines a healthy workplace as follows: growth and stock performance as secondary
indicators of effectiveness.xlvi
“A healthy workplace is a place where
everyone works together to achieve an A theme running through many articles and
agreed vision for the health and well-being publications on healthy workplaces is the
of workers and the surrounding community. concept of inclusiveness or diversity. The
It provides all members of the workforce with discussion may have different foci – ethnicity,xlvii
physical, psychological, social and gender,xlviii disabilityxlix – but the concept is the
organizational conditions that protect and same: a healthy workplace should provide an
promote health and safety. It enables open, accessible and accepting environment for
managers and workers to increase control people with differing backgrounds,
over their own health and to improve it, and demographics, skills and abilities. It should also
to become more energetic, positive and ensure that disparities between groups of
contented.”xliii workers or difficulties affecting specific groups of
workers are minimized or eliminated
The American National Institute for Occupational
Safety & Health (NIOSH) has a WorkLife Benach, Muntaner and Santana, writing for the
Initiative that “envisions workplaces that are free Employment Conditions Knowledge Network,
of recognized hazards, with health-promoting introduced the concept of “fair employment” to
and sustaining policies, programs, and complement the ILO’s concept of decent work.l
practices; and employees with ready access to They define fair employment as one with a just
effective programs and services that protect relation between employers and employees that
their health, safety, and well-being.”xliv requires certain features be present:
• freedom from coercion
Writing for Health Canada, GS Lowe • job security in terms of contracts and
differentiates between the concepts of a “healthy safety
workplace” and a “healthy organization.” He • fair income
• job protection and social benefits especially important in developing countries and
• respect and dignity at work; and with small and medium-sized enterprises
• workplace participation (SMEs), where community resources (or lack of
them) may have a significant impact on the
The ILO decent work concept and this fair health of workers.
employment definition tie into the principles
promoted by the Global Compact. These Based on these considerations, the following is
principles link business ethics with human rights, proposed as the WHO definition of a healthy
labour standards, environmental protection and workplace:
protection against corruption.li
A healthy workplace is one in which workers and
B. The WHO Definition of a Healthy managers collaborate to use a continual
Workplace improvement process to protect and promote the
Three things are clear from this small sampling health, safety and well-being of all workers and
of definitions of a healthy workplace, as well as the sustainability of the workplace by
others in the published literature: considering the following, based on identified
1. Employee health is now generally assumed needs:
to incorporate the WHO definition of health • health and safety concerns in the physical
(physical, mental and social) and to be far work environment;
more than merely the absence of physical • health, safety and well-being concerns in
disease; the psychosocial work environment
2. A healthy workplace in the broadest sense including organization of work and
is also a healthy organization from the point workplace culture;
of view of how it functions and achieves its • personal health resources in the workplace;
goals. Employee health and corporate and
health are inextricably intertwined. • ways of participating in the community to
3. A healthy workplace must include health improve the health of workers, their families
protection and health promotion.∗ and other members of the community.
Health, the objective of the Regional Plan is to discussed relating to the Cochrane Collaboration
encourage member states to take action on in Chapter 5.)
physical, biological, chemical and psychosocial
factors, as well as organizational factors and In addition to what AMRO is doing region-wide,
dangerous production processes that adversely individual countries are addressing the issues in
affect workers’ health in both the formal and various ways. The United States and Canada
informal sectors. The values of equity, vary considerably in their approach to workplace
excellence, solidarity, respect, and integrity are health, probably in part due to their very different
underscored in the Regional Plan, as well as the primary health care systems.
“3 Ps” of prevention, promotion, and protection
of all workers. United States: In the USA, where there is some
inequity in access to primary health care,
The priorities of the Regional Plan include: employers have taken on a significant role in
• strengthening the countries’ capabilities to providing or paying for health care or health care
anticipate, identify, evaluate and control or insurance for their employees. Adding in the
eliminate risks and dangers in the litigious nature of American medicine, many
workplace; doctors fearing lawsuits practice “defensive
• promoting the update of workers’ health medicine,” which drives up the cost of that
legislation and regulations, and the health care dramatically.lxi Employers have
establishment of programmes designed to therefore recognized the high cost of poor health
improve the quality of the work environment; and chronic diseases among their employees.
• fostering programmes for health promotion
and disease prevention in occupational The recent Buck Survey mentioned above found
health and encouraging better health that for American companies, “reducing health
services for the working population. care or insurance costs” was the number one
reason for providing wellness programmes for
AMRO supports and facilitates many region- employees. All other parts of the world cite
wide initiatives related to improving workers’ improvements in worker health or morale, and
health, currently including projects that focus decreases in absenteeism and presenteeism as
on:lix their number one reasons.lxii
• health of health-care workers (focusing on
transmission of blood-borne pathogens and Possibly for this reason, American efforts
other communicable diseases, including towards healthy workplaces have focused on
pandemic H1N1/09 influenza two areas:
• elimination of silicosis • traditional occupational health and safety,
• elimination of asbestosis dealing with the physical work
• preventing and controlling occupational and environment. This is in response to strong
environmental cancers labour legislation and enforcement
through the Occupational Safety and
Details about AMRO activities in this area are Health Administration (OSHA).
posted on a PAHO website specifically • workplace health promotion, in the
dedicated to Workers’ Health. Its goal is “to restricted∗ sense of encouraging
disseminate accurate and thorough information employees to adopt healthy lifestyle
to anyone interested in Workers’ Health in the practices on an individual basis, and
Americas.”lx
organizational culture, and personal health A recent global survey of large employers found
resources. that among Latin American respondents to the
survey (primarily Brazil), 44% provided some
In both Canada and the USA, the American form of “wellness” or health promotion
Psychological Association has in recent years programmes for their employees. The most
developed and implemented the Psychologically common programme offered was
Healthy Workplace Awards, which are mostly immunizations/flu shots (by 73% of respondents)
based on the psychosocial work environment and the least common was a cycle-to-work
(including organizational culture, and programme (5%). On-site medical facilities were
organization of work.) Their main criteria for a provided by 59% of respondents.lxxviii
healthy workplace are in five key areas:
employee involvement, work-life balance, 3. Regional Office for the Eastern
employee growth and development, health and Mediterranean (EMRO)
safety, and employee recognition.lxxiv In 2005 a conference was attended by 16
countries in the WHO Eastern Mediterranean
The Buck Survey survey of large employers Region to discuss the status of occupational
found that among Canadian respondents to the health services in the Region.lxxix It had been
survey most provided some form of “wellness” or agreed by Member States in the past that the
health promotion programmes for their primary health care systems were probably the
employees. The most common programme best positioned to provide occupational health
offered was immunization’s/flu shots (by 81% of services. It was noted that most countries were
respondents) and the least common was making progress towards the provision of basic
personal health coaching (4%). On-site medical occupational health services within the primary
facilities were provided by 17% of health care systems, but there were vast
respondents.lxxv differences among countries. In addition, the
focus of the services provided is mainly curative
Brazil: One of the most comprehensive or tertiary prevention. Member States identified
approaches to worker health in AMRO is being barriers to improving coverage of occupational
taken in Brazil. SESI (Serviço Social da health services as lack of enabling legislation,
Indústria), a WHO Collaborating Centre in lack of standards and expertise, lack of
Occupational Health works with Brazilian coordination (and sometimes conflict) between
industry in 27 states to help reduce occupational the concerned authorities (notably the ministries
injuries and illnesses, and to improve worker of health and labour), lack of participation from
lifestyles through leisure activities. They do this employers’ organizations and NGOs, insufficient
through training, consulting and providing direct
medical services for workers. In addition, SESI
“So I see the healthy workplace
collaborates with other Latin American countries
to address mental health issues, in particular as a broad concept which will
drug and alcohol abuse among workers.lxxvi In improve the health of the
addition to SESI, Brazil has ABQV (Associação workers, not only directly at the
Brasileira de Qualidade de Vida), the Brazilian
Quality of Life Association. It is a national non-
workplace, but using workplace
profit organization that facilitates the networking as an excellent contact point
of private and public enterprises, communities, with health - personal health -
and health professionals all over the country,
to approach them and to
with the purpose of encouraging and helping
organizations to implement wellness and quality promote healthy lifestyles.”
Interview #1, Egypt, OHS Professional
of life interventions for their employees.lxxvii
financial and human resources and the lack of health and safety hazards. The informal sector,
educational programmes to develop human gender issues, and small enterprises have been
expertise. identified as of particular concern. A unique
approach has been taken by the Region through
In responding to the GPA, a regional workshop the publication of a series of “Health Education
on developing national strategies and plans of Through Religion” booklets that discuss health
action on workers’ health was organized by the promotion, primary health care, environmental
Region in May 2008. The most important protection and other health-related topics in the
outcome of this workshop was the adoption of context of Islamic Law.lxxxiii
the suggested regional framework for
implementing GPA for the period 2008-2012, 4. Regional Office for Europe (EURO)
which underlined the importance of adoption of The European Region may have one of the most
the healthy workplaces initiative as one of the comprehensive, resource-rich and sophisticated,
main strategic directions. Based on WHO if not always unified, approaches to healthy
efforts, the 3rd Arabian Conference on workplaces. Many Member States are known
occupational safety and health, organized by the globally for their strengths in this area, and
Arab Labour Organization in November 2008, provide the model for others. WHO
adopted the healthy workplaces initiative Collaborating Centres in Occupational Health
officially in the Manama Declaration.lxxx from this Region regularly provide assistance
and support to other regions. The European
In 2008 the Region published a health promotion Union (EU) has provided a unifying forum to
strategy for the Eastern Mediterranean for the facilitate the development of region-wide
years 2006-2013. While it generally supports definitions, approaches, and standards.
the settings approach for health promotion, it However, since countries in the Region are
does not specifically link health promotion to the joining the EU over a period of years,
workplace.lxxxi differences among the early members and more
recent members are emerging and will continue
In 2009, the Ministers of Health of the Gulf to challenge the consistency of approaches
Cooperation Council (GCC) endorsed the Gulf across the Region.
Strategy for Occupational Health and safety,
which adopted the healthy workplaces initiative. There are numerous groups and networks of
European countries, enterprises and institutions
Individual countries have addressed workplace that are addressing workplace health:
health in different ways. Since 2007, Oman has • Directorate General of Employment, Social
been a pioneer in EMRO, as shown by their Affairs and Equal Opportunities of the
facilitation of a partnership for healthy European Commission (EU)lxxxiv
workplaces with the majority of companies • Enterprise for Health.lxxxv
working in the country. • European Agency for Safety and Health at
Work, EU-OSHA (set up under the EU)lxxxvi
Beginning in 1994, Pakistan was part of a pilot • European Network Education and Training
of an ILO-based programme with the acronym in Occupational Safety and Health
POSITVE (Participation Oriented Safety (ENETOSH)lxxxvii
Improvements by Trade Union Initiative), which • European Network for Workplace Health
was quite successful in reducing workplace Promotion (ENWHP)lxxxviii
injuries and risk factors.lxxxii • European Network of Safety and Health
Professional Organisations (ENSHPO)lxxxix
As in the African Region, the workplace priorities • European Network of WHO Collaborating
at this time deal with the physical work Centres for Occupational Healthxc
environment, to eliminate or control physical
• European Network of WHO National Focal health and stress, and corporate culture,
Points on Workers’ Healthxci including leadership and staff development.
• Eurosafe: European Association for Injury
Prevention and Safety Promotionxcii The 2009 Buck Survey of large employers found
• Federation of European Ergonomics that among European respondents, 42%
Societies (FEES)xciii provided some form of “wellness” or health
• Federation of Occupational Health Nurses promotion programmes for their employees.
within the European Union (FOHNEU)xciv The most common programme offered was
gym/fitness memberships (by 71% of
While each of these groups or networks has its respondents) and the least common was
own unique twist and emphasis, in total they vending machines with healthy foods (15%).
provide a very comprehensive scope. Some On-site medical facilities were provided by 54%
deal with the more traditional aspects of of respondents.xcvi
occupational health and safety, addressing
physical, chemical, biological, ergonomic and 5. Regional Office for South-East Asia
mechanical risks. Others focus more on the (SEARO)
psychosocial environment and organizational A Regional Strategy for Occupational and
culture. But all make a strong connection Environmental Health has been established,
between the health of employees, the health of after the WHO Regional Office for South-East
the enterprise, and the health of the community. Asia realized in 2002 that this region has the
For example, ENWHP has defined Workplace highest regional burden of disease attributable
Health Promotion as: “the combined efforts of to occupational risk factors. These factors
employers, employees and society to improve include workplace injuries, workplace exposure
the health and well-being of people at work. to carcinogens, dust, noise, and ergonomic
This is achieved through a combination of: factors.xcvii The Regional Strategy is focused on
• improving the work organisation and the developing national policy and plans of action,
working environment with special emphasis on the informal sector.
• promoting the active participation of The emphasis is on providing basic occupational
employees in health activities health services through linkage with the primary
• encouraging personal development”xcv health care system.
This interpretation goes on to say that activities A separate Regional Strategy for Health
for workplace health promotion include Promotion was developed by SEARO in 2005
corporate social responsibility, lifestyles, mental and reconfirmed in 2008. The strategy does not
particularly emphasize links with the workplace,
“To ensure that the workers go except as one of a number of “settings-based”
approaches.xcviii
home as healthy and safe as
they arrived to work. Workers There is inter-regional cooperation at times with
should not experience risks respect to workplace health, as a number of
SEARO countries (Bangladesh, Nepal,
from chemical and physical to Thailand) have participated in an EMRO
psychosocial and bullying and so (Pakistan) POSITIVE programmexcix and in
on. The most important is the WISE/WIND programmes organized by the
Western Pacific Region.c
control of risks and hazards at
work.” Some individual countries have embarked on
Interview #23, Germany, OH
comprehensive healthy workplace initiatives.
For example, in 2007 the WHO Country Office in
Chapter 4:
Interrelationships of
Work, Health and Community
No one would disagree that work, health and excessive force; flying fragments that could
community are related. But how exactly? A injure an eye; or risk of a work-related motor
number of questions come to mind: vehicle crash. Physical safety hazards, with the
• Do poor working conditions cause poor notable exception of motor vehicle crashes, are
mental and physical health? usually the first type of hazard to be included in
• Does poor mental or physical health result in health & safety legislation, when it exists. If
poor performance and productivity at work? injuries result from these hazards, they are also
• Does the health of workers have any impact the most probable to be covered by any kind of
on the success and competitiveness of the workers’ compensation that is in place (again,
organization? with the exception of motor vehicle crashes and
• Does the community in which a workplace also musculoskeletal disorders (MSDs).
operates affect the health of workers?
