Work and health country profiles

Country profiles and national surveillance indicators in occupational health and safety

Jorma Rantanen Timo Kauppinen Jouni Toikkanen Kari Kurppa Suvi Lehtinen Timo Leino

People and Work • Research Reports 44

Finnish Institute of Occupational Health Helsinki 2001

Layout of the cover page: Tuula Solasaari-Pekki Technical editing: Suvi Lehtinen

Printed in Edita Helsinki 2001 ISBN 951-802-443-X ISSN 1237-6183

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Preface Over five years ago the 49th World Health Assembly (WHA) at its plenary meeting on 25 May 1996 in Geneva endorsed the WHO Global Strategy on Occupational Health for All. The strategy has been prepared and to a large extent is being implemented by the WHO global network of Collaborating Centres in Occupational Health. However, even now it is rather difficult to monitor the expected outcome of its implementation due to lack in many countries of well-structured information systems. The additional stimulus for the development of a holistic and well-structured information system on the occupational health and safety management comes from the objectives of WHO, ILO, Member States and the European Union health strategies aimed at ensuring the health equity and reducing health gap between different countries. The London 1999 Ministerial Declaration on Action in Partnership recognizes the rights and needs of workers to be informed of occupational and environmental health hazards in the workplace, and of the public to be informed of hazards posed to the community by the activities of enterprises. It asks for creation or strengthening of information systems on health, environment and safety management and performance in enterprises, and for making them accessible to employers and employees as well as to national and foreign investors. The provision of good working conditions, workers’ health and safety protection and the environmental management in enterprises is an important issue in free trade negotiations within the World Trade Organization. To harmonize the scope of the work and health country profile considerable efforts should be undertaken at an international level. The analysis of recent policy documents issued by the international institutions shows that the definition of occupational health has broadened considerably and there has been a transition from the strict concept of “prevention of occupational injuries and diseases” to overall protection and promotion of workers’ general health. The Twelfth Session of the Joint ILO/WHO Committee on Occupational Health, held in 1995, revised this definition to focus on three different objectives: 1. The maintenance and promotion of workers' health and working capacity 2. The improvement of work environment and work to become conducive to safety and health; and 3. The development of work organization and working cultures in a direction, which supports health and safety at work, and in doing so also promotes a positive social climate and smooth operation and may enhance productivity of the undertaking. The concept of the working culture is intended, in this context, to mean a reflection of the essential value systems adopted by the undertaking concerned. Such a culture is reflected in practice in the managerial systems, personnel policies, principles for participation, training policies and quality management of the undertaking. In line with this definition the holistic concept of good practice in health, environment and safety management in enterprises (GP HESME), launched in 1999 by the London Ministerial Declaration, put emphasis on stakeholders’ partnership. In this concept the responsibility for health at work is not only on occupational health professionals. The employers, but also employees, make at work a huge number of decisions which have an impact on quality of living and working environment, work organization and work culture, but also on use of natural resources and quality of ambient environment. These decisions have an obvious impact on their own health as well as on health and well-being of their families, neighbours and customers. Therefore GP HESME is a process of comprehensive workplace health

