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WHO Healthy Framework and Model: Background and Supporting Literature and Practices by Joan Burton

Readers’ comments: Kazutaka Kogi, President, International Commission on Occupational : “The draft Framework is well framed and excellently prepared. The document will be a solid basis for future developments in promoting healthy internationally.”

Tom Shakespeare, Health , Headquarters: “Excellent review of evidence; good, clear, workable conclusions and recommendations.”

Marilyn Fingerhut, National Institute for Occupational 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, -life , issues and their impact on the safety and health of the is important and not always recognized. I also liked your discussion of the need and challenges regarding rigorous 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 , 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, “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 document – a real tour de force.”

Rob Gründemann, TNO, The : “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 on the effectiveness of workplace health interventions.”

February 2010 Submitted to Evelyn Kortum WHO Headquarters, Geneva,

Table of Contents

Table of Contents …………………………………………………………………………………………. i

List of Tables and Figures ………………………………………………….…………………………….. iii

Acknowledgements ……………………………………………………………………………………….. iv

Executive Summary ..……………………………………………………………………………………… 1

Chapter 1: Why Develop a Healthy Workplace Framework? …………..…………………………….. 5 A. It is The Right Thing To Do: Ethics ………….………..……………..…….. 5 B. It is The Smart Thing To Do: The Business Case ……..……………………………. 6 C. It is the Legal Thing to Do: The …………………………………………………… 7 D. Why a Global Framework?……………………………….…………………………….. 7

Chapter 2: History of Global Efforts To Improve Worker Health ……………………………….…..... 11

Chapter 3: What Is a Healthy Workplace? ………………………………….……………………….…. 15 A. General Definitions ………………………………………….……………………..…... 15 B. The WHO Definition of a Healthy Workplace………………………………………… 16 C. Regional Approaches To Healthy Workplaces ……………………………………... 17 1. Regional For Africa (AFRO) …………………..………………….…... 17 2. Regional Office For the Americas (AMRO) …………...……………………. 17 3. Regional Office For the Eastern Mediterranean (EMRO)…………………. 20 4. Regional Office For (EURO) ………………………….…………….. 21 5. Regional Office For South-East Asia (SEARO)……………….……………. 22 6. Regional Office For the Western Pacific (WPRO).…………….…………... 23

Chapter 4: Interrelationships of Work, Health and Community……………………………………….. 25 A. How Work Affects the Health of Workers ……………………………..………..…… 25 1. Work Influences Physical Safety and Health..…………………..……….… 25 2. Work Affects Mental Health and Well-Being……………………..………… 28 3. Interrelationships…………………………………………………………….... 32 4. The Positive Impact of Work on Health ……………………………………. 33 B. How Worker Health Affects the Enterprise………………..………………………..... 34 1. and Acute Affect the Enterprise ……………………...... 34 2. The Physical Health of Workers Affects the Enterprise …….………...... 35 3. The Mental Health of Workers Affects the Enterprise……...... 36 C. How Worker Health and the Community Are Interrelated …………………………. 37

Chapter 5: Evaluating Interventions …………………………………..………………………………… 41 A. The Cochrane Collaboration ………………………………………………………….. 41 B. General Evaluation Criteria ……………………………………………………………. 41 C. Grey Literature ………………………………………………………………………….. 43 D. The Precautionary Principle …………………………………………………………... 43 E. Interrelatedness of Worker Participation and Evaluation Evidence ………………. 44 F. Evaluating the Cost-Effectiveness of Interventions ………………………………… 44

Chapter 6: Evidence For Interventions That Make Workplaces Healthier ….……………………….. 47 A. Evidence For Effectiveness of Occupational Health & Safety Interventions ..……. 47 B. Evidence For Effectiveness of Psychosocial/Organizational Interventions 49 C. Evidence For Effectiveness of Personal Health Resources in the Workplace …… 51 D. Evidence For Effectiveness of Enterprise Involvement in the Community ...... 55

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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

Chapter 8: Global Legal and Policy Context of Workplace Health…………………………………… 69 A. Standards-setting Bodies…………………………………………………………….. 70 B. Global Status of Occupational Health & Safety……………………………………… 72 C. Workers’ Compensation ……………………………………………………………….. 73 D. Legislation …………………………………………………………..…… 75 E. Standards……………….…………….……………………………….… 76 F. Psychosocial …………………………………………...……………………. 78 G. Personal Health Resources in the Workplace ………………...……….………….. 79 H. Enterprise Involvement in the Community ………………………………………….. 80 I. The Informal Economic Sector ………………………………………………………. 81

Chapter 9: The WHO Framework and Model..…………………………...……………………………. 82 A. Avenues of Influence for a Healthy Workplace …………………………………….. 83 1. The Physical Work Environment ………………………………………………...... 84 2. The Psychosocial Work Environment …………………………………………….. 85 3. Personal Health Resources in the Workplace ………………………………….. 86 4. Enterprise Community Involvement……………………………………………….. 87 B. Process For Implementing a Healthy Workplace Programme …………………….. 89 1. Mobilize……………………………………………………………………………… 89 2. Assemble…………………………………….……………………………………… 90 3. Assess…………………………………………………………..…………………… 90 4. Prioritize……………………………………………………………………………… 92 5. Plan…………………………………………………………………………………… 93 6. Do…………………………………………………………………………………….. 94 7. Evaluate……………………………………………………………………………… 94 8. Improve……………………………………………………………………………… 96 C. Graphical Depiction …………………………………………………………………...... 96 D. Basic Occupational Health Services – the Link ……………………………………… 96 E. The Broader Context ………………………………………………………………….... 97 F. Conclusion ………………………………………………………………………………. 98

Annex 1: Acronyms Used in this Document …………………………………………………..………… 99 Annex 2: Glossary of Terms and Phrases .………………………………………………………..…….. 101 Endnotes ……………………………………………………………………………………………………. 108

NOTE ABOUT THE INSERTED QUOTATIONS: Throughout this document there are numerous quotations inserted in text boxes on the pages. Each has a designation at the bottom as “Interview #xx [], []” These are quotations taken from the transcription of 44 interviews with global professionals from various disciplines, carried out for WHO by Stephanie Mia McDonald, Institute of Work, Health and Organisations, University of Nottingham, during July and August, 2009.

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Tables and Figures List of Figures Page

Figure ES1 WHO Healthy Workplace Model: Avenues of Influence, Process and Core Principles ……………. 3 Figure 1.1 The Business Case in a Nutshell ………………………………………………………………………….. 6 Figure 2.1 Timeline of Global Workplace Health Evolution …………………………………………………………. 14 Figure 4.1 American Institute of Traumatic Model ……………………………...... 26 Figure 4.2 Relationship Between Health and Wealth …………………………………………………..…………… 40 Figure 9.1 WHO Four Avenues of Influence ………………………………………………………………………….. 83 Figure 9.2 WHO Model of Healthy Workplace Continual Improvement Process ……………...... 89 Figure 9.3 Maslow’s Hierarchy of Needs ……………………………………………………………………………… 93 Figure 9.4 WHO Healthy Workplace Model: Avenues of Influence, Process and Core Principles……………… 97

List of Tables and Boxes Table 4.1 Work-Related Symptoms of Common Mental Disorders ………………………………...... 37 Table 4.2 Work- Conflict Effects On Worker Health, the Enterprise and Society ……………….………... 39 Table 6.1 Evidence for Effectiveness of Occupational Health & Safety Interventions …………………………… 48

Table 6.2 Evidence for Effectiveness of Psychosocial Interventions …………………………………….………… 50 Table 6.3 Evidence for Effectiveness of Personal Health Resource Interventions in the Workplace …………... 52 Table 6.4 Examples of Enterprise Involvement in the Community….…………………………………..…………... 57 Table 7.1 Comparison of Continual Improvement/OSH Management Systems ……………………………..…… 60 Box 7.1 Learn from Others: WISE, WIND and WISH …………………………………………………….…………. 65 Table 8.1 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 8.3 ILO Workers’ Compensation Conventions and Ratifications ……………………………………...…….. 74 Table 8.4 Comparison of Selected Workers’ Compensation Features in USA, , 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

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Acknowledgements

This document was written by Joan Burton, Canada, as result of Agreement for 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, • Aditya Jain, Institute of Work, Health and Organisations, • 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:

• Said Arnaout, World Health Organization, EMRO, Egypt • Janet Asherson, International Employers Organization, Switzerland • Linn I. V. Bergh, Industrial Occupational Association, and Statoil, • Joanne Crawford, Institute of , United Kingdom • Reuben Escorpizo, Swiss Paraplegic Research (SPF), Switzerland • Marilyn Fingerhut, National Institute for Occupational Safety & Health, USA • Fintan Hurley, Institute of Occupational Medicine, United Kingdom • Alice Grainger Gasser, World Heart Federation, Switzerland • Nedra Joseph, National Institute for Occupational Safety & Health, USA • Wolf Kirsten, International Health Consulting, • Rob Gründemann, TNO, The Netherlands • Kazutaka Kogi, International Commission on Occupational Health • Ludmilla Kožená, National Institute of , • Wendy Macdonald, Centre for Ergonomics & Human Factors, Faculty of Health , La Trobe University, Australia • Kiwekete Hope Mugagga, Transnet Freight Rail, South Africa • Buhara Önal, Ministry of Labour and Social Security, Occupational Health and Safety Institute, • Teri Palmero, National Institute for Occupational Safety & Health, USA • Zinta Podneice, European Agency for Safety and Health at Work, • Stephanie Pratt, National Institute for Occupational Safety and Health, USA • Stephanie Premji, CINBIOSE, Université du Québec à Montréal, Canada • David Rees, National Institute of Occupational Health, South Africa • Paul Schulte, National Institute of Occupational Safety & Health, USA • Tom Shakespeare, World Health Organization, Headquarters, Disability Task Force, Switzerland • Cathy Walker, Canadian Auto Workers (retired),Canada • Matti Ylikoski, Finnish Institute of Occupational Health,

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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 , 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 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 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 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 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 issues In recent years, more attention has been paid to may put workers at increased risk.iii,iv,v In this , 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 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 , many employers have for decades to 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 of workers and their families. Corporate . 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.

Chapter 1 Why Develop a Healthy Workplace Framework? 5 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

B. It is the Smart Thing To Do: The “Employers are recognizing the Business Case competitive advantage that a The second reason that creating healthy healthy workplace can provide to workplaces is important is the business argument. It looks at the hard, cold facts of them, in contrast to their economics and money. Most private sector competition, who would feel that a enterprises are to make money. healthy and safe workplace is just Non-profit and institutions are in business to be successful at achieving their a necessary cost of doing business.” Interview #3 Canada, OSH missions. All these workplaces require workers in order to achieve their goals, and there is a strong business case to be made for ensuring that workers are mentally and physically healthy Chapter 4, Section B, How Worker Health through health protection and promotion. Figure Affects the Enterprise, and Section C, How 1.1 summarizes the evidence for the business Worker Health and the Community are case.vii This is expanded upon at length in interrelated. There is a wealth of data

6 Chapter 1 Why Develop a Healthy Workplace Framework? WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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 “.” 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 or illness. Many have much third of back pain, 16% of , nearly more extensive and sophisticated regulations. 10% of ; 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 (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 (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 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

Chapter 1 Why Develop a Healthy Workplace Framework? 7 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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, 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, 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 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 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

8 Chapter 1 Why Develop a Healthy Workplace Framework? WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices developed this framework and associated guidance for a healthy workplace.

By raising this as a global issue, WHO also hopes to get a ‘critical mass’ in the movement towards healthy workplaces to create a tipping point. If enough countries ‘sign up’ for healthy workplaces, then: • Countries can get encouragement and practical help from one another, learn from one another’s good practices; • Poor practices in some countries will not be an excuse for poor practices in others, in the name of ‘fair competition’; and • There will be national ‘peer pressure’ between nations and enterprises, as it becomes more and more the norm to have healthy workplaces that go far beyond legal minimums.

One word of caution is warranted, however. This framework is not intended as a “one size fits all” template, but rather a statement of principles and guidelines. Naina Lal Kidwai, Chairperson of India’s National Committee on Population and Health notes:

“… there can be no template of healthy workplace practices that can be followed. While there are a few basic guidelines that every organization needs to follow, the concept of an ideal workplace will differ from industry to industry and company to company. A healthy must be designed to fit the unique history, culture, market conditions and employee characteristics of individual organizations.”xxiv

It is intended that this framework will provide that flexible guidance, which can then be adapted to any workplace setting.∗

∗ 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 1 Why Develop a Healthy Workplace Framework? 9 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

10 Chapter 1 Why Develop a Healthy Workplace Framework? WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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 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 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, 1978 – Declaration of Alma-Ata.25 After the generated at WHO’s First International International Conference on Primary 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 : “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 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 , 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 2: History of Global Efforts to Improve Worker Health 11 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

Centres hold an international meeting be achieved through a combination of: approximately every two years to ensure improving the work organization and the coordinated planning and activities. At the working environment; promoting active Second Meeting of WHO Collaborating Centres in participation; encouraging personal Occupational Health, held in in 1994, a development.” The subsequent text went on to Declaration on Occupational Health for All was make it clear that WHP included improvement signed by the participants. One notable aspect of of the physical and psychosocial work this Declaration was the clear statement that the environment, and also the personal term, “occupational health” includes accident development of workers with respect to their prevention (health & safety), and factors such as own health, or traditional health promotion. psychosocial stress. It urged Member States to increase their occupational health activities. 1998 – Cardiff Memorandum on WHP in Small and Medium-Sized Enterprises.35 The 1996 – Global Strategy on Occupational Health European Network for WHP followed up on the for All.32 The Global Strategy drafted at the 1994 Declaration by adopting this Beijing meeting of Occupational Health Memorandum that emphasized the importance Collaborating Centres was approved by WHA in of SMEs to the economy, and outlined the 1996. It presented a brief situation analysis, and differences and difficulties in implementing recommended 10 priority areas for action. Priority WHP in SMEs. The Memorandum outlined Area 3 pointed out the importance of using the priorities for the European nations to apply workplace to influence workers’ factors WHP in SMEs. (health promotion) that may impact their health. 1998 – World Health Assembly Resolution 1997 – on Health 51.12.36 The Fifty-first World Health Assembly Promotion.33 Signed after the Fourth passed a resolution (51.12) on health International Conference on Health Promotion, promotion endorsing the Jakarta Declaration, this declaration reinforced the Ottawa Charter, but and called on the Director General of WHO to emphasized the importance of social responsibility “enhance the Organization’s capacity and that for health, expanding partnerships for health, of Member States to foster the development of increasing community capacity and empowering health-promoting , islands, local individuals, and securing the infrastructure for communities, markets, schools, workplaces health. [ added] and health services.”

1997 – Luxembourg Declaration on Workplace 2002 – Barcelona Declaration on Health Promotion in the European Union.34 Developing Good Workplace Health While each WHO Region has been active in some Practice in Europe.37 This Declaration, ways (see Chapter 3) in relation to workers’ following the 3rd European Conference on health, the European Member States’ political WHP, stressed, “there is no public health activities in coming together in the European without good workplace health.” It went so far Union has accelerated their ability to work as to suggest that the world of work might be together on certain themes. The European the single strongest social determinant of Network for Workplace Health Promotion was health. It also noted the strong business case formed in 1996, and at a meeting in Luxembourg that exists for WHP. A clear message was the the following year, passed this Declaration, which importance of having the occupational health & reported the group’s consensus on the definition safety and public health sectors to work of Workplace Health Promotion (WHP). They together on WHP. defined WHP as “the combined efforts of employees, employers and society to improve the 2003 – Global Strategy on Occupational health and well-being of people at work. This can Safety and Health.38 At its 91st annual

12 Chapter 2: History of Global Efforts to Improve Worker Health WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices conference, the International Labour Organization to promote an OSH management systems endorsed this global strategy dealing with the approach with continuous improvement of prevention of occupational injuries and illnesses. occupational health and safety, to implement a The importance of using an OSH management national policy and to promote a national system approach of continual improvement was preventive safety and health culture. stressed, as was the need, and a commitment, to take account of gender specific factors in the 2007 – Global Plan of Action on Workers context of OSH standards. Health. As noted in the first Chapter, this milestone document operationalized the 1995 2005 – Bangkok Charter for Health Promotion Global Strategy on Occupational Health for All, in a Globalized World.39 This second charter providing clear objectives and priority areas for was signed after WHO’s Sixth Global Conference action. on Health Promotion. While noteworthy for several reasons, a significant one was a key Figure 2.1 shows the two parallel timelines for commitment to make health promotion “a health promotion and occupational health. As requirement for good corporate practice.” For the noted above, the overlap between the two first time, this explicitly recognized that domains has become greater with the passage employers/corporations should practice health of time. Now “occupational health” activities promotion in the workplace. It also noted that are understood to include not only health women and men are affected differently, and protection, but also health promotion in the these differences present challenges for creating workplace; and “health promotion” is workplaces that are healthy for all workers. understood to be an activity that should include workplace settings for implementation. 2006 – Stresa Declaration on Workers Health.40 Participants at the Seventh Meeting of the WHO Collaborating Centres in Occupational Health at Stresa, , in 2006 agreed on this statement, which expressed support for the draft Global Plan of Action on Workers Health. It specifically noted that “There is increasing evidence that workers’ health is determined not only by the traditional and newly emerging occupational health risks, but also by social inequalities such as employment status, income, gender and race, as well as by health-related behaviour and access to health services. Therefore, further improvement of the health of workers requires a holistic approach, combining occupational health and safety with prevention, health promotion and tackling social determinants of health and reaching out to workers families and communities.”

2006 – ILO Convention 187.41 This Promotional Framework for Occupational Health and Safety Convention was approved at the 95th session of the ILO in 2006. Designed to strengthen previous Conventions, this expressly urges Member States

Chapter 2: History of Global Efforts to Improve Worker Health 13 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

Figure 2.1 Timeline Of Global Workplace Health Evolution.

Health Promotion Occupational Health

1950 Joint ILO/WHO Committee on Occ. Health : : Declaration of Alma-Ata 1978 1979 1980 1981 ILO Convention C155 OH&S 1982 1983 1984 1985 ILO Convention C161 OH Services Ottawa Charter 1986 1987 1988 1989 1990 1991 1992 1993 1994 Global Declaration of OH for All 1995 1996 Global Strategy of OH for All Jakarta Declaration 1997 Luxembourg Declaration WHA Resolution 51.12 1998 Cardiff Memorandum 1999 2000 2001 2002 Barcelona Declaration 2003 ILO Global Strategy on OSH 2004 Bangkok Charter 2005 2006 Stresa Declaration; ILO Convention C187 Promotion 2007 Global Plan of Action 2008 2009

14 Chapter 2: History of Global Efforts to Improve Worker Health January WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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 . 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 • security in terms of contracts and differentiates between the concepts of a “healthy safety workplace” and a “healthy organization.” He • fair income

Chapter 3: What is a Healthy Workplace? 15 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

• 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.

