Occupational Medicine 2003;53:378–383 DOI: 10.1093/occmed/kqg118

IN-DEPTH REVIEW

Occupational health issues affecting the pharmaceutical sales force G. Harris, G. Mayho and L. Page

Background The sales force forms a significant sub-population in the pharmaceutical industry workforce. Role and organizational characteristics, such as isolation, peripatetic working and car travel and the psychosocial and ergonomic hazards related to work tasks, present particular occupational health risks. Aim

To review the occupational risks associated with peripatetic sales force work and evidence for the effectiveness of preventive interventions.

Methods

We carried out a review of the available literature between 1990 and 2003.

Results

The following hazards were identified as significant and worthy of further investigation for this occupational group: driving on company business; violence in the workplace; stress; ergonomic issues; and mobile phone use.

Conclusion

To ensure effective prevention and management of employee health problems, specific health management strategies and interventions must be developed to meet the occupational health needs of this group.

Key words

Drug and alcohol misuse; ergonomic risks; low back pain; mobile phone use; occupational risks; pharmaceutical sales force; road traffic accidents; violence; workplace stress.

Received

15 May 2003

Revised

20 June 2003

Accepted

24 July 2003

ments and the trend is for an increasing number of people to work away from an office base. It is essential to recognize the types of health issues associated with peripatetic workers, as this will then enable occupational health professionals to develop and implement strategies to address these problems. This paper highlights the main occupational health issues associated with working remotely from the nucleus of a business. It also addresses ways in which a comprehensive and effective occupational health service can be made accessible to such individuals. Medline, Pubmed and HSEline were the three databases used for researching this paper over the time interval of January 1990–January 2003. The key words used during the search were pharmaceutical, peripatetic, sales force and occupational health risks.

Introduction A significant part of the UK pharmaceutical industry workforce is the peripatetic sales staff, comprising between 5 and 20% of individual companies’ workforces. The primary responsibility of these employees is the successful promotion and marketing of new and existing products. The provision of occupational health support for these individuals presents a challenge, as they spend significant time working in isolation and driving. The industry now recognizes the importance of having a healthy, fit and fulfilled sales force and its occupational health providers have a pivotal role in preventing and minimizing the effect of occupational ill-health or injury in this group. Remote working is now feasible as a result of technological and information technology (IT) developOccupational Health Service, Pfizer Ltd, Sandwich, Kent CT13 9NJ, UK.

Occupational risks

Correspondence to: G. Harris, Occupational Health Service, Pfizer Ltd, Sandwich, Kent CT13 9NJ, UK. e-mail: [email protected]

There are several risks to consider when assessing the

Occupational Medicine, Vol. 53 No. 6, © Society of Occupational Medicine; all rights reserved

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occupational health problems associated with the sales force. The predominant issues fall into five categories: driving on company business; violence in the workplace; stress; ergonomic issues; and mobile phone use. Driving There is compelling evidence that company car drivers are at increased risk of accidents compared to the general population [1,2]. One study found company car drivers to be 49% more likely to be involved in an accident [3]. The annual risk of dying in a road accident for drivers who average >25 000 miles per year is 1 in 7000, a figure comparable with coal mining and worse than the construction industry [4]. In the UK, the Trades Union Congress (TUC) estimate that 300 of the 1200 drivers killed on Britain’s roads every year are driving for their work, which is greater than the number of employees killed on employers’ premises. The reasons for the high accident rate in company drivers are varied. Adams-Guppy and Guppy [5] indicated that it was due to strong demands on time, which ultimately affected decision-making regarding speeding and overtaking. However, Lynn and Lockwood [3] found that the increased accident liability of company car drivers extended to non-work driving and they concluded that the increased risk was due to ‘driving style’ rather than increased time pressures. Chapman et al. [6] warned that this increased risk varies and is dependent on the type of vehicle and also the purpose for which the vehicle is used. There is an association between personality type and risk of road traffic accident. Type A behaviour pattern, which is characterized by excessive impatience, competitiveness, hostility and time pressure, is associated with a higher risk of accidents [7]. Time pressure was noted as one of the most significant risk factors for ‘near accidents’, when factors such as age, gender, annual mileage and urban driving were controlled. The implications for the busy sales representative, working in a competitive field with a large geographical patch, should be appreciated and the benefits should be recognized of educating and training these individuals (e.g. advanced driving course and stress self-risk assessment) to improve driving and time management techniques. Falling asleep while driving accounts for a considerable proportion of accidents under monotonous driving conditions. Circadian factors are as important in determining driver sleepiness as is the duration of the journey, but only duration of the drive is built into legislation protecting professional drivers. It has also been shown that the accident rates of company car drivers have been linked with daytime sleepiness. Alcohol consumption is a major influence on driver fatigue and nocturnal snoring increases accident potential by ~30% [8–10]. This reinforces the need to educate about: the requirement to