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promotion involving all stakeholders inside and outside the enterprise. It takes into account occupational, environmental, lifestyle and social health determinants and encourages using a workplace as setting for health. GP HESME makes a link between traditional occupational health and implementation of public health and environmental health policies. It aspires to turn enterprises into major setting for achieving the WHO objective (WHA, 1977): Attainment by all people of the world of a level of health that will permit them to lead socially and economically productive lives. However, indicators used in most of countries for the evaluation of performance in occupational health do not reflect the importance of the role and impact of the workplace as a setting for the promotion and protection of health of social partners at work nor do they sufficiently reflect the need for change in occupational health practice. The need to develop the guidelines on the occupational health and safety country profiles has been pointed out in several meetings organized by the WHO Regional Office for Europe. It is believed that the country profiles prepared by the national institutions could be a valuable source of information for different stakeholders inside and outside the country. The concept of occupational health country profiles has been introduced and initially discussed at the meetings of the Baltic Sea Network in Occupational Health and Safety. The work and health country profile should be designed to serve several levels and bodies, such as decision-makers within government authorities, regional and local authorities, social and health insurers, occupational health services and other enterprise consultants in HES, social partners, training, education and information bodies, research institutions, and the general public. It is foreseen that in practice such a country profile would be compiled using data from different national sources. It could be presented and maintained, preferably on the Internet Website by the WHO Collaborating Centres in Occupational Health. It is assumed that the country profile will be prepared in the national language but be made available in addition also in one of the WHO/EURO official languages. The document prepared on this topic by the team of experts from the Finnish Institute of Occupational Health in Helsinki is a first major step to prepare the guidelines on preparation of the health and work country profiles. It is a very comprehensive document presenting Finnish experience and providing essential data from other countries or international organizations. It will be fully discussed during the Second European Meeting of WHO Collaborating Centres in Occupational Health, to be held in Budapest, 17–18 September 2001. I would like to thank Professor Jorma Rantanen, Director General of the Finnish Institute of Occupational Health and all his colleagues who have contributed to the preparation of this document. They made a major progress on the way to develop harmonized criteria and indicators for developing and auditing the performance of the national workplace health systems.

Boguslaw Baranski Regional Adviser, Healthy Workplaces WHO Regional Office for Europe Scherfigsvej 8, 2100 Copenhagen Ø, Denmark

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CONTENTS PREFACE FOREWORD ........................................................................................................................................7 1. INTRODUCTION .............................................................................................................................8 1.1 Structure of the document........................................................................................................................................................... 8 1.2 Aims ................................................................................................................................................................................................... 8 1.3 Concepts and definitions ...........................................................................................................................................................11

2. INDICATORS AND THEIR SOURCES OF INFORMATION.......................................................14 2.1 Choosing indicators ....................................................................................................................................................................14 2.1.1 Conceptual model................................................................................................................................................................14 2.1.2 Validity and comparability.................................................................................................................................................17 2.2 Constructing indicators .............................................................................................................................................................19 2.2.1 Types of indicators ..............................................................................................................................................................19 2.2.2 Feasibility..............................................................................................................................................................................21 2.3 Sources of indicator data...........................................................................................................................................................22 2.3.1 Administrative registers and statistics .............................................................................................................................22 2.3.2 Questionnaire-based surveys.............................................................................................................................................25 2.3.3 Expert assessment systems ................................................................................................................................................27 2.3.4 Observational surveys ........................................................................................................................................................30

3. INDICATORS OF PREREQUISITES OF OCCUPATIONAL HEALTH AND SAFETY...............32 3.1 Occupational health and safety legislation and its coverage ...........................................................................................32 3.2 Coverage of occupational health service system.................................................................................................................32 3.3 Performance and resources of the occupational health and safety system..................................................................33 3.4 Recommended core indicators of an occupational health and safety system..............................................................34

4. INDICATORS OF WORKING CONDITIONS...............................................................................36 4.1 Physicochemical and ergonomic factors ...............................................................................................................................36 4.2 Psychosocial factors ....................................................................................................................................................................39 4.3 Working time arrangements ....................................................................................................................................................39 4.4 Life-style of the employed..........................................................................................................................................................40 4.5 Recommended core indicators of working conditions ......................................................................................................40

5. INDICATORS OF OCCUPATIONAL HEALTH AND SAFETY OUTCOMES.............................42 5.1 Accidents at work ........................................................................................................................................................................42 5.2 Occupational diseases ................................................................................................................................................................43 5.3 Occupational mortality..............................................................................................................................................................44 5.4 Occupational disability...............................................................................................................................................................44 5.5 Occupational morbidity.............................................................................................................................................................45 5.6 Work ability..................................................................................................................................................................................45 5.7 Work-related health problems and absenteeism due to sickness...................................................................................46 5.8 Recommended core indicators of occupational health and safety outcomes ..............................................................46