Discussions with healthy workplace This definition is intended chiefly to address professionals globally also indicate there is an primary prevention, that is, to prevent injuries or important linkage and opportunity for interaction illnesses from happening in the first place. between the workplace and the community. As a However, secondary and tertiary prevention may result of extensive consultation with experts in also be included by employer-provided the field, as well as reference to the Jakarta occupational health services under “personal Declaration, the Stresa Declaration, The resources” when this is not available in Compact and the Global Plan of Action for the community. In addition, it is intended to Workers Health, interactions with the community create a workplace environment that does not are therefore also considered in this document cause re-injury or reoccurrence of an illness to be an essential component to be borne in when someone returns to work after being away mind when efforts are being made to create with an injury or illness, whether work-related or healthy workers and healthy workplaces. This is not. And finally, it is intended to mean a workplace that is supportive and

*See Annex 2, Glossary, for definitions of these terms. Or, accommodating of older workers, or those with for a thorough discussion of the differences between these chronic diseases or disabilities. terms and their areas of overlap, see Madi HH and Hussain SJ. Health protection and promotion: evolution of health promotion: a stand-alone concept or building on primary Subsequent chapters will provide evidence and health care? Eastern Mediterranean Health Journal context for this definition, and conclude in 2008,14(Supplement):S15-S22. http://www.emro.who.int/publications/emhj/14_S1/Index.htm Chapter 9 by suggesting a model, and accessed 17 July 2009.

16 Chapter 3 What is a Healthy Workplace? WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices expanding on the content and process for implementing it in enterprises. “A healthy workplace is a workplace

C. Regional Approaches To Healthy that enhances health, broadly Workplaces speaking, and looking at the WHO’s six regions have interpreted the concept determinants of health broadly of healthy workplaces in differing ways, as set out below. rather than looking narrowly at the traditional occupational health and 1. Regional Office for Africa (AFRO) A safety issues. And all this extends WHO/ILO Joint Effort on Occupational Health & to the community as well, looking at Safety in Africa began in 2000 with many partners (WHO, ILO, EU, USA, ICOH) for the the families and the communities purposes of information sharing, capacity that provide the workers and in our building, and policy and legislation in the area of country we have important issues workers’ health and safety. Early initiatives involved on pesticides, the informal such as HIV.” Interview #15, South Africa, , OH economy and setting up a website. An important success factor was the signing of a letter of support from the WHO Regional There is a separate Regional health promotion Directors of AFRO, EMRO and ILO Regional programme and strategy.lvi While health- Directors for Africa.lii promoting schools is one area of focus, at this time there are no workplace-related foci related In 2005, an international meeting was held in to health promotion. In general, workplace Benin to review the status of occupational health efforts to date in the African Region are focused and safety in Africa.liii In response to stimulus on the physical work environment, addressing from the Joint WHO/ILO effort, many African traditional occupational health and safety issues. nations are in the process of policy formulation and planning for national strategies. Inadequate A 2009 global survey of large employers by human resources, insufficient level of Buck found that among African collaboration between ministries of health and respondents to the survey (primarily South labour, weak policies, lack of essential Africa), 32% provided some form of “wellness” preventive and curative services, and insufficient or health promotion programmes for their budget were determined to be barriers to employees, which is lower than other parts of developing and implementing consistent and the world surveyed. The most common satisfactory policies and services. Some programme offered was biometric health countries were looking at the ILO’s WISE (Work screenings (by 82% of respondents) and the Improvement in Small Enterprises)liv and WIND least common was caregiver support (26%). (Work Improvement in Neighbourhood On-site medical facilities were provided by 56% Development)lv programmes that have been of respondents.lvii successfully implemented in the Western Pacific and South-East Asia regions (discussed in more 2. Regional Office for the Americas (AMRO) detail in the Western Pacific section, below). The Pan American Health Organization (PAHO) serves as the WHO Regional Office for the Participants in the meeting from eight African Americas. In 2001, AMRO developed and countries agreed that a Regional action plan on published a Regional Plan on Workers’ Health.lviii occupational health and safety was required. This outlined the framework for improving workers’ health specifically in the Americas. Similar to the Global Plan of Action on Workers’

Chapter 3 What is a Healthy Workplace? 17 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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 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 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 and presenteeism as on:lix their number one reasons.lxii • health of health-care workers (focusing on transmission of blood-borne and Possibly for this reason, American efforts other communicable diseases, including towards healthy workplaces have focused on H1N1/09 two areas: • elimination of • traditional occupational health and safety, • elimination of dealing with the physical work • preventing and controlling occupational and environment. This is in response to strong environmental 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

AMRO has a strong relationship with the Cochrane Collaboration, and in particular the ∗ The term “restricted” is used to avoid confusion with the more comprehensive definition of workplace health occupational health section. (More will be promotion used by ENWHP, described in the section below on the European Region.

18 Chapter 3 What is a Healthy Workplace? WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

thereby reduce health care costs that employers must bear. NIOSH has for some time emphasized a comprehensive approach to workplace health. The well-recognized Corporate Health In general, American business has moved in Achievement Awards programme, sponsored by recent years to a more holistic approach. the American College of Occupational and , gives prestigious Canada: Canada has taken a different awards to organizations that meet its criteria for approach. In the 1970s Health Canada a healthy workplace. These criteria are based developed a comprehensive model called the primarily on these two areas, physical health Workplace , which proposed a and safety, and health promotion.lxiii three-pronged approach to healthy workplaces.lxviii This involved three “avenues of In 2009, the American College of Sports Influence” by which the employer could influence Medicine established the International a worker’s health and well-being: the physical Association for Worksite Health Promotion as an and psychosocial work environments, personal affiliate.lxiv This organization advances concepts health resources, and personal health practices. related to individual health improvement within The model was subsequently modified and enterprises. adopted by the National Quality Institute, to form the basis for the Canada Awards for Excellence, The recent global survey referred to above Healthy Workplace.lxix The IAPA (Industrial found that among American respondents to the Accident Prevention Association), a Canadian survey, most provided some form of “wellness” WHO Collaborating Centre in Occupational or health promotion programmes for their Health, played a leadership role by facilitating employees. The most common programme meetings of three Ontario Ministries (Health, offered was immunizations/flu shots (by 89% of Labour, and Health Promotion), as well as other respondents) and the least common was a Canadian stakeholders, in which they all agreed cycle-to-work programme (13%). On-site to promote a similar model to all their members medical facilities were provided by 25% of and clients.lxx,lxxi This model has been expanded respondents.lxv upon in a number of IAPA publications.lxxii,lxxiii The three avenues are now generally agreed to An exception to this overall national approach comprise occupational health & safety, has been taken by the health care sector in America. In recent years they have realized the importance of psychosocial factors, “I believe healthy workplace organizational culture and work organization, represents a workplace where and have come out with criteria that include physical harm and physical injury as these areas to ensure a healthy workplace for lxvi well as mental harm and mental nurses and other health care professionals. And as far back as the 1980s a group of injury are being managed and American hospitals became known as “Magnet reduced. I think it also Hospitals” that were successful in recruiting and incorporates a third component and retaining nurses during a national nurses’ shortage. The characteristics of these hospitals that is the wellness component of were later formalized by the American Nurses workplace parties so what are we Credentialing Centre to form a Magnet doing to help employees achieve recognition programme for hospitals. These characteristics include many items related to the the lifestyle which would be most organization of work and the psychosocial work beneficial to their health.” environment.lxvii Interview #3, Canada, OSH Specialist

Chapter 3 What is a Healthy Workplace? 19 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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 .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 (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 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 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.” of life interventions for their employees.lxxvii Interview #1, Egypt, OHS Professional

20 Chapter 3 What is a Healthy Workplace? WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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 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 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

Chapter 3 What is a Healthy Workplace? 21 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

• 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 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 with healthy (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 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 , dust, , 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 ”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 c control of risks and hazards at Western Pacific Region.

work.” Some individual countries have embarked on Interview #23, Germany, OH comprehensive healthy workplace initiatives. For example, in 2007 the WHO Country Office in

22 Chapter 3 What is a Healthy Workplace? WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

• create a healthy, supportive and safe work “A healthy workplace is often seen environment; as a very controlling environment, • ensure that health promotion and health and it is often seen as one where protection become an integral part of management practices; the risks are controlled and • foster work styles and lifestyles conducive to inspections take place and hazards health; are prevented. But there is also • ensure total organizational participation; • extend positive impacts to the local and the other understanding which is surrounding community & environment. the health promoting environment where workplaces are giving The Guideline promotes five principles that must opportunities for promoting health be ingrained in any healthy workplace programme: and preventing ill health.” 1. Comprehensive: Interview #13, India, Public Health incorporating a range of individual and organizational interventions, India supported a study by the Confederation of which create a healthy and safe Indian Industry to examine and make environment as well as behaviour change. recommendations regarding healthy workplaces 2. Participatory and empowering: workers at all in that country.ci One of the key messages in levels must be involved in determining that report is that the case for healthy needs as well as solutions. workplaces should be made in the context of 3. Multisectoral and multidisciplinary business excellence, because of the strong cooperation: to address the multiple interconnection of worker health and determinants of health, a wide range of organizational health. Other messages were the sectors and professionals must be involved. importance of worker participation, the need for 4. Social justice: all members of the workplace a continual improvement process with ongoing must be included in programmes, without measurement and evaluation, the importance of regard for rank, gender, ethnic group or including health promotion in the workplace, and employment status. the need for corporate social investments in the 5. Sustainability: changes must be community. incorporated into the workplace culture and management practices in order to be 6. Regional Office for the Western Pacific sustained over time. (WPRO) As one of the most ethnically and economically The Guideline then goes on to outline a diverse regions, and with one-third of the global continual improvement process that should be population, the Western Pacific Region of WHO followed to implement the programme and has the opportunity to make a significant impact ensure its success and sustainability. on global health. In 1999 the Region played a Suggestions are provided for actions at the leadership role by developing a comprehensive national, provincial and local levels. It outlines guide for workplace health: Regional Guidelines an 8-step process for the workplace as follows: for the Development of Healthy Workplaces.cii This guideline is based on the definition of a 1. Ensure management support healthy workplace noted above (first page of this 2. Establish a coordinating body chapter). It expands this definition to say that: 3. Conduct a needs assessment 4. Prioritize needs A healthy workplace aims to: 5. Develop an action plan 6. Implement the plan

Chapter 3 What is a Healthy Workplace? 23 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

7. Evaluate the process and outcome 8. Revise and update the programme. Healthy workplaces can be classified in 3 key areas: safety The Guideline continues with more detail, and from machines or equipment; includes case studies and tools that enterprises can use. second, there should be no hazards or danger arising from physical, The Western Pacific Region then piloted the chemical and biological agents; and model in four workplaces in Malaysiaciii,civ,cv,cvi and two cities in Viet Nam, where the model was the third one is human factors - introduced into several hundred SMEs, and then the workers should be free from evaluated after one year.cvii Results of the the psychosocial factors - stress - evaluations showed that it is possible to and also there should be health successfully use this model to improve both worker health and organizational effectiveness. from their lifestyle.” Interview #11, Republic of Korea, OH Physician and Epidemiologist In addition to these activities using the WHO Guidelines, ILO has promoted community-based workplace improvement initiatives, such as WISEcviii,cix, WINDcx, and WISH (Workplace Improvement for Safe Home)cxi for SMEs and As with other Regions, individual countries have the informal sector in Asian countries. These shown leadership. In WPRO, Singapore has models are all based on the idea of participatory shown how the government can play an active action-oriented training programmes. The six and successful role in workplace health principles are: promotion. The government’s Health Promotion 1. Build on local practice Board has a comprehensive Workplace Health 2. Use learning-by-doing Promotion Programme that provides resources, 3. Encourage exchange of experience tools, and incentives for businesses to promote 4. Link working conditions with other health effectively in the workplace.cxiii management goals 5. Focus on achievements The 2009 Buck Survey of large employers found 6. Promote workers’ involvement that among Asian respondents to the survey (primarily China, and Singapore), 43% The WISE process begins with a series of short provided some form of “wellness” or health training programmes with small groups of promotion programmes for their employees. owners/managers of SMEs. The physical work The most common programme offered was environment, the environment, and biometric (by 87% of respondents) some personal health factors are covered in the and the least common was a cycle-to-work interactive training, in which participants are programme (5%). On-site medical facilities were encouraged to share ideas and problem-solve provided by 30% of respondents.cxiv together. This is followed by the use of a WISE action- 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.cxii

24 Chapter 3 What is a Healthy Workplace? WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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 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 / 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

Chapter 4 Interrelationships of Work, Health and Community 25 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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 • badly events.120 They also found that the existence of • over-medicate themselves high-quality 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 .121 sense of unfairness or injustice) and Safety When people engage in these behaviours or fall 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, to • put their bodies under stress, increasing the feelings of anger that may be directed against a potential for strains and sprains 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 • assault • suicidal behaviour • recklessness.

Workplace violence is of particular importance to women, who are at special risk of becoming victims of violence at work.122 While the majority of cases of aggression or violence overall are experienced by men, the rate of exposure to workplace homicide is several times higher for Leadership and Safety women than men.123 As well, exposure to Since the leadership style of managers usually mental violence (bullying, ) is defines the amount of control or influence that significantly higher for women than for men.124 workers have, it is reasonable to assume that a “transformational” style of leadership• as Physical Health Physical health includes a spectrum of conditions, from having a diagnosed illness at • Transformational leadership is a style that includes one extreme, through a condition in which the idealized influence (making decisions based on ethical determinants), inspirational (motivating workers person has no specific disease yet is not at their by inspiring them rather than demeaning them), intellectual maximum health potential, all the way to stimulation (encouraging workers to grow and develop) and individualized consideration (allowing flexibility in how exuberant health and well-being at the other situations are handled.)

26 Chapter 4 Interrelationships of Work, Health and Community WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices extreme. Work can impact any worker’s position MSDs on this continuum. Musculoskeletal disorders (MSDs), sometimes known as repetitive strain injuries or cumulative While traumatic injuries are usually immediately trauma disorders, are a form of physical injury apparent to both the victim and observers, this is that can be discussed in the context of not true in the case of work-related diseases and occupational diseases. As in the case of an cumulative injuries such as noise-induced illness, an MSD is not immediately apparent, hearing loss and many musculoskeletal and may take days, months or even years of disorders. Often it may take years for a disease exposure to the hazard before it affects the to become evident in a worker, and then the link worker. Commonly understood risk factors for to workplace exposure may be unclear or not MSDs are excessive force, awkward posture recognized at all. For this reason, occupational and repetition. These factors are very often diseases and cumulative injuries have been found in jobs with a large physical component, grossly under reported and generally under especially those that have a great deal of recognized in terms of their toll. WHO estimates monotony or repetitive tasks. The jobs may that each year 1.7 million people die from either involve heavy labour, or may be “white occupational diseases and 160 million new collar” jobs with a significant amount of computer cases of occur.125 These work. In developed countries, women are include communicable and noncommunicable exposed more than men to highly repetitive diseases (NCD): infectious diseases such as movements and awkward postures, and their HIV, hepatitis B and C among health care risk of MSDs is several times greater.128,129,130 workers; various forms of cancer such as from asbestos exposure, or other What is not commonly understood is that cancers from solvent exposure; chronic psychosocial conditions related to the respiratory diseases such as silicosis or organization of work can also act as risk occupational ; skin diseases such as factors.131,132 The idea that malignant melanoma from sun exposure, or can contribute to, or cause, MSDs is not from solvent exposure; physical intuitively obvious, and much research is being neurologic disorders such as noise-induced done to determine the mechanisms by which this hearing loss; reproductive problems such as occurs. Many different physiological infertility and miscarriages resulting from mechanisms that occur during stress probably exposure to chemical or biological agents; and contribute to this relationship, including many others. increases in non-voluntary muscular tension and cortisol levels, changes in pain perception and Estimates vary as to the contribution of decreases in muscle repair and blood workplaces to the burden of these diseases, testosterone levels.133 which may also have non-work-related causes. But the toll is significant: WHO estimates 16% of Work and Personal Health Practices hearing loss, 11% of asthma, 9% of lung cancer Protecting health by removing hazards in the cases worldwide are due to occupational workplace, and thus avoiding disease, does not exposure, while 40% of hepatitis B and C guarantee that workers will experience superb in health care workers are due to health. An employee’s health is also influenced needle-stick injuries suffered at work.126 WHO by his or her personal health practices. Does states that 200,000 people die from work-related the worker smoke? Eat a nutritious ? Get cancers each year.127 And as noted in Chapter enough ? Enough good quality sleep? 1, these diseases are not evenly distributed, with Drive safely? Abuse alcohol or drugs? There is women and other vulnerable workers no need to explain or provide more scientific experiencing more than their share. evidence that these behaviours have a tremendous impact on health. The question is,

Chapter 4 Interrelationships of Work, Health and Community 27 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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 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 ;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 , it will be difficult for them to or mental disorders.140 incorporate physical activity into their . 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, , history and communicable and non-communicable diseases. experiences, access to supports, and 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 repairs and car anxiety, burnout, etc.) Mental distress may not maintenance, women generally do cooking, reach the level of a diagnosable , 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

28 Chapter 4 Interrelationships of Work, Health and Community WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

Abundant and ongoing research in this field “In terms of the psychosocial continues to refine the earlier findings. For example, a recent population-based study found environment of the worker, it links that male workers who reported high demand directly to the mental health that and low control in the workplace were more is promoted or not in the likely to have a major depression, while women workplace, and also to the ability in the same situation were more likely to have more minor depressive symptoms; job insecurity that the worker feels that he is in men, but not women, was associated with able or not to perform his job. So major depression; and an imbalance between it relates to the concept of self- work and family life was the strongest factor associated with mental disorders for both efficacy, not only in terms of 146 . The Mayo states that burnout caring for his own health while is more probable for people with little or no performing his job, but also using control over work.147 Health Canada his job as part of his mental well- summarized much of the literature in this area in their 2000 document, “Best Advice on Stress being.” in the Workplace” and Interview #42, Switzerland, MSD Prevention concluded that these factors (demand, control, effort, reward) can double or triple the risk of a Research in the past 30 years has clearly shown like depression or anxiety.148 that various situations in the workplace can be labeled “psychosocial hazards” because they Efforts to determine the proportion of mental are related to the psychological and social illness due to organization of work factors are conditions of the workplace rather than physical ongoing, but the etiologic fraction has been conditions, and they can be harmful to mental estimated to be in the realm of 10% to 25%, (and physical) health of workers. These are depending on the characteristics of the sometimes referred to as work stressors. workplace.149