• Does the health of workers, or workplace In spite of the likelihood that most countries have
conditions, affect the community? some sort of legislation to prevent these types of
injuries, they continue to occur at a distressing
The answer to all of these questions is probably rate. Out of the two million estimated deaths
a qualified “yes” in some way. Let’s look at from occupational injuries and illnesses, in 1998
some of the evidence. (Types of evidence will be approximately 346,000 were due to traumatic
discussed in Chapter 5.) workplace injuries115 with an additional 158,000
due to motor vehicle crashes that occurred in the
A. How Work Affects the Health of course of commuting.116 What is most disturbing
Workers is that the estimated fatality rate per year per
This section has separated the effects of work 100,000 workers ranges from a low of <1 to a
on physical health & safety from the effects of high of 30 in different countries. And the
work on mental health & safety, followed by a estimated accident rate (an injury requiring at
discussion of the interactions between the two. least three days absence from work) ranges
This is done to note the often separate bodies of from a low of 600 per year per 100,000 workers,
evidence, as well as to emphasize the fact that to a high of 23,000.117 The human and
the work environment contains psychosocial as economic toll of these dry statistics is
well as physical hazards. But in many ways this incalculable.
is a very artificial division. Mind and body are
one, and what affects one, inevitably affects the While it is customary to think only of physical
other. Other ways of organizing this chapter hazards as having an effect on the safety of
might have been to separate safety effects from workers, this is not always the case. Sometimes
health effects, but that division is equally non-physical, or psychosocial hazards in the
artificial. The reader is therefore asked to workplace can also affect physical safety. (See
forgive the overlap and any apparent duplication. discussion of psychosocial hazards below,
Section A2.) For example, the perception of
1. Work influences physical safety and health work overload has a strong association with
Hazards that pose threats to physical safety of injuries among young workers.118
workers include, for example, mechanical
/machine hazards; electrical hazards; slips and In fact, psychosocial hazards can be associated
falls from heights; ergonomic hazards such as with injuries in either a direct or indirect manner.
repetitive motion, awkward posture and When employees lack sufficient influence over
hazardous conditions in the workplace, they lack opposed to an authoritarian style might influence
the control necessary to abate threats to life and safety outcomes. This has now been shown to
limb. Thus, lack of control can contribute directly be true. Research done by Barling et al found
to an injury. However, indirect influences can be that leadership style affects occupational safety
just as dangerous. Workers experiencing through the effects of perceived safety climate,
psychosocial hazards may: safety consciousness, and safety-related
• sleep badly events.120 They also found that the existence of
• over-medicate themselves high-quality jobs that include a lot of autonomy
• drink excessively (control or influence), variety and training,
• feel depressed directly and indirectly affect occupational injuries
• feel anxious, jittery and nervous through the mediating influence of employee
• feel angry and reckless (often due to a morale and job satisfaction.121
sense of unfairness or injustice)
Violence and Safety
When people engage in these behaviours or fall Workplace violence is a serious threat to the
prey to these emotional states, it is more safety of workers in many developed and
probable they will: developing countries. An imbalance between
• become momentarily distracted effort and reward may result in a sense of
• make dangerous errors in judgement injustice or unfairness in workers, leading to
• put their bodies under stress, increasing the feelings of anger that may be directed against a
potential for strains and sprains supervisor or co-worker. Other psychosocial
• fail in normal activities that require hand-eye hazards such as ongoing harassment may also
or foot-eye coordination. create deep feelings of anger and frustration.
The anger may manifest itself in many ways that
The American Institute of Stress has developed are the expressions of potential violence:
the following Traumatic Accident Model:119 • threatening behaviour
• emotional or verbal abuse
• bullying, harassment or mobbing
• assault
• suicidal behaviour
• recklessness.
does work have an influence on these “You can have advice and you can
behaviours?
have access to physical activity, to
Research has shown that smoke-free tobacco cessation, healthy food at
workplaces are associated with a lower daily the workplace. These are healthy
cigarette consumption by employees, and a behaviours. But you need to have
reduced prevalence of smoking;134 and
conversely, that increased workplace stress can
healthy enablers. These are the
lead to increased cigarette smoking.135 This is boss that would allow you to engage
one proven example of how a workplace affects in those behaviours - eating
a personal health behaviour. In addition, energy
better, exercising, not smoking.”
expenditure during working hours is negatively Interview #17, Switzerland, Med Epidemiologist
associated with physical activity in leisure
time.136
resulting in women’s leisure time being more
There are many other “common sense” answers fragmented than men’s.139
to this question, which are not necessarily based
on scientific evidence. For example, if an 2. Work affects mental health and well-being
enterprise has a company cafeteria for workers For some time there has been a general
with inexpensive, free or subsidized food, and observation that mental illnesses among workers
serves only “junk food,” it is probable this will can impact negatively on work performance, and
influence workers to eat unhealthy food, at least among enlightened employers, even a
while they are at work. If work is stressful, many realization that the workplace is a setting that
employees will react to the stress by increasing can assist in the identification of mental illness,
bad habits that help them (temporarily) cope with and facilitation of proper treatment. But there
the stress, such as drinking excessive amounts has been little understanding of how work
of alcohol or smoking more. If workers are impacts on mental health or possibly even
expected to work long hours and significant contributes to the development of mental illness
overtime, it will be difficult for them to or mental disorders.140
incorporate physical activity into their schedule.
It is quite apparent that work can, and does, Most mental illnesses have multiple causes,
influence personal health choices that can including family history, health behaviours,
increase risk factors for both acute and chronic, gender, genetics, personal life history and
communicable and non-communicable diseases. experiences, access to supports, and coping
skills.141 Joti Samra and her colleagues at the
The work-related factors that influence a Consortium for Organizational Mental
worker’s ability to adopt a healthy lifestyle are Healthcare (COMH)142 (a collective of mental
not always gender neutral. Women tend to have health researchers, consultants and practitioners
jobs with a lower degree of decision latitude137, at Simon Fraser University, Canada) have
so that even when flexibility is provided to allow reviewed the literature on this subject. They
time for exercise, women may not have as much conclude that “Workplace factors may increase
actual leeway as men. In addition, it is well the likelihood of the occurrence of a mental
known that women who work outside the home disorder, make an existing disorder
generally do more unpaid labour in the home, worse….may contribute directly to mental
before and after work, than men do.138 While distress (demoralization, depressed mood,
men tend to do household repairs and car anxiety, burnout, etc.) Mental distress may not
maintenance, women generally do cooking, reach the level of a diagnosable mental disorder,
cleaning, and caring for children or sick relatives. and yet be a source of considerable suffering for
This type of work usually cannot be postponed, the employee…”143
While this research was done in a developed • recruitment and training costs for
country, the conclusions can also be applied to replacement workers
developing nations, with an increased emphasis • damage to equipment and materials
on the provisos. • reduction in product quality following the
accident if less experienced replacement
B. How Worker Health Affects the Enterprise∗ workers are used
The facts are clear: work can affect the mental • reduced productivity of injured workers on
and physical health, safety and well-being of modified duties
employees, and often, unfortunately, in very • overhead cost of spare capacity maintained
negative ways. But a cynical or resource-poor in order to absorb the cost of accidents
employer may say, “So what? I have a business • legal costs if any174
to run. Their health isn’t my problem!” So let’s
look at the other side of the equation. Does ill These categories of cost are based on research
health among employees affect the health, from larger enterprises in industrialized
effectiveness, productivity or competiveness of countries. When an accident occurs in a small
an enterprise? or medium-sized enterprise, or in a developing
nation, the proportion of indirect costs is
1. Accidents and acute injuries affect the probably smaller. However, data consistently
enterprise show that the safest enterprises are the most
While this statement seems obvious in some competitive.175 In fact, one of the business
ways, it is not always easy to recognize and advantages to an SME of having a good health
quantify all the costs to, and other effects on, an & safety record is that it helps them meet the
enterprise. The greatest effect is usually the OSH requirements of business clients in order to
unquantifiable personal costs. The win and retain contracts.176
owner/operator and co-workers of an injured
worker will be affected emotionally to some EU-OSHA has specifically looked at the
degree whenever an employee, friend or economic benefits of occupational health and
colleague is injured. These effects may be safety in small and medium-sized industries, and
devastating in a small company, in the extreme states that reasonably effective occupational
case of a worker being killed. health and safety measures can help an SME
improve its performance. They note that SMEs
In addition to the personal effects, there are the are particularly vulnerable, because the relative
economic costs to an enterprise. When impact of a serious accident is greater than with
someone suffers an acute injury at work, and is a larger enterprise. In fact, 60% of SMEs that
required to take time away from work, there are have a disruption lasting more than 9 days go
many direct and indirect costs to the employer, out of business.177
for example:
• Immediate payments to a physician or Although the cost of one accident to one
health care system enterprise is significant, the cost to an individual
• Insurance costs employer is dwarfed by the cost to countries or
• interruption in production immediately regions: in 2005 workplace injuries cost
following the accident American businesses US$ 150 billion in direct
• personnel and time allocated to investigating and indirect costs, exceeding the combined
and writing up the accident profits of the 16 largest Fortune 500
companies.178
∗
The term “enterprise” means a company, business, firm,
institution or organization designed to provide goods and/or
services to consumers. While often used to imply a for-profit
business, in this document it is intended to include not-for-
profit organizations or agencies, and self-employed
individuals.
2. The physical health of workers affects the “I also see it [a healthy workplace]
enterprise
as a place where the productivity
When employees are ill, regardless of the cause,
their productivity at work will be decreased. If and efficiency is its best because
the employee is too ill to come to work, there are people are actually performing
the absenteeism-related costs of recruiting and better.”
bringing in a replacement worker, training that Interview #40, Croatia, OH Psychologist
worker, and potentially experiencing reduced
quality or quantity of work from that replacement. costs were more than 4 times greater than
If the ill employee comes to work in spite of the medical and pharmacy costs.183
illness, a phenomenon occurs that has recently
been labeled “presenteeism,” which describes The direct costs for the employer of poor heath
the reduced productivity of someone who is among workers depends very much on the
either physically or mentally ill, and therefore not regulatory system in the country involved, and
as productive as he or she would normally be. the way primary health care is provided. For
Either way, the employer pays. example, in Europe and Canada, there are
usually well-functioning primary health care
One detailed comprehensive study quantified systems that are available for everyone --
the cost of various illnesses to American employed, self-employed or unemployed. In
employers.179 Ranges of condition prevalence in Canada for example, employers may pay for this
the population, and associated absenteeism and in some indirect way through taxes, but it is not
presenteeism losses were used to estimate linked directly to the health of their employees.
condition-related costs. Based on average Employers may choose to provide some
impairment and prevalence estimates, the supplementary health insurance to pay for drugs
overall economic burden of illness to an not covered by the government, dental care, or a
employer for hypertension (high blood pressure) private room in a hospital; these supplementary
per year, per employee (all covered employees, costs are influenced by the health of employees.
not just those with the condition) was US$ 392, In a country like the United States, however, the
for heart disease US$ 368, and for arthritis US$ health care system is not so universally
327. That means, for example, that an accessible to all residents, and employers often
American SME with 100 employees is paying provide comprehensive health insurance that is
US$ 39,200 per year because of high blood extremely costly. In a survey of American and
pressure among employees. The authors note European employers, when asked why they
that presenteeism costs were higher than provided wellness or health promotion
medical costs in most cases, and represented programmes to their employees, the Americans’
18%-60% of total costs. An associated study top two reasons were to reduce health care
showed that the price tag of a diabetic worker to costs and improve productivity; the Europeans’
an employer is more than five times that of top two were reducing employee absences and
workers without diabetes.180 morale.184
Numerous studies have shown that poor health In developing nations, it is not as probable that
negatively impacts productivity. Cockburn et al the employer will pay for health insurance, but
determined that people suffering from poorly they still pay the price of missing employees. In
controlled allergies were 13% less productive parts of sub-Saharan Africa, the cost of
than other workers.181 Burton et al developed a HIV/AIDS to employers is staggering in terms of
sophisticated Worker Productivity Index and absenteeism due to sickness and attendance at
showed that as the number of health risk factors funerals of friends, families and co-workers;
increased, productivity decreased.182 Another presenteeism due to sickness; and increased
study reported that health-related productivity
experiencing high work-family conflict demonstrate up C. How Worker Health and the Community
to 13 times as much absenteeism, and have a 2.3 Are Interrelated
times higher intention of quitting. 195 So far this paper has looked at ways in which
the work environment of the enterprise affects
In addition to the immediately obvious effects of poor the physical and mental health and safety of
mental health on the enterprise, there are direct and workers; and the ways the health, safety and
indirect costs to society as a whole. well-being of workers affects the enterprise.
But all workplaces exist in communities and
For example: societies. The community or society in which
• Mental health problems were estimated to cost the enterprise exists also has a tremendous
Canadian businesses $33 billion Canadian impact on worker health and enterprise
dollars per year in 2002, if non-clinical success – and vice versa.
diagnoses are included (e.g., burnout,
subclinical depression, etc.) 196 As such, there are very big regional
• In France in 2000 a total of 31 million working differences based on the level of development
days were lost due to depression.197 of countries. The examples listed below are
• The cost of reduced performance due to probably not issues in most of Western
untreated depression is estimated to be five Europe, North America, or in more developed
times as great as the cost of absenteeism198 parts of the Western Pacific Region.
• A conservative estimate of productivity losses
alone for depression, anxiety and substance
abuse in Canada is $11.1 billion per annum.
• In the European Union, the cost of work-related
stress∗ was estimated to be 2 billion Euros in itself. It may be considered mental distress, but if it is
2002.199 short-lived, it usually has no long-lasting effect. (The
exception to this would be post-traumatic stress, when an
individual has a severe stress reaction to being the victim
∗ of, or observing a horrific event.) However, if the stress is
Much has been written about the “cost of stress” to business. prolonged and continual, it may lead to a mental illness,
There is considerable confusion and inconsistency in the literature mental disorder, or a variety of physical ailments. When
regarding use of the word “stress.” For the purposes of this paper, the literature refers to the “cost of stress” it is assumed to
“stress” will be used to describe the subjective feelings that may mean the cost of the mental, physical and behavioural
result from any number of conditions at work (“stressors” or symptoms, diseases and disorders that result from
psychosocial hazards), such as being overwhelmed by work prolonged stress. For example, a behavioural symptom of
demands that are out of the worker’s control, or being harassed by excessive stress in a worker may be increased
a co-worker. Stress is not a mental illness or a mental disorder in absenteeism from work.
Examples Of How The Community Affects Health Of trying to cope with the aftermath, and
Workers: experience negative health
• No matter how healthy and safe a workplace consequences.
may be inside the doors of the enterprise, if
there is no clean, safe water to drink in the • If road conditions and/or community
community, workers will not experience good driving practices are poor, workers who
health. drive for work will be at increased risk of
injury.
