10.5.3. Workplace
10.5.3.1.
Introduction
In modern societies, work is the source of most
individual, corporate and community wealth. The world of work therefore is
particularly vulnerable to disruption caused by illness among employees.
Illness can involve a temporary absence, lead to reduced productivity,
long-term disability or even premature death. It can also end careers with a
consequent loss of knowledge, skills and experience from companies and public
organisations. However, what is becoming more widely recognised is how work
itself can make people ill, with a high price to be paid by individuals,
organisations and the society in general.
This interrelation is what makes workplace health such an
important element of modern public health policies. This is beginning to be
reflected in EU policy; indeed, the EU Commission now considers workplace
health as one of the most important aspects of EU policy-making on employment
and social affairs and is striving for consistency with public health policies
(European Commission, 2007).
There are currently great challenges to workplace health
from ongoing demographic and structural changes in the world of work, regional
health and safety discrepancies in Europe (especially among the new Member
States), the imbalance in access to preventive services (especially with
respect to small and medium enterprises) and to migrants.
In times of globalisation, improvement of health at work
requires a holistic approach, combining health promotion
and prevention, occupational health and safety as well as addressing social
determinants and employability
Health reporting is an effective instrument in pinpointing
priority fields in public health policy. However, working life issues so far
play only a minor role in EU health monitoring which is focused mainly on work
accidents and occupational diseases which are only a small portion of the
work-related diseases. The main strength of work-related health monitoring is
that it can point to the most important actions for health
promotion and disease prevention and can serve as a tool for policy
implementation. However, health monitoring is only effective when the results
are accepted and shared with relevant stakeholders. Against this backdrop, a
policy cycle-model of work-related health monitoring has been developed by the
EU funded WORKHEALTH project which puts workplace health in the context of the
wider policy environment (Kreis and Boedeker, 2004a).
Work-related health reporting needs to address the working
conditions as well as health problems. This chapter therefore takes two
perspectives. First, information on the burden of diseases on work is provided
followed by presenting the impact of work on health. Furthermore, current and
future working conditions will be addressed and strategies to improve workplace
safety outlined. The text follows the concept developed by the WORKHEALTH
consortium, exemplarily for the report Hearts and Minds at Work in Europe
(Bödeker and Klindworth 2007).
10.5.3.2 Data sources
It is known from previous projects that European data
sources on diseases as a rule do not include work-related information like
employment status, occupations or economic sectors and as such can not be used
for work-related health reporting. However, a major source for data about work-related
health problems as well as on working conditions are European Surveys carried
out by the European Foundation for Improvement of Living and Working Conditions
since the early nineties. The fourth and latest European Working
Conditions Survey was convened 2005 in the EU25 countries and additionally in Bulgaria, Romania, Croatia, Turkey, Norway and Switzerland. Among other
things participants are asked about the number of days of absence during the
previous 12 months. Furthermore, perceived health problems caused by work are
reported. All information can be stratified by occupations and economic sectors
as well as socio-demographic items. The data are provided as public use file.
Data on accidents at work are available from the Eurostat
Online Database. This data collection covers all accidents at work which
involve absence of more than 3 days and fatal accidents occurring at work. The
data collection was set up in the context of the project “ESAW - European
Statistics on Accidents at Work”. Eurostat receives the ESAW data from the
Member States’ national registers or other national bodies responsible for the
collection of data on accidents at work. These data are based on the
declaration of the accidents according to the different systems in the Member States.
Mainly two types of reporting procedures take place in the Member States:
Insurance based systems where care benefits and the payment require the
accident being notified to the (public or private) insurer. In these systems
the level of accident reporting is high, probably about 100%. On the other
hand, in some the Member States there is a legal obligation for the employer to
report accidents to the relevant national authorities (often National Labour
Inspection Service), but the payment of benefits does not depend on them
reporting the accident. For these systems, the reporting levels are lower,
usually ranging between 30 to 50 percent. On the basis of the reporting levels,
Eurostat estimates the actual number of accidents occurring in these countries.
Data on accidents at work can be stratified according to occupations economic
branches and other work-related information. The total numbers as well as
incidence rates are provided for fatal and non fatal accidents at work.
The Eurostat Online Database also includes data on
occupational diseases following standards developed by the project EODS –
European Statistics on Occupational Diseases. The project was aimed at a
harmonised, comparable and reliable data set and indicators on occupational
diseases in Europe by collecting data gathered from administrative sources in
the Member States. During a pilot project, data on recognised cases for 31
items of the European Schedule of Occupational Diseases were collected in 1998.
This was the first attempt to collect these data on European level. In
September 2003, the Commission published a new European Schedule on
Occupational Diseases. The statistics are based on case-by-case data for
occupational diseases recognised by the national authorities as being caused by
a factor at work. Since the recognition practices vary between the Member
States the EODS specifications cover 68 disease entities covered by all
national recognition schemes. In addition, 41 entities are included in an
optional way.
A further data source dealing with self-reported work
related problems are the ad-hoc-modules of the European labour force surveys in
1999 and 2002. The European labour force survey is an annual survey of
households and has been carried out in the EU since 1983. In order to address certain topics which are not covered by the standard survey so called ad
hoc modules are included. Beside accidental injuries the ad-hoc-module 1999 of
the Labour Force Survey covered all diseases, disabilities and other physical
or psychological health problems, suffered by individuals during the past 12
month which irrespective of their severity were caused or made worse by work.
However, given the rapid changes of the world of work, these sources are rather
outdated. A repetition of the ad hoc module was planned for 2007.
10.5.3.3 Data
description and analysis
This chapter presents the impact of diseases on work. This
relationship is usually overlooked in work-related heath reporting, which
focuses almost exclusively on the impact of work on diseases. However, private
companies as well as public services are affected by diseases and accidents
through absenteeism of employees or reduced productivity. We will therefore
provide data on the differential distribution of morbidity and mortality across
occupations and economic sectors. Furthermore, disease related absence from
work, early retirement and costs from production losses will be presented.
Absence from work
According to the fourth European Working conditions
survey, 23% of European workers are absent from work due to health problems at
least once in 12 months (Table 10.5.3.1). This results on an average of 4.5
days per worker and 20 days per worker with absence. Economic sectors are very
differently affected by absence. E.g. whereas 14% of women working in
agriculture report sick leave due to health problems the
percentage is 3-fold higher in electricity supply. Maximum figures are observed
in public administration with 31% of employees affected resulting in app. 8
days per employee and 27 days per sick leave spell. In
general, slightly higher figures are reported by women in contrast to men. This
applies especially to women in electricity supply and those engaged in health
& social work.