Demand/Control, and Effort/Reward An extensive review of the scientific evidence for Pioneer work by Karasek and Theorell beginning the effects of work on mental health is beyond in the 1970s noted that certain job factors, the scope of this paper. As long as 15 years specifically high demand and low control or ago, Barnett & Brennan reported over 100 decision latitude, greatly increased the risk of a empirical studies dealing solely with the variety of physical and mental illnesses or demand-control-support model150 and research disorders, including anxiety and depression.144 continues to proliferate. Kelloway and Day They developed the well-known demand-control- reviewed the vast literature on the subject of support theory of . Since women tend how work impacts health, and report that there is to hold jobs with lower control than men, they solid scientific evidence that mental heath is are more adversely affected than men in this negatively impacted by: overwork; role stressors regard. The other key researcher in this field for such as conflict, ambiguity and inter-; decades has been Johannes Siegrist, who working nights and overtime; poor quality developed a model showing that an imbalance leadership; aggression in the workplace, such as between the mental effort expended for work, harassment and bullying; and perceived job and the rewards received (in terms of control.151 They also note that other aspects of recognition, appreciation, respect, etc., as well work can positively enhance mental health of as financial) was linked to a variety of mental workers. and physical problems.145

Chapter 4 Interrelationships of Work, Health and Community 29 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

Work-Family Conflict and performing the usual ‘women’s work’ of One specific area of worker health that is cooking and housework, gives new meaning to receiving significant attention in recent years is the phrase work-family conflict. the area of work-life balance, or work-family conflict. Research indicates there are four major Job Insecurity areas of work-family conflict that all have varying It has been shown that self-perceived job effects on employee health, organizational insecurity may be the number one predictor of a health, families, and society. These four broad number of psychiatric conditions, such as minor areas are role overload, caregiver strain, work- depression. This is especially pronounced in family interference, and family-work interference. cases of chronic job insecurity. Even when In general, workers who report high levels of those exposed to chronic job insecurity regain work-family conflict experience up to 12 times as some degree of , the psychological much burnout and two to three times as much effects are not always fully reversed upon depression as workers with better work-life removal of the threat.155 balance.152 Inclusive Work Culture The relationship between work-family conflict While morale and job satisfaction are not and gender is extremely complex, and necessarily components of mental or physical sometimes surprising, as determined by health, they do contribute to, and have an impact Canadian researchers. Different types of conflict on the mental and physical health of employees. affect the two genders differently, and the One of the factors of a healthy workplace that various workplace interventions and personal has been discussed earlier is the concept of an coping strategies differ in their effectiveness for inclusive organizational culture – one that is the two genders as well. For example, in the open and accepting of different ethnic groups, Canadian research done in 2001, the role of genders, and individuals with various disabilities. “caregiver” was not as strongly associated with For example, reasonable accommodation of gender as it was in the past. Men appear to be people with disabilities has been shown to not spending as much time in care activities as only increase productivity, but to create greater women. However, the researchers point out, “It trust and improved alignment of corporate should be noted that this ‘enlightened’ attitude values with worker values.156 with respect to the distribution of ‘family labour’ does not extend to home chores, which still Workplace Risk Factors for Mental Disorders appear to be perceived by many as ‘women’s COMH has recently developed an internet- work.’” In addition, men and women find based resource titled Guarding Minds @ different aspects of an organization’s culture to Work,157 which includes measurement tools to be particularly problematic, from the perspective assist employers to assess psychosocial risks of work interfering with family; and there are and develop strategies to overcome them. They different root causes for the two genders for based their tool on twelve psychosocial risk family interference with work.153 factors that have a solid scientific evidence base for their effects on mental health. These are as While the cited work was done in Canada and follows: may well apply to most developed countries, the 1. Psychological support: a work situation in developing nations is undoubtedly environment where co-workers and much different with respect to masculine- are supportive of feminine roles in the family. Globally, women are employees’ psychological and mental much more likely to work in the informal sector, health concerns, and respond and to work from their homes.154 This situation, appropriately as needed. in which a woman is doing paid work in her home, while simultaneously caring for children

30 Chapter 4 Interrelationships of Work, Health and Community WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

2. Organizational culture: a work 12. Psychological protection: a work environment characterized by trust, environment where employees’ honesty and fairness. psychological safety is ensured.158 3. Clear leadership and expectations: a work environment where there is As well, the Health and Safety Executive in the effective leadership and support that United Kingdom some years ago developed helps employees know what they need Management Standards in an effort to reduce to do, how their work contributes to the psychosocial risks in workplaces. They did a organization, and whether there are similar literature review, and came up with six impending changes. factors for which they found solid scientific 4. Civility and respect: a work evidence of having an impact on mental health: environment where employees are respectful and considerate in their 1. Demands: , work patterns and interactions with one another, as well as the work environment with customers, clients and the public. 2. Control: how much say the person has 5. Psychological job fit: a work in the way they do their work environment where there is a good fit 3. Support: this includes the between employees’ interpersonal and encouragement, sponsorship and emotional competencies, their job skills, resources provided by the organization, and the position they hold. line management and colleagues 6. Growth & development: a work 4. Relationships: this includes promoting environment where employees receive positive working to avoid conflict and encouragement and support in the dealing with unacceptable behaviour development of their interpersonal, 5. Role: whether people understand their emotional and job skills. role within the organization and whether 7. Recognition & reward: a work the organization ensures that they do environment where there is appropriate not have conflicting roles acknowledgement and appreciation of 6. Change: how organizational change employees’ efforts in a fair and timely (large or small) is managed and manner. communicated in the organization.159 8. Involvement & influence: a work environment where employees are WHO recently published a guide and website included in discussions about how their devoted to Psychosocial Risk Management.160 work is done and how important Again, extensive research identified the following decisions are made. psychosocial factors as having the greatest risk 9. Workload management: a work to workers’ health: environment where tasks and • Job content: lack of variety, short work responsibilities can be accomplished cycles, fragmented or meaningless successfully within the time available. work, underuse of skills, uncertainty 10. Engagement: a work environment • Workload and work pace: work where employees enjoy and feel overload or underload, machine pacing, connected to their work, and where they time pressure feel motivated to do their job well. • Work schedule: shiftwork, night shifts, 11. Balance: a work environment where inflexible schedules, unpredictable there is recognition of the need for hours, long or unsociable hours balance between the demands of work, • Control: low participation in decision- family and personal life. making, lack of control over workload, pacing, shifts

Chapter 4 Interrelationships of Work, Health and Community 31 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

• Environment and equipment: 3. Interrelationships inadequate equipment availability, The preceding two sections discuss physical suitability or maintenance, poor and mental health & safety separately. environmental conditions such as lack of However, it is of paramount importance to space, light, excessive noise understand that these two aspects of health are • Organizational culture and function: not separate and distinct entities, but in fact are poor communication, lack of support for very closely intertwined. When physical health problem-solving and personal is impaired, it affects the mind, and when mental development health and well-being are impaired, it affects the • Interpersonal relationships at work: physical body. social or physical isolation, interpersonal conflict, poor relations with supervisor or Hazards that affect both physical & mental co-workers, lack of health • Role in organization: role ambiguity, High Demand/Low Control workplace conditions role conflict, responsibility for people at the extreme (highest 25% demand level, • Home work interface: conflicting lowest 25% control level) compared with high demands of work and home, low support demand/high control conditions are associated at home, dual problems. with both physical and mental outcomes, including:162 Lastly, the EU recently looked at 42 • more than double the rate of heart and psychosocial hazards and rated them according cardiovascular problems to which ones were “emerging” OSH hazards, by • significantly higher rates of anxiety, which they meant the risks are both new and depression and demoralization getting worse.161 There were eight in which • significantly higher levels of alcohol use, there was strong agreement that they are and prescription and over-the- drug emerging: use • unstable labour market, precarious • significantly higher susceptibility to a wide contracts range of infectious diseases. • globalization • new forms of employment, contracting High Effort/Low Reward workplace conditions at practices the extreme (highest 33 percent effort level, • job insecurity lowest 33 percent reward level) compared with • the ageing workforce high effort/high reward conditions are associated • long working hours with both mental and physical outcomes, • intensification of work, high including:163,164 workload/work pressure • more than triple the rate of cardiovascular • lean production/. problems • significantly higher incidence of anxiety, Clearly, while there are different terms used or depression and conflict-related problems slightly different interpretations of which • increased risk of new onset type 2 particular psychosocial factors related to the diabetes organization or work or the organizational culture • increased body mass index and alcohol are the most important in affecting mental use. health, there is much agreement. And there is no disagreement that these factors do have a Shiftwork has long been recognized as having profound affect on the mental health and well- deleterious effects on both physical and mental being of employees. health. Some of the physical effects of working rotating shifts are increased risk of breast cancer, irregular menstrual cycle, miscarriage,

32 Chapter 4 Interrelationships of Work, Health and Community WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices ulcers, constipation, diarrhoea, insomnia, high , and heart disease.165 Some of “To safeguard ones’ existence. the mental well-being effects of working shiftwork are increased levels of anxiety, That means to have a fixed and depression, work-family conflict, and social reliable income. That is extremely 166 isolation. important and it doesn’t depend on

Job Insecurity not only has an effect on mental the level of income. The point is to health as mentioned earlier, but on physical have security in the job. This is health as well. Downsizing of an enterprise, the main criteria [for a healthy which can lead to significant job insecurity, is workplace] indicated by the linked to poor self-reported health and prolonged related to musculoskeletal disorders. employees.” Those working continually in precarious Interview #22, Germany, Physician OH employment are at higher risk for mental and physical ailments, including musculoskeletal mental health, safety and well-being. However, disorders, and risk of death from smoking- this paper would be incomplete and misleading if related cancers and alcohol abuse.167 In we did not point out the overall positive impact addition, increased cardiac mortality among that working usually has on workers. workers has been seen in situations when there is a significant downsizing (more than 18% of Generally, speaking, work is good for physical the workforce).168 and mental health, when compared to worklessness, or .172 Employment Interrelationships between workplace and is usually the main means of obtaining adequate personal risk factors economic resources for material well-being and Another interesting perspective looks at the full participation in society, and is often central to interrelationships between risk factors in the individual identity and . In addition, workplace environment and personal risk the negative health effects of unemployment are factors. There is a growing body of evidence also well documented. Those who are sick or that illuminates synergies between these two have some form of disability are also generally groups of hazards. For example, smoking is better off in terms of health if they can be known to increase the risk of occupational accommodated in some form of paid work. allergies169, and may multiply (rather than just Waddell and Burton have explored the evidence add to) the risk of lung cancer from asbestos for the positive effects of work in detail, and exposure170. has a complex relationship conclude that “There is a strong evidence base with occupational hazards. PA Schulte and showing that work is generally good for physical others state that obesity “has been shown to and mental health and well-being. affect the relationships between exposure to Worklessness is associated with poorer physical occupational hazards and disease or injuries. It and mental health and well-being. Work can be may also be a co- for them. Obversely, therapeutic and reverse the adverse health workplace hazards may affect obesity-disease effects of unemployment. That is true for relationships, be co-risk factors for disease or healthy people of working age, for many injuries or for obesity. Workplace design, work disabled people, for most people with common organization and work culture may also influence health problems, and for social security disease risk.”171 beneficiaries. The provisos are that account must be taken of the nature and quality of work 4. The positive impact of work on health and its social context; jobs should be safe and The pages above highlight the negative effects accommodating.”173 that work can have on workers’ physical and

Chapter 4 Interrelationships of Work, Health and Community 33 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

While this research was done in a developed • 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 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.

34 Chapter 4 Interrelationships of Work, Health and Community WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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 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 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 ; 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 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

Chapter 4 Interrelationships of Work, Health and Community 35 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices due to deaths from the disease among workers.185 “It [] could be

The literature is full of reports stating the cost of also a situation where everybody is ill-health to employers and to national dealing with 1000 different economies. Some Canadian data provide a activities and you don’t have any conservative estimate of costs to employers in developed nations: flexibility to say no, so you always • The cost of supplemental health plans for keep on taking more, and basically Canadian employers increased by 26% you are very frustrated because between 1990 and 1994.186 what you produce is bad quality and • The private sector (Canadian employers) paid 29% of total health care in 2000, up this is a big frustration.” from 24% in 1994.187 Interview #6, Switzerland, OH Engineer • Short-term absence costs in Canada more than doubled between 1997 and 2000, going engaged, innovative and creative employees to from 2% of to 4.2%188 keep finding ways to stay ahead of the • Short- and long-term disability costs competition. More than ever before, they require together in Canada are more than double the minds of workers to be functioning at a high the costs of workers’ compensation, and the capacity. ratio has been increasing since 1997.189 Even if the enterprise is one that depends • Every Canadian employee who smokes almost entirely on brute force or simple repetitive costs a company $2500 per year (1995 tasks with little room for innovation or creativity, dollars) mostly due to increased an engaged and committed worker is more absenteeism and decreased productivity.190 productive and useful than one who is apathetic, depressed or constantly stressed. It is generally well recognized that people in most parts of the world, but especially in and medicine support the developed countries, are becoming less common sense. After mentioning examples of physically active, more poorly nourished (in ways in which employers can create workplaces terms of quality, not quantity of food), and more that encourage good mental health, the recently obese, with a resultant increase in many of the published Mental Health Strategy for Canada conditions mentioned above: hypertension, states, “In addition to improving overall mental cardiovascular disease, diabetes, arthritis. As health and well-being, such efforts can also help the population ages, these will become even to improve the productivity of the workforce and more prevalent, and the impact on productivity in reduce the growing costs of insurance claims for the workplace is frightening to project. both physical and mental health conditions.” 191 Table 4.1 shows some symptoms of three 3. The mental health of workers affects the mental illnesses or disorders, clearly showing enterprise characteristics that affect work. Clearly, workers Common sense says this is true. Imagine you exhibiting these symptoms will have a negative are the owner of a medium-sized enterprise. impact on productivity and quality of work, Would you rather have employees who are therefore directly affecting the enterprise. engaged, focused, enthusiastic, committed to their work, innovative and creative? Or would Poor mental health and/or job dissatisfaction you prefer workers who are stressed-out, angry, related to work-family conflict also has a depressed, burned out and apathetic? In significant impact on productivity at work, today’s knowledge-based enterprises, specifically related to absenteeism and intent to employers depend on highly functioning, turnover. Research indicates that workers

36 Chapter 4 Interrelationships of Work, Health and Community WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

Table 4.1 Work-related Symptoms of Common Mental Disorders

Work-related Symptoms of Work-related Work-related Symptoms of Depression192 Symptoms of Burnout194 • Trouble concentrating Anxiety • Becoming cynical, sarcastic, 193 • Trouble remembering Disorders critical at work • Trouble making decisions • Feeling • Difficulty coming to work and • Impairment of performance at work apprehensive getting started once at work • Sleep problems and tense • More irritable and less patient • Loss of interest in work • Difficulty with co-workers, clients, • Withdrawal from family, friends, co- managing customers workers daily tasks • Lack of energy to be • Feeling pessimistic, hopeless • Difficulty consistently productive at • Feeling slowed down concentrating work • Fatigue • Tendency to self-medicate with alcohol or drugs

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 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.

Chapter 4 Interrelationships of Work, Health and Community 37 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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 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 , 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 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, 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 rate in the community and among employees is low, they will be unable to read water, and , 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.” affected immediately, or may be overwhelmed Interview #34, Republic of Korea, OSH

38 Chapter 4 Interrelationships of Work, Health and Community WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

“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

Worker Enterprise Society Role overload 12x more burnout 3.5x higher 2.6x Increased use of 3.5x high stress absenteeism mental health services 3.4x depression 2.4x more likely to 1.4-2.4x more 3.1x poor physical miss work due to child physician visits, health care hospital admissions 2.3x more likely to turnover/quit Work-Family 5.6x as much burnout 2.8x as likely to 1.7x as many visits to Interference 2.4x more depression turnover/quit mental health 2.4x poor/fair health 1.9x absenteeism professional 2.3x poor physical 0.5x as likely to have 1.4-1.7x visits to or health a positive view of admissions to hospital employer 6x more reports of high job stress Lowest levels of commitment to the employer of all groups. Family-Work 1.6x stress, burnout, 6.5x more 1.9x use of mental Interference depression absenteeism due to health services 2x fair/poor health problems 1.3-1.4x visits to or 1.6x more admission to hospital absenteeism overall Caregiver strain 1.5x stress & burnout 13x more 1.4-1.8x as many 2x depressed mood absenteeism due to visits to doctors, 1.8x less life elder care issues admission to hospital, satisfaction 1.4x more spend more on 1.6x poor/fair physical absenteeism overall prescription health medications, emergency visits, use of mental health care. Greatest use of health care system of all groups.

Chapter 4 Interrelationships of Work, Health and Community 39 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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, , 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.

Figure 4.2 Relationship Between Health And Wealth.

40 Chapter 4 Interrelationships of Work, Health and Community WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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 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

Chapter 5: Evaluating Interventions 41 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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 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 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.