• If primary health care in the community is
inadequate, and workers and their families are While these examples are generally not the
unable to get health care such as treatment or legal responsibility of the workplace or
immunizations against communicable diseases, employer, they are factors that can often be
workers and their families will not experience influenced by the enterprise or organization.
good health. When employers choose to become involved
in some of these issues, it may be referred to
• If community tobacco control laws are weak, as Corporate Social Responsibility (CSR), or
poorly enforced, or non-existent, community Enterprise Community Involvement, which will
members (including workers) will be exposed to be discussed more in Chapters 6 and 9.
toxic fumes and are more likely to become ill,
and/or addicted to tobacco. How Work Conditions And Worker Health
Affect Society And The Community
• If there are no sidewalks, public transport is The reverse is true as well: the mental and
poor, roads are hazardous, there is much crime physical health of workers will ultimately affect
or pollution, then inactive transport (cars or the health of the community and society. For
motorbikes) may be the only option for workers example, If workers experience violence or
to get to and from work, reducing physical abuse at work and leave work angry, clearly,
activity and limiting possibilities to counter the effects of this violence are not restricted to
work-induced physical inactivity. effects on the workplace, but will spill over into
worker homes and communities. A worker
• If the air and water in the community are who is abused at work may exhibit “road rage”
contaminated by factories belching toxins into on the drive home, or display violence towards
the air, or dumping pollutants into the water, a spouse or other family member. Thus the
workers living in the community will experience workplace can contribute to increased societal
a variety of illnesses. costs for law enforcement, social services and
primary health care. Shain refers to this as the
• If HIV/AIDS is common in the community, and
infected workers are unable to afford the
recommended antiretroviral medications, their “In countries where the basic
health will rapidly deteriorate. priorities are not there, where for
example, when you refer to clean
• If the literacy rate in the community and among
employees is low, they will be unable to read water, sanitation and cleanliness, and
health and safety information, and may put their organization in the workplace, and
health and safety at risk as a result. where people don’t have the
• If a natural disaster affects the community (e.g.,
appreciation of this need, then your
flood, earthquake) the employees may be priorities will be different.”
Interview #34, Republic of Korea, OSH
affected immediately, or may be overwhelmed
“social exhaust” from an enterprise.200 In an analogy home lives and their jobs, it will create
with environmental emissions from factories that significant costs for society, particularly in the
pollute the air or water, this kind of fear, anger or case of use of the health care system.
other emotions that leave work with workers who
have been treated unfairly also pollutes their families, Another relationship between work conditions
society and the community. and the community concerns the issue of
disability. If workplaces make reasonable
Canadian research into work-family conflict also accommodations for people who have some
demonstrates this point. Duxbury and Higgins form of disability, they will contribute to
documented the effects of four kinds of work-family decreasing unemployment in the community,
conflict not only on workers and employers, but also which will have positive outcomes for
on society as a whole, in terms of usage of the health society.202
care system.201 Table 4.2 illustrates the point that
when there is a lack of harmony between workers’
Table 4.2 Work-Family Conflict Effects on Worker Health, the Enterprise and Society203
The general effects of worker health on the health The Business Case
and prosperity of society were recognized at an This model reinforces the business case for
international conference in 2008. In June of that healthy workplaces, which was implied in
year, a WHO Ministerial Conference on Health Section 4B. Creating a healthy workplace is
Systems was held in Tallinn, Estonia, with the not just a matter of caring for the well-being of
theme, “Health Systems, Health and Wealth.” At employees. As indicated above, the health
the end of the conference the Tallinn Charter was and well-being of workers strongly impacts on
approved, which noted the connection between the ability of the enterprise to perform its
health and wealth. The charter states, “Beyond its functions, and to meet its vision and mission.
intrinsic value, improved health contributes to The Tallinn model restates that fact, that good
social well-being through its impact on economic health is related to worker productivity. And
development, competitiveness and productivity. clearly highly productive workers will contribute
High-performing health systems contribute to to business competitiveness. When many
economic development and wealth.”204 businesses in a community are highly efficient
and competitive, that contributes to the
In other words, good worker health contributes to economic development and prosperity of the
high productivity and success of the enterprise, community and ultimately the country as a
which leads to economic prosperity in the country, whole. This economic prosperity filters down
and individual social well-being and wealth of to the individual, creating social well-being and
workers. And to complete the cycle, it has long wealth for all individuals in the community.
been known that socioeconomic status is one of And as noted, wealth and socioeconomic
the primary determinants of health: generally status have always been regarded as primary
wealthy people are healthier than poorer people. determinants of health. So the Tallinn Charter
demonstrates that worker health, business
This could be demonstrated graphically as shown prosperity and even national prosperity and
in Figure 4.2. development are inextricably intertwined.
Chapter 5:
Evaluating Interventions
The previous chapters paint a clear picture, available, and the Cochrane Collaboration
showing that work and community environments provides invaluable resources to assist in this.
and conditions can have serious impacts on the The Cochrane Collaboration prefers to limit most
health, safety and well-being of workers; and of its reviews to interventions that have been
that worker health impacts tremendously on the tested in randomized controlled trials. This is the
productivity and effectiveness of “gold standard” of scientific research, and is
enterprises/organizations and of society as a what is normally used to test new drugs or other
whole. This provides a strong motivation for medical therapy interventions. This sort of
both workers and employers to wish to create rigour has not generally been applied to
healthier workplaces. But is that possible? occupational health interventions, although
What are some solutions to the problems? And some researchers have called for this.ccv In
how do we know what is effective and what is recent years, a Cochrane Occupational Health
not? Field has been established, and there are also
groups related to public health/health promotion
There have been countless interventions by (Cochrane Public Health Group) and injuries
employers and workers to attempt to make (Cochrane Injury Group.)
workplaces healthier, in many countries and
many diverse settings. The intention of this So far, the evaluation of workplace health
document is to sort out the wheat from the chaff, interventions is somewhat limited, but when it is
to find the common approaches that generally available through the Cochrane Collaboration,
seem to work well to accomplish the aims of the information is invaluable. There is certainly
improved worker health and enterprise a large research base testifying to the harmful
productivity. In other words, to sort out what effects of many physical, chemical and biological
works and what doesn’t. So before discussing agents, which, if present in the workplace, can
promising interventions, it is appropriate to cause physical harm to workers. There are
spend some time discussing the issue of many time-tested control measures for them,
evaluation, as it relates to protecting and some of which have been carefully evaluated.
promoting workplace health, safety and well- However, evidence-based data that would meet
being. the Cochrane standards is much more limited
when it comes to the effectiveness of
A. The Cochrane Collaboration interventions dealing with mental health of
The Cochrane Collaboration is an international, workers, or the effectiveness of work
non-profit, independent organization established organization or organizational culture
to ensure that current, accurate information interventions.
about the effects of health care interventions is
readily available worldwide. More than 15,000 B. General Evaluation Criteria
volunteers in over 90 countries participate in the When an employer is attempting to improve a
reviewing process. The Collaboration produces workplace, it is with the assumption that
and disseminates Cochrane Reviews, which are whatever is being done will make things better
systematic reviews of the research on various for workers. There would therefore be a natural
interventions. As such, it provides an extensive ethical reluctance to do a controlled trial, and to,
resource when looking for evidence about the in essence, deny or delay the intervention to half
effectiveness of any intervention. Evidence- the workers (the control group).
based medicine aims to make decisions about
treatment based on the best scientific evidence
Workplace health promotion programmes are • Too short a time frame for follow-up. Clinical
especially difficult to evaluate well. To evaluate literature generally shows that to ascertain a
these interventions in the same way as behaviour change is permanent, at least six
experimental studies is not always feasible. months must elapse, and many studies
Interventions attempt to change human report results after a shorter time. Some
behaviour, which depends on so many researchers suggest that an intervention
conditions impossible to control: motivation both must be maintained for 3-6 months to bring
of interveners and of intervened, their about a reduction of a health risk, and 3-5
personalities, life experience, education, actual years to demonstrate cost-effectiveness.
state of health, tradition and countless other
factors. • Dropouts in the intervention group. If
participants who do not succeed at making a
As a result, the vast majority of those behaviour change drop out of the study
interventions that are undertaken to improve before it is finished, the results reported at
workplace health are not evaluated using strict the end (when mostly the successful people
evidence-based research criteria. Even those will be left) will overestimate the impact.
designed to be evaluated and published often
fall short of the gold standard. Kreis and • Self-selection. It is not possible in most
Bödeker attempted a comprehensive evaluation companies to force employees to participate
of the health promotion literature and have the in an experiment, especially one that
following comment, after noting the high number involves behaviour change. Therefore,
of studies available: “Contrary to the quantity, people who volunteer to participate may
however, the quality of the studies on the face of already be highly motivated and interested
it unfortunately often leave a lot to be in the process and outcome of the
desired.”ccvi intervention. Again, this means that the
results attained for the intervention will
Published studies in the arena of occupational overestimate the effects, when compared to
health, safety or health promotion frequently projected results on all employees.
have one or more problems:ccvii
• Gender bias. Occupational health research
• There is no control group. A common way of in general has been criticized for a lack of
evaluating the effects of a workplace gender perspective. Women have often
intervention is to collect baseline data before been excluded from studies, or results have
the intervention, and compare the same been adjusted for sex rather than being
parameters immediately after the examined for sex or gender-specific
intervention, and/or after some differences.ccviii
predetermined time period has passed (“pre-
post measurements”). However, if there is
no control group that does not participate in “I think we believe a lot of things
or be exposed to the intervention, the
about what could be improved, but
changes that occur may simply be indicative
of changes in society as a whole. For I think we do not have enough
example, a smoking cessation programme knowledge on the effectiveness of
that sees a decrease in smoking of 5% by these measurements which we are
the end must consider this in the light of the
decrease in smoking that may have saying. I think there is a need to do
occurred in the general population at the more studies on effectiveness.”
same time. Interview #20, USA, OH & Sports Med.
scientific evidence of the intervention’s could have been better spent on increasing their
effectiveness. wages. On the other hand, if the employer and
workers and their representatives sit down
This may be a rather heretical statement to together to discuss a problem and come up with
some, and of course comes with one major possible solutions, they may very well come up
caveat: it must be clear without a doubt that the with the same intervention. However in this
intervention will do no harm, either to the health case, when the intervention is applied, (a) it has
of workers, or to the sustainability of the a better chance of being effective because the
enterprise. This is where some of the grey workers and their representatives were part of
literature can play a significant role. Published the decision to do it, and (b) even if it fails, the
accounts of case studies or models of good workers will probably forgive and forget, and
practice can provide valuable guidance to probably be willing to meet with the employer
employers and workers who are motivated to again to try something else.
make positive change in the workplace, with or
without scientific proof of efficacy. This principle is so important that in some cases,
it may well be worth implementing a measure
The workplace parties in enterprises that are that the literature suggests to be of uncertain or
attempting to improve worker health through low effectiveness, if it is something that comes
health promotion activities should keep in mind out of a serious collaboration between workers
that behaviour change is a slow process that and the employer. In that situation, the process
requires several invisible, internal changes to by which the intervention was determined,
occur before actual visible behaviour is modified. planned and implemented, may be as important
This means that patience and persistence in as the content of the intervention. If the process
providing ongoing information and education results in improving trust between workers and
may be required, even in the face of an apparent the employer, that in itself will have a
lack of impact. tremendously positive impact on the mental
health, engagement and commitment of
E. Interrelatedness of Worker workers, the organizational culture, and morale.
Participation and Evaluation Evidence
A theme that has been heard repeatedly in the F. Evaluating the Cost-Effectiveness of
literature regarding healthy workplaces is the Interventions
importance of worker participation. Whether the In addition to knowing that an intervention is
term is “control over work” or “input into likely to be effective in improving health and/or
decisions” or “worker empowerment,” the fact productivity, employers want to have some idea
remains that the involvement of workers is one of the cost-effectiveness of the intervention.
of the most important and critical aspects of a Employers generally are not willing to expend
healthy workplace.ccxii Fortuitously, this healthy great amounts of resources for minimal results,
workplace indicator and criterion also may even if positive. For this reason, many
provide the answer to the dilemma of scarcity of sophisticated employers ask for a cost-
efficacy evidence. Consider the following. If an effectiveness analysis before implementing an
employer decides unilaterally to implement a intervention, or require return-on-investment
questionable practice into the workplace (ROI) data.
because the employer believes it will be good for
the workers, (a) it may fail because of worker The literature is rife with accounts of ROI
resistance to being imposed upon and (b) if it calculations for health protection and promotion
fails, the workers may react with anger, blame interventions. Some statements are:
the employer, and complain that there should be
no intervention without solid evidence for “Research shows every Euro invested in WHP
effectiveness; or they may complain the money leads to Returns on Investment (ROI) between
2.5 € and 4,8€ due to reduced absenteeism discussed above. To further confuse the issue,
costs.”ccxiii terms such as “return on investment”, “cost-
benefit” and “cost-effectiveness” are bandied
“…the so-called “return of about interchangeably, although some of them
investment” (ROI) in respect of the have very specific mathematical/accounting
reduction of medical costs is meanings.
between 1: 2.3 and 1: 5.9 – this
value is all the more impressive Sockoll et al conclude, “As the literature shows,
because it is to be found in a study there is a clear lack of assessment methods for
controlled at random.”ccxiv determining the connection between health and
work performance and/or productivity. This
“While there are often difficulties results in the fact that to date, the evidence base
quantifying some of the results, for the cost-effectiveness of workplace health
there is growing evidence that the promotion and prevention focusing on work
cost-benefit ratio ranges from $1.50 performance is still very limited.”ccxviii They do,
to $6.15 for every dollar however, make it clear that data on the
invested.”ccxv economic benefits of health protection and
promotion related to absenteeism and medical
“Eighteen of 18 intervention studies costs are sufficiently proven.ccxix
found that absenteeism dropped
after the introduction of the health Consequently, it is wise to take cost-
promotion programme and the six effectiveness data with a grain of salt unless
studies which reported cost benefit exact details are known about the methodology.
ratios averaged savings of $5.07 for In addition, plans to evaluate cost-effectiveness
every dollar invested. Twenty eight of an intervention prospectively must be
of the 32 intervention studies found carefully planned with experts in research
that medical care costs dropped design to ensure the results are meaningful.
after the introduction of a health This additional planning and consultation may
promotion programme and the 10 require significant resources, both financial and
studies which reported cost benefit administrative.
ratios averaged savings of $3.93 for
every dollar invested.”ccxvi Nevertheless, many employers do not wish to
simply take the word of academic researchers
“For health care costs, the studies and trust that healthy workplace interventions
assume a cost-benefit ratio (return will be cost-effective. Often, boards of directors
on investment, ROI) of 1:2.3 to or funding bodies require proof that what is
1:5.9. The savings for absenteeism being done to improve worker health is actually
are stated as 1:2.5 and/or 1:4.85 to being effective, and at a reasonable cost.