Table 10.5.3.1. Absence from work in last 12 month due to health
problems
Production losses
Production losses are caused by absence from work due to
diseases and by reduced productivity due to sickness. Production losses have
not been calculated for all diseases but are available for cardiovascular
diseases (CVD) as well as for mental disorders - both diseases being of high
public health relevance.
The economic burden of CVD in the EU25 is estimated to
amount to €169 billion a year, of which 62% was due to healthcare (€105
billion), 21% to productivity losses (€ 35 billion) and 17% due to informal
care (€ 29 billion) in 2003 (Leal et al, 2005).
According to this study 2.18 million working years were lost because of CVD
mortality. This was estimated to cost about €24.4 billion. Additionally, 268.5
million working days were lost because of CVD morbidity (i.e. 591 days per 1000
population) at a cost of € 10.8 billion. Thus, premature CVD deaths were
responsible for nearly two-thirds of the indirect costs and CVD illness, in
those of working age, for one-third of these costs.
In view of their high prevalence, it is not surprising
that mental disorders and mental health problems are the major contributors to
production (and productivity) losses in the workplace. An increasing number of
studies show that mental illness is a leading cause of short-term absenteeism,
long-term sick leave, early retirement and disability
pension. Because of the combination of high prevalence, early onset and
possibly unfavourable long-term course of the illness, the economic burden
associated to mental disorders is immense. The total annual costs for the year
2004 was estimated at €240 billion in Europe. Most of these costs (55%) are
related to indirect costs which amounted to €132 billion
(Andlin-Sobocki et al, 2005). These are primarily due to reduced
productivity during years of employment and to pre-mature retirement. Amongst
mental disorders, the indirect costs of mood disorders (depression and bipolar
disorders) was the highest (€ 77 billion), followed by the indirect costs for
addictions (alcohol, drugs).
Impact of work on mortality, morbidity and disability
This chapter addresses the impact of working conditions on
the development of diseases and is centred around the question of what is
work-relatedness. Whereas the EU Member States have legal definitions for
occupational diseases, the term “work-related diseases” has several different
meanings. However, nowadays the term is used for health problems totally or
partially caused by working conditions, including occupational diseases. There
are several ways to address work-relatedness. Besides estimating attributable
risks for specific outcome – risk factor associations, it is common to simply
ask employees. This method is used in several studies for different purposes
although it is well known that ill people are more likely to scrutinise their
working conditions, so that false positive associations may be inferred. The
view of employees however, is considered a valuable and complementary
information from inside the “risk environment”. In this chapter, the impact of
work on disease is highlighted by first, providing figures on occupational
diseases and work accidents. This is then followed by the perceived impact on
health from the point of view of employees.
Occupational diseases
Only a limited number of diseases are recognized as being
related to the workplace. According to Eurostat, in 2004 app. 54,000 recognised
non fatal occupational diseases occurred in Europe additionally to 1900 fatal
events (table 10.5.3.2). The incidence rate is twice in men (80 per 1000,000)
compared to women. In both sexes an increase has been seen since 2001. However,
in 2003 and 2004 the figures seem to be quite stable. The five most common
occupational diseases were hand or wrist tenosynovitis, noise-induced hearing
loss, lateral epicondylitis, contact dermatitis and carpal tunnel syndrome
(Table 10.5.3.3).
Economic sectors are very differently affected by
occupational diseases (table 10.5.3.4). A top incidence rate of app. 1800 per
100,000 is reported for the mining industry. Construction as well as
manufacturing follows with incidence rates still two times above the average
rates of app. 60 per 100,000.
Table 10.5.3.2.
Number and incident rate of occupational diseases.
Table 10.5.3.3.
Number of non fatal occupational diseases by ICD10.
Table 10.5.3.4.
Number and incident rate of non fatal occupational diseases per economic sector
According to a study of EUROGIP (2004), compensation for
occupational disease in 2000 summed up to 2.8 billion Euro in 7 European
countries43. However, due to the heterogeneity of the national
compensation schemes, the rate per 100,000 insured people varied between 0.7
million Euro for Austria and 12.6 for Belgium. In many countries, the expenses
were rather stable between 1996 and 2002. In all studied countries, over 75% of the compensation was due to only 5 disease groups. Among these, the
distribution of costs depends very much on the previous and current economic
activities. E.g. in Belgium and Germany compensation is still caused by
exposures to silica even though the mining industry has strongly declined. In
France 48% compensation is caused by exposures to asbestos dust. This
occupational disease is almost always the most costly disease but it ranks only
sixth among the most commonly recognised occupational diseases. An updated
comparison of compensation schemes in selected EU Countries has been carried
out for the UK Industrial Injuries Advisory Council (Walters, 2007).
Work Accidents.
European Statistics on Accidents at Work (ESAW) refer to
accidents at work resulting in more than 3 days’ absence from work (serious
accidents) (Table 10.5.3.5) and accidents which leads to death within one year
from the accident (fatal accident). In what follows, data on serious accidents
are provided. For fatal accidents see also Chapter 7.
Table 10.5.3.5. Incidence
of work accidents EU 15
In 2004, approximately 4 million serious
work accidents were reported in Europe, three quarters of them occurring to
men. In general there has been a remarkable decrease in accidents since 1994.
However, in women this decrease seems to have started only recently after a
peak in the year 2000.
Table 10.5.3.6 gives time trends with respect to European
member states. As we can see, a 20% reduction of accidents at work took place
compared to 1998 in EU 25 as well as in EU 15. However, some member states such
as Ireland, Spain, France Luxembourg and Slovenia performed less well, whereas
Estonia, Cyprus, and Romania saw increasing index figures.
Work accidents occur very differently across economic
sectors. Table 10.5.3.7 points to especially accident prone sectors such as the
manufacturing of wood as well as construction with incident rates two-fold
above average. In contrast to the general trend, in electricity, gas and water
supply as well as in the air transport sector the rate of accidents at work
increased.
Table 10.5.3.6.
Change in the number of serious accidents at work per 100 thousand persons in
employment from 1994 to 2004
Table 10.5.3.7.