plan journeys; the dangers of driving whilst sleepy or at vulnerable times such as at night or following a shift; and the benefit of regular breaks. The sales force often interact with clients in circumstances where alcohol may be available and a clear alcohol policy is needed to educate these potentially exposed employees on the dangers of drinking when driving. Additionally, the sales force drive regularly in adverse weather conditions, which can further compound these factors. In response to the increasing number of road accidents involving at-work vehicles, an inter-agency Work Related Road Safety Task Group was established in May 2000 by the UK Department of Transport, local government and the Health & Safety Executive (HSE) [1,11–13]. The Task Group aimed to establish the main causes and related methods of preventing incidents and subsequently proposed minimum health and safety management standards. Their main findings were as follows. Men were more frequently involved in traffic accidents · and were particularly represented in the more severe

·

· · · · ·

accidents. Among the 16–20 and 21–24 year age groups, the male population-based fatality rates were observed to be more than twice as high as those rates for females. The nature of the accidents experienced by women and men differed, as men were more likely to have an accident linked to a traffic violation. The odds of an at-fault crash decreased almost twice as quickly for women as for men, per year of licensure. Men were three times more likely to report driving after drinking and were less likely to use seatbelts. Men also made up the majority of aggressive drivers. Women were more likely to be involved in crashes as a result of perceptual or judgmental errors or as a result of lower driving confidence. Younger drivers were at greater risk than older drivers. Risk appeared to be proportionately associated with increased levels of education. Certain personality characteristics were associated with increased risk, with sensation-seeking and risktaking being the most frequently reported characteristics associated with accidents. Stress and major life events were associated with increased accident frequency. There is an association between ‘seemingly benign medications’ and sleep-related crashes, with evidence that minor tranquilisers, antidepressants, analgesics and antihistamines can all impair driving.

The Task Group concluded that their findings had implications for employers. They recommended that employers should be aware of the benefits associated with robust occupational road safety policies and procedures, in particular, recruitment, training, safety culture, medical screening and stress management. In addition,

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this Task Group demonstrated models of good practice regarding road safety risk management and showed how organizations, both large and small, with varying types of driving activities and vehicles, could implement effective procedures with benefit. In a similar vein, the Scottish Executive has been working closely with the Department of Transport and the HSE [14]. They examined the risk factors associated with road traffic accidents. This confirmed that travel by peripatetic, professional or sales staff was the most typical driving activity, and that the majority of accidents occurred during travel by this group. This identified the sales force as a ‘high-risk’ group for road accidents and advised on the benefits to be gained from the introduction of clear policies to ensure that these individuals are protected. Their recommendations were as follows: is a need to motivate employers to introduce · There road safety policies that reduce accidents and associ-

· · · ·

ated losses. Procedures should be employed to address workrelated road safety, including: risk assessment; driver training; incident reporting; mobile phone use; vehicle maintenance; ergonomics; breakdown guidance/ assistance and alternative means of transport; incentive programmes; and awareness campaigns. Policies are more effective when co-ordinated by health and safety specialists in conjunction with the fleet manager and insurance/risk management staff. Commitment by senior managers, inclusion of employees when developing procedures and risk assessments and accurate data by which to measure improvement are vital characteristics of effective systems. Scrutiny by employers is important, alongside regulatory reporting of road traffic accidents occurring at work under the Reporting of Injuries, Diseases and Dangerous Occurrence Regulations 1995 (RIDDOR).

Moreover, the TUC proposes that employers with substantial numbers of drivers should have to submit a ‘safety case’ to the HSE for a licence to operate. This duty would parallel the requirement in other hazardous industries. Finally, car design features are also important in the prevention of serious injuries in a road traffic accident. These include wearing of seat belts, the weight of the car, the age of the car and the proper positioning of head restraints [15]. Prior availability of such information and advice when choosing a company car may prove invaluable in minimizing serious injury should an accident occur. The effectiveness of risk controls has been demonstrated clearly. In 1996, Gregerson et al. [16] evaluated four different organizational measures used to decrease road incidents: individual driver training, group discus-