6. PRESENTATION OF INDICATORS.............................................................................................48 7. RECOMMENDATIONS.................................................................................................................51

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7.1 Proposed core set of indicators ................................................................................................................................................51 7.2 Other proposals............................................................................................................................................................................55

REFERENCES AND INTERNET ADDRESSES ................................................................................56 ANNEX 1. COMPILED CONCEPTS AND TERMS...........................................................................60 ANNEX 2. AN EXAMPLE OF A COUNTRY PROFILE: FINLAND (DRAFT).................................68 Basic information on Finland and its health system.................................................................................................................68 Area and population......................................................................................................................................................................68 Economy ..........................................................................................................................................................................................69 Labour force....................................................................................................................................................................................69 Public health and health care system..........................................................................................................................................70 Indicators of prerequisites of occupational health and safety................................................................................................72 Infrastructure of OH&S ................................................................................................................................................................72 Legislation and coverage of OH&S............................................................................................................................................74 Human resources in OH&S..........................................................................................................................................................74 Indicators of working conditions ...................................................................................................................................................77 Physicochemical exposures .........................................................................................................................................................77 Physiological and ergonomic factors .........................................................................................................................................83 Psychosocial factors ......................................................................................................................................................................86 Working time arrangements ........................................................................................................................................................89 Life-style of the employed...........................................................................................................................................................91 Indicators of occupational health and safety outcomes ...........................................................................................................93 Accidents at work and occupational diseases ...........................................................................................................................93 Work ability....................................................................................................................................................................................95 Work-related health problems .....................................................................................................................................................96

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Foreword This working document of guidance on country profiles in occupational health and safety (OH&S) has been prepared by the Finnish Institute of Occupational Health (FIOH) on the basis of the initiative of Dr. Baranski of the WHO/EURO. In addition to several earlier initiatives of the International Organizations to improve the compilation of OH&S data, the Third Ministerial Conference on Environment and Health, held in June 1999 in London, also noted a need to strengthen the information systems on safety and health at work. This Conference supported the implementation of the comprehensive concept of good practice in health, environment and safety management in enterprises (HESME). This prompted WHO/EURO to propose the preparation of two parallel working documents on preferable indicators of occupational health and safety at the enterprise level, and at the national/regional level. This document presents a variety of indicators used to describe the status and trends of OH&S at the national/regional level, and recommends a core set of indicators to be considered predominantly for European use. Although the project is based on a European initiative, global aspects have influenced the selection of some recommended indicators. During this work, the WorkSafe Programme of the International Labour Office, ILO, has shown interest in adopting a similar approach to country profiles, including OH&S indicators at the global level. However, data collection and indicator construction rely mainly on work carried out in different projects of the European Foundation for the Improvement of Living and Working Conditions (in Dublin, Ireland), of the European Agency for Safety and Health at Work (in Bilbao, Spain), of EUROSTAT, and of research institutes and statistical offices in the Nordic countries. The basic ideas of this document have been introduced at the First European Meeting of the WHO Collaborating Centres in Occupational Health, held in Lodz on 11–12 September 2000, and a more detailed review is expected to take place in the next meeting of the European Network of the WHO Collaborating Centres, planned to be held in September 2001. We hope that this document can be utilized in the evaluations of national/regional OH&S situations, and will thus be used as a tool for developing occupational health and safety in the countries.

The Authors

Helsinki, December 2000

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1. Introduction 1.1 Structure of the document This document starts by introducing the aims of this exercise and the basic concepts used in national/regional surveillance of occupational health and safety (OH&S). The OH&S indicators are then discussed in general terms with illustrative examples from the OH&S domain by type of data source (administrative source, questionnaire-based surveys, expert assessment systems and observational surveys). The next chapter deals in more detail with relevance, validity, comparability and feasibility of indicators in three basic domains of OH&S (prerequisites of OH&S, working conditions, OH&S outcomes). The technical aspects and presentation of indicators are discussed in the next chapter. The document ends in a recommendation of a core set of OH&S indicators and a proposal on piloting. A comprehensive annex presents a draft country profile of Finland, which serves as example country whose data are used throughout the document to discuss the pros and cons of different indicators. Finland and Finnish approaches were chosen as examples in this document because comprehensive data on OH&S were available from Finland, and the authors had long experience on the use of these data.