Standardised incidence rate of accidents at work in EU15 by economic activity
(rate per 100 000 workers)
Perception of the work impact on health
According to the Fourth European Working
Conditions Survey, 37% of men and 31% of women perceive their work affects
their health. Furthermore, 33% of the male and 22% of the female respondents
consider their health or safety at risk because of their work (table 10.5.3.8).
This perceived impact of work on health differs remarkably across European
member states. Whereas in Greece Poland, Latvia, and Slovenia more than 60% of
employees feel their health affected by work, this applies to less than 25% in
Ireland, the Netherlands and the UK. Every second male worker in Greece,
Latvia, Poland, Sweden, Bulgaria, and Romania sees his health or safety at risk
because of his work.
When asked how their health was affected, the
five most often mentioned health problems were backache, muscular pains,
overall fatigue, stress and headache (table 10.5.3.9). There seems to be only
little difference between sexes. Table 10.5.3.10 finally gives the prevalence
of these health problems with respect to the economic sectors. Again it becomes
visible that the perceived health impact differs widely between sectors. On
top, employees in agriculture are found to report all health problems above
average. Manufacturing as well as construction follow with high scores on
musculoskeletal disorders. Employees in the education sector and those engaged
in health & social work report more often headache and stress as a health
impact of their work.
Table 10.5.3.8. Perceived
impact of work on health per country
Table 10.5.3.9. Perceived
impact of work on health per symptoms.
Table 10.5.3.10.
Perceived work-related symptoms per economic sector
Workforce in Europe
Knowledge about the workforce is considered necessary for
an integrated work-related health reporting because working conditions are to a
large extent influenced by structural elements of work economies. Figure
10.5.3.1 summarizes the European workforce as assessed by the 2005 European
Union Labour Force Survey (LFS); among the 380.3 million people aged 15 or more
living in private households in the EU25 (Eurostat, 2006):
·
197.5
million people resident in the European Union held a job or had a business
activity during the reference week of the survey, 44.1% of which were women.
·
The
employment rate, which measures the share of employed people in the population
aged 15 to 64 years, stood at 63.8% in 2005 in the EU25, 3.2 percentage points below the 2001 Stockholm European Council target for 2010.
·
The
female employment rate reached 56.3% in the EU25 (0.7 points below the Stockholm mid-term target). This is the result of a continuous increase in female
participation in employment since 1997.
·
In Denmark, Estonia, the Netherlands, Austria, Portugal, Finland, Sweden and the United Kingdom, more than 60% of women aged 15 to 64 were employed. In Greece, Italy, Malta and Poland, this proportion was below 50% in 2005.
·
The
employment rate of older people (55 to 64 years old) was 42.5% in 2005, up by
5.9 percentage points since 2000.
·
11.4%
of people aged 15-64 were part-timers. 17.9% of the women of the same age group
worked part-time, with large disparities among countries, from 2.0% in Slovakia to 49.8% in the Netherlands.
·
164.8
million workers were employees. Their average usual working hours were 40.4
hours a week for those working full-time and 20.0 hours for those working
part-time. 14.5% of them hold a contract with limited duration (19.5% in Portugal, 25.7% in Poland, 33.3% in Spain).
·
19.5
million people were unemployed (of which 48.9% were women and 8.0% were people
aged 55-64).
·
8.7
million were in long term unemployment (one year and more).
·
8.4%
of the young people aged 15-24 were unemployed (more than 10% in Poland, Slovakia, Finland and Sweden).
·
163.3
million people aged 15 or more were economically inactive.
Figure 10.5.3.1. Work status of people
aged 15 or more
Due to non-response, certain sub-totals may not exactly
sum up to the corresponding aggregate. Source: Adapted from Eurostat,
Statistics in focus – Population and social conditions – 13/2006
Current working conditions
A long-term monitoring of working conditions in Europe is now possible thanks to the repeated European Working Condition Survey. In
general, as a most striking result the perceived work intensity has increased
in European Member States. This is assessed by the EWCS composite index from
“working at a very high speed” and “working to tight deadlines”. This perceived
work intensity has increased, passing from 33% in 1991 to 44% in 2004, a confirmation of the growing importance of organisational work load factors.
Work organisational risk factors
Working at very high speed, with tight schedule deadlines
and/or with monotonous and repetitive tasks may have a negative impact on
health. Other stressing factors at work include fear of loosing the job,
perception of inadequate compensation and/or bullying and harassment. There are
currently great challenges to workplace health resulting from ongoing
demographic and structural changes in the world of work; regional health and
safety discrepancies in Europe (especially among the new Member States) and the
imbalance in the access to preventive services (especially with respect to
small and medium enterprises and to migrants). In times of globalisation,
improvement of health at work requires a holistic approach, combining health
promotion and prevention, occupational health and safety as well as
addressing social determinants and employability.
It has been stressed that, in industrialised countries, a
lack of autonomy and control at work (Karasek & Theorell,
1990) and a
mismatch of occupational efforts spent and rewards received (Siegrist, 1996) both predict poor
health (for an overview see Siegrist J &
Theorell T, 2006). Furthermore, unemployment is strongly associated to poor health –
something that cannot be fully explained by the ‘healthy worker effect’, i.e.
that only people in good health remain in the work force, while those who have
a poor health are selected for the pool of the unemployed. In the long run,
individual unemployment is associated to premature mortality (Martikainen &
Valkonen, 1996).
In 2005, almost two-thirds of all workers in the EU25
reported working with tight deadlines for at least one quarter of their time
and a similar proportion reported having to work ‘at very high speed’ - more so
with men than women (table 10.5.3.11). About 40% of all workers are
additionally exposed to monotonous or repetitive tasks.
Table 10.5.3.11.
Work organisational risks factors at work per gender
A lack of job control and low social support is also
common: more than one-third of workers have no control over the order of tasks,
slightly lower proportions report no control over work methods or pace.
One-third of all workers report low social support from colleagues.
Sixteen percent of all workers report long working days,
particularly male workers. Shift work affects 17% of the workforce and occurs
most likely accompanied by no control over tasks, methods and rate of the work.
Furthermore, there is a clear relationship between shift work and the perceived
difficulty of balancing work and other commitments.
More than every second male worker believes that he is not
well paid for the work he does and almost two-thirds consider that their job
does not offer good prospects for career advancement. Both opinions are a
little more frequent among women. 13% of all workers feared that they might
lose their jobs in the next six months.