1:10.1.”ccxvii Therefore, it is important that simple tools be
provided to assist enterprises to do some basic
The caveat with statements like these is that calculations to determine their own return on
there is often little detail provided as to what investment, without too great a requirement for
exactly was done in the interventions. Going academic support or costly research budgets.
back to the original papers reveals that the WHO has published a number of tools in this
interventions range from single-focus activities regard, which may be of assistance to the
such as a smoking cessation programme, to a workplace parties.ccxx,ccxxi
more comprehensive approach involving
organizational change. In addition, the research
design frequently exhibits many of the flaws
Chapter 6:
Evidence for Interventions
That Make Workplaces Healthier
In spite of the grave limitations in evaluation paper, because no systematic review has
data discussed in the previous chapter, it is been found on the topic.
important to review the evidence that is
available for effectiveness of various One disadvantage to this approach is that it
interventions. Knowing that evidence exists may give the impression that little has been
or does not exist can form the basis for achieved, that successes are few and minor.
beginning a conversation between the However, global statistics show this is far from
employer and workers and their the truth. ILO data show that the estimated
representatives when assessing needs and workplace fatality rate per year per 100,000
planning interventions. workers ranges from a low of less than 1 to a
high of 30 in different countries. And the
This paper does not attempt to address in estimated accident rate (an injury requiring at
any comprehensive way the actions that least three days absence from work) ranges
national, state/ provincial or local from a low of 600 per year per 100,000
governments should or could take to workers, to a high of 23,000.222 Clearly, there
influence worker health. The focus of the are many effective approaches that have been
framework is on things that employers and put in place in the “good” countries that may
workers can do in collaboration. Having said not have been proven effective in a Cochrane
that, governments clearly have more power Review, but have made a huge difference to
than individual enterprises or workers, or worker health and safety.
even groups of enterprises or groups of
workers. Governments can provide the A. Evidence for Effectiveness of
conditions to facilitate, enforce and support Occupational Health and Safety
improvements in worker health, or they can Interventions.
create barriers and impediments. Much of For the reasons discussed, evaluation reports
the work of WHO and ILO is devoted to of most health and safety interventions fall into
influencing the actions of governments in the category of grey literature. Nevertheless,
this regard. (This is discussed at greater some rigorous research has been done, and
length in Chapter 8.) The scope of this several systematic reviews of the literature
chapter is primarily to provide information have been published.
and guidance to employers and workers
about things that are within their sphere of One qualifier is related to the issue of gender
influence to accomplish, with or without the bias that was noted in Chapter 5. Very little
assistance of government. research looks at the effects of workplace
interventions on men and women separately.
Reviewing all the individual research and Women and men tend to work in different jobs,
other publications that examine and within the same jobs they sometimes
effectiveness of workplace health and safety perform different tasks. There are also social
interventions would require teams of people differences (e.g. family responsibilities) and
working for years. For the purposes of this biological or physiological differences (e.g.
framework, we have chosen to report on the differences in average height) that interact
systematic reviews that have been done by differentially with the workplace. For all these
the Cochrane Collaboration and others. As reasons, there are very often significant
a result, there may be many excellent and differences in the risks to women versus men,
effective interventions not mentioned in this
and in the effectiveness of interventions for Table 6.1 shows some samples of measures
women and men. deemed to be either effective, ineffective, or
inconclusive/inconsistent.
Table 6.1 Evidence for Effectiveness of Occupational Health & Safety Interventions
Effective Inconclusive or Inconsistent Not Effective
Disability management/return- Hearing protection policies – Ergonomic workstation
to-work programmes (using a effectiveness depended on adjustments alone.225
participatory approach that whether the policy was
includes a health care mandatory or voluntary.224
provider, supervisors and
workers, and workers’
compensation carriers) (strong
evidence)223
Apart from the research on worker studies are inconclusive, no strong research
participation, the number of studies looking at has been identified to date showing that
interventions that involve the psychosocial psychosocial interventions in the organization
work environment, organization of work or of work or organizational culture are
organizational culture is much smaller and ineffective.
more limited than that examining health and
safety interventions. Nevertheless, some Table 6.2 shows some samples of
have been evaluated, with somewhat positive psychosocial interventions deemed to be
findings. It is noteworthy that while some either effective or inconclusive/ inconsistent.
Inconclusive or
Effective Not Effective
Inconsistent
A combination of individual and No studies were
organizational approaches to workplace Some systematic reviews of identified that found
stress is the most effective, and important organizational intervention consistent evidence
success factors are participation of studies to reduce sources of a lack of
employees in planning, implementation and of stress concluded there effectiveness of
evaluation of changes, and the role of was no impact; however the psychosocial
management in supporting employees authors suggest these interventions.
through effective communication.250 results were the result of
the very small numbers of
studies involved.251
Inconclusive or
Effective Not Effective
Inconsistent
statement to be made and
further research is
required.255
C. Evidence for Effectiveness of Personal equally mixed, though there is evidence that
Health Resources In The Workplace health promotion activities in the workplace
The evidence for efficacy of providing can make a difference, at least in the short
personal health resources in the workplace term, if carefully planned. It is consistently
(often largely limited to health promotion) is noted that including workers and their
Table 6.3 Evidence for Effectiveness of Personal Health Resource Interventions in the
Workplace (most limited to health education)
Inconclusive or
Effective Not Effective
Inconsistent
Individual stress
Key elements of successful management A Cochrane Review of short
workplace health promotion programmes show psychological debriefing for
programmes include having clear varying effectiveness on the management of distress
goals and objectives, links to perception of stress and after trauma to prevent post
business objectives, strong mental well-being, with traumatic stress disorder
management support, employee cognitive-behavioural (PTSD) concluded that there
involvement at all stages, supportive approaches the most is no evidence that a single
environments, adapting the successful. However, session is useful, and in fact
programme to social norms.263 they tend to be short-lived may actually increase the
and to have little effect on incidence of depression and
productivity or PTSD. The authors stated
organizational bluntly, “compulsory
measurements.264 debriefing of victims of
trauma should cease.”265
A Cochrane Review of
Work-related exercise programmes alcohol and drug testing
increase physical activities of of occupational drivers to There is moderate evidence
employees, prevent MSDs, and prevent injury or absence that job stress management
decrease fatigue and exhaustion. from work related to injury training has no effect on
These are especially effective when concluded there is upper extremity MSD
scientific behaviour change theory is insufficient evidence to outcomes.268
incorporated, and when sports recommend for, or
facilities are provided.266 against this practice.267
Inconclusive or
Effective Not Effective
Inconsistent
A Cochrane Review of
incentive- or competition-
Workplace health promotion based smoking cessation There is moderate evidence
programmes targeting physical programmes concluded that biofeedback training, in
inactivity and diet can be effective in that while there are short- which monitoring instruments
improving health related outcomes term improvements, there are used to provide
such as obesity, diabetes and is no long-term effect.274 information about increased
cardiovascular risk factors.273 muscle tension, has no effect
on upper extremity MSD
outcomes.275
Recent studies on
incentives conclude that
Increasing participation rates by appropriately targeted Workplace exercise
using a participatory process to incentives could reduce programmes have little effect
involve workers and their inequalities in health on muscle flexibility, body
representatives in the preparation outcomes, but that weight, body composition,
and execution of the measures276 ongoing assessment of blood lipids, blood
their affordability, pressure278
effectiveness, cost
effectiveness, and
unintended
consequences is
needed.277
A comprehensive programme to
increase physical activity that
includes individual counseling, health
promotion education and fitness
facilities is more effective than
single-focus programmes.283
Inconclusive or
Effective Not Effective
Inconsistent
Individual and organizational
approaches to improving nutrition
that include point of purchase
information and environmental
supports can influence employee
nutrition habits while at work.284
Inconclusive or
Effective Not Effective
Inconsistent
multicomponent workplace
interventions were effective that:
o provide healthy food and
beverages at the workplace
o provide space for fitness or
encourage stair use
o involve the family
o provide individual behaviour-
change strategies.290
Potential Response by an
Situation Potential Result
Enterprise
Lack of safe, clean water Assist in the digging of local Improved health among workers,
to drink in the community deep wells; lobby government less time lost due to
for infrastructure; train workers gastrointestinal illness in workers
to boil drinking water; provide or their families
water filters for use at home.
Low literacy levels among Arrange after-work classes to Increased ability of workers to
workers teach workers and their understand written instructions or
families to read and write. signage, resulting in improved
health and safety. Increased self-
esteem among workers, resulting
in higher engagement, loyalty,
commitment to employer.
Potential Response by an
Situation Potential Result
Enterprise
Weak tobacco control, Support enactment and Reduce exposure in community to
especially smoke-free enforcement of 100% smoke- tobacco smoke; reduce incidence
policy in community free law in community and of heart attacks and other health
exposes community other effective tobacco control hazards of secondhand smoke
members to secondhand measures as outlined in the among workers and other
smoke and makes it more WHO Framework Convention community members.
difficult to enforce smoke- on Tobacco Control.
free policy at the
workplace.
Lack of health system Work with other employers to Better access to primary care
resources, privatization of develop innovative insurance improves community health and
health care, lack of schemes, or with existing worker health by reducing both
compensation for primary insurers to include primary communicable and
care and preventive health, and find ways to noncommunicable disease.
services may make support and increase capacity
primary care and of existing primary care
preventive health services services.
inaccessible or
unaffordable.
Lack of suitable and Provide subsidized child care Access to good-quality and
affordable child care for employees; work with affordable child care reduces
increases work-family community governments, civil stress of workers and improves
conflict and compromises society and private sector to child welfare, health and
wellbeing of children of support provision of affordable education, as well as decreasing
working parents. and decent child care. absenteeism and presenteeism at
work.
Crime, lack of public Work with city authorities and Improved health of workers and
facilities, air pollution, lack planners to ensure provision of increased community solidarity.
of parks and safe public safe public areas and support
places and lack of sporting or other physically-
grassroots sporting active leisure activities.
activities limit community
options for leisure activity.
Chapter 7:
The Process: How to Create a Healthy Workplace
Earlier chapters have discussed the “What?” A plan is made (Plan), implemented (Do),
and the “Why?” of a healthy workplace. But evaluated (Check) and improved upon
knowing what a healthy workplace is, and why (Act), a new approach is planned,
it is important to move in that direction are not implemented, evaluated and improved
enough. This chapter will discuss the “How?” upon, in a never-ending upward spiral,
of creating a healthy workplace. always getting closer to the ideal. This is
based on the belief that people’s
An enthusiastic and motivated leader may sit knowledge and skills may be limited, but
at his or her desk and dream up the ideal will improve with experience. Repeating
healthy workplace, push it through as much the PDCA cycle brings us closer and
as possible, and then wonder why others do closer to the goal.
not support it, or why it fails after a short time.
In many ways, the process of developing a In the world of workplace health, safety
healthy workplace is as critical to its success and well-being, the PDCA cycle has been
as the content. There are probably as many modified and sometimes expanded by
paths to a healthy workplace as there are individuals and organizations. Some
enterprises. However, there are some general variations are highly complex, suitable only
principles that are important to include in the for the most sophisticated, complex
process, in order to be sure that a health, hierarchical organizations. There are
safety and well-being programme meets the variations with four differently named
needs of all concerned, and is sustainable steps, variations with seven, eight, or ten
over the long run. steps. These process models may be
known as continual improvement systems,
A. Continual Improvement Process or as health and safety management
Models systems. Table 7.1 compares some of the
When some people get an idea for a project, best known models, which are discussed
they may jump into it with no planning, and below the table.
then wonder why it fails. At the other end of
the spectrum are those who plan, plan and
then plan some more, and fall into “analysis
paralysis” in an attempt to think of everything
and get everything perfect the first time. With
an appropriate process, these pitfalls can be
avoided.
Canadian Centre for Occupational Health & participation, and formalizing the development of
Safety (CCOHS) an occupational health and safety policy. The
This WHO Collaborating Centre provides other steps are the same as Deming’s original,
information on all aspects of health and safety to but are fleshed out considerably to provide more
Canadians and the global community through guidance as to the activities that would occur in
web-based services. Its OSH-Works each step.
programme is an occupational health & safety
management system that enterprises may WHO Regional Office for the Western Pacific
subscribe to, and receive administrative and As discussed in Chapter 3, the WHO Western
data management services.ccxcv It is based on Pacific Regional Office developed a model
Deming’s PDCA, with the addition of the first consisting of eight steps.ccxcvi The first five steps
component titled “Lead.” This includes gaining are all activities that would fall into Deming’s
management commitment, ensuring worker “Plan” section, emphasizing the importance of
this first step. As in the CCOHS example, the Improvement includes preventive and corrective
importance of gaining commitment from actions and continual improvement.
stakeholders is emphasized. It then suggests
that a coordinating body or committee be B. Are Continual Improvement/OSH
established to share the work. The first activity Management Systems Effective?
of the committee is doing a proper needs One of the most common recommendations in
assessment, followed by setting priorities and the literature is for employers to use some sort
formalizing an action plan. These actions are of OSH management system that includes a
then implemented, evaluated and revised as strong emphasis on evaluation and continual
required. This model has been tested in many improvement. This is sometimes referred to as
SMEs in developing and developed countries as a process based on systems theory. A rigorous
discussed in Chapter 3, and found to be Cochrane-type systematic review of reports in
workable and appropriate. the literature on this subject was carried out in
2007 by the Institute for Work and Health, a
OHSAS 18001 research institute in Toronto. The reviewers
OHSAS 18001 is the internationally recognized looked at the type of management system
assessment standard for occupational health intervention, its implementation, intermediate
and safety management systems.ccxcvii It was results (such as increased action on OSH
developed by a selection of leading trade issues) and final effects including changes in
organizations, international standards workplace injury rates. They also looked at
associations and certification bodies to address economic outcomes such as work productivity.
a gap where no third-party certifiable The results of the studies that met the research
international standard previously existed. It has criteria were almost all positive, with some
been designed to be compatible with neutral findings. There were no negative
international quality standards, such as ISO findings. The authors concluded that the body
9001 and ISO 14001. It is used mostly by large of evidence was insufficient to recommend for or
corporations as part of their risk management
strategy to address changing legislation and “I would position healthy workplaces
protect their workforce. It has five steps,
as part of organizational culture, and
emphasizing the importance of starting with an
OH&S policy. in a managed system, organizational
culture is seen as the responsibility of
International Labour Organization the leadership group, to establish a
In 2001 the ILO developed their OSH
management system,ccxcviii which is a five-step
culture of continual improvement, to
process. Beginning with the establishment of an establish a culture of empowerment
OH&S policy that emphasizes participation of and participation and involvement.
workers and their representatives, the model
Those are all part of the components
then sets an Organizing step. This is intended
to include establishing accountabilities and from a healthy workplace perspective,
responsibilities, documentation and of a respectful and safe workplace. So
communication, to ensure that the infrastructure they very much go hand-in-hand. In
is in place to properly manage OH&S. Planning
and Implementation includes doing a baseline
fact I believe the managing system
review, determining OH&S hazards and setting can’t be affective unless it has
objectives. Evaluation comprises performance these tenets. It’s the foundation of
monitoring and measurement, investigation of
the healthy workplace.”