1.2 Aims The third Ministerial Conference on Environment and Health held in June 1999 in London recognized the need for developing and strengthening information systems on safety and health at work. The Conference supported the idea of a comprehensive approach in the development of national indicators for health and safety at work to support the design and follow-up of the implementation of appropriate national policies. The Member States were also encouraged to develop good practices in health, environment and safety management in enterprises (HESME) for company and workplace level to implement such policies. Throughout the industrialized world the basic requirements for health, safety and environment have been stipulated by legislation, including the Directives on Safety and Health at Work by the European Union. The further development of policies for occupational health and safety and those for environment and health are nevertheless increasingly based on information steering. Such a policy is critically dependent on up-todate information describing the current status of health and safety, the exposures and risks threatening health, and information on the consequences of such exposures at individual and population levels. Such information is also of critical importance for setting priorities for further development, identification of needs for actions, including the development of capacities and infrastructures, and attracting partners and allies to join the WHO in actions to implement Health for All (HFA) 21 targets of the Regional Strategy. Appropriate indicator systems can also be used for comparing the needs of policies in different parts of the Region, and for the recognition of the impact of actions and programmes undertaken for health and safety.

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The new information-based strategy also requires effective networking of actors at all levels, i.e., policy, administrative, managerial and practical levels. Such networking can be effectively stimulated and supported through appropriate, relevant and reliable information. It is important that the indicator systems which provide an opportunity to build up national profiles are made as descriptive as possible, without rendering them too complex, and kept manageable and feasible for very heterogeneous suppliers of information. It is also most important to compile even a limited amount of reliable and valid information rather than to try to establish too heavy, complex and less practical systems with high numbers of parameters. In such attempts compromises between ideal and feasible systems need to be done. The objective of the present document is to provide suggestions for national profiles that describe the most important parameters in occupational health and safety, starting from a limited number of selected and relevant key parameters, and providing a possibility for more complex profiles with a growing degree of sophistication, according to the needs and possibilities of the countries. WHO/Euro has produced a document for indicators on Good Practices in Health, Environment and Safety Management in Enterprises (HESME) intended to satisfy the information needs at the company and workplace levels. Our Work and Health Indicator Profile (WHIP) approach covers national and regional/provincial levels. These two documents are intended to be complementary, helping to cover all the levels of societal structures with appropriate indication systems (Figure 1). Plans have been made to apply a similar approach at the global scale in collaboration with the ILO.

Scale of coverage

Global level National level WHIP Regional/Provincial level Local level (community) Enterprise level

HESME

Number of data providers

Figure 1. Relationships between different indicator systems International and inter-regional comparisons provide excellent possibilities for benchmarking and for finding common topics for collaboration. Such comparisons, however, require an indicator system for which data are available in as many countries as possi-