The economic sectors most affected by working at very high
speed and on tight deadlines are construction, hotels and restaurants and
transport and communications (all with more than 70% in at least one of the two
categories). Working in these sectors is also more likely to be associated to
the performance of short repetitive tasks and monotonous work, especially in
manufacturing and agriculture (table 10.5.3.12). A lack of job control is more
common among workers in manufacturing and mining, hotels and restaurants,
transport and communication.
Table 10.5.3.12.
Work organisational risks factors at work per economic sector
Workers in agriculture and fishing as well as in hotels
and restaurants reveal a relatively high rate of long working days. By
occupation, it is agriculture workers, legislators and managers who most often
work ten hours a day. Shift work is most common among employees in hotels and
restaurants, transport and communication and manufacturing (in each case,
around every fourth employee is a shift worker). In the health sector, about
one third of employees works shifts.
Workers in hotels and restaurants and construction are
most worried that they might lose their jobs in the next six months. Workers in
education, health, hotels and restaurants report higher-than-average levels of
bullying and harassment.
High work intensity, indicated by responses to questions
about ‘working at very high speed’ and ‘working to tight deadlines’, is more
common across the EU15 countries than in the New Member States, while
monotonous tasks and work shifts are more widespread in reverse. The highest
rates for shift work were found in Slovenia (30%) and Slovakia (28%), the lowest in Denmark (9%) and Portugal (10%). Support from colleagues and
assistance from superiors is more common among workers in the New Member States
than in the ‘Old’ Member States.
Every fourth worker in the New Member States reports that
he might lose his job in the next six months compared to every tenth in the
EU15. With regard to exposure to bullying and/or harassment, the EWCS found
wide variations between countries, ranging from 17% in Finland and 12% in the Netherlands to 3% in Cyprus, Estonia and Hungary and 2% in Italy44.
Physical risk factors
Current working conditions in Europe comprise a large
variety of physical risk factors (table 10.5.3.13). Exposures to vibrations and
noise - which were reported by app. 15% as occurring almost all the working
time and 35% resp. 39% at least one quarter of the time – are most common in
men. Exposures to inconvenient temperatures and to smoke - fumes as well as to tobacco
smoke - are also rather common. Exposures in general are less often
reported by women.
With respect to the work tasks standing or walking,
repetitive hand or arm movements, and tiring or painful positions seem to be
quite common in Europe, affecting up to 70% of the employees at least a quarter
of their working time and up to 40% almost all the time. A considerable
percentage of men furthermore report their tasks involving carrying or moving
heavy loads.
Physical work load is reported differently with respect to
the economic sectors (table 10.5.3.14). Especially employees working in
construction, manufacturing and agriculture are affected to a large extent. In
these sectors, often twice as many workers report exposures to vibrations and
noise as well as forced body positions, heavy work and repetitive movements.
The latter is common also in hotels & restaurants, where 44% of employees
state to be affected almost all the working time.
Table 10.5.3.13.
Physical risks factors at work per gender.
Table 10.5.3.14.
Physical risks factors at work per economic sector.
The changing world of work
The nature of work is changing rapidly. Today’s world of
work is unrecognisable from the workplace of only a few years ago. Employers
and employees have embraced revolutionary communications advances, the
introduction of flexible working arrangements, greater diversity in the workplace
and significant restructuring of working arrangements through outsourcing and
off-shoring. General trends include changing work patterns (new technology,
increase of the service sector) as well as changes in employment patterns
(downsizing, outsourcing, flexibility and mobility). In response to
globalisation and economic pressures, companies have looked for greater
flexibility to respond rapidly to peak production demands and seasonal
variations whilst controlling labour costs. Their approach has included
introducing new working practices such as ‘just-in-time’ production and casual
labour such as temporary work and fixed-term contracts (OSHA, 2002). For many
people, change provides welcome opportunities for more rewarding and satisfying
work and a better life. For others it is worrisome, closing off rather than
opening up chances for improved living and working conditions (ILO, 2006) and exposing them to new potentially
hazardous physical and chemical substances and straining psychosocial situations.
The rapid evolvement of nanotechnology is an example of this sort of emerging
issue, in which there is little or no knowledge on potential negative health
effects from such kind of exposure to a great extent .
All these issues can have implications for workplace
health and safety. They can affect the type and nature of risks present in the
workplace and they influence how risks need to be managed. For example, in many
work areas, job demands have increased, including an intensification of work
and requirements on workers to be more flexible and rapidly learn to carry out
new tasks. These conditions can contribute to health problems, although
traditional risks also remain on the agenda. Changes in management structures
and responsibilities will affect the management of workplace health and safety.
The use of subcontractors, for example, also complicates the process,
especially when several different organisations are working on one site.
Detecting a pattern of change in working conditions is
difficult as the main feature revealed by labour market researchers is
increasing diversity. The situation is even more complex for workers from the
new member countries. In many of these countries the traditional occupational
health and safety hazards still constitute the main challenge. But,
simultaneously, new ways of working are bringing their own problems for
employees. One of the most pressing problems is that most employment
relationships are informal and insecure, hampering the transition to more
complex and productive systems for organising productive work.
Information and communication technologies (ICT)
The process of innovation and profusion of new information
and communication technologies (ICTs) constitutes a radical transformation of
the means of production, distribution and exchange. It has already profoundly
affected international trade and investment, the movement of capital and labour
and work processes and products and has accelerated the shift towards services
and their outsourcing at international level.
The direct employment effects of ICTs are, on the one
hand, new jobs created in producing and delivering new products and services
and on the other hand, the loss of jobs in redundant technologies or in
companies that fail to keep up with the competitors’ rate of innovation.
Indirect effects include the impact of technological change on productivity,
skill requirements and associated organisational adaptation. The process of
structural change driven by competition and new technologies is often described
as “creative destruction” (Schumpeter, 1975).
The introduction of new forms of technology can be a
stressful experience for some workers. The pressure of information-intensive
work and the learning process may be particularly stressful for some older workers.
Nevertheless, ‘information overload’ and psychological stress are not
restricted to older employees or those with low training levels; ICT experts
have also shown an elevated risk of psychological exhaustion.
Growth of the service sector
A growing proportion of workers is employed in the service
sector. In contrast to industrial employment, services went up as a share of
global employment from 66 per cent in 1995 to 71 per cent in 2005 in developed countries. Services include wholesale and retail trade; hotels and restaurants;
transport; storage and communications; finance; property and business
activities including research and development; public administration;
education; health and social work; community and personal services and domestic
service.