42 Chapter 5: Evaluating Interventions WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

• Unclear or inconsistent terminology. strong impact on the health of the Researchers often say in the literature that workplace, regardless of the impact of the “comprehensive” programmes are the most intervention. These confounding factors effective. However, the term make it difficult to draw any kind of reliable “comprehensive” is defined in some reports conclusion about the outcome, especially to mean health promotion programmes that when there is no control group. integrate the environment of the enterprise; or to mean those that provide an ongoing C. Grey Literature integrated programme of health promotion Supplementing the workplace health research and disease prevention that is consistent literature discussed above is an abundance of with corporate objectives and includes materials termed “grey literature.” This includes evaluation; or it may just mean a programme published material that is not found in peer- that is targeted at more than one risk factor. reviewed scientific journals, but may include project reports, publication of “best practices” or • The Hawthorne Effect. This is well known in “models of good practice.” In the majority of workplace research, and means that the cases, these reports do not include exact behaviour or attitude of workers being descriptions of the measures implemented, the subjected to an intervention tends to detailed outcomes, the original baseline improve simply because someone is paying conditions or the determining factors. In attention to them. It could be considered addition, there is often incomplete contact or akin to the effect in an individual follow-up information, so that reaching the patient. Although the validity of the original authors for more information is difficult Hawthorne Effect has been challenged or impossible. recently, there is still some evidence that people being watched or experimented upon D. The Precautionary Principle change their behaviour simply because of Given the extremely limited amount of being observed or studied.ccix scientifically solid, evidence-based data on the effectiveness of many health protection and • Stages of Change. All change is not easily promotion interventions, it would be easy to sit measured. The Stages of Change model of back and do nothing. With respect to health Prochaska and DiClemente shows that promotion interventions in particular, aside from people go through a number of internal smoking and disease, medical causal evidence changes before actually changing is lacking; rather, factors such as diet, obesity, behaviour.ccx Therefore, if only actual and sedentary living have statistically significant changes in behaviour or physiological associations with illness and disease, but no markers are measured to determine solid causal evidence. However, doing nothing effectiveness of health promotion in these cases would fly in the face of the spirit interventions, significant internal changes of the precautionary principle. may be missed. The principle states that In the case of serious or • Other confounding factors. It is unlikely that irreversible threats to the health of humans or a single intervention is the only thing that the ecosystem, acknowledged scientific changes in a workplace over time. uncertainty should not be used as a reason to Everyday occurrences in a workplace such postpone preventive measures.”ccxi In other as a change of managers, a merger or words, in the context of this paper, employers acquisition, an increase or decrease in and workers should not delay implementations demand for the enterprise’s products or to improve workplace conditions and promote services, or changes in the state of the health simply because there is no strong global economy, for example, can have a

Chapter 5: Evaluating Interventions 43 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices scientific evidence of the intervention’s could have been better spent on increasing their effectiveness. . 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 ,” 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

44 Chapter 5: Evaluating Interventions WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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 5: Evaluating Interventions 45 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

46 Chapter 5: Evaluating Interventions WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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

Chapter 6: Evidence for Interventions that Make Workplaces Healthier 47 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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

Ergonomic workstation Ergonomic training alone.228 adjustments combined with Training alone on manual lifting ergonomic training (moderate showed inconsistent results.227 evidence)226

A Cochrane Review of the Pre-employment strength effectiveness of lumbar programmes are testing policies had positive supports for prevention of effective229,230,231,232 effects for musculoskeletal low-back pain found there is injuries and costs, and no moderate evidence that they effects for non-musculoskeletal are not any more effective injuries.233 than no intervention or training.234 235

To return employees to work A Cochrane Review of after experiencing back pain, manual material handling there is clear evidence that it Prevention of any kind of advice and the provision of is important for patients to stay computer-related MSDs or assistive devices to prevent active and return to ordinary visual problems by means of back pain concluded that activities as early as possible; ergonomic training, arm there was no significant a combination of optimal supports, alternate keyboards, difference in outcomes clinical management, a rest breaks, screen filters (these between groups who rehabilitation programme and factors all generally showed received training on proper workplace interventions is weak positive but inconsistent lifting and assistive devices, more effective than single effects)237 and those who received no elements alone; taking a training, exercise training, or multidisciplinary approach back belts. It did not matter offers the most promising if the training was intensive results; temporarily modified or short.238

48 Chapter 6 : Evidence for Interventions that Make Workplaces Healthier WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

Effective Inconclusive or Inconsistent Not Effective work is an effective return-to- A Cochrane Review states work intervention if embedded A Cochrane Review of there is strong evidence that in good occupational interventions for preventing shoe insoles do not prevent management; and some exposure back pain.240 evidence supports the and subsequent hearing loss effectiveness of exercise reported contradictory results, therapy, back schools and and no clear evidence of behavioural treatment.236 effectiveness, partly due to lack of quality programmes with sufficient worker instructions.239

Technical ergonomic Rest breaks combined with measures can reduce the A Cochrane Review of exercise during the rest workload on the back and interventions to enhance the breaks (these studies upper limbs without the loss of wearing of hearing protection showed moderate evidence productivity and evidence that among workers exposed to of no effect)243 these measures can also noise in the workplace did not reduce the occurrence of show whether tailored MSDs. (strong)241 interventions are more or less effective than general interventions.242 Patient handling systems to A Cochrane Review of reduce back pain (multi- A Cochrane Review of interventions to prevent component systems that interventions for preventing injury in the agricultural included a policy change, occupational noise exposure sector concluded that purchase of patient lifting and subsequent hearing loss educational interventions technology and training on the reported contradictory results, alone are not effective.246 new machines)244 and no clear evidence of effectiveness, partly due to lack of quality programmes with sufficient worker instructions.245 A Cochrane Review of There is strong evidence that interventions for preventing A Cochrane Review of training on working methods injuries in the construction educational interventions to in manual handling is not industry concluded there is reduce eye injuries at work effective if it is used as the some limited evidence that a concluded that studies do not only measure to prevent low multifaceted safety campaign provide reliable evidence of back pain.249 and a multifaceted drug reducing injuries, due to the programme can reduce non- poor quality of the studies.248 fatal injuries.247

B. Evidence for Effectiveness of workers and their representatives has been Psychosocial/Organizational Culture identified as a key success factor for many of Interventions the effective physical work environment interventions mentioned above, and many of the One of the key psychosocial factors that health promotion interventions described in contributes to a healthy workplace is worker Section C. participation in decision-making. Participation of

Chapter 6 : Evidence for Interventions that Make Workplaces Healthier 49 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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.

Table 6.2 Evidence for Effectiveness of Psychosocial Interventions

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

Health Circles as implemented in German enterprises are a formalized participatory A systematic review method for assessing and dealing with concluded there is currently workplace needs or deficiencies. Because insufficient evidence of of lack of good studies, evidence of their quality to judge the effectiveness is weak, but is nevertheless effectiveness of the use of consistently positive in reducing stress and organizational participatory work satisfaction, as well as certain health interventions in the risk factors.252 workplace to improve mental wellbeing and further research is required.253

Psychological ill-health can be prevented/improved by interventions that The Institute of combine personal with Occupational Medicine organizational efforts to increase (Edinburgh) examined the participation in decision-making and impact of different types of problem-solving, increase social support, supervisory training on the and improved organizational mental well-being of communication.254 subordinates and concluded there is insufficient evidence to allow any positive

50 Chapter 6 : Evidence for Interventions that Make Workplaces Healthier WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

Inconclusive or Effective Not Effective Inconsistent statement to be made and further research is required.255

A Cochrane Review of work-directed interventions to prevent concluded that those interventions that include communication or delivery change can be effective in reducing burnout, stress and general symptoms in healthcare workers when compared to no intervention.256

Organizational efforts to reduce stress by job redesign can reduce workplace stress.257

Measures “calling on organizational culture are particularly effective” in improving musculoskeletal health.258

There is evidence that changing the shift system of officers from 7 day consecutive shifts to the 35 day Ottawa system can positively impact on mental well- being.259

Psychosocial intervention training of employees to improve skills or job role can have a positive impact on burnout in the short term.260

There is moderate evidence that a combination of several kinds of interventions (multidisciplinary approach) including organizational, technical and personal/ individual measures is better than single measures in preventing MSDs. However, it is not known how such interventions should be combined for optimal results.261

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

Chapter 6 : Evidence for Interventions that Make Workplaces Healthier 51 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices representatives in programme planning and deemed to be either effective, or interventions brings positive outcomes.262 inconclusive/ inconsistent, or ineffective. Table 6.3 shows some samples of health promotion activities in the workplace

Table 6.3 Evidence for Effectiveness of Personal Health Resource Interventions in the Workplace (most limited to )

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

Asking participants to pay for a programme appears Work-related programmes can help to negatively impact Physical activity programmes reduce smoking behaviour, control participation, but reduce at work show no effect on weight (in the short term), improve drop-out rates. The workplace stress, work attitude towards , lower benefits of incentives satisfaction or productivity.271 blood cholesterol, increase physical cannot be demonstrated activity (all these were effective in the long term, and may 270 Programmes restricted to among the participants, not have negative effects. offering information or advice necessarily the workforce as a 269 on health issues are whole) ineffective (“necessary but inadequate”)272

52 Chapter 6 : Evidence for Interventions that Make Workplaces Healthier WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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

Health promotion programmes that Self-help smoking cessation utilize a “stages of change” approach programmes, either to individualize the intervention to the computerized or paper- individual employee’s characteristics based have little effect, are more effective.279 according to a Cochrane Review.280

Work-related exercise programmes were found effective in reducing Worksite programmes to workplace injuries.281 prevent or reduce obesity over the long term have not been shown to be effective.282

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

Chapter 6 : Evidence for Interventions that Make Workplaces Healthier 53 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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

Smoking bans in the workplace are more effective than limiting smoking locations, and decrease not only the number of smokers, but also the number of cigarettes smoked per continuing smoker.285

A Cochrane Review shows that smoking cessation group programmes can be effective, and that individual counseling was a very important success factor for individualized programmes286

A Cochrane Review on person- directed stress management programmes concluded these could be effective in reducing burnout, anxiety, stress and general symptoms in healthcare workers when a cognitive-behavioural approach, either with or without a component, was used.287

A Cochrane Review that evaluated the effectiveness of hepatitis B in healthcare workers found it to be highly effective in preventing hepatitis B .288

Web based health promotion and lifestyle training packages can improve mental wellbeing as measured using non-standard questionnaire at baseline and at 6 months after the web site and related components being available.289

A WHO review of interventions to improve diet and exercise found

54 Chapter 6 : Evidence for Interventions that Make Workplaces Healthier WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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

Promising practices for success in health promotion include: o integrating health promotion programmes into the organization’s operations o simultaneously addressing individual, environmental, policy and cultural factors affecting health and productivity o targeting several health issues o tailoring programmes to address specific needs o attaining high participation o rigorously evaluating programmes o communicating successful outcomes to key stakeholders.291

Because of their voluntary nature, and the D. Evidence for Effectiveness of image of benevolence that they project, Enterprise Involvement in the Community enterprises carrying out these activities may By its very nature, enterprise/ organizational not be as (overtly) interested in proving involvement in the community is voluntary, going above and beyond what is legislated “We have to consider workers in or expected. Some of these activities may be considered “Corporate Social the context of their families Responsibility” (CSR) activities, and typically and communities, which could address aspects of an enterprise’s sometimes be a spill-over into behaviour with respect to such key elements their companies and work, and as health and safety, environmental protection, human rights, human resource then considering the management practices, community environmental factors such as development, consumer protection, transport systems.” business ethics, and rights. Interview #30,Norway, OH, OH Med.

Chapter 6 : Evidence for Interventions that Make Workplaces Healthier 55 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices effectiveness or cost-effectiveness. Having • decreased vulnerability through stronger said that, an employer may see benefits to relationships with communities, and workers and to productivity, and may • improved reputation and branding”293 communicate these benefits to other employers in an effort to encourage similar Often the large multinational companies are activities. For example, Rosen et al have the progressive employers in the community provided a strong business case for and provide community services (for engaging in HIV/AIDS prevention and example, or transportation), helping treatment programmes for employees in them to become the employer of choice, areas where HIV is prevalent.292 Writing in a with clear advantages for attracting and journal like the Harvard Business Review, retaining employees. their aim clearly is to appeal to senior executives, and to appeal to their business In addition to these business advantages, sense. there are often immediate, obvious and sometimes personal reasons that an The reality of business is that while ethical enterprise, even an SME, may want to get employers may genuinely feel connected involved in the community in which it and want to do good things for the operates and from which it draws its communities in which they operate, they are employees. Table 6.4 lists just a few also not averse to attaining some financial or hypothetical examples of how an business benefit from the activities. Even if organization could become involved in its the senior managers of a are community, and some of the obvious altruistic in nature, they have boards of advantages. directors to report to, as well as shareholders. As a result, any employer will Evidence that this type of activity has been try to find a business rationale for recognized by the business community as community efforts in which he or she is being important for business success is engaged, regardless of any benevolent seen in the Dow Jones Sustainability underlying motives. Indexes. Launched in 1999, these indexes track the financial performance of the There are probably no randomized leading (top 10%) sustainability-driven controlled studies of the effects on business companies worldwide. The identification of of becoming involved in their community, these leading companies is based on an since an enterprise/ organization would have assessment that looks at economic, to shed any pretense of altruism in order to environmental and social perspectives, engage in such a study. However, there are which include workplace health & safety, many commonly held beliefs about the value business ethics, environmental controls, of such activities: gender balance and labour practices, among other factors.294 “Corporations can be motivated to change their in response to the It is therefore quite apparent that when an business case which a CSR approach enterprise finds ways to go beyond the legal potentially promises. This includes: minimums in their country or community, • stronger financial performance and there can be significant positive impacts on profitability (e.g. through eco-efficiency), worker health, and also on the health and • improved to and sustainability of the enterprise. Therefore assessments from the investment this type of activity can be considered an community, important part of a healthy workplace, albeit • enhanced employee commitment, a voluntary one.

56 Chapter 6 : Evidence for Interventions that Make Workplaces Healthier WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

Table 6.4 Examples of Enterprise Involvement in the Community

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.

High levels of HIV Provide medical care, Improved health of employees, infection among workers antiretroviral medication, and less sick time, less turnover due to who are unable to afford anonymous testing, not only employee deaths. Treating family treatment for workers, but also for the members as well will decrease families of workers. absenteeism of workers who have to stay home to care for ill family.

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.

Discharge of legally Go beyond legal minimums Long-term improved health of the allowable, but toxic, and change operating community source of employees. chemical effluent into the practices to avoid discharging Immediate improvement of environment from toxins into the environment. corporate image. enterprise, resulting in pollution.

Community projects Encourage workers to Increased employee loyalty, require volunteer workers. volunteer, allow scheduled commitment, pride in employment. time off to engage in volunteer activities. Traffic hazards, crime and Work with planners to Workers more physically active, lack of infrastructure build and ensure practicality contributing to reduction of make active transport and safety of bike paths, noncommunicable diseases difficult to and from work sidewalks, public transport including cardiovascular disease, and elsewhere in system, improved security. cancer, depression, and community. musculoskeletal problems.

Chapter 6 : Evidence for Interventions that Make Workplaces Healthier 57 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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 resources, privatization of develop innovative insurance improves 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 , 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, , 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.

58 Chapter 6 : Evidence for Interventions that Make Workplaces Healthier WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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.

Dr. Edward Deming popularized the PDCA or Plan, Do, Check, Act model in the 1950s. It arose out of the scientific method of “hypothesize, experiment, evaluate.” The concept recognizes that when undertaking any new endeavor, it is unlikely it will be perfect from the start, so process of continual improvement is a way to avoid costly errors or paralysis. The iterative principle in scientific research is reflected in the PDCA approach.

Chapter 7: How to Create a Healthy Workplace 59 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

Table 7.1 Comparison of Continual Improvement/OSH Management Systems

Deming CCOHS WHO Western Pacific OHSAS 18001 ILO (PDCA) (OSH Works) Regional Guideline (OSH Management) Plan Lead: Ensure management OH&S policy Policy management support commitment, worker participation, OH&S Establish a coordinating Organizing policy body

Plan: Conduct a needs Planning Planning & legal & other, hazards assessment implementation & risks, workplace Prioritize needs health, objectives & targets Develop an action plan

Do Do: Implement the action plan Implementation prevent & protect, & operation emergency plans, train, communicate, procure, contract, manage change, document control, record control.

Check Check: Evaluate the process and Checking and Evaluation measure & monitor, outcome corrective investigate incidents, action & inspect, evaluate & correct

Act Act: Revise and update the Management Action for review, improve programme review improvement

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 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

60 Chapter 7: How to Create a Healthy Workplace WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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 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

Chapter 7: How to Create a Healthy Workplace 61 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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.

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In many situations, achieving appropriate input from workers may require workers “The process is very important - having a collective voice, through a trade the participatory process that union or other system of worker engages workers themselves is very representation. Schnall, Dobson and Rosskam, when reviewing successful important…. By being invited into workplace interventions, go so far as to the process, the process can be state unequivocally that “…strong collective part of the solution… so this is voice is the singularly most important element found among all of the various key.” Interview #31, Netherlands, OSH interventions described. To date, few work organization change initiatives have succeeded in the absence of strong to ensure input from them, and to reflect collective voice.”ccciv their perspectives in the data. Even in supposedly advanced Western cultures, The term worker “empowerment” is often women hold more subordinate jobs sometimes used, though this can be than men and may simply feel misconstrued to mean a shifting of uncomfortable speaking their thoughts in a responsibility to workers without mixed audience. concomitant authority - a recipe for disaster. One of the basic principles of This principle of worker involvement action research is the active participation of underlies the internal responsibility system those who will be affected by the changes. that forms the basis for health and safety legislation in place in most jurisdictions in Due to the power imbalance that exists in Canada, Europe and Australia. This most workplaces between labour and usually takes the form of a legislated management, it is critical that workers have requirement for a joint labour-management a voice that is stronger than that of the health and safety committee within an individual worker. Participation in trade enterprise, with a mandate to make unions or representation by regional worker recommendations to the senior representatives can provide this voice. management of the enterprise, related to Chapter 7 mentioned some innovative any health, safety and well-being concerns ways of providing a collective voice for in the workplace. Shifting the responsibility workers, even in small enterprises. for health and safety to everyone in the workplace, including workers, and away It should be noted here that effort must be from a total reliance on external made to specifically include female government enforcement, has been found workers, who tend to have the least control to be highly effective in reducing workplace over their work, and even fewer injuries and illnesses.cccv, cccvi,cccvii,cccviii opportunities for input into decisions than men in the workplace.∗ In cultures where In addition, this involvement will ensure that women are not encouraged to, or even the specific needs and requirements of the allowed to speak in front of men, it will be local culture and conditions are important to hold women-only focus groups incorporated into the health and safety activities in the workplace. ∗ This speaks to the aspect of power relations at work and how this can be an obstacle to the creation of healthy 3. Gap analysis: It is important to do the right workplaces. Powerlessness may be because of gender but also because of age, education, legal status, language, things. What is the situation now? What ethnicity, etc. should conditions be like ideally? And what

Chapter 7: How to Create a Healthy Workplace 63 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

is the gap between the two? When it comes to creating a healthy workplace, is it more The principles of knowledge transfer can important to remove a hazardous chemical assist here. Knowledge transfer can be from the workplace or reduce the amount of defined as “a process leading to unplanned overtime? The answer to these appropriate use of the latest and best questions may depend on who is asked. research knowledge to help solve concrete So it is important to assess the current problems; information cannot be situation: collect baseline data, do a needs considered knowledge until it is assessment and hazard identification to applied.”cccix If there are researchers in a determine the current state of affairs. Then local university or experts in a local safety determine the desired future, by means of a agency, they may be able to assist in the survey or other tool, and literature review to translation of complex information into find out what is most important to, and will practical applications. Union have the most impact on the people who representatives who have received special work in the enterprise /organization. In a OSH training through their union, or large corporation, determining needs and occupational health and safety experts in assessing hazards may involve a larger enterprises in the community may comprehensive literature review, baseline have expert knowledge and be very willing data analysis, multiple site inspections and to mentor and assist SMEs. There are a comprehensive survey of all workers. In many good sources of information on the an SME, it may be a walk-through with one internet. manager and worker, followed by a focused discussion with all the workers or a Therefore, after determining what the representative group. What is critical is needs are in the workplace, part of the getting the involvement of workers and planning step may be to visit other similar managers, and together determining what enterprises to see what local good practice are the most important things to do first. exists; access helpful websites such as those of WHO, ILO, CCOHS or EU-OSHA; Sometimes well-meaning multinational and investigate resources that may be corporations assume that what works in a available in the community. (See Box 7.1 developed country will work in a developing on WISE, WIND and WISH programmes.) nation, and try to use a “one-size-fits-all” approach. Doing a good needs 5. Sustainability: There are a number of assessment will ensure that local factors that ensure sustainability of healthy conditions and culture are assessed and workplace programmes. One that is key is incorporated into any plans that are made, to ensure that healthy workplace initiatives so that they are applicable and effective in are integrated into the overall strategic the specific workplace involved. business plan of the enterprise, rather than existing in a separate silo. Another is to 4. Learn from others: This principle is evaluate and continually improve. After the especially important in developing nations chosen programmes or initiatives have and small businesses in any country. Often been developed and implemented, it is the people in charge of making the important to check the efficacy of workplace healthier and safer are lacking interventions. Did the initiative do what it the information or knowledge to do so. was supposed to do? If not, how can Even if all the components of the process things be changed to make it work? This is are in place, the success of interventions the way the continual improvement cycle is depends on doing the right things, which closed: one cycle ends and the next one requires some expert knowledge. begins. Without this important step, there

64 Chapter 7: How to Create a Healthy Workplace WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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

Box 7.1 Learn from Others: WISE, WIND and WISH

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 5 of the workplace.