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ble. Due to the heterogeneity of countries, the parameters which can be compared are very few. This implies the principle of parsimony (i.e., avoiding too many parameters) particularly in the early stages of indicator development. On the other hand, the indicator system is a good stimulus for countries to develop their information systems for the production of more detailed profiles with time. Some countries can already do that and are encouraged to draw up more detailed descriptions. The comparability of data requires the harmonization of concepts, definitions and methods for data compilation. This is a difficult task due to many differences, for example, in the legal systems of different countries. Therefore, the construction of profiles requires not only the mechanical compilation of registered data, but full knowledge and understanding of the principles on which the data are collected and how they should be interpreted. We have two major sources of official information for indicator systems, a) the official statistics on registration of data for defined purposes, such as for the follow-up of impact of safety and health policies (e.g., official accident statistics) and b) statistics for insurance and compensation purposes (insurance statistics). Such information systems have several merits with their wide coverage, stable definitions and usually long history. But even they are vulnerable to poor implementation and variation in practices. Criteria, concepts and definitions are bound to the national laws and practices which may vary substantially between countries. Differences in the efficiency of registration may lead to under-registration or registration gaps which may substantially bias the results and invalidate comparisons. Even more they may lead to the so-called registration paradox showing a worse situation for countries which very accurately register all the relevant events, while poor registration may be interpreted as a low level of risk. Official statistics are also rigid, and cannot be adjusted to give answers to questions which crop up unexpectedly on issues that are not included in the original registration schemes. Furthermore, the delay time in the registries may be substantial. In terms of the rapid changes in work life, the data need to be collected with short delays and the questions to be answered need to be flexible according to the context and situation. For this purpose surveys provide a useful tool. But surveys also have their strengths and weaknesses (see sections 2.3.2 and 2.3.4). This report proposes an indicator system that is based on the combination of registered data and data provided by surveys and expert assessments. As several types of integration and collaboration processes are ongoing in Europe, where EU integration is proceeding and the interdependence of all the 50 European countries is growing as regards economic and social development, it is important to get reliable and comparable information on the conditions of health and safety in the Member States. Such information can be used for planning policies and for drawing up programmes for the further advancement of health and safety at work, and thus for the support of balanced socio-economic development of the Region (Figure 2).

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PERFORMANCE INDICATORS O H & S I N D I C A T O R S

ACTION P O L I C Y

ACTION PROGRAMME

ACTION

STATE OF OH & S

ACTION

INDICATORS FOR IMPACT EVALUATION

Figure 2. Use of indicators in policy making and implementation

1.3 Concepts and definitions This document deals with country profiles and national/regional surveillance indicators of occupational health and safety. A country profile on occupational health and safety refers to a combination of (qualitative) descriptions and (quantitative) data on the state and trends of occupational health and safety. Quantitative data are presented in the form of indicators. Indicators may in principle be also qualitative, but in this document we use only quantitative indicators. One example of a country profile is presented in Annex 2. An indicator is a device which indicates some quality, change, etc., of a situation or system, and draws attention or gives warning. While efforts are normally made to quantify indicators, this is not always possible. Moreover, evaluations cannot always be made by aggregating numerical values alone. Qualitative indicators are therefore often used, for example to assess people's involvement and their perception of the health status. WHO has proposed four categories of indicators: health policy indicators ; social and economic indicators ; indicators of health care delivery; and indicators of health status , including quality of life. It should be emphasized that, while indicators help to measure the attainment of targets, they are not in themselves targets. Indicators have to be selected carefully to make sure that they are responsive to current trends of development and that they are useable for the analysis of ongoing activities. When selecting indicators, full account has to be taken of the extent to which they are valid, objective, sensitive and specific. Validity implies that the indicator actually measures what it is supposed to measure. Objectivity implies that even if the indicator is used by different people at different times and under different circumstances, the results will be the same. Sensitivity means that the indicator should be sensitive to changes in the situation or phenomenon concerned. However, indicators should be sensitive to more