Many of these jobs involve contact with members of the
public — clients, customers, patients and so forth — which can lead to risks of
stress and violence at work. The necessity to carry out additional
administrative tasks has increased in professions such as health-care work and
teaching and there has been an increase in delivering health and social
services care in the community, thus more staff work away from a fixed
workplace (OSHA, 2003).
Integration and globalisation
The progressive reduction of barriers that first took
place between local and national, then regional and now intercontinental
markets, is a dominant topic in recent economic history. Liberalisation of
trade controls on manufacturers, an easing of restrictions on foreign direct investment
and other capital movements, as well as sharply reduced costs of transportation
and telecommunications, have fostered the emergence of a global market economy.
More businesses face fiercer competition in their domestic and export markets.
As a result of these changes, intensified global competition for products and
services feeds through into pressures to adapt workplaces and match the
efficiency and quality of market leaders – or else close down.
Changing management structures
According to the Agency Changing World of Work report,
several significant new developments in work organisation have emerged, for
example: teamwork; decentralisation of supportive tasks such as quality and
maintenance; job enlargement, job rotation, including interdepartmental job
rotation; knowledge management; teleworking; virtual networks and new working
time patterns.
Some of these changes have been introduced from a
management efficiency perspective and others with the aim of improving work
organisation and the quality of working life for the employees. The study
reveals that high performance work practices do indeed have a positive effect
on work satisfaction. Key factors for workers’ well-being are autonomy in the
workplace, participation in decision-making and increased communication with
colleagues. However, the research concludes that teamwork, job rotation and
supporting human resource practices have only a limited impact.
Changes in the workforce
The European workforce has changed in its composition and
will continue to change over the next decades. Three major trends can be seen
(OSHA, 2003).
The first trend is the ageing of the workforce. In all
European countries, the average age of the workforce is rising and the
percentage of workers over 50 will continue to grow. By 2006, it had reached
the stage where employees in their fifties had outnumbered those in their
thirties. A forecast compiled by Eurostat shows that the number of older
workers (aged 55 to 65) will increase by almost 9% from 2005 to 2010, but the number
of young adults (25-39) will decrease by 4% in the same period. This trend will
continue from 2010 to 2030 (older workers + 15.5%, young adults -10%).
A second trend is the increasing percentage of women in
the workforce. However, it is uncertain to what extent jobs have been changed
on the basis of this issue. Traditional differences remain in the types of jobs
carried out by men and women, the type of employment contracts and career
development opportunities. Many women work in the caring services where there
are high risks of stress, violence and psychosocial risk factors. More women
than men work in jobs where demands are high but there is little individual
control over the work.
A third trend is immigration of new groups into European
Member States. The EU is confronted with a high rate of migration, as well as
with demographic challenges. In 2002, the annual crude net migration rate was
2.8 per 1000 pople in EU25. The First Annual Report on Migration and
Integration of the Commission points out that especially in countries like
Greece, Italy, Slovenia, Slovak Republic and Germany, which are experiencing
negative natural growth, migration represents an important contribution to
population increase. According to estimates, the number of Europeans of working
age (between 15 and 64) will shrink by 20 million by the year 2030, even taking
into account 1.8 million immigrating into the EU every year. Migrant workers
include two major categories: the highly skilled, much sought-after employee
who can usually obtain the necessary papers to live and work in the host
country and the unskilled, who are often equally in demand but for
low-status/low-paid jobs that few nationals want to do. The unskilled often
have difficulty in obtaining visas and work permits and are concentrated in
unskilled jobs characterised by poor working conditions. An additional problem
in these jobs is that written health and safety notices are important but
ineffective if they are not in a language workers can read or if literacy levels
are weak. Recent studies show that the position recent migrant workers occupy
within the labour market puts their health and safety at increased risk,
compared to other workers in similar positions. Therefore, it will be a
challenge for workplace health and safety to develop new ways to integrate
migrants and immigrants - whose behaviour and attitudes are influenced by their
cultural backgrounds - while at the same time support strategies that balance
the demands of both family and career and promoting the workability of ageing
workers.
New forms of work
Modern organisations are often more decentralised and may
use ‘lean production methods’. The result of these changes has been a reduction
in directly employed staff. Many companies now only carry out core functions
in-house, while auxiliary functions have been outsourced. This results in
chains of suppliers and subcontractors. The way organisations operate and work
together with others has become more complicated and less stable. There is now
more instability in work contracts and job descriptions. Companies make greater
use of short-term contracts, temporary employees, freelancers or self-employed
people. Increasingly, employees are flexibly deployed over multiple tasks. Some
contractual relationships have become more informal. Part-time workers are now
more used, with women making up the majority. New technology may also influence
the way people are employed, for example by creating more possibilities for
people to work self-employed from their home (OSHA, 2002).
Both case studies and quantitative data show that
employees with temporary or fixed-term contracts have less job security, less
control over their working time, fewer career prospects, reduced access to
training and perform less skilled tasks. These issues can result in
work-related stress. Studies have shown that an increase in work-related stress
also increases cardiovascular mortality. These issues have a gender dimension,
since women are relatively over-represented in non-permanent and part-time
jobs.
New qualifications
The current process of economic and technological
transformation requires a constant renewal of skills by some workers, employers
and managers and favours those countries who are better at fulfilling this
demand for enhanced skills. In other words, current growth is skill-biased in
developed countries (Ashton and Sung, 2002). Perceived lack of control over
work is a well-documented factor that contributes to work-related stress, which
also increases cardiovascular mortality.
In industrialised countries, high-skilled occupations,
including professional, technical and administration categories, recorded the
highest growth of all occupations in the 1980s and 1990s. Given the
skill-biased nature of the current economic and technological transformation,
worker training (formal education, vocational training and training in
firm-specific activities) assumes an increasingly crucial role for assisting
individuals in developing skills to find and retain formal employment.
Small and medium-sized enterprises (SMEs)
The percentage of small and medium-sized enterprises has
increased. European figures from Eurostat show that work-health problems are
far higher in small businesses. SMEs may lack resources and know-how for the
management of workplace health. In SMEs, particularly in micro-enterprises,
there can also be a lack of a formal management structure that will also affect
the health and safety management process. As the number of SMEs grows, this
places additional demands on labour inspectorates and so forth, seeking to
reach and support a larger number of workplaces and those that generally have
fewer resources and knowledge to deal with workplace safety issues.