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

Chapter 7: How to Create a Healthy Workplace 65 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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 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 must teach people to • Create and have senior management accept 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

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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 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 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 healthy workplace programmes, it is less Division, Ontario Ministry of Labour, Canada. For more 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 [email protected] or Christina Della-Spina, Healthy Workplace Project Assistant: health into organizational health. Similarly, if +1.905.577.1327, [email protected]

Chapter 7: How to Create a Healthy Workplace 67 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices key workers or supervisors do not demonstrate appropriate healthy workplace attitudes and behaviours, isolated healthy workplace “programmes” could still exist in a very toxic work environment, and there would be no integration of the various healthy workplace components.

68 Chapter 7: How to Create a Healthy Workplace WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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 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 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 316 workers. 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,

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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, , France, Germany, US, UK, Canada Norway , Spain Semi-periphery Informal Labour Informal Labour Informal Labour Institution Market, More Market, Less Successful Successful , , , 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

Clearly, the enterprise in Ethiopia will face ILO Conventions challenges that could scarcely be imagined in Since 1919, the International Labour Sweden, and the overall level of health among Organization has approved and published workers will be widely disparate between the nearly 190 Conventions, which are statements two enterprises, despite the best efforts of the of legally binding international treaties related workplace parties. to various issues regarding work and workers. They cover a wide range of working conditions Governments and their agencies are in a such as hours of work, the right of association position to provide comprehensive standards for workers, , employment and laws, and to enforce them. Governments discrimination, labour inspections, maternity and their agencies can and do create the leave, health and safety, workers’ systems and infrastructure of primary health compensation, medical examinations, care, which in turn may provide many basic minimum working age, holidays with pay, and occupational health services functions. In contracts of employment for indigenous other words, governments provide the workers. Once ILO has passed them, conditions to facilitate and support worker Member States are asked to ratify them, which health, or to create barriers and impediments. means they are making a formal commitment Clearly, the efforts of employers and workers to implement them. Ratification is an to create healthy, safe and health-promoting expression of the political will to undertake workplaces pale in comparison to the power of comprehensive and coherent regulatory, the political will of a nation. enforcement and promotional action in the area covered by the Convention. Ratifying A. Standards-setting Bodies nations are then required to make regular There are a number of standards-setting reports to ILO providing evidence of their bodies that have attempted to create progress towards implementation of the standards for workplaces, and to have them Conventions. voluntarily adopted by governments and/or individual enterprises. In theory, looking at the Conventions and the countries that have adopted them should

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WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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% Average 44% 38% 31% 54% 25% 16% 35%

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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

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WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices management, Plan-Do-Check-Act process 90/270/EC Display Screens) to the psychosocial discussed in Chapter 7. environment (Directive 2003/72/EC Employee Involvement) to basic employment conditions Given the dynamic and progressive nature of (Directive 93/104/EC ).327 the subject, any discussion of the degree of implementation of the Convention must be C. Workers’ Compensation done over time. For the Member States that When prevention efforts fail and a worker is have ratified the Convention, the ILO’s injured or made ill at work and is unable to Committee of Experts has been able to follow continue to work, he or she has an immediate this process, since reports are required financial situation to deal with, as income from annually. The 2009 report concluded that only work ceases. Many countries have installed 31 of the 52 ratifying countries are currently in “workers’ compensation” systems to financially complete compliance with the Convention, compensate injured workers while they are while the others are making progress towards recovering, until they are able to go back to full implementation. In addition, among work. In the absence of such a system, countries that have not ratified the Convention, workers with the means and the capacity to do there are 25 nations that have developed so have often pursued litigation against the national policies on occupational safety and employer to recover some financial health, and another 20 are in the process of compensation for their injury. In many developing such a policy.326 countries, employers and workers have chosen to endorse state or private insurance The ILO report describes in detail the many schemes to provide guaranteed income to provisions and variations of health and safety injured workers, sometimes giving up the right policy and legislation that have been to sue. implemented globally. In their conclusions and recommendations, however, they note the There are five ILO Conventions related to lack of policy relating to the informal sector in workers’ compensation, which are listed in most countries, and they urge governments to Table 8.3. Again, a minority of countries in the revise and extend their policies and legal six WHO Regions has ratified these framework to cover these workers. Other Conventions. And as in the discussion above opportunities for improvement that are noted related to occupational health and safety, are strengthening labour inspectorates; merely looking at the countries that have improving data collection regarding ratified these conventions does not provide a occupational injuries and illnesses; increasing complete picture. efforts to assess chemical hazards; assessing the impact of work organizational changes on A review of workers’ compensation laws in workers’ health; addressing newer issues such Canada, the United States and Australia 328 as MSDs and stress at work; and the was recently published. In these three continuing occurrence of very basic life- countries, workers’ compensation law is a threatening situations faced by untrained provincial/state responsibility, so there is workers in many countries. no national consistency. In all cases, however, workers’ compensation systems A unique situation exists in Europe, where all the are entirely under the control of legislative countries of the European Union are subject to bodies and administrative agencies. The laws and directives passed by the Union. There reviewers noted that workers’ are many Directives relating to workplace health compensation law is inherently extremely and safety, ranging from issues related to the complex and it is difficult to compare physical work environment (e.g. Directive coverage in one jurisdiction to that in

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Table 8.3 ILO Workers’ Compensation Conventions and Ratifications

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 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

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Table 8.4 Comparison of Selected Workers’ Compensation Features in USA, Canada, Australia331 Canada Feature USA (% of responding Australia (% of states) provinces) (Victoria) Options for employer to Private carriers Exclusive state fund Exclusive state fund insure through Self-insurance allowed? Yes No Yes Exclusion for small Yes, 36% Yes, 28% Yes employers? Exclusion for agriculture? Yes, 72% Yes, 57% No Exclusion for domestic Yes, 86% Yes, 86% No workers? Limitations on medical Limits on chiropractic Limits on chiropractic and No number limits treatment? and in physical therapy in 14% about 18% of states choice of treating Employer chooses or Worker chooses Worker chooses physician provides a list of acceptable physicians in 42% of states Length of time benefits paid 80% of states may pay Till age 65 Till age 65 for permanent disability for life Coverage of mental stress 64% may pay under 86% of provinces cover Yes claims when no physical limited circumstances under very limited injury circumstances Maximum burial coverage $800 - $15,000 $4000- no limit $9,300 after a workplace fatality

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 , 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.

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In most countries, it is primarily workers in • Time allowed for meals larger enterprises that are represented by • Pregnancy/maternity leave unions or works councils, while those in SMEs • Paid vacation are much less likely to have formed • Paid sick time associations. For example, a recent review of • Work on public holidays trade unions in various countries noted that in • Availability of contracts Japan, “trade unions are rarely formed in • Minimum working age smaller companies, and the interests of such • /forced overtime workers are often not sufficiently protected, • thereby resulting in a great disparity of working • Non-discrimination in hiring (on the basis conditions between those in large companies of sex, disability, ethnicity, etc.) and those in other companies.”336 It would be • Accommodation of disabilities in the fair to say this statement is typical of most workplace countries. There are many ILO conventions that address As a result, legislators in some countries have this type of issue, and as with the cases taken innovative measures to ensure that discussed above, they are often ratified by a workers at SMEs are protected and have a minority of countries. Having said that, many collective voice. For example, in Spain, while countries that have not ratified the conventions it is usually companies of 250 or more workers have very good laws relating to these factors. that have trade union representation, Whether or not they are enforced and applied companies with 50 or more workers must set consistently in any given country is another up a Works Council to represent workers. question. For example, ILO Convention 100 Enterprises with fewer than 50 employees mandates equal pay for work of equal value may elect Employee Delegates to represent between men and women, and the Convention workers’ interests. These Works Councils and has been ratified by over 90% of countries. Employee Delegates have broad legal rights Yet there is still a significant financial gap and responsibilities to ensure worker between men and women. The report goes on participation and protection. In Sweden, there to say that “Contrary to popular belief, is a system of regional safety delegates, women’s lower educational qualifications and nicknamed “roving reps” who have earned a intermittent labour market participation are not high degree of respect from both employers the main reasons for the . The and employees, as they often provide the only gap is in fact a visible symptom of deep, health and safety information source for small structural sex discrimination.”338 employers.337 The convention dealing with discrimination in E. Employment Standards employment and occupation is Convention There are many standards or regulations 111. As noted in Table 8.2, over 80% of related to non-physical conditions in the countries have ratified this Convention, which workplace that might be considered basic forbids employment and occupational conditions of work, and which can make the discrimination on the basis of ethnicity, gender difference between jobs being healthy or being and other criteria. That is an impressive very bad for the worker’s health. These record – and yet the reality is that include but are not limited to policies related discrimination on the basis of social to: characteristics exists in greater or lesser • Hours of work (number of hours, and also degrees in most countries of the world. The time of day, nights versus day shifts) ILO bluntly states that “No society is free from • Wages (relative to cost of living) sex discrimination.... Enforcement of the laws • Consecutive hours of rest per week in practice needs improvement.”339

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Even in countries that have enforced The Employment Conditions Knowledge legislation related to these aspects of Network compiled data regarding employment employment, they only apply to situations in conditions in “wealthy” (meaning which there is a formal employment industrialized, developed) nations, and “poor” relationship. Consequently, countries with a (meaning developing) countries. They put it large proportion of informal workers will have a into a historical context, to show the striking large proportion of workers who do not benefit parallels between the conditions in many from these laws. Since women are developing nations now, and in developed disproportionately represented in the informal nations in the late 19th century. This sector, they tend to have less access to these information is provided in Table 8.5.341 laws and benefits.340

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 workforce workforce sector Minimum No 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 , Age pension/social Age, disability and No age pension, social security social security, security, unemployment security, safety net unemployment – cut back unemployment benefits (sickness, age, benefits benefits unemployment benefits)

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F. Psychosocial Hazards • 7 of 8 AMRO nations There are currently no ILO conventions or ISO • 0 of 1 EMRO nations standards dealing with psychosocial hazards • 13 of 15 EURO nations in the workplace, and few countries have • 1 of 2 SEARO nations specific laws dealing with this area of • 4 of 8 WPRO nations. workplace health. Some health and safety legislation, for example that of Peru, states The Mental Health Commission of Canada that the employer must protect workers from commissioned a report in 2008 on the legal various types of hazards, including implications of harm being done to employees psychosocial hazards; as well as identify, plan by stress at work in Canada. However, for and control workplace hazards, including because of the way the law frames the issue, psychosocial hazards.342 However, no the inquiry was redefined as a search for legal guidance is provided on how employers might principles governing liability for mental injury at do that, and no definitions of psychosocial work. This was released in 2009 as the hazards are provided. report, “Stress at Work, Mental Injury and the Law in Canada: A discussion paper for the The EU Framework Directive 89/391 provides Mental Health Commission of Canada.”345 a legal requirement for all employers in the EU The author, Martin Shain, notes that there is a to protect the occupational health & safety of great deal of inconsistency between provinces workers from “all risks.” This has been in Canada, with one province (Saskatchewan) interpreted to include psychosocial risks by a including mental issues in its occupational group of European associations, who have health and safety legislation; one province published a framework agreement on work- (Ontario) covering issues of harassment and related stress. They state that, “this voluntary discrimination under particularly robust human European framework agreement commits the rights legislation; covering it under a members of UNICE/UEAPME, CEEP and specific Employment Standards law related to ETUC … to implement it [the framework psychological harassment; and other agreement on work-related stress] in provinces dealing with it through trade union accordance with the procedures and practices grievances and litigation case law. He states specific to management and labour in the that, “These uncertainties notwithstanding, Member States and in the countries of the one trend is clear: taken as a whole, the law is European Economic Area.”343 imposing increasingly restrictive limitations on management rights by requiring that their The most common psychosocial hazard to exercise should lead, at a minimum, to no have any related legislation associated with it serious and lasting harm to employee mental is harassment or bullying in the workplace. In health.” this case, the form of harassment most commonly mentioned is sexual harassment, After discussing the current Canadian with harassment on other grounds usually not situation, Shain makes a recommendation that mentioned. As noted in Chapter 4, women are Canada pursue a standards-based approach disproportionately the victims of workplace such as that seen in the United Kingdom. As sexual harassment, so this is an area where a mentioned in Chapter 4, the Health & Safety particular group is far more vulnerable than Executive (HSE) in the UK has developed and others. A recent review of legislation in 35 implemented Management Standards that countries in 5 of 6 WHO Regions (none from deal with a number of issues related to the AFRO) revealed that there is some form of organization of work. The Standards are explicit sexual harassment legislation in place intended to provide guidance to employers for in:344

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WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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 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 348 promotion exists in Germany, where the national sickness most Canadian jurisdictions. 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

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WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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

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WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices unions, various non-governmental organizations (NGOs), civil societies, health “I think one of the key problems insurance companies and other private that we are facing now is really corporations. related to the traditional type

I. The Informal Economic Sector issues where many workers are not While it has been mentioned before, it bears just doing one job but they may be repeating that the informal economic sector, in multiple occupations in terms of by definition, is not covered or protected by occupational health & safety laws or social earning a living. So they could be in security legislation in most countries. The ILO the formal workplace for part of has repeatedly urged nations and enterprises the day and then going and doing to extend coverage to those workers not other things in the evening, and covered by formal employment contracts.353 often it has been quite difficult in The informal sector is not a small minority of terms of the multiple activities workers. In India, 80% of enterprises are that they are involved in.” unregistered, and therefore not covered by Interview #30, Norway, OH, Occ Med. health & safety regulations.354 This translates into 86% of the working population, or nearly 400 million people who work in the informal example, the ILO provides assistance in this sector and are not covered by any form of area, with a programme called PATRIS social security.355 In some countries in the (Participatory Action Training for Informal Persian Gulf area, informal workers who are Sector Operators).359 In addition, enterprises non local/immigrant workers make up the that believe in the principles of the Global majority of the workforce.356 Women are Compact can indicate their commitment to fair disproportionately represented among informal treatment of workers by requiring all members workers, as those who work in their homes, in of their supply chains to practice responsible the homes of others as domestic workers, or health and safety, even if they are informal as street vendors are usually female.357 workers or workplaces.

The size of the informal sector provides an argument for including occupational health services in the primary health care system of a country, so that all citizens and residents are at least covered by basic health care. However, that is a purely reactive approach, which does nothing to prevent these workers from being exposed to harmful situations at work. The Seoul Declaration on Occupational Safety and Health at Work states that the right to a safe and healthy work environment is a basic human right358, not just a right for formal employees. Creative and innovative approaches are needed to ensure that these workers have a voice, are able to be represented by trade unions, and are covered by the same legislation that covers employees with formal employment contracts. For

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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

82 Chapter 9: Suggested Framework and Model WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices legislative, policy and regulatory situation in their country. Governments have the power to create supportive and facilitative environments for healthy workplaces, or to create environments that put up barriers and impediments at every turn. WHO and ILO will continue their hard work with governments of Member States to move them closer towards the ideal situation of support for healthy workplaces.

The informal sector also presents challenges for creating healthy workplaces. Informal work is often unhealthy due to the uncertainty and precarious nature of the work.360 Since women tend to work more in the informal sector, or in unpaid work, they are affected more than men by these 361 conditions. In the absence of a formal 3. Personal health resources in the or even a consistent workplace place of work, it is difficult for even a motivated 4. Enterprise community involvement employer to create a workplace that fosters health. Nevertheless, any employer who These four areas relate to the content of a wishes to make things as healthy and safe as healthy workplace programme, not the possible for the informal workers who provide process. As such, the four avenues are not services for the enterprise should become discrete and separate entities. In practice, familiar with the elements of this framework each intersects and overlaps with the others. and look for ways to apply them to informal Therefore, they are represented in the workers in unofficial ways if necessary. suggested graphical model as four overlapping circles, as shown in Figure 9.1. A. Avenues of Influence for a Healthy Each of these avenues is defined below, Workplace with examples of potential workplace To create a workplace that protects, promotes problems that fall into each, and examples and supports the complete physical, mental of healthy workplace interventions that an and social well-being of workers, an enterprise/organization could institute.∗ enterprise/organization should consider addressing content in four “avenues of It should be clarified that every enterprise influence,” based on identified needs. These may not have the need to address each of are four ways that an employer working in these four avenues all the time. The way an collaboration with employees can influence the enterprise addresses the four avenues must health status of not only the workers but also be based on the needs and preferences the enterprise/organization as a whole, in identified through an assessment process terms of its efficiency, productivity and that involves extensive consultation with competitiveness.