sions, campaigns and bonus schemes. Driving training and discussion groups resulted in a significant reduction in accident rates, whereas campaigns and bonus schemes produced only a small reduction. Other employers adopting preventive policies and procedures have seen a reduction in accidents, insurance premiums, costs of vehicle damage and absence due to driving-related injuries. This is illustrated in Figure 1, where the success of accident prevention procedures was largely judged on a reduction in the amount of reports/claims/accidents (35%) and on elimination of accidents (23%). A tripartite approach involving occupational health, senior management and sales force staff can raise awareness throughout the company of respective duties under health and safety legislation, the aim being to reduce absence through injury. The UK Driver and Vehicle Licensing Authority (DVLA) recommends that companies adopt this type of approach for their company car drivers. Regular meetings highlighting the pertinent health and safety issues affecting this unique group of employees can ensure that health and safety is kept at the top of the agenda, that issues are recognized and managed promptly and effectively, that specific hazards in the job are identified and that the employees receive the appropriate health and safety training. Violence in the workplace The sales force spends long periods of time alone and they also have the task of marketing their products to as many potential clients as possible within a limited time frame. These customers are often busy general practitioners and hospital specialists who may resent intrusion upon their own demanding work schedule, thus making the job of a sales representative more difficult. Following the British Crime Survey, the Home Office and the HSE have recognized that violence in the workplace is a significant problem and they have also identified high-risk occupational groups [17,18]. The survey defines violence at work as ‘all assaults or threats, which occurred while the victim was working and were

Figure 1. Positive impact of driving accident prevention policies [14].

G. HARRIS ET AL.: OCCUPATIONAL HEALTH AND THE PHARMACEUTICAL SALES FORCE 381

perpetrated by members of the public’. The report highlights the following. In 1999, there were an estimated 1.3 million incidents of violence at work in England and Wales, comprising 634 000 physical assaults and 654 000 threats of violence (Figure 2). Occupations with above-average risks of violence were identified. These figures describe the incidence per year; the average risk of assaults is 1.2% and average risk of threat is 1.5%. Although the sales force do not as a group fall into a ‘high-risk’ category when compared with the national average, the report finds that employees who work in the evenings are at greater risk of violence at work and feel more exposed to threat and harassment. The sales force is at times required to do ‘out of hours’ work, e.g. when hosting evening conferences. Employees of small and medium-sized businesses are also at greater risk of violence in the workplace, a factor to be considered by smaller pharmaceutical companies. There is a high level of repeat victimization among victims of previous assault. It is therefore important that victims of violence are identified so that measures can be taken to try to prevent re-victimization. This may involve giving staff appropriate advice and training to improve awareness, or changing a particular aspect of their job that seems to put them at risk. The provision of formal training to assist staff in dealing with violent situations, even in high-risk occupations, is patchy. This gives weight to the argument for including training and advice on how to deal with violence at work when reviewing company policy. Employers have a legal duty under the Health and Safety at Work Act 1974 to ensure, so far as is reasonably practicable, the health, safety and welfare at work of their employees. The Management of Health and Safety at Work Regulations 1999 require employers to assess the risks to employees’ health and safety. The risks include the need to protect employees from exposure to reasonably foreseeable violence. This involves: identifying the extent and nature of the risk of violence or harassment at work; designing and implementing intervention strategies to

Figure 2. Number of incidents and victims of violence at work in 1999 [17].

minimize these risks; and subsequently monitoring to evaluate the effectiveness of interventions and identify new problems as they arise. The Health & Safety Commission and the HSE have issued general and specific guidance to help employers prevent, manage and control violence at work. All industries, including the pharmaceutical industry, have an obligation to consider violence to staff, undertake a risk assessment and remove or mitigate the risk. Ergonomic issues The sales force spends long periods driving and repeatedly lifts and loads bulky promotional material unaided. Promotional goods may be delivered in bulk to the employee’s home, posing additional manual handling hazards, especially where employees live in apartments. Time pressures may limit communication with colleagues and line manager, compromising the ability to explore solutions to these problems. There is strong evidence linking fixed postures and prolonged seating with occupational low back pain [19]. Pope et al. [20] found that a seated posture leads to inactivity, which ultimately causes accumulation of metabolites, accelerating disc degeneration and leading to disc herniation. They found that drivers’ postures could also lead to musculo-skeletal problems, with postural stress leading to back, neck and upper extremity pain. The individual was at greater risk of low back pain in occupations involving lifting, particularly involving awkward postures. Heavy and repetitive lifting was also related to low back pain. A study by Skov et al. [21] revealed that both psychosocial and physical factors were associated with musculo-skeletal symptoms when questioning 1306 salespeople in Denmark. Multivariate analyses demonstrated that high job demands were related to neck and shoulder symptoms and a tendency to feel overworked or lack of social support from colleagues was related to back pain. Lack of job variation, low control and high competition were related to neck symptoms. Driving long distances and sedentary work were noted to be related to neck and low back pain, whereas length of time in the car was associated with shoulder pain. Only one personality characteristic, the tendency to feel overworked, increased the prevalence of musculo-skeletal symptoms. The most important factor in reducing the risk of low back pain is the implementation of a robust manual handling policy for employees, combined with a risk assessment and management approach involving line manager and employee. Great emphasis must be placed on educating and training both the employee and the line manager on the ergonomic risks associated with working in the field. The employer needs to be aware of the range of potential ergonomic risks and ensure that adequate measures are in