Increasing work pace and workload
Work intensity is increasing in all countries in Europe
with more weekend work, irregular and less predictable working hours and the
increasing use of both very limited hours (involuntary part-time work) and
excessively long hours (involuntary overtime). Greater work intensity and time
unpredictability do not seem to have been matched by an increase in employees’
autonomy over their work. These “new” risk factors are associated to
psychological issues; moreover, non-standard working times increase the risk of
cardiovascular diseases.
Consequences of these changes in the future
The world of work has radically altered in its
organisation and composition and will continue to change over the next decades.
European Member States will need to deal with these changes which can have a
positive or negative impact on workplace health and safety. It is clear that
public health and workplace health interventions among workers will be a major
challenge in the future for the maintenance of a healthy workforce.
10.5.3.4. Control
tools and policies
In this chapter it is pointed out that interventions to
improve workplace health, although embedded in different concepts, have common
goals, characteristics and benefits. These interventions can effectively
improve health, reduce risk factors and diseases and show a positive
return-on-investment. Furthermore, it has now been understood that returning to
work after sickness absence can be of utmost importance for the recovery and
social inclusion of the people concerned. Recognising that the likelihood of an
individual returning to work is influenced by factors other than the severity
of the disease, returning-to-work measures have to balance the capabilities of
workers and the requirements of their jobs (Thomas and Secker, 2002).
Workplace health interventions are most effective when
work health and public health aspects are addressed together in the course of health
promotion, disease prevention and return-to-work-measures. However,
in practice, it is still common to find many approaches operating using
different methods, with staff not knowing each other. For merely historical
reasons, occupational health and safety and workplace health
promotion responsibilities are usually allocated to different
ministries on national and European policy level. This complicates the
implementation of common activities. One aim of this chapter is to point out
the common targets and the need to closely act together for creating healthy
work and work environments.
Concerns about workplace safety have long been a major
preoccupation of employees, prompting considerable research, legislation and
workplace initiatives. However, the full impact of work accidents and occupational
diseases beyond the workplace has only recently been understood. The damaging
effects as well as the consequences for employees’ families also pose a
challenge to the wealth of modern societies (Boedeker and Klindworth, 2007).
In 1981, the International Labour Organisation (ILO)
adopted the Occupational Safety and Health Convention. This convention (ILO-
No:C155, 1981) gave support to the development of occupational safety and
health as a field of scientific study in its own right, as well as best practice
in companies. 1985 was the year of the Occupational Health Services Convention
(ILO- No:C161), which requested member States to develop occupational health
services for all workers. However, to date, the first convention has been
ratified by only 50 countries out of more than 200 ILO member states and the
latter convention by only 26 countries (ILO, 2007). Among the countries who
have not signed the conventions there are many EU Member States.
Yet the need for effective workplace health and safety practices
in both industrialised and developing societies is high. According to the WHO,
workplace fatalities, injuries and illnesses remain at unacceptably high levels
and involve an enormous and unnecessary health burden, suffering and economic
loss amounting to 4–5% of GDP. Estimates expect 2.0 million work-related deaths
per year, yet only 10-15% of workers have access to basic occupational health
services (WHO, 2007).
WHO Member States, at the 60th World Health Assembly in May 2007,
endorsed a Global Plan of Action on Workers'Health (2008-2017)
(http://www.who.int/gb/ebwha/pdf_files/WHA60/A60_R26-en.pdf), which aims at the
following objectives: devise and implement policy instruments on workers’
health; protect and promote health at the workplace; improve the performance
and access to occupational health services; provide and communicate evidence
for action and practice; incorporate workers’ health into other policies.
The scope, objectives and minimum OSH requirements for the
protection of workers in the EU, are laid down in the Council Directive
89/391/EEC (European Commission, 1989). The term “worker” is general and not
restricted to a wage or salary relationship (but for domestic servants). The
employer determines the conditions under which work is carried out and is
therefore responsible for occupational health and safety (OSH), including all
measures of organisation, implementation and improvement of OSH. The employer
may involve external experts, e.g. OSH services, or assign OSH duties to
individual employees. Consultation and involvement of the workers and of the
workers’ representatives are major obligations.
According to the EU Commission, EU legislation has had a
positive influence on the national standards for OSH (European Commission,
2004). Health and safety improvement measures are reported to have made a
significant contribution to better working conditions, boosting productivity,
competitiveness and employment. However, there are still too many accidents and
diseases caused by work and there is not yet a systematic access for all
enterprises to protective and preventive workplace health services in Europe.
The concept of Occupational Health and Safety (OSH) has
been widened in recent years. It has traditionally been focused on reducing
work accidents and occupational diseases by identifying and preventing risk
factors in the working environment, such as noise or dangerous chemicals.
However, it has become clear that this scope is far to narrow:
“There is increasing evidence that workers’ health is
determined not only by the traditional and newly-emerging occupational 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 disease prevention, health
promotion and tackling social determinants of health and reaching out
to workers' families and communities.” (WHO, 2006)
This widened scope brings OSH closer to the concept of
workplace health promotion which has been introduced
following the Ottawa Charter. This charter, adopted in 1986 by the WHO,
recognised that creating healthy environments and enabling people to take
responsibility for their health in specific settings, is just as important as
preventing single risk factors - and also more sustainable. In this broader
view, work is an important setting for health promoting activities. This
realisation led to the creation of a workplace health
promotion movement, one which focuses on bringing the concerns of
public health to the workplace setting (WHO, 1986).
The European Network for Workplace Health
Promotion (ENWHP) was established in 1996 and is supported by the
European Commission through the Programme for Action on Health
Promotion, Information, Education and Training (part of the Framework
for Action in the Field of Public Health). In the past 11 years, the ENWHP has
been at the leading edge of developments in European workplace health
promotion. Through various joint initiatives, it has developed good
practice criteria for a variety of organisations and supported the
establishment of infrastructures for WHP in EU Member States. Using these
national forums and networks, ENWHP facilitates the cross-border exchange of
information and the dissemination of good workplace practice.