∗ These four avenues are: When reading about the four avenues and the examples in each, individual readers may think certain 1. The physical work environment situations or solutions would better belong in a different 2. The psychosocial work environment avenue. It is not critical into which avenue any particular example fits; rather, it is important that all four avenues not be forgotten when planning a healthy workplace.

Chapter 9: Suggested Framework and Model 83 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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, , workers on a daily basis. And even in 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 to avoid • biological (e.g., hepatitis B, , 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.

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• Personal protective equipment: Provide , respectful performance respirators (masks) for employees working management); in dusty conditions; provide hard hats and • inconsistent application and protection safety boots for construction workers. of basic worker rights (legislated These need to be chosen in sizes and employment standards for contracts, configurations that fit women as well as maternity leave, non-discriminatory men. hiring practices, hours of work, time off, vacation time, OSH rights, etc.); Return to work • shiftwork issues; When a worker is returning to work after an • lack of support for work-life balance; injury or illness, whether work-related or not, • lack of awareness of and competence in some modifications may have to be made to dealing with mental health/illness the physical work environment to avoid the issues; risk of re-injury. Examples might be to lower • fear of job loss related to mergers, or raise a working surface, or provide better acquisitions, reorganizations, or the . This sort of intervention is labour market/economy. considered secondary prevention. Examples of ways to influence the 2. The Psychosocial Work Environment psychosocial work environment: Non- Definition: The Psychosocial Work physical hazards should be addressed in the Environment includes the organization of work same way as physical hazards, though they and the organizational culture; the attitudes, will be assessed with different tools (for values, beliefs and practices that are example, using surveys or interviews rather demonstrated on a daily basis in the than inspections). They should be enterprise /organization, and which affect the recognized, assessed and controlled mental and physical well-being of employees. through a hierarchy of controls that seeks to These are sometimes generally referred to as eliminate the hazard if possible or modify it workplace stressors, which may cause at the source; lessen the impact on the emotional or mental stress to workers. worker; or help the worker protect him or herself from its effects. Some examples are: Examples of psychosocial hazards: These • Eliminate or modify at the source: non-physical hazards include, but are not Reallocate work to reduce workload, limited to: • poor work organization (e.g., problems “It’s important to tell them with work demands, time pressure, decision latitude, reward & recognition, when they are doing well and to , support from supervisors, job congratulate them and to say,’ clarity, job design, job training, poor Well done, without you I communication); couldn’t have done that, without • organizational culture (e.g., lack of policies and practice related to dignity or respect you the work will not be done, so for all workers; harassment & bullying; it’s thank you very much.’ And I discrimination on the basis of HIV status; think this is important - it’s a intolerance for diversity of sex, ethnicity, sexual orientation, religion; lack of support key, key situation. When people for healthy lifestyles); tell you that you are doing well, • command & control management style after you feel very good. (e.g., lack of: consultation, negotiation, Interview #6, Switzerland, Public Health Engineer two-way communication, constructive

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remove or retrain managers /supervisors their efforts to improve or maintain healthy in communication and leadership skills; personal lifestyle practices, as well as to enforce zero tolerance for harassment, monitor and support their ongoing physical bullying or discrimination in the workplace; and mental health. apply all legal standards and laws regarding workplace conditions or put Examples of personal health resource policies in place to supplement the laws issues in the workplace: Workplace (e.g., maternity leave supplemental conditions or lack of information and compensation; accommodation of nursing knowledge may cause workers to mothers; smoke-free workplace). experience difficulty adopting healthy • Lessen the impact on the worker: Allow lifestyles or remaining healthy. For flexibility to deal with work-life conflict example: situations; provide supervisory and co- • Physical inactivity may result from work worker support (resources and emotional hours, cost of fitness facilities or support); allow workers to choose their equipment, lack of flexibility in when and shift schedules as much as possible; allow how long breaks can be taken. flexibility in the location and timing of work; • Poor diet may result from lack of access provide timely, open and honest to healthy snacks or meals at work, lack communications about coming of time to take breaks for meals, lack of organizational changes. refrigeration to store healthy lunches, • Protect the worker: Train workers on lack of knowledge about healthy eating. stress management techniques, including • Smoking may be allowed or enabled by cognitive approaches. Raise awareness the workplace environment. and provide training for workers, for • Alcohol use or abuse may be example, in the prevention of conflict or encouraged, tolerated or enabled by harassment situations. (This could fall workplace practices. under Personal Health Resources, below). • Poor quality or quantity of sleep may result from workplace stress, workloads Return to work or shiftwork. As with the physical work environment, when • Illnesses may remain undiagnosed or someone is returning to work after an injury or untreated due to lack of accessible illness, there may need to be adjustments to and/or affordable primary health care. the psychosocial work environment, in order to • Lack of knowledge or resources for prevent reinjury, or another recurrence of an prevention of sexually transmitted illness. For example, work could be diseases (STDs) may result in high reorganized, the workload could be reduced, levels of HIV infection or other blood- work hours changed, or more flexibility borne STDs. allowed in terms of the way work is done. If the illness was a result of harassment or other Examples of ways to provide personal behaviours at work that type of behaviour health resources in the workplace: The must be eliminated before return. enterprise may provide a supportive environment and resources in the form of 3. Personal Health Resources in the medical services, information, training, Workplace financial support, facilities, policy support, Definition: Personal Health Resources in the flexibility or promotional programmes to workplace means the supportive environment, enable and encourage workers to develop health services, information, resources, and continue healthy lifestyle practices. opportunities and flexibility an enterprise Some examples are: provides to workers to support or motivate

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• Provide fitness facilities for workers, or a Return to work financial subsidy for fitness classes or If a worker has been absent from work for equipment. some time, the time when he or she is • Encourage active transport as opposed to returning to work may be a good time to passive transport in work activities provide health education information and a whenever possible, by adapting workload supportive environment related to the cause and processes. of the illness or injury that caused the • Provide and subsidize healthy food absence. For example, if a worker has been choices in the cafeteria and vending off work due to a heart attack, his or her machines. return to work and optimal health can be • Allow flexibility in timing and length of work facilitated by encouraging exercise and breaks to allow for exercise. healthy food availability, enforcing no- • Put no smoking policies in place and smoking policies in the workplace, and enforce them. reducing sources of stress in the workplace. • Implement promotional campaigns or competitions to encourage physical 4. Enterprise Community Involvement activity, healthy eating, or other “fun” Enterprises exist in communities, affect and activities in the workplace. are affected by those communities. Since • Provide information about alcohol and workers live in the communities, their health drugs, and employee assistance is affected by the community physical and counseling services. social environment. • Provide smoking cessation programmes (information, drugs, incentives) to assist Definition: Enterprise community smokers to quit smoking. involvement comprises the activities, • Implement healthy shiftwork policies, allow expertise, and other resources an enterprise worker choice of shifts as much as engages in or provides to the social and possible, and provide guidelines for restful physical community or communities in which and effective sleep. it operates; and which affect the physical • Provide confidential medical services such and mental health, safety and well-being of as health assessments, medical workers and their families. It includes examinations, medical surveillance (e.g. Measuring hearing loss, blood lead levels, It [Healthy Workplace] applies HIV status testing) and medical treatment if not accessible in the community (e.g., also to the services & products antiretroviral treatment for HIV). that the work produces…. Focus • Provide confidential information and on the interaction of work and resources (e.g. ) for prevention of community, the process of STDs. manufacturing strategies. For This avenue of influence is perhaps the most example, employment of child difficult to apply to workers in the informal labour in the workforce. sector, since generally any existing benefits, programmes and policies do not apply to Employees extend to family and them. However, a motivated employer can interaction of work and choose to unofficially extend benefits, services immediate community, and flexibility in scheduling to informal promotion of sales of the workers, and provide health education information to informal workers. product (ethical aspects).” Interview #44. Switzerland, Health Promotion

Chapter 9: Suggested Framework and Model 87 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices activities, expertise and resources provided to • Implement voluntary controls over the immediate local environment, but also the pollutants released into the air or water broader global environment. from the enterprise. • Implement policies and practices to Examples of community issues that affect the employ workers with physical or mental workplace: Some global and local community disabilities, thus influencing problems that may affect workers are: unemployment and cultural issues in the • poor air quality in the community; community. • polluted water sources in the community; • Encouraging and allowing workers to • lack of expertise or knowledge about volunteer for non-profit organizations health or safety in the community; during work hours. • lack of access to primary health care for • Provide financial support to worthwhile workers and their families; community causes without an • lack of national or regional laws protecting expectation of concomitant enterprise the rights of women or other vulnerable advertising, or requirements for groups; community purchase of enterprise • lack of literacy among workers and their products. families; • Go beyond legislated standards for • community disasters such as floods, minimizing greenhouse gas emissions earthquakes; and finding other ways to minimize the • lack of funds for local non-profit enterprise’s carbon footprint. enterprises or causes; • Provide antiretroviral medications not • high levels of HIV infection in the only for employees but for family community, and little access to affordable members as well. prevention or treatment resources; • Work with community planners to build • lack of community infrastructure or safety and ensure practicality and safety of to encourage active transport to and from bike paths, sidewalks, public transport work and during leisure time. system, and improved security.

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

88 Chapter 9: Suggested Framework and Model WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices will be very different from those in a , because of the vastly different legal and policy environments in the countries. So, therefore, the types of initiatives and solutions that are appropriate for the enterprise will be different. In a highly developed country with excellent national health care and strong, well-enforced legislation related to health, safety, human rights, etc., the things an enterprise may do to become involved in the community may be more discretionary and have less immediate and obvious impact on the community. In a developing nation, in the absence of accessible health care or enforcement of labour laws, the activities of the enterprise in the community may make a world of difference to the quality of life of employees and their families. 1. Mobilize In Chapter 7 we noted that it is critical to B. Process for Implementing a Healthy mobilize and gain commitment from the Workplace Programme major stakeholders and key opinion leaders Implementing a healthy workplace programme in the enterprise and community before that is sustainable and effective in meeting the beginning. If permission, resources, or needs of workers and the employer requires support are required from an owner, senior more than knowing what kinds of issues to manager, union leader, or informal leader, it consider, as are outlined above in the four is important to get that commitment and buy- avenues of influence. To successfully create in before trying to proceed. This is an such a healthy workplace, an enterprise must essential first step. follow a process that involves continual improvement, a management systems It should be recognized that sometimes in approach, and which incorporates knowledge order to mobilize key stakeholders to invest transfer and action research components. in change, it is necessary to do some up- front information collection. People hold The process recommended by WHO is based different values and operate in differing on an adaptation of WPRO’s Regional ethical frameworks. They are motivated and Guideline discussed in Chapters 3 and 7362. It mobilized by different things – by data, or is a cyclic or iterative process that continually science, or logic, or human stories, or plans, acts, reviews and improves on the conscience, or religious beliefs. Knowing activities of the programme. It is graphically who the key opinion leaders and influencers represented in Figure 9.2. are in an enterprise, and what is likely to mobilize them, will assist in gaining this As noted in Chapter 7, two of the core commitment. principles are leadership engagement based on core values and ethics, and worker The term “mobilize” is used here involvement.363,364,365,366 These are not merely deliberately. This step is about more than steps in the process, but are ongoing just getting an “OK” from the owner. Key circumstances that must be tapped into at evidence of this commitment is the every of the process. development and adoption of a comprehensive Policy that is signed by the

Chapter 9: Suggested Framework and Model 89 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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

90 Chapter 9: Suggested Framework and Model WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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 & 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 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 368 how to control these risks, and Development of Healthy Workplaces suggests the following methods of data monitor, and ensure that they stay in 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 , 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

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• environmental monitoring and to deal with all at once. If the enterprise is health/medical surveillance - with the small and the number of significant issues is assistance of experts in occupational low (~5-10) then the employer and workers hygiene and medicine, it is possible to can probably use a relatively simple obtain data about physical and chemical approach to choose the top items to deal agents in the workplace and the amount of with first. worker exposure; • written survey - a confidential and Before attempting to set priorities, however, anonymous survey, either on paper or it is wise to discuss and agree upon the delivered electronically, to ask about the criteria to be used in making decisions about issues discussed above; priorities. How will a decision be made as to • focus group discussion - small group which is more important – providing meetings facilitated by a leader with respirators for workers doing sand-blasting, specific objectives in mind and structured or eliminating racial harassment from the questions. These are particularly useful in workplace? In making these decisions, small enterprises or with groups of there are two critical things to take into workers with low literacy. Focus groups consideration: are also useful to flesh out, or validate 1. the opinions and preferences of the information obtained from a written survey. workplace parties, including • Interviews - more in-depth, face-to-face managers, workers and their interviews may be held with key representatives; and stakeholders or professionals; 2. the position on Maslow’s hierarchy of • suggestion box - a way of soliciting needs. anonymous suggestions, which may be more candid than opinions ventured in a The first point is of paramount importance, group discussion. but potentially dangerous if workers and their representatives are not knowledgeable Whatever methods are used to collect this enough about the risks to make informed information, it is important to make sure that decisions. This reinforces the importance of women have as much opportunity for input as training and learning from others, which is men. Survey instruments should be discussed in Chapter 7. confidential and anonymous, but should collect information regarding the sex of the The second point refers to a system of participant, so that the information collected ranking human needs proposed by Abraham can be analyzed separately, to tease out Maslow369, which is often characterized as issues that are more important to one gender illustrated in Figure 9.3. Clearly, it is than the other. If information is collected from important to deal with issues closer to the focus groups, it is essential to provide a safe base of the pyramid before worrying about setting for women to freely voice their those higher up. In most cases, problems opinions, and not feel intimidated by male related to physical safety and health are workers. In addition, men may sometimes feel more basic and immediately threatening reluctant to express their fears or concerns in than those concerned with mental health a mixed gender group. and well-being, which is why countries usually develop legislation in this area first. 4. Prioritize Put crudely, inhaling silica in the workplace Once all the information has been collected, will kill a worker much more quickly than the Healthy Workplace Team must set experiencing demeaning racial harassment priorities among the many issues identified, will, although both are very unhealthy. since there will possibly be too many problems

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enterprise. Ask for a volunteer with some authority who can accept responsibility for doing the B items right away. Then make a plan for the team to do the C items after A and B have been done. If there are any items on the list that are considered unimportant and not urgent, they can be removed from the list.

In larger corporations or in complex work situations, there may be too many items to deal with by these simple methods, and a more complex priority-setting process may be required. To make decisions as objectively as possible a ranking system and priority grid may be used to quantify Other criteria that may be considered are: preferences. • how easy it would be to implement a solution to the problem (consider “quick When setting priorities, it is wise to provide wins” that may motivate and encourage opportunities to determine if there are continued progress); different priorities for women than for men. • the risk to workers (this is a combination of Care should be taken to ensure that the severity of the exposure to the hazard priorities for both genders are addressed. and the probability that it will occur); The ILO notes that “research provides • the possibility of making a difference compelling arguments for the consideration (including the existence of effective of women’s and men’s biological solutions to the problem, readiness of the differences, in order to ensure that the employer to make a change, or the workplace is adapted to the physical aspects likelihood of success); and capacities of both sexes; the findings • the relative cost of the problem if it is seem to have been ignored.”370 ignored; • “political” considerations (this may include 5. Plan actual issues related to the political The next big step is to develop a health situation in a country or community, or so- plan. In a large enterprise, this would be a called “internal ” issues related to “big picture” plan for the next 3-5 years. This enterprise power and influence. will set out the general activities to address the priority problems, with broad timeframes. Once agreement on the criteria has been If additional permission is required from reached there are various ways to select senior leaders to go forward, then the priorities. One way is simply to list all the rationale and supporting data for each problems and let everyone choose their top recommendation should be included in the three. Then total the numbers for each item plan to ensure their support. In the overall and see how the ranking falls out. Another plan, the Healthy Workplace Team may not method is to categorize each of the problems yet have the details of the actions to be as (a) important and urgent; or (b) urgent but taken, and may include items such as not important; or (c) important but not urgent. “develop and implement a programme to Put the A items at the top of the list and plan increase worker physical activity” without yet for the group to address them first, in knowing the details. The overall plan should consultation with the owner/operator of the have some long-term goals and objectives

Chapter 9: Suggested Framework and Model 93 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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

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Table 9.1 Application of WHO Continual Improvement Process in Large and Small Enterprises

Step Large Corporation Small Enterprise Mobilize • Get buy-in from the senior management team and trade • Explain the healthy workplace concept to the owner or operator union leaders or other worker representatives. and get permission to proceed. • Ensure that a comprehensive health, safety and well-being • Get permission to hold short meetings with the workers to Policy is in place. determine needs and ideas for solutions. • Ensure that worker health and well-being is mentioned in • Get a commitment for enough time to plan and implement the mission or vision of the corporation. programmes. • Ensure that resources and an annual budget have been • Help the owner/operator to develop a short health and allocated for healthy workplace activities safety/well-being Policy statement that can be signed and posted in the workplace. Assemble • Set up a committee of 10-15 people representing different • Ask for 2-3 volunteers to help with the work (the Healthy departments and work locations. Workplace Working Group). • Develop terms of reference. • If there are very different types of jobs in the company (e.g., • Set up regional subcommittees if the corporation has many drivers and labourers) try to get one of each to help. sites. • If you can find experts from larger enterprises or community • Ensure cross-representation with the joint management- associations willing to help, include them. labour occupational health and safety committee. • Find a space to meet and gather together any materials you will need. Assess • Gather demographic data about the workforce, baseline • If possible (and deemed necessary), find a way for the data on absenteeism, short and long-term disability, and Working Group to learn about health, safety and well-being as turnover. it relates to your industry. • Conduct a confidential comprehensive survey of all staff • Obtain a checklist from WHO, ILO, EU-OSHA, or make one up asking about their health status, their health, safety and yourself, and do a walk-through of your workplace, looking for well-being concerns, sources of stress in the workplace or hazards. Determine local good practice and consult outside at home, leadership, , etc. experts as appropriate. • In the survey, ask what they would like to do as individuals • Hold a meeting of all workers. Ask the owner/operator to start to improve their health, and how they think the employer the meeting by assuring them of his/her commitment to the could help. healthy workplace concept. • Do a comprehensive audit to assess all hazards and risks • Lead a discussion with the workers about their health, safety in the workplace; or review results of regular workplace and well-being concerns. Include family and community inspection reports. concerns as they relate to work. • Brainstorm ideas on what the employees and the employer could do to make things better. • Be sure to ask about stress-related concerns as well as physical concerns. • Have the Working Group meet with the owner/operator separately to ask for his/her ideas on the same topics. Prioritize • Analyze the results of the survey and audit/inspection • Do this at the same time as the initial meeting if possible or at results. a subsequent meeting. • Prioritize by pairing high need areas with high “want” areas • List problems and solutions and ask people to choose their top from employees. 3-5. Plan • Develop a broad 3-5 year plan. • Plan some short-term activities to address smaller projects or • Develop annual plans with detailed action plans for each immediate high priority needs. Again, local good practice can specific activity, programme or new policy. be a guide. • Base action plans on stages of change when appropriate. • Develop a long-term plan to accomplish bigger projects. • Include activities addressing awareness, knowledge and • Use ideas from the Working Group as well as other employees skill-building, behaviour change, and or other enterprises. environmental/organizational adjustments. • Write out the plan and make a list of what you’ll need to • In each specific action plan, include process and outcome accomplish each activity, and present to the owner/operator goals as well as evaluation plans, timelines, budgets and for approval or negotiation. maintenance plans. • Plan to do one thing at a time. Do • Divide responsibilities among those on the committee. • Carry out the action plans with assistance from the • Hold monthly or bimonthly meetings to assess progress on owner/operator and the Working Group. all projects Evaluate • Measure the process and outcome of each activity against • At a pre-determined time after beginning a project or initiative, the evaluation plans. repeat the walk through inspection to see if previous deficiencies have improved. • Ask workers if they think the project worked, why or why not, and what could be improved. Improve • On at least an annual basis, re-evaluate the 3-5 year plan • Based on what you see and hear from workers, change the and update it. programme to improve it. • Repeat the survey every 2 years and monitor changes over • Begin on another project, based on your list of priorities. time. • Develop annual plans on the basis of the evaluations from the previous year.