work-related injuries and illnesses, audit and Interview #3, Canada, OSH
management review. The last step, Action for
against OSH management systems. In the However, all of them have some common
authors’ words: “This was due to: the features that are regarded as essential
heterogeneity of the methods employed and the components for success, as evidenced by their
OHMS studied in the original studies; the small appearance in virtually all models. Ensuring that
number of studies; their generally weak the following five key principles are included in
methodological quality; and the lack of the process used will therefore raise the
generalizability of many of the studies.”ccxcix likelihood that the process will move smoothly
They emphasized, however, that this is a and achieve the desired results.
promising approach with generally positive
results, and should be continued to be used 1. Leadership engagement based on core
while waiting for more rigorous evaluations.ccc values: It is important to mobilize and gain
commitment from the major stakeholders
The Institute has concluded that while many before trying to begin, since a healthy
work injuries and illnesses may be preventable, workplace programme must be integrated
effective prevention requires coordinated action into the business goals and values of the
by multiple stakeholders. A systems theory on enterprise. If permission, resources, or
its own may not be enough. In trying to achieve support are required from an owner, senior
coordinated action, practitioners can learn manager, union leader, or informal leader,
valuable lessons not only from systems theory, it is critical to get that commitment and buy-
but also from knowledge transfer and action in before trying to proceed. This is an
research. Systems theory, through a continual essential first step. Key evidence of this
improvement approach, provides a broad view commitment is the development and
of the factors leading to injury and disability and adoption of a comprehensive Policy that is
a means to refocus stakeholder energies from signed by the highest authority in the
mutual blaming to effective strategies for system enterprise and communicated to all
change. Experiences from knowledge transfer workers, and which clearly indicates that
can help adopt a stakeholder-centered approach healthy workplace initiatives are part of the
that will facilitate the practical and concrete business strategy of the organization.
application of the most current occupational Understanding the underlying values and
health scientific knowledge. Action research is a ethical positions of enabling stakeholders is
methodology endorsed by WHO and the US critical. Commitment from them will only be
Centers for Disease Control and Prevention that sincere and solid if it is in line with their
provides methods for successfully engaging the deeply held beliefs and values.
stakeholders needed to attain sustainable
change. Researchers affiliated with the Institute 2. Involve workers and their
have proposed a five-step framework they call representatives: One of the most
MAPAC (Mobilize, Assess, Plan, Act, Check) consistent findings of effectiveness
that combines concepts from the three fields.ccci research is that for successful
These concepts are incorporated into the programmes, the workers affected by the
principles discussed below, as well as the programme and their representatives must
process model recommended in Chapter 9. be involved in a meaningful way in every
step of the process, from planning to
C. Key Features of the Continual implementation and evaluation.cccii,ccciii
Improvement Process in Workplace Workers and their representatives must not
Health and Safety simply be “consulted” or “informed” of what
Enterprises will no doubt have different needs is happening, but must be actively involved,
and situations that require them or motivate their opinions and ideas sought out,
them to adopt one of these continual listened to, and implemented.
improvement models or some other one.
is no way to know if something has worked, named after the vertical cylindrical storage
is working, and is continuing to meet the structures used to store grain or other bulk
changing needs of workers and the materials in some parts of the world. The silo
enterprise. Lack of this step is what causes metaphor in the world of work refers to groups of
many initially good interventions to be people who work in isolation from each other
forgotten or not sustained. Evaluation can without collaboration or communication between
be as complex or as simple as resources the groups. “Breaking down silos” is one of the
allow, but it must be carried out, most common reasons given for reorganizations
documented, and acted upon in order to within an enterprise, as it is recognized that this
ensure ongoing success. isolation of various work groups leads to
inefficiency. In many large organizations, health
D. The Importance of Integration and safety personnel work in one silo, “wellness”
The larger an enterprise becomes, the more professionals work on health education in
difficult it is for employees and managers to be another silo, and human resource professionals
aware of all that is going on, and the more are in their own silo, dealing with many issues
probable it is that specialist positions will be related to leadership, staff development and the
created to divide the work to be done. This psychosocial work environment. All of these
often leads to work being done in “silos” – people in their individual areas are working on
The ILO programmes named WISE (Work Improvements in Small Enterprises)1,2 WIND
(Work Improvements in Neighbourhood Development)3 and WISH (Workplace
Improvement for Safe Home)4 have been applied with great success in several WHO
Regions. These models are all based on the idea of participatory action-oriented training.
Their six principles are:
1. Build on local practice
2. Use learning-by-doing
3. Encourage exchange of experience
4. Link working conditions with other management goals
5. Focus on achievements
6. Promote workers’ involvement
The WISE process begins with a series of short training programmes with small groups of
owners/managers of SMEs. Both the physical work environment, the social work
environment and some personal health factors are covered in the interactive training, in
which participants are encouraged to share ideas and problem-solve together. This is
followed by the use of a WISE action-checklist in the workplaces, setting priorities and
implementing solutions, followed by review and improvement. A key to success is the
network of WISE trainers in the communities. Results have shown this method can result
in very low-cost interventions that make significant improvements to the health and safety
of the workplace.5
1.
Work improvement in small enterprises: an introduction to the WISE programme. International Labour Office [1988].
2.
Krungkraiwong S, Itani T and Amornratanapaitchit R. Promotion of a healthy work life at small enterprises in Thailand by
participatory methods. Industrial Health, 2006;44:108-111.
3.
Kawakami T, Khai TT and Kogi K. Work improvement in neighbourhood development (WIND programme): training
programme on safety, health and working conditions in agriculture. 3rd ed. Can Tho City, Viet Nam: The Centre for
Occupational Health and Environment, 2005.
4.
Kawakami T, Arphorn S and Ujita Y. Work Improvement for safe home: action manual for improving safety, health and
working conditions of home workers. Bangkok, ILO 2006.
5.
Kogi K. Low-cost risk reduction strategy for small workplaces: how can we spread good practices? La Medicina del Lavoro,
2006;92(2):303-311
issues that directly relate to the health of • additive and synergistic relationships to
workers, yet they are often unaware of, and disease risk
even working at cross-purposes with, each • overlapping risks for high risk workers
other. In addition, the enterprise’s management • programme impacts on participation and
team, in particular those dealing with the effectiveness, and
operational areas of production or customer • broader benefits for work organization.
service, are working hard trying to increase
quality and quantity of the product or service Sorensen’s subsequent research illustrated this.
being delivered. Often these activities will work Combining health promotion with occupational
in direct opposition to the health of workers, health and safety interventions in manufacturing
even though, as we have seen in earlier worksites to attempt to change smoking
chapters, the health of workers is critical to high behaviour in blue-collar workers was more than
levels of production and quality. twice as effective as health promotion alone.cccxii
How can integration be accomplished? There
All of this points to the importance of integration are probably as many ways of integration as
of healthy workplace concepts, not only amongst there are enterprises, and each must find
those working on those aspects in particular, but pathways to integration that work in the
also across the whole enterprise/ organization. particular culture of the enterprise. Here are a
Integrating workplace health, safety and well- few examples to stimulate thinking about ways
being into the way an organization is managed to achieve integration:
is the only way to ensure the health of workers
and the enterprise at the same time. As Lowe • Strategic planning must incorporate the
points out, “a healthy organization has human side of the equation, not simply the
embedded employee health and well-being into business case, because inevitably the
how the organization operates and goes about business case depends on the humans in an
achieving its strategic goals.”cccx enterprise. Kaplan and Norton, two well-
known experts in business strategic
Sorensen points out other reasons for planning, developed a “Balanced Scorecard”
integrating the various aspects of a healthy approach to management that has been
workplace, specifically integrating health adopted by many major corporations in
industrialized nations. It points out the
“Another idea I’m thinking of is the requirement of measuring not only financial
notion of integration between performance, but also customer knowledge,
internal business processes, and learning
safety and health approaches… And and growth of employees, in order to
also integration between preventive develop long-term business success.cccxiii
and clinical medicine. Clinical
• Create and have senior management accept
physicians must teach people to
and use a health, safety and well-being “filter”
prevent occupational diseases… And for all decisions. Regardless of the decision
also integration between public being made by senior management, when it is
health and the committee approach time to make the decision, they normally
would run it through several other criteria,
must be combined in every such as the cost in terms of money, time and
country.” resources; the impact on their reputation in the
Interview #19, Japan, Public Health, Occ Med.
community, etc. Workers’ health must
become one of these standard criteria that are
promotion with occupational health & safety. considered in the decision-making process. To
She notes that there are:cccxi integrate health, safety and well-being into the
process, it can be formalized in a checklist and interpersonal skills that will contribute to
until it becomes second nature, just as a healthy organizational culture, then healthy
considering cost is second nature.∗ workplace practices have a greater chance of
being integrated into everyday work. It will
• Keep the various components of a healthy happen naturally because healthy workplace
workplace in mind whenever an initiative to behaviours and attitudes will be second
solve a health, safety or well-being problem is nature in the managers and workers being
being planned. (See WHO definition of a hired.
healthy workplace in Chapter 3). For
example, if there were a problem with MSDs • What is rewarded is reinforced. A
among people who work all day at sewing performance management system that
machines, a common practice would be to rewards high output, regardless of how the
examine the ergonomics of the operators in results are achieved, will encourage people
their workstations, and fix the physical to take shortcuts or to use less-than-healthy
environment to make it more comfortable. interpersonal skills to get work done. On the
However, other contributors to the problem other hand, a performance management
might be psychosocial issues such as system that sets behavioural standards as
workload and time pressure. And there may well as output targets, can reinforce the
be personal health issues related to physical desired behaviour and recognize people who
fitness and obesity that are contributing to the demonstrate behaviours and attitudes that
problem. Or a lack of primary health care lead to a healthy workplace culture. Again,
resources in the community may mean this is a way to integrate healthy workplace
workers cannot be assessed in the early aspects into the fabric of the organization
stages of pain. Therefore, an integrated
approach combining work environment- • Use of cross-functional teams or matrices
directed (both physical and psychosocial), can help reduce silos. If an organization has
community-directed, and person-directed a health and safety committee and a
approaches to examine all aspects of the workplace wellness committee, they could
problem and potential solutions would be most avoid working in silos by having cross-
effective. membership, so that each is aware of, and
able to participate in, the activities of the
• It is easier to develop technical skills in other. This principle can be applied to many
personnel than interpersonal or social skills, other examples of working matrices.
or to change attitudes. Therefore, one way to
ensure that health, safety and well-being The integration challenge illustrates one area
become integrated into the fabric of an where SMEs have an advantage. It is much
enterprise is through the employee less probable that silos will exist in a small
recruitment process. If the Human enterprise, since it is harder to compartmentalize
Resources process for recruiting new activities. However, even in a very small
workers, and new managers in particular, enterprise, if people (including the owner) do not
includes criteria that consider attitudes understand the importance of communication,
towards health (physical and psychosocial) silos can still exist. This underscores the
importance of worker participation discussed
above. If workers in an SME are fully involved in
∗
This kind of Healthy Workplace Decision Filter checklist the assessing, planning and implementation of
was developed in 2007 and is in use in the Operations
Division, Ontario Ministry of Labour, Canada. For more
healthy workplace programmes, it is less
information, contact: Dawn Cressman, Healthy Workplace probable that poor communication skills will be a
Program Coordinator: +1.905.577.8395, factor in the integration of all aspects of worker
Dawn.Cressman@ontario.ca or
Christina Della-Spina, Healthy Workplace Project Assistant: health into organizational health. Similarly, if
+1.905.577.1327, Christina.Della-Spina@ontario.ca
Chapter 8:
Global Legal and Policy Context
of Workplace Health
As mentioned in Chapter 6, governments have psychosocial and physiopathological
more power than individual enterprises or pathways.
workers, or even groups of enterprises or
groups of workers. Differences in the The report discusses the global situation by
distribution of political and economic power placing countries in one of nine categories,
have a profound influence on the work based on two factors: economic level (core,
environment and health of workers. Benach et semi-periphery and periphery) and labour
al note, “In scientific papers, reports or other market policies (leading to more or less
publications on public health, little attention is economic equality.) Table 8.1 illustrates where
paid to the political issues that shape health a number of nations fall according to this
policy. Policies and interventions on health characterization.317
cannot be thought of as a financial or a
technical value-free process; rather, it is The authors of the report note that there is a
influenced by the political ideology, beliefs and strong correlation between labour market
values of governments, unions, employers, inequalities and poor health in the population.
corporations or scientific agencies, among For example, among peripheral countries,
others.”314 higher labour market inequality results in
higher probability of dying for men and
Governments create the broader context of women, higher infant and maternal mortality
employment that influences not only working rates, and more deaths from cancer and
conditions, but also health inequities. injury. The implications for workplace health
Underlying everything is the way that are clear. Think of an enterprise in Sweden
governments view the health of their populace. that is attempting to become a healthy
If governments see differences in health as workplace, with the cooperation and
the inevitable result of individual genetic collaboration of workers and managers. Now
determinants, individual behaviours, or market think of the same type of enterprise in
conditions, they will respond in one way. If Ethiopia, with the same commitment from the
they see inequalities in health as an avoidable employer to create a healthy workplace.
outcome that needs to be remedied, they will
respond much differently.315
“I actually think the most
A report to the WHO Commission on Social important aspect is probably the
Determinants of Health provides an excellent national culture on health. I think
summary and discussion of the extremely
broad and complex network of forces that the appreciation by people at work
interact to create and influence the health of of all the work-related impact on
workers.316 The authors illustrate both a health and the impact of health on
macro model, which includes power relations
work is absolutely crucial, but it is
in the market, government and civil society, as
well as social policies according to the degree sometimes not facilitated by the
of social protection and general view; and a national systems.”
micro model focusing more on employment Interview #36, Australia, OSH
and working conditions, which result in health
inequities through a variety of behavioural,
Table 8.1 Countries Classified By National Economic Level And Labour Market Policies
More Equal LABOUR MARKET Less Equal
Core Social Democratic Corporatist Labour Liberal Labour
Labour Institution Institution Institution
Sweden, Denmark, France, Germany, US, UK, Canada
Norway Austria, Spain
Semi-periphery Informal Labour Informal Labour Informal Labour
Institution Market, More Market, Less
Successful Successful
Chile, Hungary, Poland, Turkey, Thailand, South Botswana, Gabon, El
Malaysia Africa, The Bolivarian Salvador
Republic of Venezuela
Periphery Informal Market, More Insecurity Maximum Insecurity
successful
Indonesia, India, Nigeria, Jordan, Algeria, Ethiopia, Ghana,
Armenia, Pakistan, Morocco, Egypt, The Kenya, Bhutan,
Bulgaria, Tajikistan, The Islamic Republic of Iran China, Bangladesh,
Sudan, Sri Lanka Angola
provide a good picture of international This is the first, and to date the only, global
workplace health, safety and well-being convention negotiated under the auspices of
legislation and policy. However, that is far WHO. Passed in 2003, the treaty requires the
from the truth. For one thing, few Conventions signatory countries, numbering 168 to date, to
have been ratified by a majority of countries. control tobacco advertising, sales, promotion
In addition, some of the most sophisticated and many other factors. Key to workers is the
developed nations have ratified very few, while requirement to eliminate smoke exposure in
some developing nations have ratified most. workplaces or public places. The treaty states,
Unlike rulings of the World Trade Organization “Each Party shall adopt and implement in
(WTO), ILO conventions and areas of existing national jurisdiction as
recommendations do not include punitive determined by national law and actively
measures for countries that fail to meet these promote at other jurisdictional levels the
standards. adoption and implementation of effective
legislative, executive, administrative and/or
Table 8.2 shows the percent of countries in other measures, providing for protection from
the six WHO Regions that have ratified seven exposure to tobacco smoke in indoor
very basic ILO Conventions. It is clear that workplaces, public transport, indoor public
there is no consistency among regions, or places and, as appropriate, other public
even among topics, as to what is ratified and places.”319 As with ILO Conventions,
what is not. In some cases, countries with countries sign or ratify the convention
extremely good reputations for workplace voluntarily, but once signed, the treaty has
health have “denounced” their earlier legal standing and must be implemented.
ratification, presumably because their
legislation now goes beyond the demands of ISO Standards
the Convention or because some aspects of The International Organization for
their law are now in contravention to the Standardization (ISO) is the world’s largest
Convention. As well, the ILO finds that many developer and publisher of international
Member States may ratify a Convention but standards. It is a non-governmental network of
then fail to report any progress in actually the national standards institutes of 162
implementing it within their country.318 countries. It develops standards that are
based on the best scientific evidence
WHO Framework Convention on Tobacco available, and which are agreed to by
Control consensus among all participating nations.