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place to address these. A possible solution is the provision of an accessible risk assessment package for both the physical and psychosocial difficulties that the sales force may encounter; an electronic format may improve accessibility to all members. Attention should be paid to optimal posture in choosing make of company car. Advice should be provided on appropriate breaks. The importance of regular communication between the sales force, employee and manager must be emphasized. Ready access to an occupational health service for advice, by telephone or in person, accompanied by an appropriate referral system for physiotherapy and ergonomic assessment, may avert problems at an early stage, thereby minimizing the progression to chronic problems. Mobile phone use Analysis of the scientific studies on the hazard potential of mobile phones when used in vehicles unequivocally shows a marked impairment of driver performance [22,23]. The evidence reveals that the use of mobile phones while driving has a detrimental effect on the driver’s reaction time [24]. Indeed, it was evident that neither a ‘hands-free’ or ‘voice-activated’ interface removed the safety problems associated with the use of mobile phones when driving. This potential hazard should be recognized and incorporated into the risk assessment. The common-sense approach must be to advise employees not to use these devices when driving, but to switch on their voice mail and to check messages at regular intervals, e.g. during frequent breaks from driving. The importance of a comprehensive safety culture within the company, from top to bottom, is paramount in order to ensure that company policies on these issues are put into effective practice. Concerns have been raised about the possible health effects of exposure to radiofrequency fields from mobile phones or their base stations [25]. Some scientific studies have proposed potential links between cancer and mobile phone use. These studies have been inconclusive, but concern in this area persists, prompting the World Health Organization to establish the International EMF project in 1996 to address these issues. A ‘precautionary approach’ to the use of mobile phones has been recommended while uncertainty remains in this field [26].

Other occupational issues Employers should be encouraged to have a clear policy relating to drugs and alcohol [27–31]. This policy should actively discourage all employees from using such substances during working hours or when driving on business. The sales force is a group which may be placed in a difficult position, as the role includes organizing and participating in late meetings and conferences where

alcohol may be available, possibly placing the individual under pressure to engage in social drinking. Company policy must clearly address this issue. The role of a sales representative is demanding in terms of both time and energy. Their working environment can be inhospitable at times, with periods spent working alone, sometimes with difficult customers. Communication with colleagues and line management may be difficult to maintain. These factors may increase the risk of stress-related symptoms in the workplace. To help address these issues at an early stage, the employer should have a robust mental health policy [32,33]. This policy should enable early recognition of the problem by the employee and should identify support measures to deal with the difficulties [34]. One tool is an individual mental health risk assessment, which gives the line manager and employee the opportunity to discuss the relevant issues and concerns in the field [35]. Finally, the provision of occupational health to this group of workers has its own difficulties. The peripatetic nature of the work may result in limited access to occupational health services. Rehabilitation of sales force employees is challenging, as it can be difficult to overcome the geographical constraints to provide the appropriate resources in a consistent manner throughout the UK.

Conclusion There are many potential occupational health issues associated with being a member of the sales force, including the following. Long-distance driving is related to increased risk of · road traffic accidents and use of mobile phones when

· · · · ·

driving adversely affects drivers’ performance. Ergonomic problems may arise from long periods spent driving, prolonged laptop use, and manual handling of computer equipment and product information. The very nature of a sales representative’s role can result in limited opportunities for direct interaction between colleagues. This can lead to frustration and feelings of isolation. Working over a wide area equates with being remote from the office, making it difficult for both the employee and manager to identify and address problems at an early stage. Access to occupational health and rehabilitation services may be limited. Awareness of personal safety issues and strategies to reduce personal risk are important components of sales force training programmes.

This paper highlights the risks associated with being a member of the fieldforce and has examined the ways in

G. HARRIS ET AL.: OCCUPATIONAL HEALTH AND THE PHARMACEUTICAL SALES FORCE 383

which the employer can assess and manage these risks, with a universal safety culture being key [36]. Much research is available that identifies the risk factors in this group and considers ways in which the employer can actively intervene and manage those problems. Occupational health practitioners have an opportunity to support this work with active measures to promote and maintain a fitter, safer, happier and, ultimately, a more productive sales force.

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