96 Chapter 9: Suggested Framework and Model WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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 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

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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.

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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

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Annex 1: Acronyms Used in this Document

ACGIH American Conference of Governmental Industrial Hygienists AFRO WHO Regional Office for Africa AMRO WHO Regional Office for the Americas BOHS Basic Occupational Health Services CCOHS Canadian Centre for Occupational Health & Safety CEEP European Centre of Enterprises with Public Participation and of Enterprises of General Economic Interest COMH Consortium for Organizational Mental Healthcare (Canada) CSR Corporate Social Responsibility EMCONET Employment Conditions Knowledge Network EMRO WHO Regional Office for the Eastern Mediterranean ENWHP European Network for Workplace Health Promotion ETUC European Trade Union Confederation EU European Union EU-OSHA European Agency for Safety and Health at Work EURO WHO Regional Office for Europe FCTC WHO Framework Convention on Tobacco Control GPA Global Plan of Action for Workers Health HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HSE Health and Safety Executive (United Kingdom) IAPA Industrial Accident Prevention Association (Canada) ICOH International Commission on Occupational Health ILO International Labour Organization IRS Internal Responsibility System MSD Musculoskeletal disorder NCD Noncommunicable diseases NGO Nongovernmental organization OH Occupational Health OH&S Occupational Health & Safety OHS Occupational Health Services OSH Occupational Safety & Health PAHO Pan American Health Organization PDCA Plan, Do, Check, Act POSITIVE Participation Oriented Safety Improvements by Trade Union Initiative PTSD Post Traumatic Stress Disorder ROI Return on Investment SEARO WHO Regional Office for South-East Asia SESI Serviço Social da Indústria (Brazil) SME Small or medium-sized enterprise STD Sexually transmitted disease UEAPME European Association of Craft, Small and Medium-sized Enterprises UK United Kingdom of Great Britain and Northern Ireland UNEP United Nations Environment Programme UNICE Union of Industrial and Employers’ Confederations of Europe US, USA United States of America WEF World Economic Forum WHA World Health Assembly

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WHO World Health Organization WHP Workplace Health Promotion (as defined by ENWHP) WIND Work Improvement in Neighbourhood Development WISE Work Improvement in Small Enterprises WISH Work Improvement for Safe Home WPRO WHO Regional Office for the Western Pacific WTO World Trade Organization

Annex 1: Acronyms 101 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

Annex 2: Glossary of Terms and Phrases

NOTE: This glossary attempts to define Caregiver Strain: One type of work-family terms and phrases as they are used in this conflict; with the understanding that a document. These should not be considered “caregiver” is a person providing assistance universally accepted definitions. to a young, elderly or disabled dependent, caregiver strain is sum total of the Active transport: Active transport is emotional, physical, and financial changes in physical activity undertaken as a means of the caregiver’s day-to-day life that are transport and not purely as a form of attributable to the need to provide that care. recreation. Active transport generally refers to and cycling for travel to and/or Case study of good practice: An example from a destination, but may also include and description of how a programme, model other activities such as the incidental activity or tool that meets the agreed criteria has associated with the use of public transport. been implemented in one workplace, community or other setting. AFRO: WHO Regional Office for Africa. This Region includes all of Africa except for Civil society: The arena in any community Djibouti, Egypt, Libya, Morocco, Somalia, of voluntary collective action around shared Sudan, and Tunisia. interests, purposes and values, distinct from those of the state. Civil societies include AMRO: WHO Regional Office for the organizations such as registered charities, Americas. This Region includes all of North, non-governmental organizations, women's Central and South America, and is organizations, faith-based organizations, administered by PAHO. trade unions, self-help groups, business associations, and advocacy groups. Audit: A systematic and documented process for obtaining evidence from Cochrane Collaboration: An international, inspections, interviews and document non-profit, independent organization review, and evaluating it objectively to established to ensure that current, accurate determine the extent to which relevant information about the effects of health care criteria are fulfilled. interventions is readily available worldwide, through the publication of Cochrane Avenues of influence: Broad over-arching Reviews (systematic reviews of the ways or content areas through which an literature.) employer working in collaboration with workers can influence the health, safety and Continual improvement process: A well-being of employees. Specifically, the cyclical process that repeats stages of four avenues of influence are interventions planning, action, measurement & evaluation, in the physical work environment, and correction & improvement, leading to an interventions in the psychosocial work ongoing overall improvement in conditions. environment, health promotion in the workplace, and involvement in the enterprise Convention, ILO: Legally-binding community environment. international treaties related to various issues related to work and workers. Once a Basic occupational health services: See Convention has been passed by ILO, occupational health services Member States are required to submit it to

102 Annex 2 Glossary and Endnotes WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices their parliament for consideration for ratification. Enterprise: A company, business, firm, institution or organization designed to Cost of stress: The financial cost to a provide goods and/or services to business or society of the mental, physical consumers. While often used to imply a for- and behavioural symptoms, diseases and profit business, in this document it is disorders that result from prolonged stress. intended to include not-for-profit For example, a behavioural symptom of organizations or agencies, and self- excessive stress in a worker may be employed individuals. increased absenteeism from work. Enterprise community involvement: The Decent work: A term developed by the ILO activities, expertise, and other resources an meaning work that is productive, and enterprise engages in or provides to the delivers a fair income, security in the social and physical community or workplace and social protection for families, communities in which it operates; and which better prospects for personal development affect the physical and mental health, safety and social integration, freedom for people to and well-being of workers and their families. express their concerns, organize and It includes activities, expertise and participate in the decisions that affect their resources provided to the immediate local lives, and equality of opportunity and environment, but also the broader global treatment for all women and men. environment.

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 . 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,

Annex 2 Glossary and Endnotes 103 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices 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 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.

Health protection: Measures taken in a ILO convention: See Convention, ILO workplace to protect workers from illness or injury due to exposure to physical, chemical, Informal economic sector: The non- biological, ergonomic or psychosocial regulated labour market, which usually hazards or risks that exist in the workplace. involves workers with informal (unwritten) arrangements with an employer, and who Health risk assessment (used in this are not documented as workers in document synonymously with the term government records. In many countries health risk appraisal): A type of entitlement for social benefits (such as sick

104 Annex 2 Glossary and Endnotes WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices or maternity leave, paid , 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 , 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).

Knowledge transfer: A process leading to OSH Management System: A management appropriate use and application of the latest system is a framework of processes and and best research knowledge to help solve procedures used to ensure an organization concrete problems; information cannot be can fulfill all tasks required to achieve its considered knowledge until it is applied. objectives. An Occupational Safety and enables Model: The abstract representation of the organizations to improve their overall OSH structure, processes and system of a performance through a process of continual healthy workplace concept. improvement.

Musculoskeletal disorders: Disorders of PAHO: The Pan American Health the muscles, joints, tendons, ligaments and Organization. PAHO was established in nerves. Most work-related MSDs develop 1902 as an international public health over time and may be caused by or agency to improve health and living exacerbated by the work itself or the working standards of the countries of the Americas. conditions, especially by excessive force, It now serves as the WHO Regional Office awkward posture, or repetitive motions. for the Americas. They generally affect the back, neck, shoulders, wrists and upper extremities: less Personal Health Resources (in the often the lower extremities. Other terms workplace): The supportive environment, used for MSDs are repetitive strain injuries health services, information, opportunities, or cumulative trauma injuries. Disorders and flexibility an enterprise provides to may range from discomfort, minor aches workers to support or motivate their efforts and , to severe injury and disability. to improve or maintain healthy personal lifestyle practices, as well as to monitor and Occupational health services: Includes support their ongoing physical and mental primary, secondary and tertiary health health. prevention and promotion services, plus

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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.

Precarious employment: Employment Primary prevention: The part of preventive terms that may reduce social security and medicine that attempts to avoid the stability for workers, defined by temporality, development of a disease. Most population- powerlessness, lack of benefits, and low based health promotion activities are income. Flexible, contingent, non-standard primary prevention measures. In workplace contracts do not health, primary prevention includes most of necessarily, but often provide an inferior the activities related to prevention and economic status. protection of workers against harm due to elements of the physical or psychosocial Precautionary principle: A principle that work environment, as well as health suggests employers and workers should not promotion activities and many interventions delay interventions to improve workplace of the enterprise in the community. conditions and promote health simply because there is no strong scientific Psychosocial work environment: The evidence of the intervention’s effectiveness. organization of work and the organizational Specifically, it states, “In the case of serious culture; the attitudes, values, beliefs and threats to the health of humans, practices that are demonstrated on a daily interventions to protect or promote health basis in the enterprise, and which affect the should not be delayed due to acknowledged mental and physical well-being of scientific uncertainty.” employees. These are sometimes generally referred to as workplace stressors, which Presenteeism: The reduced productivity of may cause emotional or mental stress to someone who is present at work, but either workers. physically or mentally unwell, and therefore not as effective, efficient or productive as Ratification: When referring to ILO they would normally be. Conventions, ratification by the government of a country means making a formal Primary care: The element within primary commitment to implement the Convention. health care (see below) that focuses on It is an expression of the political will to health care services, including health undertake comprehensive and coherent promotion, illness and injury prevention, and regulatory, enforcement and promotional the diagnosis and treatment of illness and action in the area covered by the injury. Convention.

Primary health care: An approach to Risk: A combination of the probability of health and a spectrum of services beyond exposure to a hazard, plus the severity of the traditional health care system. It includes the impact from exposure to that hazard.

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perceptions and opinions from employees Role overload: One form of work-family through (preferably) confidential, conflict; having too much to do in a given anonymous, written/electronic means. May amount of time, when the total demands in also include collection of this type of time and energy associated with the information through focus groups when/if prescribed activities of multiple work and appropriate. family roles are too great to perform the roles adequately or comfortably. Systematic review: A literature review of a single issue or question that attempts to Safety: The state of being protected against identify, select and synthesize all high- physical, social, spiritual, financial, quality research evidence relevant to that psychological, or other types or question. Systematic reviews of high-quality consequences of failure, error, accidents, or randomized controlled trials are the “gold harm. This can take the form of being standard” for evidence-based medicine. protected from the event or from exposure to something that causes health or economical Tertiary prevention: The part of preventive losses. It can include protection of people or medicine designed to reduce the negative of possessions. impact of an already established disease by restoring function and reducing disease- SEARO: WHO Regional Office for South- related complications. In occupational East Asia. This Region includes health, return-to-work activities and Bangladesh, Bhutan, Democratic People’s rehabilitation after an injury would be Republic of Korea, India, Indonesia, considered tertiary prevention. Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. Tool: A concrete instrument or measure that can be used by an individual or organization Secondary prevention: The part of to collect and/or analyze and/or apply preventive medicine that is aimed at early information, such as a questionnaire, disease detection, thereby increasing checklist, protocol, flow chart, audit, opportunities for interventions to prevent procedure, etc. progression of the disease and emergence of symptoms. In occupational health, Transformational leadership: A style of periodic health examinations, medical leadership that includes idealized influence screening or medical surveillance activities (making decisions based on ethical would be considered secondary prevention. determinants), inspirational motivation (motivating workers by inspiring them rather Stress: Subjective feelings and than demeaning them), intellectual physiological responses that result from stimulation (encouraging workers to grow workplace (or other) conditions that put an and develop) and individualized individual in a position of being unable to consideration (allowing flexibility in how cope or respond appropriately to demands situations are handled.) being made upon him or her. Work - Family interference: One form of Stressor: A condition or circumstance in a work-family conflict; a type of role workplace (or other setting) that elicits a interference that occurs when work stress response from workers. demands and responsibilities make it more difficult to fulfill family role responsibilities. Survey: A formalized collection of quantitative and qualitative information,

Annex 2 Glossary and Endnotes 107 WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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, , 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:

108 Annex 2 Glossary and Endnotes WHO Healthy Workplace Framework and Model: Background Document and Supporting Literature and Practices

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190 Smoking and the bottom line: the costs of smoking in the 202 Employers’ Forum on Disability The business case for workplace. Ottawa: Conference Board of Canada 1997. disability confidence. http://www.efd.org.uk/disability/disability-confidence- 191 Toward recovery and well-being: a framework for a business-case accessed 15 Sept 2009 mental health strategy for Canada. Mental Health Commission of Canada, 2009. 203 Duxbury L and Higgins C. Work-life conflict in Canada in http://www.mentalhealthcommission.ca/SiteCollectionDocum the new millennium: Report 6: Key findings and ents/boarddocs/15507_MHCC_EN_final.pdf accessed 30 recommendations from the 2001 National Work-Life Conflict December 2009 Study. 2009 Health Canada. http://www.hc-sc.gc.ca/ewh- semt/pubs/occup-travail/balancing_six-equilibre_six/index- 192 Centre for Addiction and Mental Health. eng.php accessed 6 August 2009 http://www.camh.net/About_Addiction_Mental_Health/Mental _Health_Information/depression_mhfs.html accessed 20 204 Tallinn Charter: Health Systems for Health and Wealth. July 2009 2008 http://www.euro.who.int/healthsystems/Conference/Docume 193 Centre for Addiction and Mental Health. nts/20080620_10 accessed 17 July 2009. http://www.camh.net/About_Addiction_Mental_Health/Mental _Health_Information/Anxiety_Disorders/anxiety_anxiety_diso ccv Verbeek J. Evidence-based occupational health and the rders.html Cochrane Collaboration: an introduction. International Congress Series 2006;1294:3-6. 194 Mayo Clinic. http://www.mayoclinic.com/health/burnout/WL00062/NSECTI ccvi Kreis J and Bödeker W. Health-related and economic ONGROUP=2 accessed 20 July 2009 benefits of workplace health promotion and prevention: Summary of the scientific evidence. IGA-Report 3e. Essen, 195 Duxbury L and Higgins C. Work-life conflict in Canada in BKK Bundesverband, 2004: 11. the new millennium: Report 6: Key findings and recommendations from the 2001 National Work-Life Conflict ccvii Kreis J and Bödeker W. Health-related and economic Study. 2009 Health Canada. http://www.hc-sc.gc.ca/ewh- benefits of workplace health promotion and prevention: semt/pubs/occup-travail/balancing_six-equilibre_six/index- Summary of the scientific evidence. IGA-Report 3e. Essen, eng.php accessed 6 August 2009 BKK Bundesverband, 2004: 11-12.

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http://www.euro.who.int/InformationSources/Publications/Cat highlights of a systemic review. April 2008. alogue/20041119_1 accessed 22 July 2009 http://www.iwh.on.ca/sbe/are-workplace-prevention- programs-effective accessed 24 July 2009 ccxii Grawitch MJ et al. Leading the healthy workforce: the integral role of employee involvement. Consulting 225 Institute for Work and Health 2008. Are workplace Psychology Journal: Practice and Research, prevention programs effective? Sharing best evidence: 2009;61(2):122-135. highlights of a systemic review. April 2008. http://www.iwh.on.ca/sbe/are-workplace-prevention- ccxiii European Network for Workplace Health Promotion. programs-effective accessed 24 July 2009 Healthy employees in healthy organisations: for sustainable social and economic development in Europe. Essen, 226 Institute for Work and Health 2008. Are workplace European Network for Workplace Health Promotion, 2005: prevention programs effective? Sharing best evidence: 10. highlights of a systemic review. April 2008. http://www.iwh.on.ca/sbe/are-workplace-prevention- ccxiv Aldana S. Financial impact of health promotion programs-effective accessed 24 July 2009 programs: a comprehensive review of the literature. 227 American Journal of Health Promotion, 2001;15(15):296. Institute for Work and Health 2008. Are workplace

ccxv prevention programs effective? Sharing best evidence: Burton J. The business case for a healthy workplace. highlights of a systemic review. April 2008. Mississauga, Canada: Industrial Accident Prevention http://www.iwh.on.ca/sbe/are-workplace-prevention- Association, 2008:7. programs-effective accessed 24 July 2009 http://www.iapa.ca/main/Resources/resources_downloads.a 228 Institute for Work and Health 2008. Are workplace spx#healthy accessed 23 July 2009. prevention programs effective? Sharing best evidence:

ccxvi highlights of a systemic review. April 2008. Aldana S. Financial impact of health promotion http://www.iwh.on.ca/sbe/are-workplace-prevention- programs: a comprehensive review of the literature. programs-effective accessed 24 July 2009 American Journal of Health Promotion, 2001;15(15):296. http://healthpromotionjournal.com/mm5/merchant.mvc? 229 Cole D et al. Effectiveness of participatory ergonomic abstract only accessed 11 July 2009 interventions: a systematic review. Institute for Work and

ccxvii Health 2005. http://www.iwh.on.ca/sbe/effectiveness-of- Sockoll I, Kramer I, Bödeker W. Effectiveness and participatory-ergonomics-summary-of-a-systematic-review economic benefits of workplace health promotion and accessed 24 July 2009 prevention. iga-Report 13e, 2009 page 54.