Table 8.2 Percent Of Countries In WHO Regions That Have Ratified Selected ILO
Conventions320
ILO Conventions Ratified Year AFRO AMRO EMRO EURO SEARO WPRO Ave
Passed (46) (36) (21) (53) (11) (27)
C14 - 24 hr of weekly rest for industrial 1921 74% 67% 57% 74% 55% 15% 57%
workers
C17 – Workmen’s Compensation for 1925 48% 36% 33% 47% 9% 11% 34%
accidents
C18 – Workmen’s compensation for occ. 1925 43% 11% 24% 47% 45% 7% 30%
diseases
C103 – Maternity Protection, Revised 1952 7% 19% 5% 32% 9% 7% 13%
C155 – Occupational Safety & Health 1981 24% 19% 5% 51% 0% 26% 21%
C111 – Discrimination (Employment and 1958 100% 92% 90% 98% 55% 48% 81%
Occupation)
C161- Occupational Health Services 1985 11% 19% 0% 30% 0% 0% 10%
ISO has developed over 17,500 standards to Chemical Safety (IPCS) produces
date, and normally adds about 1100 new International Chemical Safety Cards, which
standards each year. 321With respect to are peer-reviewed assessment documents.
workplace health and safety, ISO has International organizations, such as ISO and
developed at least 18 standards, and has the International Atomic Energy Agency
another 13 under development. Topics produce technical standards on the
include issues related to welding fume, measurement and control of several ambient
nanoparticles, personal protective equipment factors with the objective of their being
such as safety boots or respirators, and transferred to regional or national
exposure to noise, heat or cold. While the legislation.324
standards are voluntary, they often find their
way into law in adopting countries. These bodies set standards that are voluntary
until accepted by a national government.
Exposure Limits Countries adopt and implement them in
There are a number of standards setting various ways, with or without modification.
organizations that make recommendations for They may be implemented into regulations
exposure limits. These are the levels of that have the force of law, or may remain as
exposure to a chemical or other type of agent recommendations, depending on the
to which a worker can be exposed without government concerned.
serious injury. The term ‘exposure limit’ is a
general term that covers the various B. Global Status of Occupational Safety &
expressions employed in national lists, such Health
as “maximum allowable concentration”, In 2009 the ILO published a very
“threshold limit value” (TLVs), “biological comprehensive report on the global status of
exposure indices” (BEIs), “occupational implementation of Convention Number 155,
exposure limits” (OELs), etc. These limits are the Occupational Safety and Health
determined for the average worker, and do not Convention passed in 1981.325 In reviewing
generally provide different recommended the status of implementation of this
levels for those who may have differences in Convention globally, the ILO notes that at the
susceptibility due to sex or other factors such date of publication, only 52 countries (out of
as age, etc.322 The ILO notes that “OSH 183) or 28% had ratified this Convention.
research should capture any sex-based However, they note optimistically, more
disparities; yet, at present, there is a dearth of countries are continuing to ratify the
information about the different risks for men Convention on an accelerating schedule.
and women of exposure to certain
chemicals.”323 This Convention adopts a comprehensive
approach based on a cyclical process of
A large number of international, national and development, implementation and review of a
other authorities have published lists of legal policy, rather than a linear one of laying down
or recommended exposure limits of various prescriptive legal obligations. It emphasizes
sorts, but usually only for chemicals. The most the continual improvement approach to
wide-ranging is the American Conference of eventual total prevention of illness and injury
Government Industrial Hygienists (ACGIH) list to workers. This policy approach is
of Threshold Limit Values, updated annually, recommended first for Member States to adopt
which includes recommended exposure limits at the national level, but also for enterprises to
values for airborne chemicals; biological adopt in their own internal programmes. It
monitoring limits; ionizing, non-ionizing and says that the Member States should
optical radiation; thermal stress; noise; and “formulate, implement and periodically review”
vibration. The International Programme on a national policy, following in general the OSH
ILO Conventions Ratified Year AFRO AMRO EMRO EURO SEARO WPRO Ave.
Passed (46) (36) (21) (53) (11) (27)
C12 – Workmen’s Compensation in 1921 37% 58% 10% 55% 0% 26% 31%
agriculture
C17 Workmen’s Compensation for 1925 48% 36% 33% 47% 9% 11% 34%
accidents
C18 Workmen’s compensation for 1925 43% 11% 24% 47% 45% 7% 30%
occupational diseases
C42 Workmen’s compensation for 1934 17% 42% 5% 42% 18% 19% 24%
occupational illnesses, revised
C121 Employment injury benefits 1964 7% 14% 5% 26% 0% 4% 9%
Average 40% 31% 24% 50% 22% 12% 26%
another, due to differences in terminology, replacement until the injury has healed and
differences in meanings for the same terms, the worker can go back to work, in Ireland
and differences in calculations. For instance, the compensation insurance schemes
consider two examples of jurisdictions where generally pay a lump sum based on the
after a 3-day waiting period, a worker is paid injury – X Euros for a broken leg, Y Euros
67% of his regular wages for temporary total for a broken finger, for example. As a result,
disability benefits. The actual benefit payable there is no incentive for a worker to go back
may be modified by exemptions and to work earlier if the injury heals quickly.
qualifications related to: Also, there is no limit on the right to sue, so
• when the first day of disability begins if a worker does not like the amount of the
• how intermittent periods of disability are settlement, he or she is free to sue the
treated employer, and a significant percentage of
• what compensation is included in workers’ compensation claims go to
calculating the original “regular wages” litigation.330
• time period over which the average wage
is calculated It is clear that there are significant
• caps on wages earned by the injured differences among workers’ compensation
worker systems even within English-speaking
• differences in the calculation of the industrialized countries, so differences
compensation rate between systems in developing nations will
• reductions due to safety violations probably be even greater, even when
• additions due to the worker’s age, or the related ILO conventions have been ratified
fact that he was an apprentice.329 and implemented. The differences will have
Even though these three countries have a large impact on:
systems that seem similar on the surface, • quality of medical care the injured/ill
there are a number of major differences, as worker receives
indicated in Table 8.4. If there are this many • likelihood of the worker returning to work
differences among workers’ compensation • speed with which the worker returns
systems that are state-run, it is easy to • direct and indirect costs to the employer
imagine the vast differences that must occur • likelihood of the injured worker being
between these and systems that are privately given meaningful work upon return to
run. For example, in Ireland, employers must work
have workers’ compensation insurance • financial security of the injured worker
coverage for their employees, but they are and his/her family while away from work
free to choose from among a number of • financial security of the worker’s family
private carriers and determine the levels of after a fatal injury.
coverage. In addition, rather than wage
Quite apart from the actual legal provisions for • Convention 87, Freedom of Association
workers’ compensation that may exist in and Protection of the Right to Organize,
countries, the application of the laws is not passed in 1948, ratified by 150 countries;
always equitable. Swedish research indicates • Convention 98, Right to Organize and
that compensation claims for women are more Collective Bargaining, passed in 1949 and
likely to be turned down than they are for men, ratified by 160 countries.
even when the type of injury is the same.332,333
The legislation covering formation of trade
D. Trade Union Legislation unions and collective bargaining varies
In any enterprise, the owner or operator of the tremendously from country to country, as does
organization has greater power than any one the percentage of the workforce that is
worker. This makes it difficult for workers to unionized. For example, in Sweden, 75% of
make changes in health or safety conditions, if the workforce is represented by a union, while
the employer is not interested. There are in Chile only 16% of non-agricultural workers
several ILO Conventions that aim to even out are unionized.334 Within the United States, an
this power imbalance by giving workers a overall average of 12% of the workforce is
collective voice that is more powerful than the unionized, with only 8% of the private sector
voice of a single worker. These conventions represented by unions.335
are related to the right of association of
workers, and the rights to collective In addition to trade unions, many countries,
bargaining. Many of them have been ratified especially those in the European Union, have
by a significant majority of countries: legislation related to the formation of Works
• Convention 11, Right of Association Councils. These are “shop floor”
(Agriculture), passed in 1921, ratified by organizations representing workers, which
122 countries; function as local/firm-level complements to
national labour negotiations.
Table 8.5 Work and the Protection of Workers’ Health in Wealthy and Poor Countries, 1880-2007
Wealthy Countries Poor Countries
1880 1970 2007 2007
Employment No regulated job Secure jobs norm Decline in job No regulated job
security and security and (except women), security and security and
contingent substantial small contingent growing contingent large/growing informal
work contingent work workforce workforce sector
Minimum No minimum wage Universal minimum Minimum wage and No or ineffective
labour or hours laws wage and hours hours laws, some minimum wage or
standards (except children) laws erosion hours laws
(wages and
hours)
Union Union density low Union density 25- Substantial decline Union density low,
membership (<10%) and 50% and extensive in union density declining and limited
and collective limited collective collective and collective collective regulation of
bargaining bargaining bargaining bargaining work
Vulnerable Extensive Still vulnerable Expansion of Highly exploited
workers exploited groups (women, vulnerable groups vulnerable groups
vulnerable groups immigrants and (women, home- (children, women,
(women, home-workers) but workers, immigrants, homeless,
immigrants, home- more circumscribed immigrants, indentured/forced
workers, young homeless, old and labour)
and homeless, young; child labour
old) reemergence)
Occupational Limited OHS law Expansionary Expanded OHS law Little OHS law and
health & (factories, mines) revision of OHS but under indirect hardly enforced (and
safety law and poorly laws initiated threat then only in formal
enforced sector)
Workers’ No workers’ Mandated workers’ Workers’ Limited workers’
compensation compensation comp/injury comp/injury compensation and only
system system insurance system insurance; some in formal sector
erosion
Public health Little public health Extended public Public health Little public health
infrastructure infrastructure – health infrastructure – infrastructure
(water, sewers, hospitals, infrastructure, some erosion (hospitals,
hospitals, water health insurance water/sewer) except in
sewers etc.) ex socialist countries,
where being cut back
Social No age pension, Age pension/social Age, disability and No age pension, social
security social security, security, unemployment security,
safety net unemployment unemployment benefits – cut back unemployment benefits
(sickness, age, benefits benefits
unemployment
benefits)
the six areas HSE believes to be the most prevent discrimination or harassment by
serious sources of workplace stress.∗ employers on the basis of lifestyle factors,
such as smoking, obesity, lack of physical
The Standards in themselves have no legal activity, or unhealthy dietary practices. In
force. HSE specifies a minimum percentage some jurisdictions, for example, an addiction
of the workforce that confirms the existence of to tobacco is regarded as a disability, and
a certain state of organizational affairs, a therefore subject to anti-discrimination laws.346
“threshold” within each standard. For Thus it reinforces the point that when
example, the threshold for demands of the job employers choose to help employees adopt a
is that at least 85% of employees should healthy lifestyle, they must do so with finesse.
agree that they are able to deal with the Their role must be to determine, and then
demands of their job (as described in the support, the lifestyle changes that workers
criteria.) The percentages achieved in a wish to make, and never cross the line to
workplace are measured by means of pressure employees or discriminate in any
Indicator Tools or survey instruments provided way against those with unhealthy lifestyles.
to enterprises by HSE. There is a legal
requirement for employers to assess risks to There are some exceptions to this statement.
mental health using these instruments, but no If a personal health habit or condition
legal guidance on what employers are to do interferes with the employee’s ability to do the
with the results. In practice, the results of the job, the employer does have the right to
surveys are educational for the employer, and become involved. For example, a fire
HSE provides training and consultation to department has the right to make a certain
assist the employer to improve the situation in level of physical fitness a condition of
areas found to be weak. These activities are employment for fire fighters, because fire
believed to be helpful in proving “due fighters would be unable to perform the key
diligence” for the employer in case of litigation functions of the job otherwise. Even in this
by an employee, and in fact by encouraging situation though, treading the line between sex
worker-employer consultation, normally lead to discrimination and ensuring employees can
improvements in the organizational culture perform the job is sometimes delicate.347
and climate.