The first task undertaken by the ENWHP was to develop the
Luxembourg Declaration. This is a statement which outlines and defines what
workplace health promotion is and provides the basis for
the subsequent development of good practice criteria. The Luxembourg
Declaration states that:
“Workplace Health Promotion (WHP) is
the combined efforts of employers, employees and society to improve the health
and well-being of people at work. This can be achieved through a combination of
improving the work organisation and the working environment, promoting active
participation and encouraging personal development.” (www.enwhp.org)
The ENWHP has produced a set of quality criteria for good
practice in WHP, which is based on the Luxembourg Declaration and on the
quality model of the European Foundation for Quality Management. The European
Network for Workplace Health Promotion is an informal
network of national occupational health and safety, public health, health
promotion and statutory social insurance institutions. Through the
joint efforts of all its members and partners, it aims at improving workplace
health and well-being and reducing the impact of work related ill health in the
European workforce. The ENWHP is a platform for all stakeholders interested in
the improvement of workplace health and committed to working towards the vision
and mission of the ENWHP: “healthy employees in healthy organisations”.
Currently, the Network has National Contact Offices in 31 countries.
In contrast with their different origins, there are common
intervention strategies for both OSH and Workplace Health
Promotion. Workplace health interventions have been shown to have
pointed effects on the improvement of the health of employees as well as on the
economic position of enterprises. The scientific consensus is that preventive
measures lead to a reduction of risk factors and diseases and have a positive
return-on-investment.
With respect to the economic effects, a summary evaluation
of many studies on various health promotion programmes
(Aldana, 2001; Chapman, 2003; Golaszewski, 2001)) emphasised that all of them
reported a reduction in absenteeism in the range of 12% to 36% with a
return-on-investment of up to 1:5. This means that for every 1 € spent on the
programme, potentially 5 € could be saved due to reduced absenteeism costs. The
effect of workplace health promotion on the direct medical
costs was also studied and turns out in lower health expenditure. Observed
effects are, among other things, fewer visits to the doctor, less
hospitalisation as well as fewer days spent in hospital etc. The results show
an average reduction in medical costs of 26%, the return-on-investment is
reported to be between 1:2 and 1:6 (Kreis and Boedeker, 2004b).
The overall benefits – including financial savings - of health
promotion programmes may not become fully apparent until many years
after the health risks have been reduced – which makes the observed short-term
effects even more remarkable. Summed up, this positive economic effect is a
most powerful health promotion argument for companies and
social insurance institutions.
Diseases often have multiple causes. They are associated
with working and living conditions, individual characteristics and
socio-economic status. Health promotion and prevention
activities must therefore take a multi-disciplinary approach. However, there is
still a tendency in some areas to treat these issues in isolation. It has to be
emphasised that effective and sustainable health promotion
and prevention calls for collaboration across different professions and policy
fields.
Decision makers and advisers in the field of public
health, occupational health and safety and social insurance need to influence
policies through the principles of advocating health, enabling people and
mediating processes as laid out in the WHO Ottawa Charter of health
promotion.
Health and Safety at work has been one of the main
provisions of the European Union since 1952, its legal basis being Article 137
of the EU Treaty. A comprehensive package of measures has therefore been
adopted aimed at alleviating the risks. In 1989 the Community adopted a
Framework Directive on health and safety at work (Directive 89/391/EEC), laying down a series of
measures for the protection of workers in their workplace. This Framework
Directive has been supplemented by 19 individual directives.
In order to support the existing legislative
framework, the Community has also adopted a series of action programs in the
field of health and safety aimed at analysing the actual implementation of
adopted texts and evaluating the evolving future needs:
-
Community
program 1996-2000
was set in place to ensure the effective implementation of the existing
legislation in the Member States
-
Community
strategy on health
and safety in the workplace 2002-2006, the
objective of which was to put forward proposals in new areas of action due to
the changing world of work and its more flexible nature (different forms of
employment such as temporary work, teleworking etc.), and an ageing population
together with new types of risks (stress, depression, violence etc.)
-
The new
strategy for the period 2007-2012, directly linked to the Social Policy Agenda, calls for action by players at all levels:
European, national, local and workplace, and aims at achieving an overall 25%
reduction of occupational accidents per 100.000 workers in the EU27.
Apart from the adoption of the abovementioned legislation,
the Commission has expanded its activities, in cooperation with the European Agency for health and safety at work,
which was set up in 1996, and the European
Foundation for the Improvement of Living and Working Conditions in order to
promote information and guidance for a healthy working environment, in
particular for small and medium-size enterprises.
Musculoskeletal injuries:
Musculoskeletal disorders (MSDs) comprise the most common
occupational problem at European level (European Agency for Health &
Safety at Work, 2007). Almost 24% of the EU25 workers report suffering from
backache and 22% complain about muscular pains. The situation is worse in the
new Member States, where the two mentioned conditions represent 39% and 36%
respectively (Eurofound, 2005).
European directives, Member States’ regulations and good
practice guidelines are already formed for MSD prevention, supplemented by a
series of European standards (EN standards). The main European directives
relevant to preventing MSDs are:
-
89/391/EEC: general
improvements in the safety and health of workers
-
89/654/EEC: minimum
requirements for the workplace
-
89/655/EEC: suitability
of work equipment
-
89/656/EEC: suitability
of personal protective equipment
-
90/269/EEC:
identification and prevention of manual handling risks
-
90/270/EEC: minimum
health and safety requirements for work with display screen equipment
-
93/104/EC: organisation
of working time
-
98/37/EC: machinery
-
2002/44/EC:
identification and prevention of risks arising from vibration
Work-related skin /eye /hearing
injuries:
The framework directive sets out the general principles of
prevention, while the more specific directives, such as the 2003 noise
directive, provide more detailed principles (European Agency for Health &
Safety at Work, 2005).
Employers are required to control risks at source level,
eliminating or reducing noise risks to a minimum, taking account the technical
progress and the availability of preventive measures. According to the 2003
noise directive the control of noise risks includes:
-
working
methods that need less exposure to noise
-
the choice
of work equipment emitting the least possible noise
-
the design
and layout of workplaces and workstations
-
information,
instruction and training of workers
-
noise
reduction by technical means
-
maintenance
programs for work equipment, the workplace and its systems
-
noise
reduction through a better organisation of tasks
-
limiting the
duration and intensity of the exposure through work scheduling
The main relevant European Directives are:
-
89/391/EEC:
general improvements in the safety and health of workers
-
89/656/EEC: suitability
of personal protective equipment
-
89/686/EEC:
approximation of the laws of the Member States relating to personal protective
equipment
-
92/85/EEC:
measures to encourage improvements in the safety and health at work of pregnant
workers and workers who have recently given birth or are breastfeeding
-
94/33/EC:
protection of young people
-
98/37/EC:
approximation of the laws of the Member States relating to machinery
-
2000/14/EC:
approximation of the laws of the Member States relating to the noise emission
in the environment by equipment for outdoor use
-
2003/10/EC:
the minimum health and safety requirements regarding the exposure of workers to
the risks arising from physical agents (noise), which replaces Council
Directive 86/188/EEC on the protection of workers from the risks related to
noise exposure at work, setting a new daily exposure limit value of 87 dB(A).