230 ccxviii Institute for Work and Health 2008. Factors for success Sockoll I, Kramer I, Bödeker W. Effectiveness and in participatory ergonomics. Sharing best evidence: economic benefits of workplace health promotion and highlights of a systemic review. March 2008. prevention. iga-Report 13e, 2009) page 54. http://www.iwh.on.ca/sbe/factors-for-success-in-

ccxix participatory-ergonomics accessed 24 July 2009. Sockoll I, Kramer I , Bödeker W. Effectiveness and

economic benefits of workplace health promotion and 231 Kreis J and Bödeker W. Health-related and economic prevention. iga-Report 13e, 2009, page 48. benefits of workplace health promotion and prevention:

ccxx Summary of the scientific evidence. IGA-Report 3e. Essen, Mossink JCM. Understanding and performing economic BKK Bundesverband, 2004: 11. p38. assessments at the company level. Protecting Workers’

Health Series No. 2. World Health Organization 2004 232 Podneice Z. Work-related musculoskeletal disorders: http://www.who.int/occupational_health/publications/ecoasse Prevention report. European Agency for Safety and Health ssment/en/ accessed 30 December 2009 at Work. Luxembourg 2008.

ccxxi http://osha.europa.eu/en/publications/reports/TE8107132EN Lahiri S et al. Net-cost model for workplace C/view accessed 5 October 2009 interventions. Journal of Safety Research – ECON

Proceedings, 2005;36:241-255. 233 Institute for Work and Health 2008. Are workplace www.who.int/entity/occupational_health/topics/lahiri.pdf prevention programs effective? Sharing best evidence: accessed 30 December 2009 highlights of a systemic review. April 2008. http://www.iwh.on.ca/sbe/are-workplace-prevention- 222 Hamalainen P, Takala J, and Saarela KL. Global programs-effective accessed 24 July 2009 estimates of occupational accidents. Safety Science 234 van Duijvenbode I, et al. Lumbar supports for prevention 2006;44:137-156. and treatment of low back pain. Cochrane Database of http://www.ilo.org/public/english/protection/safework/accidis/i Systematic Reviews 2006, Issue 4, Art. No.:CD001823. DOI: ndex.htm accessed 20 July 2009 10.1002/14651858.CD001823.pub3.

223 Institute for Work and Health 2008. Are workplace 235 Podneice Z. Work-related musculoskeletal disorders: prevention programs effective? Sharing best evidence: Prevention report. European Agency for Safety and Health highlights of a systemic review. April 2008. at Work. Luxembourg 2008. http://www.iwh.on.ca/sbe/are-workplace-prevention- http://osha.europa.eu/en/publications/reports/TE8107132EN programs-effective accessed 24 July 2009 C/view accessed 5 October 2009

224 Institute for Work and Health 2008. Are workplace 236 Podneice Z. Work-related musculoskeletal disorders: prevention programs effective? Sharing best evidence: Back to work report. European Agency for Safety and

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Health at Work. Luxembourg 2007. 248 Shah A et al. Educational interventions for the prevention http://osha.europa.eu/en/publications/reports/7807300/view of eye injuries. Cochrane Database of Systematic Reviews accessed 5 October 2009 2009, Issue 4. Art. No.: CD006527. DOI: 10.1002/14651858.CD006527.pub3. 237 Van Eerd W et al. Workplace interventions to prevent musculoskeletal and visual symptoms and disorders among 249 Podneice Z. Work-related musculoskeletal disorders: computer users: a systematic review: a summary. Institute Prevention report. European Agency for Safety and Health for Work and Health 2008. at Work. Luxembourg 2008. http://www.iwh.on.ca/sbe/preventing-msds-among-computer- http://osha.europa.eu/en/publications/reports/TE8107132EN users-summary-of-a-systematic-review accessed 24 July C/view accessed 5 October 2009 2009.

250 238 Jordan J et al. Beacons of excellence in stress Martimo K-P et al. Manual material handling advice and prevention. Robertson Cooper Ltd. and UMIST. Research assistive devices for preventing and treating back pain in Report 133. 2003. workers. Cochrane Database of Systematic Reviews 2007,

Issue 3, Art. No.: CD005958. DOI: 251 Sockoll I, Kramer I and Bödeker W. Effectiveness and 10.1002/14651858.CD005958.pub2. economic benefits of workplace health promotion and

239 prevention: summary of the scientific evidence 2000 to 2006. Verbeek JH et al. Interventions to prevent occupational Iga report 13e . Essen: Federal Association of Company noise induced hearing loss. Cochrane Database of Health Insurance Funds (BKK Budnesverband) March 2009. Systematic Reviews 2009, Issue 3. Art. No.: CD006396. http://www.iga-info.de/index.php?id=143 accessed 11 July DOI: 10.1002/14651858.CD006396. 2009. p.28

240 Sahar T, et al. Insoles for prevention and treatment of 252 Sockoll I, Kramer I and Bödeker W. Effectiveness and back pain. Cochrane Database of Systematic Reviews economic benefits of workplace health promotion and 2008, Issue 4. Art. No.:CD005275. DOI: prevention: summary of the scientific evidence 2000 to 2006. 10.1002/14651858.CD005275.pub2 Iga report 13e . Essen: Federal Association of Company

241 Health Insurance Funds (BKK Budnesverband) March 2009. Podneice Z. Work-related musculoskeletal disorders: http://www.iga-info.de/index.php?id=143 accessed 11 July Prevention report. European Agency for Safety and Health 2009. p.21 at Work. Luxembourg 2008. http://osha.europa.eu/en/publications/reports/TE8107132EN 253 Graveling RA et al. A review of workplace interventions C/view accessed 5 October 2009 that promote mental well-being in the workplace. Institute of

242 Occupational Medicine, Edinburgh, February 2008. El Dib R et al. Interventions to promote the wearing of http://www.nice.org.uk/nicemedia/pdf/MentalWellbeingWorkF hearing protection. Cochrane Database of Systematic inalReport.pdf accessed 2 October 2009 Reviews 2006, Issue 2. Art. No.:CD005234. DOI:

10.1002/14651858.CD005234.pub2. 254 Michie S and Williams S. Reducing work related

243 psychological ill health and sickness absence: a systematic Van Eerd W et al. Workplace interventions to prevent literature review. Occupational and Environmental Medicine musculoskeletal and visual symptoms and disorders among 2003;60:3-9. computer users: a systematic review: a summary. Institute for Work and Health 2008. 255 Graveling RA et al. A review of workplace interventions http://www.iwh.on.ca/sbe/preventing-msds-among-computer- that promote mental well-being in the workplace. Institute of users-summary-of-a-systematic-review accessed 24 July Occupational Medicine, Edinburgh, February 2008. 2009. http://www.nice.org.uk/nicemedia/pdf/MentalWellbeingWorkF

244 inalReport.pdf accessed 2 October 2009 Institute for Work and Health 2007. Prevention programs for health-care workers. Sharing best evidence: highlights of 256 Marine A et al. Preventing occupational stress in a systemic review. April 2007. healthcare workers. Cochrane Database of Systematic http://www.iwh.on.ca/sbe/prevention-programs-for-health- Reviews, 2006, Issue 4. Art. No.: CD002892. DOI: care-workers accessed 24 July 2009 10.1002/14651858.CD002892.pub2.

245 Verbeek JH et al. Interventions to prevent occupational 257 Caulfield N et al. A review of occupational stress noise induced hearing loss. Cochrane Database of interventions in Australia. International Journal of Stress Systematic Reviews 2009, Issue 3. Art. No.: CD006396. Management 2004;11(2):149-166. DOI: 10.1002/14651858.CD006396.

258 246 Westgaard R and Winkel J. Ergonomics interventions Rautianinen R et al. Interventions for preventing injuries research for improved musculoskeletal health: a critical in the agricultural industry. Cochrane Database of Systemic review. International Journal of Industrial Ergonomics Reviews 2008, Issue 1. Art. No.:CD006398. DOI: 1997;20(6):463-500. 10.1002/14651858.CD006398.

259 247 Graveling RA et al. A review of workplace interventions van der Molen H. Interventions for preventing injuries in that promote mental well-being in the workplace. Institute of the construction industry. Cochrane Database of Systematic Occupational Medicine, Edinburgh, February 2008. Reviews 2007, Issue 4. Art. No.:CD006251. DOI: http://www.nice.org.uk/nicemedia/pdf/MentalWellbeingWorkF 10.1002/14651858.CD006251.pub2 inalReport.pdf accessed 2 October 2009

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260 Graveling RA et al. A review of workplace interventions promotion and disease management programs at the that promote mental well-being in the workplace. Institute of worksite: 1998-2000 update. American Journal of Health Occupational Medicine, Edinburgh, February 2008. Promotion 2001; 16(2):107 – 116. http://www.nice.org.uk/nicemedia/pdf/MentalWellbeingWorkF inalReport.pdf accessed 2 October 2009 273 Preventing non-communicable diseases in the workplace through diet and physical activity: WHO/World Economic 261 Podneice Z. Work-related musculoskeletal disorders: Forum Report of a joint event. Geneva: World Health Prevention report. European Agency for Safety and Health Organization 2008. at Work. Luxembourg 2008. http://osha.europa.eu/en/publications/reports/TE8107132EN 274 Cahill K and Perera R. Competitions and incentives for C/view accessed 5 October 2009 smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 2. Aart. No.: CD004307. DOI: 262 Interventions on diet and physical activity: what works. 10.1002/14651858.CD004307.pub3. Summary Report. World Health Organization 2009. http://www.who.int/dietphysicalactivity/whatworks- 275 Institute for Work and Health 2009. Do workplace workplace/en/index.html accessed 3 Sept 2009 programs protect upper extremity musculoskeletal health? Sharing best evidence: highlights of a systemic review. 263 Preventing non-communicable diseases in the workplace February 2009. http://www.iwh.on.ca/sbe/do-workplace- through diet and physical activity: WHO/World Economic programs-protect-upper-extremity-musculoskeletal-health Forum Report of a joint event. Geneva: World Health accessed 24 July 2009. Organization 2008. 276 Janer G, Sala M, and Kogevinas M. Health promotion 264 Giga SI et al. The UK perspective: a review of research trials at worksites and risk factors for cancer. Scandinavian on organisational stress management interventions. Journal of Work, Environment and Health, 2002;28(3):141- Australian Psychologist 2003;38(2)158-164. 157

265 Rose SC et al. Psychological debriefing for preventing 277 Oliver AJ. Editorial: Can financial incentives improve post traumatic stress disorder (PTSD). Cochrane Database ? British Medical Journal 2009; 339:b3847 of Systematic Reviews 2001, Issue 4, Art. No.: CD000560. http://www.bmj.com/cgi/content/full/339/sep24_2/b3847 COI: 10.1002/14651858.CD000560. accessed 30 September 2009

266 Sockoll I, Kramer I and Bödeker W. Effectiveness and 278 Proper KI et al. The effectiveness of worksite physical economic benefits of workplace health promotion and activity programs on physical activity, physical fitness, and prevention: summary of the scientific evidence 2000 to 2006. health. Clinical Journal of Sport Medicine 2003;13:106-117. Iga report 13e . Essen: Federal Association of Company Health Insurance Funds (BKK Budnesverband) March 2009. 279 Janer G, Sala M, and Kogevinas M. Health promotion http://www.iga-info.de/index.php?id=143 accessed 11 July trials at worksites and risk factors for cancer. Scandinavian 2009. P. 10 Journal of Work, Environment and Health, 2002;28(3):141- 157 267 Cashman CM et al. Alcohol and drug screening of occupational drivers for preventing injury. Cochrane 280 Cahill K, Moher M and Lancaster T. Workplace Database of Systematic Reviews 2009, Issue 2. Art. No.: interventions for smoking cessation. Cochrane Database of CD006566. COI: 10.1002/14651858.CD006566/pub2. Systematic Reviews 2008, Issue 2. Art. No.: CD003440. COI: 10.1002/14651858.CD003440.pub3. 268 Institute for Work and Health 2009. Do workplace programs protect upper extremity musculoskeletal health? 281 Institute for Work and Health 2008. Are workplace Sharing best evidence: highlights of a systemic review. prevention programs effective? Sharing best evidence: February 2009. http://www.iwh.on.ca/sbe/do-workplace- highlights of a systemic review. April 2008. programs-protect-upper-extremity-musculoskeletal-health http://www.iwh.on.ca/sbe/are-workplace-prevention- accessed 24 July 2009. programs-effective accessed 24 July 2009

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316 Benach J, Muntaner C and Santana V, Chairs. 328 Workers compensation laws, 2nd Ed. A joint publication of Employment conditions and health inequalities. Employment the International Association of Industrial Accident Boards Conditions Knowledge Network, Final Report to WHO and Commissions (IAIABC) and the Workers’ Compensation Commission on Social Determinants of Health, 2007 Research Institute (WCRI), WC-09-30. June 2009. http://www.who.int/social_determinants/themes/employment conditions/en/ accessed 8 Sept 2009 329 Workers compensation laws, 2nd Ed. A joint publication of the International Association of Industrial Accident Boards 317 Table 2 page 42, from: Benach J, Muntaner C, and and Commissions (IAIABC) and the Workers’ Compensation Santana V. Employment conditions and health inequalities. Research Institute (WCRI), WC-09-30. June 2009. Commission on Social Determinants of Health, Final Report to WHO 2007. 330 O’Halloran M, Chief Executive Officer, Health and Safety http://www.who.int/social_determinants/themes/employment Authority, Ireland. Personal communication xx 2009. conditions/en/index.html accessed 1 September 2009 331 Workers compensation laws, 2nd Ed. A joint publication of 318 International Labour Organization. Report of the the International Association of Industrial Accident Boards Conference Committee on the Application of Standards (ILC and Commissions (IAIABC) and the Workers’ Compensation 2009), International Labour Conference, 98th Session, Research Institute (WCRI), WC-09-30. June 2009. Geneva, 2009. http://www.ilo.org/global/What_we_do/InternationalLabourSt 332 Gender equality at the heart of decent work. International andards/WhatsNew/lang--en/docName-- Labour Organization Report VI, International Labour WCMS_108447/index.htm accessed 9 August 2009 Conference, 98th Session, 2009. Pages 130-131.

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345 Shain M. Stress at work: mental injury and the law in 356 Arnaout S. Workers health in the Eastern Mediterranean. Canada. Mental Health Commission of Canada, 21 PowerPoint presentation presented at the 8th Meeting of the February 2009 (rev.) Global Network of WHO Collaborating Centres for http://www.neighbouratwork.com/view.cfm?Prod_Key=2654 Occupational Health, 20 October 2009, WHO Headquarters, &PROD_DETAIL_KEY=3884&TEMP=ContentNoLink Geneva, Switzerland. accessed 14 July 2009. (See also http://www.mentalhealthcommission.ca/English/Pages/defaul 357 World Health Organization. Gender, health and work. t.aspx accessed 14 July 2009) September 2004. www.who.int/entity/gender/other_health/Gender,HealthandW 346 Hyman J. More on smoking as a disability. Ohio orklast.pdf accessed 27 September 2009. Employer’s Law Blog October 30, 2008. http://ohioemploymentlaw.blogspot.com/2008/10/more-on- 358 Seoul Declaration on Safety and Health at Work. smoking-as-disability.html accessed 13 August 2009. International Labour Organization, International Safety and Security Organization, Korean Occupational Safety and 347 One size fits all" fitness test not a bona fide occupational Health Agency, 2008. requirement for firefighting, board finds. Lancaster’s http://www.seouldeclaration.org/index.php accessed 9 Biweekly Firefighters/Fire Services Employment Bulletin, December 2009 Dec 1, 2006. http://www.lancasterhouse.com/services/ffel/ffel-e- 359 International Labour Organization SafeWork. bulletin.asp#B accessed 13 August 2009 http://www.ilo.org/public/english/protection/safework/sectors/i nformal/index.htm accessed 10 November 2009. 348 Holmes N and Richer K. Drug testing in the workplace. 360 Benach J, Muntaner C and Santana V, Chairs. Library of Parliament PRB 07-51E, 28 February 2008. Employment conditions and health inequalities. Employment http://www.parl.gc.ca/information/library/PRBpubs/prb0751- Conditions Knowledge Network, Final Report to WHO e.htm accessed 13 August 2009. Commission on Social Determinants of Health, 2007 http://www.who.int/social_determinants/themes/employment 349 Kleinfeild NR. Costs of a crisis: diabetics in the workplace conditions/en/ accessed 8 Sept 2009 confront a tangle of laws. The New York Times, 26 December 2006. 361 Messing K and Östlin P. Gender equality, work and (http://www.nytimes.com/2006/12/26/health/26workplace.ht health: a review of the evidence. Geneva, World Health ml?_r=1&th=&oref= accessed 4 July 2009) Organization, 2006.

350 National Environmental Legislation, United Nations 362 Regional guidelines for the development of healthy Environment Programme website workplaces. World Health Organization, Regional Office for

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the Western Pacific November 1999. 369 A.H. Maslow, A Theory of Human Motivation, http://www.who.int/occupational_health/publications/wprogui Psychological Review 1943;50(4):370-96. delines/en/index.html accessed 17 Aug 2009 370 Gender equality at the heart of decent work. International 363 Bryce GK and Manga P. The effectiveness of health and Labour Organization Report VI, International Labour safety committee. Relations Industrielles/Industrial Relations Conference, 98th Session, 2009. Page 93. 1985;40(2):257-283. http://www.erudit.org/revue/ri/1985/v40/n2/050133ar.pdf 371 Janer G, Sala M, and Kogevinas M. Health promotion accessed 11 November 2009. trials at worksites and risk factors for cancer. Scandinavian Journal of Work, Environment and Health, 2002; 28(3):141- 364 Lewchuk W, Robb AL, Walters V. The effectiveness of 157 Bill 70 and joint health & safety committees in reducing injuries in the workplace: the case of Ontario. Canadian ccclxxii Rantanen J. Basic occupational health services: Public Policy-Analyse de Politiques,1996;22(3):225-243. strategy, structures, activities, resources. Helsinki: Finnish Institute for Occupational Health, 3rd ed. 2007. 365 Blewett V. Working Together: A review of the http://www.who.int/occupational_health/publications/bohsboo effectiveness of the health and safety representative and klet/en/index.html accessed 14 July 2009 workplace health and safety committee system in South Australia. Adelaide: South Australian WorkCover ccclxxiii International Labour Organization. C161 Convention Corporation; 2001. concerning Occupational Health Services, 1985. http://www.saferwork.com/contentPages/docs/hsrWorkingTo http://www.ilo.org/ilolex/english/convdisp1.htm accessed 8 getherReport.pdf accessed 11 November 2009 August 2009

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