Similarly, drug or alcohol misuse, or other
G. Personal Health Resources in the habits or conditions in employees, could
Workplace create situations where an employee was
As far as our researchers were able to unable to perform the job safely, and could
ascertain, there are no laws anywhere that endanger not only his or her own life, but the
require an employer to promote healthy lives of the public or co-workers. Here again,
lifestyle practices in the workplace.∗** To the there is a vast difference among nations as to
contrary, there may be provisions in various the legal lengths to which an employer can go,
human rights codes and laws that could without infringing on individual rights. For
example, it is widely accepted in many US
∗
As discussed in Chapter 4, the six areas are: demands states to routinely test an employee for drugs
of the job, employee control over how they work, support or blood alcohol levels after any workplace
form management and colleagues, working relationships,
role clarity, and organizational change. accident, whereas that would be unacceptable
**
and subject to immediate legal challenges in
One of the closest situations to legislated health
promotion exists in Germany, where the national sickness
most Canadian jurisdictions.348 Another
insurance providers are required to spend a certain example is that of diabetes. While it appears
amount of money per subscriber on wellness or health that an employee having diabetes is a cause
promotion programmes, and this is usually applied to the
workplace. (Personal communication 29 September 2009, for safety concerns in the USA, and likely to
Wolf Kirsten, President, International Health Consulting) have serious implications for the type of work
that can be done, it is much less an issue in impressive sets of environmental laws, their
Canada.349 implementation has often been woeful. In
recent years, environmental law has become
While legislation regarding health education in seen as a critical means of promoting
the workplace is lacking, there is some sustainable development (or "sustainability").
movement towards legal encouragement for Policy concepts such as the precautionary
enterprises to provide a workplace principle, public participation, environmental
environment that at the very least, does not justice, and the polluter pays principle have
encourage unhealthy lifestyles that lead to informed many environmental law reforms in
noncommunicable diseases. Most notable is this respect….There has been considerable
legislation regarding tobacco, as evidence of experimentation in the search for more
the impact of secondhand smoke establishes effective methods of environmental control
smoking as an environmental risk for all beyond traditional "command-and-control"
exposed. Since the passing of WHO’s style regulation. Eco-taxes, emission trading,
Framework Convention on Tobacco Control, voluntary standards such as ISO 14000 and
many countries, states/provinces or negotiated agreements are some of these
municipalities have enacted legislation innovations.”
requiring workplaces to be smoke-free, which
not only removes chemical hazards from the As with other workplace health and safety
workplace, but also indirectly encourages laws and standards then, having the policy or
workers to quit smoking. law on the books is only the first step, while
achieving compliance is another, much more
Other aspects of noncommunicable disease difficult step.
risk formerly seen as individual choice are now
understood as an environmental risk, and as The United Nations Environment Programme
such they may become more and more (UNEP) seeks to provide international
subject to legislative regulation. For example, leadership by “inspiring, informing and
a worker may choose to eat the French fries in enabling” nations to care for the natural
a workplace cafeteria, but may not choose to environment. They recognize the challenge of
have them made with trans fats. The getting all nations and enterprises in
employer who allows cooking with trans fats in compliance with environmental law, but point
a work canteen is needlessly exposing out that addressing environmental issues such
workers to a health hazard that is not a as climate change can have multiple benefits.
personal choice. For example, they state that an investment in
energy efficiency in renewable energy
H. Enterprise Involvement in the infrastructure not only stimulates the economy,
Community but fosters one that is more resource-efficient
The legislated mandates for enterprises’ too – an economy that puts people back to
effects on the community are generally limited work in numbers far greater than in the fossil
to their impact on the natural external fuel industries.
environment. All developed countries and
most developing nations have legislation to This points out again the need for a
regulate emissions from industrial workplaces, multistakeholder approach to addressing
either into the air or water.350 worker health, safety and well-being.351,352 It is
now understood that the realm of worker
Wikipedia makes this rather judgmental health can be impacted by not just the WHO
assessment of the global situation regarding and ILO but by organizations such as the
implementation of these laws: “While many World Economic Forum (WEF), World Trade
countries worldwide have accumulated Organization (WTO), EU, ISO, UNEP, trade
Chapter 9:
The WHO Healthy Workplace Framework and Model
The preceding eight chapters have reviewed provided to WHO in the Jakarta Declaration,
and discussed workplace health concepts in the Stresa Declaration, the Global Compact,
the published literature. Ideas about the the Global Plan of Action for Workers’
definition of a healthy workplace have been Health, and the consensus of workplace
discussed, as have the interrelationships health experts consulted for this framework.
between work, health, and community.
Interventions in workplaces that can make a This definition is intended chiefly to address
positive difference in both the health & well- primary prevention, that is, to prevent
being of workers and the productivity of the injuries or illnesses from happening in the
enterprise have been reviewed. And various first place. However, secondary and tertiary
models for both the content of healthy prevention may also be included through
workplace activities and effective processes of occupational health services under
continual improvement for implementing them “personal health resources” when this is not
have been discussed. available in the community. In addition, it is
intended to create a workplace environment
After compiling and analyzing all this that does not cause re-injury or
information, the World Health Organization reoccurrence of an illness when someone
has developed the comprehensive model and returns to work after being away with an
framework presented in this chapter. A WHO injury or illness, whether work-related or not.
definition of a healthy workplace is proposed: And finally, it is intended to mean a
workplace that is supportive, inclusive and
A healthy workplace is one in which workers accommodating of older workers or those
and managers collaborate to use a continual with chronic diseases or disabilities.
improvement process to protect and promote
the health, safety and well-being of workers The framework and model presented here
and the sustainability of the workplace by include both content and process, and may
considering the following, based on identified be implemented by any workplace of any
needs: size, in any country. As noted in Chapter 1,
• health and safety concerns in the there is no “one-size-fits-all” and each
physical work environment; enterprise must adapt these
• health, safety and well-being concerns in recommendations to their own workplace,
the psychosocial work environment their own culture and their own country. The
including organization of work and WHO model and framework outlined in this
workplace culture; chapter bring together the principles and
• personal health resources in the common factors that appear to be
workplace; and universally supported in the literature and in
• ways of participating in the community to the perceptions of experts and practitioners
improve the health of workers, their in the fields of health, safety and
families and other members of the organizational health.
community.
Chapter 8 on legislative and policy
All of this definition except the last bullet is considerations contains the one cautionary
based on solid scientific evidence, which has proviso regarding the universality of
been laid out in detail in the previous chapters, application. The ability of any enterprise to
especially Chapters 4, 6 and 7. As indicated in implement the healthy workplace model
Chapter 3, the last bullet is based on direction proposed below will be influenced by the
workers and their representatives (discussed borne pathogens, lack of clean water,
in more detail in Section B, Process). toilets and hygiene facilities);
• ergonomic (e.g., excessive force,
1. The Physical Work Environment. awkward posture, repetition, heavy
Definition: The Physical Work Environment is lifting, forced inactivity/static postures);
the part of the workplace facility that can be • mechanical (e.g., machine hazards
detected by human or electronic senses, related to nip points, cranes, forktrucks)
including the structure, air, machines, • energy (e.g., electrical hazards, falls
furniture, products, chemicals, materials and from heights);
processes that are present or that occur in the • driving (e.g. driving in ice storms or
workplace, and which can affect the physical rainstorms or in unfamiliar or poorly
or mental safety, health and well-being of maintained vehicles).
workers. If the worker performs his or her
tasks outdoors or in a vehicle, then that Examples of ways to influence the physical
location is the physical work environment. work environment: This is the arena of
traditional occupational health and safety.
The importance of this particular avenue To prevent exposure to hazards and the
cannot be overstated. While developed resulting illnesses and injuries, hazards in
nations may consider this to be “basic” the workplace must be recognized,
occupational health and safety, the fact assessed and controlled through a hierarchy
remains that in many parts of the world, of controls that includes elimination or
hazards in this area threaten the lives of substitution, engineering controls,
workers on a daily basis. And even in administrative controls and personal
developed nations, completely preventable protective equipment, preferably in that
injuries and illnesses continue to occur. While order. This is sometimes expressed as
each of the four avenues is important, the instituting controls at the source, along the
hazards that exist in the physical environment path, or at the worker. Examples are:
often have the potential to kill and maim • Elimination or substitution: Eliminate the
workers quickly and gruesomely. When use of benzene in a process and
setting priorities for addressing problems replace with toluene or another less
(addressed later in the chapter) it is wise to toxic chemical; eliminate driving by
consider Maslow’s hierarchy of needs, in holding teleconference meetings;
which safety and security is at the base of the remove sources of mould in the
pyramid. Many hazards in the physical work workplace.
environment would fall into this area of human • Engineering controls: Install machine
needs. guards on a tool and die stamping
machine; set up local exhaust ventilation
Examples of healthy workplace problems in to remove toxic gases before they reach
the physical environment: Many hazards may the worker; install noise buffers on noisy
exist in the physical work environment, equipment; provide safe needle systems
including: and patient lifting devices in hospitals.
• chemical (e.g., solvents, pesticides, • Administrative controls: Ensure good
asbestos, carbon monoxide, silica, housekeeping, train workers on safe
tobacco smoke); operating procedures, perform
• physical (e.g., noise, radiation, vibration, preventive maintenance on machines
excessive heat, nano particles); and equipment, use job rotation to avoid
• biological (e.g., hepatitis B, malaria, HIV, over-exposure to a hazardous chemical,
mould, pandemic threats, food or water- implement a fleet safety policy; enforce
a smoke-free policy in the workplace.
Examples of ways enterprises may become There is an important link that needs to be
involved in the community: made here between enterprise community
The enterprise may choose to provide support involvement and the material presented in
and resources by, for example: Chapter 8 (Global Legal and Policy
• Provide free or affordable primary health Context). Clearly, the types of problems
care to workers, and including access for faced by enterprises in a developed nation
family members, SME employees and
informal workers. There obviously has to be a culture
• Institute gender-equality policies within the
workplace to protect and support women
in the workplace that must involve
or protective policies for other vulnerable management, the workers trade
groups when these are not legally unions, the line managers, the
required.
individual workers. It has to
• Provide free or affordable supplemental
literacy education to workers and their involve the whole enterprise. You
families. also need to look at the general
• Provide leadership and expertise related social services that are in the
to workplace health and safety to SMEs
without such resources in the community.
region of the enterprises.
Interview #15, South Africa, Physician, OH Specialist
highest authority in the enterprise and In a large enterprise, this Healthy Workplace
communicated to all workers and their Team should include representatives from
representatives. Additional evidence is the various levels and sectors of the business,
engagement of the key leaders in mobilizing and may include health and safety
resources for change – providing the people, professionals, human resource personnel,
time and other requirements for making a engineers, and any medical personnel who
sustainable improvement in the workplace. provide services. It is critical to have
representation from the trade union(s) if
While getting initial indications of management applicable, and in any case to have at least
commitment is part of this Mobilize step, half the members be non-management
leadership engagement must continue to be employees.
demonstrated and apparent from the key
stakeholders at every step of the process, It is also critical to have equitable gender
hence its key placement graphically at the representation on this Team. As noted
core of the circular process. frequently in this document, women face
unique and serious health, safety and well-
For a detailed example of how to implement being risks in workplaces, and their voices
this and the subsequent steps in the process must be heard at every stage when creating
in both a large corporation and in a small a healthy workplace. It is not enough to add
enterprise in a developing nation, refer to a “token woman” on the team; women
Table 9.1. should be present in equal numbers to men,
ideally, or in numbers that reflect the
2. Assemble makeup of the enterprise’s workforce. If no
Once the key stakeholders have been women work in the enterprise, that in itself
mobilized and their enthusiastic commitment may be an indication that there is probably
provided, they will be able to demonstrate this employment discrimination occurring, which
commitment by providing resources. This is should be addressed as a priority.
the time to assemble a team who will work on
implementing change in the workplace. If there In a small enterprise, it is helpful to involve
is an existing health and safety committee, experts or support personnel from outside
that pre-existing group may be able to take on the organization if possible. For example,
this additional role. One caution is that in medical personnel from a neighbouring large
countries with legally mandated safety and enterprise or community occupational health
health committees, there are often numerous clinic, a representative from a local industry-
legislated requirements that the OSH specific network, or from a local health and
committee must perform, and these tasks safety agency may be invaluable.367
would take precedence over other, broader
healthy workplace activities. Often (in a larger As well as assembling the Team, this is a
enterprise) it is better to set up a separate good time to assemble other resources that
committee, as long as steps are taken to will be required. Ensuring that space to
ensure that there is integration between the meet, time to meet during work hours, a
committees (see Chapter 7, Section D, The budget, and minimal working supplies are
Importance of Integration.) For the purposes provided will mean the committee has the
of this document, we will call this the Healthy resources necessary to do the work.
Workplace Team, with the understanding that
in some circumstances it could be a pre- 3. Assess
existing committee with other functions. The first set of tasks that the Healthy
Workplace Team should perform falls under
the heading of “assessments.” There are
two broad categories of things that need to be assessments. In the case of a survey, it is
assessed: (1) the present situation for both the important to ask questions related to the four
enterprise and the workers, and (2) the avenues of influence. That means asking
desired future conditions and outcomes for questions about the organizational culture,
both the enterprise and workers. leadership issues, workplace stress, non-
work-related sources of stress, and personal
The present situation for the enterprise can be health practices, as well as their concerns
assessed using a number of different tools, about the hazards they are exposed to in
depending on the size and complexity of the their physical work environment or in their
organization. In a large corporation, baseline community.
data should be collected on employee
demographics, sickness injury data, workplace In an SME, this assessment may be a walk-
related injuries and illnesses, short-term and through with a simple checklist, and some
long-term disability, turnover, union grievances small group discussions with workers and
if applicable, and concerns that have arisen their representatives. See Table 9.1 for
from workplace inspections or hazard more suggestions.
identification & risk assessment processes.