Falls-related injuries:
Slips, trips and falls are one of the main causes of
accidents in all sectors from heavy manufacturing through to office work
resulting in more than 3 days absence from work (European Agency for Health
& Safety at Work, 2000,2001).
Requirements set in the European Directives,
such as on workplaces, safety signs, personal protective equipment, and
Framework Directive, concerning the prevention of slips and trips include:
-
Ensuring
that, as far as possible, workplaces receive sufficient natural light and are
equipped with artificial lighting adequate to protect workers’ safety and
health
-
Ensuring
that workplace floors are fixed, stable and level and have no bumps, holes or
slopes and are not slippery
-
Providing
safety and/or health signs where hazards cannot be avoided or adequately
reduced through preventive measures
-
Providing
personal protective equipment (e.g. protective footwear) appropriate for the
risks involved and where they cannot be avoided by other means. The equipment
shall be comfortable and well maintained, and not lead to any increase in other
risks
-
Following a
general Framework to manage health and safety, including: assessment and
prevention of risks, giving priority to collective measures to eliminate risks,
providing information and training, consulting employees, co-ordination on
safety with contractors.
Information campaigns:
Awareness campaigns on the reduction of occupational
accidents represent a significant part of the European Union’s action. ‘Lighten
the load’ was the theme for the 2007 European Campaign dedicated to MSDs. The
Campaign continued the European union’s action on MSDs initiated during the
first European Week in 2000, ‘Turn your back on MSDs’.
Member States’ Legislation
According to the European Commission’s evaluation
concerning the status of communication of health and safety legislation, basic
Directives and their amendments have already been communicated to 96% of EU25
member states (European Commission, 2004). In addition, by estimating the
practical implementation of Health and Safety at Work Directives 89/391
(Framework), 89/654 (Workplaces), 89/655 (Work Equipment), 89/656 (Personal
Protective Equipment), 90/269 (Manual Handling of Loads) and 90/270 (Display
Screen Equipment), the European Commission found out that EU work safety
legislation has greatly contributed to the development of a prevention culture,
mainly in Member States with weak or non-existent previous legislation. More
specifically, in Greece, Ireland, Portugal, Spain, Italy and Luxembourg
community’s legal action had relatively positive results, while before the
implementation of the abovementioned Directives they was no adequate
legislation on work safety. In Austria, France, Germany, United Kingdom, the Netherlands and Belgium, the directives supplemented the existing national
legislation. However, Denmark, Finland and Sweden had adopted and implemented
such legislation before community’s legal action, so the necessary adjustments
were limited.
During the Community Strategy 2002-2006, Member States
achieved significant progress by adopting more focused strategies and national
action programs. Over the 2000-2004 period, the rate of fatal accidents at work
in the EU15 fell by 17%, while the rate of workplace accidents leading to
absences of more than three days fell by 20% (European Commission, 2007). There
is however still considerable room for further improvement as progress has
remained uneven across the Member States, the different sectors, companies and
groups of employees.
The evaluation report (European Commission, 2007) revealed
that small and medium-sized enterprises were particularly exposed, and sectors
such as construction, agriculture, transport and health were at higher risk,
whereas young workers, migrants, older workers and those with insecure working
conditions were more affected. It is also stated (European Commission, 2004)
that small and medium-sized enterprises’ non compliance with relative European
legislation derives from lack of adequate resources. Many Member States, such
as Germany, Belgium and France, have therefore adopted measures, for example
loans for new machinery, in order to reduce the cost of implementing the
relative legislation.
The available data reveal that the United Kingdom, Sweden,
Denmark, Finland, the Netherlands, Germany and Belgium are among the best
performing countries for what concerns the reduction of occupational accidents.
United Kingdom’s good performance reveals that the adopted
measures are highly effective. UK’s work safety policy is mainly based on the
10 year strategy known as “A strategy for workplace health and safety in Great
Britain to 2010 and beyond” , which was adopted in 2004. One of its promising
targets was the reduction of the incidence rate of fatalities and major
injuries at work by 10% till 2010. However, the primary piece of legislation
covering occupational health and safety in the United Kingdom is The Health and
Safety at Work Act 1974.
10.5.3.5. Future
developments
Diseases most often have multiple
causes. They are associated with working and living conditions, individual
characteristics and socio-economic status. Health promotion
and prevention activities must therefore also take a multi-disciplinary
approach. However, there is still a tendency in some areas to treat these
issues in isolation,
As a starting point for action, policy makers should bear
in mind some simple facts:
-
the world of
work affects health and is itself affected by ill health
-
workplaces
are powerful settings for health promotion and prevention
-
workplace
health interventions are available and effective
-
workplace
health issues apply to non-working life as well
-
workplace health is an essential part of public
health.
There are currently great challenges to workplace health
from
-
ongoing
demographic and structural changes in the world of work
-
regional
health and safety discrepancies in Europe, especially among the new Member States
-
the
imbalance in access to preventive services, especially with respect to small
and medium enterprises (SME) and to migrants.
Decision makers and advisers in the field of public
health, occupational health and safety and social insurance need to influence
policies through the principles of advocating health, enabling people and
mediating processes as laid out in the WHO Ottawa Charter of health
promotion e.g. by
-
making
workplace health issues an integral part of all policy fields
-
recognising
the interdependence of illnesses and the need for integrated policies
-
combating
health inequalities
-
promoting
social inclusion
-
enhancing
intrinsic job quality
-
ensuring
policy evaluation by collecting monitoring data and information
-
treating
workplace health issues as part of employment strategies aimed at ensuring
decent work.
-
promoting
the collaboration between OSH and public health institutions e.g. develop
common training, strategies, research programmes and action plans
-
promoting
multi-dimensional, multi-professional European and national health action plans
-
taking
a broader view of workplace health as part of the social dialogue.
It cannot be repeated too often that in times of
globalisation, improvement of health at work requires a holistic approach,
combining health promotion and prevention, occupational
health and safety as well as addressing social determinants and employability
10.5.3.6.
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10.5.3.7.
Acronyms