Productivity data should also be documented The desired future for the enterprise and
as a baseline, if it is available. If a workers must also be assessed. For a large
comprehensive hazard identification & risk corporation, this may involve some
assessment has not been done, it should be benchmarking exercises to determine how
done at this time. Current policies or practices similar companies are doing with respect to
relating to any of the four avenues of influence the data just described. It may be important
should be reviewed and tabulated (for to do a literature review to read case studies
example, take note if there are policies related of good practice, or recommendations for
to flexible work hours, volunteer time, or good practice. For individual workers, it is
fitness club subsidies.) necessary to ask for their thoughts and
opinions about what they would like to do to
In addition to assessing the present situation improve their working environment and
of the enterprise, it is necessary to assess the health, and what they think the employer
present situation with respect to the health of could do to assist them.
workers. In a large enterprise, this will require
a confidential survey and/or health risk For a small enterprise, determining local
good practice is important. Talking to local
“I think one central element is the experts or visiting local enterprises that have
risk assessment plan. The whole point addressed similar situations is a good way
is to have a careful examination of to find out what can be done, and get ideas
on how to do it.
the workplace, defining potential risks
and also putting sensible measures on WPRO’s Regional Guidelines for the
how to control these risks, and Development of Healthy Workplaces368
monitor, and ensure that they stay in
suggests the following methods of data
collection:
control. And the key issue is to have • review of documents - inspection
step-by-step guidance in enterprises, reports, accident and injury statistics,
and then of course to record the safety audits, absenteeism data, etc.;
• walk-through inspection - to identify
findings in order to have review and hazards and potential health risks in the
auditing.” physical environment;
Interview #38, Czech Rep. OSH
set, so that in the future it will be possible to promotion of the programme or policy and
determine if there has been success. training for any new policy. Something often
forgotten is to include a maintenance plan
After developing the long-term plan, an annual for 3-5 years, and an evaluation plan for
plan would be developed to address as many each initiative. Ensuring that each initiative
of the higher priority items as can be handled has clearly stated measureable goals and
in the first year. An annual plan would be objectives will make evaluation easier in the
done for each of the 3-5 years of the overall future.
plan, although these do not need to all be
done at the outset. The plan developed for an SME will
probably be much simpler, depending on the
When considering solutions to the priority size and complexity of the enterprise. It may
problems, it is important to again remember just be a short list of initiatives to be
the “Learn from Others” principle, and addressed with an indication of time frames.
research ways of solving the problem. At this See Table 9.1 for more ideas.
time, it is extremely important to remember the
four avenues of influence. A common mistake 6. Do
made by enterprises is to think that solutions As the shoe company motto goes, this is the
for a problem in the physical work environment “Just Do It!” stage. Responsibilities for each
must be physical solutions, for example. action plan should be assigned in the plan,
Recalling the information in Chapter 4 about and at this stage it is just a matter of
the way physical and mental health are implementing the action plans. Again, it is
interrelated, it is critical to consider all four critical to involve workers and their
avenues when designing solutions for any one representatives at this stage, as in other
problem. For example, if there is a problem stages. Having management demonstrate
with workers’ risking amputation from their support and commitment for the
unguarded machinery (a problem in the specific programmes or policies will also
physical environment), it is not enough to help them be successful. Some research
simply place guards on the machine (a has found that integrating the “stages of
physical solution.) Consideration must also be change” model into implementation is
given to psychosocial factors such as helpful, since not everyone will be at the
workload, or an organizational culture that same stage of readiness for change.371
places productivity before safety; if these are
not considered, workers will probably remove 7. Evaluate
the guards in order to work faster. Evaluation is essential to see what is
working, what is not, and what are the
After obtaining any additional required impediments to success. Both the process
approval in principle for the 3-5 year plan, it is of the implementation and the outcomes
time to develop specific programme or policy should be evaluated, and there should be
action plans for the first annual plan. This is short-term and long-term outcome
where the detail is spelled out for each evaluations. Since each action plan
programme or policy that is to be includes an evaluation component, these
implemented. For health education evaluation plans can be implemented. In
programmes, it is important to ensure that they addition to evaluating every specific
go beyond just raising awareness to include initiative, it is important to evaluate the
skill development and behaviour change. The overall success of the Healthy Workplace
required budget, facilities and resources would Programme after 3-5 years, or after a
be included in an action plan, as well as significant change, such as a change of
planning for a launch, marketing and managers. Sometimes repeating the same
Table 9.1 Application of WHO Continual Improvement Process in Large and Small Enterprises
survey, or looking again at the kind of data small enterprise in a developing nation could
collected as a baseline can provide this overall implement the process.
assessment
C. Graphical Depiction
While it is unlikely that the changes to worker Section A above discussed the four avenues of
health will be able to be causally linked to influence that define the content of a healthy
changes in enterprise productivity or profitability, workplace programme. Another way of thinking
it is important to track these numbers as well, of this is to consider these four broad content
and compare to benchmarks. For example, if areas that an enterprise can consider to create
the insurance costs for health benefits in your a healthy workplace. Section B described the
enterprise keep increasing, even after process that should be used to implement such
implementing healthy workplace programmes, a programme, to ensure it achieves and sustains
that does not necessarily mean the programmes its goals. This continual improvement process,
have failed. Look at industry benchmarks for or OSH management system, could be seen as
comparison. If health insurance costs have the engine that drives the Healthy Workplace.
increased by 20% in similar industries, yet have And management commitment and worker
only increased by 5% in your enterprise, that is involvement, based on sound business ethics
an indicator of success. More information on and values, are the key principles at its very
returns-on-investment (ROI) is provided in core. These components of a healthy
Chapter 5. workplace are combined and illustrated
graphically in Figure 9.4 to represent WHO’s
8. Improve model for creating healthy workplaces.
The last step – or the first in the new cycle – is
to make changes based on the evaluation D. Basic Occupational Health Services –
results, to improve the programmes that have the Link
been implemented, or to add on the next How does this healthy workplace framework and
components. The evaluation may find that new model relate to the concept of Basic
needs have emerged that have not been Occupational Health Services (BOHS)? The two
addressed in the plan, so that a revision of the concepts are similar, yet different, and serve to
plan is required. Or possibly some techniques complement each other. BOHS as defined by
have not worked as well as anticipated, and Rantanen and othersccclxxii,ccclxxiii includes all the
need to be revised. On the other hand, some activities described in this model, in terms of
notable successes may have been achieved. It assessing hazards, recommending and
is important to recognize success, and to make implementing solutions, and promoting health in
sure that all the stakeholders are aware of it and the workplace. BOHS also includes medical
continue to provide support. responsibilities for:
• health examinations of workers pre-
Will the model work in developed and employment, at periodic intervals, or after
developing nations? In large and small return from an injury or illness;
enterprises? • medical surveillance of workers to detect
It may seem that this process is very exposures to hazardous agents;
complicated and bureaucratic, and far too • health record-keeping of workers;
complex for a small or medium-sized enterprise • providing first aid and training workers in first
to engage in, especially in a developing nation. aid;
However, the process can be implemented very • general health care, curative and
differently in a large corporation compared to a rehabilitation services;
small enterprise. An example is provided on the • immunization of employees against endemic
previous page (Table 9.2) that shows how both or work-related infectious diseases.
a large enterprise in a developed country, and a
These activities require medical professionals, in the enterprise community, one of the four
such as doctors and nurses, to carry them out, avenues of influence in this healthy workplace
which may be available in a large corporation, framework. By stepping up to the plate to
as part of their provision of Personal Health provide or subsidize these services not only to
Resources for their employees. But SMEs will their own employees, but also for workers in
not be able to provide these services. This SMEs in the community, their families, and
aspect of BOHS may be available through the those employed in the informal sector, they can
primary health care system of the country. If reap the benefits of healthier workers, a
not, there are other ways that Rantanen and healthier community, and an enhanced
others have suggested they could be made corporate reputation.
available. ccclxxiv Access to BOHS in many
countries is a dire need that the GPA has E. The Broader Context
addressed in Objective 3: To promote the The model presented here is intended to provide
performance of and access to occupational guidance for what a workplace can do, when
health services. workers and their representatives and the
employer work together in a collaborative
This need is a perfect example of an opportunity manner. However as Chapter 8 made clear, the
that larger enterprises have to become involved workplace exists in a much larger context.
Governments, national and regional laws and address the physical and psychosocial working
standards, civil society, market conditions, and environments, as well as promoting worker
primary health care systems all have a health and creating health-promoting work
tremendous impact, for better or for worse, on environments, enterprises can contribute to the
the workplace, and on what can be achieved by first two points above. Larger enterprises that
the workplace parties on their own. These become involved in the enterprise community by
interrelationships are extremely complex. For providing secondary and tertiary health care
those who would like to read more on this services for the community, can thus contribute
subject, the report prepared for the WHO to the third point. The working group that
Commission on Social Determinants of Health, developed this framework hopes that this
“Employment Conditions and Health background document contributes to the last two
Inequalities,”ccclxxv explains macro and micro points, and will help to motivate enabling
theoretical frameworks to explain how all these stakeholders in government, business and civil
factors interact to affect workplace health. society to work together to create a world in
which workers experience enhanced physical
F. Conclusion health and well-being as a result of their
There is much that needs to be done to improve employment. It is hoped that the day will come
the health, safety and well-being of workers when all workplaces are healthy ones, according
globally. To paraphrase the priorities of the to the WHO definition:
Global Plan of Action on Workers’ Health:
1. policies must be developed and A healthy workplace is one in which workers and
implemented at national and enterprise managers collaborate to use a continual
levels to support worker health; improvement process to protect and promote the
2. health must be protected and promoted in health, safety and well-being of workers and the
the workplace sustainability of the workplace by considering
3. access to BOHS must be improved; the following, based on identified needs:
4. evidence-based effective practices to • health and safety concerns in the physical
improve worker health must be work environment;
communicated • health, safety and well-being concerns in
5. worker health must be considered in the the psychosocial work environment
broader context of education, trade and including organization of work and
commerce, and economic development. workplace culture;
• personal health resources in the workplace;
This framework and model suggests ways that and
employers and workers and their • ways of participating in the community to
representatives in collaboration can make improve the health of workers, their families
significant contributions to these points. By and other members of the community.
developing and implementing policies that
Disease prevention: Efforts to prevent EURO: WHO Regional Office for Europe.
employees from acquiring diseases that may This Region includes 53 countries in
result from exposures in the workplace, or Europe, plus all of the Russian Federation,
from unhealthy lifestyles. Disease the constituent countries/regions of
prevention activities may encompass both Greenland and Svalbard, and Israel.
health protection and health promotion.
Fair employment: A term developed by
Employee: A worker who provides labour or EMCONET to mean one with a just relation
expertise to an employer, usually in the between employers and employees that
context of a formal employment contract. requires certain features be present:
See also Worker. freedom from coercion, job security in terms
of contracts and safety, fair income, job
Employer: A person or institution that hires protection and social benefits, respect and
employees or workers. This term is normally dignity at work, and workplace participation.
used to mean there is a formal employment
contract with workers, but in the context of Family - Work Interference: One type of
this document it also includes those who work-family conflict; a form of role
hire informal workers without a formal interference that occurs when family
contract. demands and responsibilities make it more
difficult to fulfill work role responsibilities.
EMRO: WHO Regional Office for the
Eastern Mediterranean. This Region Framework: The key principles, description
includes the primarily Islamic countries of and interpretive explanation of a healthy
Northeast Africa (those excluded from workplace model.
AFRO, above), the Arabian Peninsula, plus
Afghanistan, Iran, Iraq, Jordan, Lebanon, Global Plan of Action on Workers' Health
Syria and Pakistan. (GPA): Approved by the WHA in May 2007,
the GPA operationalizes the 1995 Global assessment tool that collects measures of
Strategy on Occupational Health for All, with health status (e.g., BMI, blood cholesterol,
the aim to move from strategy to action and nutritional analysis, heart rate response to
provide objectives and priority areas for exercise). The assessment of risk is usually
action. It takes a public health perspective in based on a combination of clinical
addressing the different aspects of workers’ reports/measures and self-reported
health, including primary prevention of information on health habits. In most cases,
occupational risks, protection and promotion a health risk assessment requires a
of health at work, work-related social professional to administer the assessment to
determinants of health, and improving the all employees. The health risk assessment
performance of health systems. usually results in individualized results and
an aggregate report for the workplace.
Hawthorne effect: A form of reactivity (NOTE: the term health risk assessment is
whereby subjects improve an aspect of their sometimes used to refer to an assessment
behavior being experimentally measured of the health risks in a workplace, through
simply in response to the fact that they are hazard identification and exposure
being studied, not in response to any assessment. It is not used that way in this
particular experimental manipulation. document.)
Hazard: A condition, object or agent that Healthy workplace (WHO definition): One
has the potential to cause harm to a worker. in which workers and the employer
collaborate to use a continual improvement
Health: A state of complete physical, mental process to protect and promote the health,
and social well-being, and not merely the safety and well-being of workers and the
absence of disease. sustainability of the workplace by
considering the following, based on
Health promotion: The process of enabling identified needs:
people to increase control over their health • health and safety concerns in the
and its determinants, and thereby to improve physical work environment;
their health. This can occur through • health, safety and well-being concerns
developing healthy public policy that in the psychosocial work environment
addresses the primary determinants of including organization of work and
health, such as income, housing and workplace culture;
employment. In many developed countries, • personal health resources in the
the understanding and common use of the workplace; and
term is reduced to health education and • ways of participating in the community
social marketing aimed at changing to improve the health of workers, their
behavioural risk factors (smoking, lack of families and other members of the
exercise, etc.) community.
or maternity leave, paid retirement, or responsibility for advising the employer and
access to health care), and applicability of workers on:
legal rules (such as limits on work hours, • the requirements for establishing and
minimum wage) require a formal job maintaining a safe and healthy working
contract. environment which will facilitate optimal
physical and mental health in relation to
Internal Responsibility System (IRS): A work; and
health and safety philosophy, often • the adaptation of work to the
supported by legal mechanisms, that is capabilities of workers in the light of
based on the principle that every individual their state of physical and mental
in the workplace is responsible for health health.
and safety. The IRS specifically emphasizes Occupational health services focuses on the
the importance of worker involvement; medical model and normally involves
supporting legal requirements often require medical personnel such as nurses,
joint labour-management health and safety physicians and other health care
committees to exist in the workplace. It professionals, ergonomists, hygienists,
contrasts with a system that relies safety professions, etc. Often referred to in
exclusively on external authorities to enforce the WHO context as Basic Occupational
health and safety in the workplace. Health Services (BOHS).
Physical work environment: The part of all services that play a part in health, such
the workplace facility that can be detected as income, housing, education, and
by human or electronic senses, including the environment. It can also be described as a
structure, air, machines, furniture, products, set of values and principles for guiding the
chemicals, materials and processes that are development of national health systems that
present or that occur in the workplace, and provide universal coverage, are organized
which can affect the physical or mental around people’s needs and expectations,
safety, health and well-being of workers. If that integrate public health with primary
the worker performs his or her tasks care, and that replace command and control
outdoors or in a vehicle, then that location is engagement or laissez-faire disengagement
the physical work environment. of the state, by participatory leadership.
Worker: A person who provides physical • improving the work organization and
and/or mental labour and/or expertise to an the working environment
employer or other person. This includes the • promoting active participation
concept of “employee,” which implies a • encouraging personal development.
formal employment contract, and also This ENWHP definition is really a definition
informal workers who provide labour and/or of a healthy workplace, and is far broader
expertise outside of a formal contract and more comprehensive than the usual use
relationship. In a larger enterprise or of the phrase “health promotion” as it is used
organization it includes managers and in this document. See “health promotion in
supervisors who may be considered part of the workplace” above, for a definition of the
“management” but are also workers. It way the term is intended in this framework.
also includes those who perform unpaid
work, either in terms of forced labour or Workplace parties: The various
domestic work, and those who are self- stakeholders that exist in a workplace;
employed. normally used to refer to workers and
managers; sometimes used to include
Workplace: any place that physical and/or additional parties such as worker
mental labour occurs, whether paid or representatives (trade union representatives
unpaid. This includes formal worksites, in the workplace).
private homes, vehicles, or outdoor locations
on public or private property. WPRO: WHO Regional Office for the
Western Pacific. This Region includes
Workplace Health Promotion (ENWHP China, Mongolia, Republic of Korea, Japan,
definition): The combined efforts of Australia, New Zealand, and all the island
employers, employees and society to nations and other countries in South-East
improve the health and well-being of people Asia that are not included in SEARO.
at work. This can be achieved through a
combination of:
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