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than one situation or phenomenon. Specificity means that the indicator reflects changes only in the situation or phenomenon concerned. Another important attribute of an indicator is its availability, namely, that it should be possible to obtain the data required without undue difficulty (see WHO 1978 in Annex 1). The indicator systems may address different geographical levels spanning from global to enterprise levels (see Figure 1). This document covers indicators of national and regional/provincial levels. Attention has been paid also to the comparative use of national indicators at the international/global level. We do not consider indicators at the enterprise level (HESME indicators) because they differ from national/regional /provincial indicators as to the type of their reference data. Valid HESME indicators require sector-specific reference data, as it is often reasonable to compare the situation in an enterprise only with that of enterprises in the same sector. Indicators are an essential tool in occupational health surveillance which includes workers' health surveillance and work environment surveillance (see ILO 1997 in Annex 1). It is the ongoing systematic collection, analysis, interpretation, and dissemination of data for the purpose of prevention, improving the health, work ability and wellbeing of the labour force. Surveillance is essential for the planning, implementation and evaluation of occupational health programmes, and the control of work-related ill health and injuries, as well as the protection and promotion of the workers' health. Health surveillance involves producing and examining indicators of mortality, work disability/ability, occupational diseases and injuries, other work-related diseases, work absenteeism, occurrence of symptoms, life-style factors, etc. Surveillance of the work environment includes the identification and evaluation of environmental factors which may affect the workers' health. It covers the assessment of sanitary and occupational hygiene conditions, factors in the organization of work which may pose health risks, collective and personal protective equipment, exposure of workers to hazardous agents, and control systems designed to eliminate and reduce them. From the standpoint of the workers' health, the surveillance of the work environment may focus on, but should not be limited to, ergonomics, accident and disease prevention, occupational hygiene in the workplace, work organization, and psycho-social factors in the workplace. The surveillance system includes the capacity for data collection, analysis and dissemination linked to occupational health programmes. It refers to all activities at individual, group, enterprise, community, regional and country levels, to detect and assess any significant departure from health caused by working conditions, and to monitor the workers' general health status. Occupational health surveillance programmes record instances of occupational exposures or work-related illness, injury or death, and monitor trends in their occurrence across different types of economic activities, over time, and between geographical areas. (see ILO 1997 in Annex 1). The surveillance process starts with data collection from various sources (registers, administrative sources, questionnaire-based surveys, expert assessment systems, etc.). The data are usually computerized, analysed statistically and displayed in tabular or graphical forms providing distributions, time trends, means, or other statistics.

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Indicators are one method to present the state of OH&S in a country or region. The data analysis phase is often followed by the interpretation and evaluation of the significance of findings carried out by experts familiar with the subject matter. The process should continue by decision making on direct prevention, dissemination of information, training, research, or other relevant activities. The resources for surveillance are limited as compared to the extent of the field. The approaches and methods applied should therefore be regularly assessed and modified before the next data collection. Ideally the surveillance process is a loop which moves continuously to a more informative and costeffective direction (Figure 3, from Tüchsen 1998, modified). Knowledge Research results Theory Methods

Information resources

Collection of Information

Evaluation

Analysis

Assessment and modification of the surveillance process

Measurements Observations Questionnaires Administrative data

Values Goals Costs Benefits

Initiatives and proposals

Research Education

Case Reports

Prevention

Risk communication Legislation

Figure 3. The surveillance process of occupational health and safety More definitions of concepts and terms related to indicators and surveillance of OH&S are given in Annex 1 of this document.

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2. Indicators and their sources of information 2.1 Choosing indicators 2.1.1 Conceptual model The aim of this approach is to define a set of OH&S indicators applicable in countries with different economic structures, cultures, levels of statistics, etc. The need for wide applicability might lead us to take feasibility (i.e., availability of data) as the starting point. However, such an approach might result in a set of indicators which are not the most relevant and scientifically most valid. An alternative to data-driven indicators is to adopt a concept-driven approach. Concept-driven indicators are developed on the basis of a conceptual framework irrespective of the availability of data. Theory determines an ideal set of indicators which then are operationalized and measured. Concept-driven indicators are primarily sciencebased and valid, whereas data-driven are primarily feasible. An approach of theoretically and methodologically well-grounded indicators was adopted in the development of European social indicators (EUSI system) (Noll 2000a). Our approach is concept-driven as far as possible, but also the availability of data and their comparability across countries are taken into account in the selection of core indicators. Choosing an indicator involves also discussing the policy/normative aims and priorities of OH&S. Indicators should address relevant phenomena in OH&S. WHO has published a list of criteria for checking the relevance of environmental health indicators (Corvalan et al. 1998). Relevant indicators are -

directly related to a specific question of concern related to conditions which are amenable to action easily understood and applicable by potential users available soon after the event or period to which it relates based on data that are available at an acceptable cost-benefit ratio selective, so that they help to prioritize key issues in need of action acceptable to the stakeholders.

The relevance of various OH&S issues varies by country and period. There is a very clear difference as to the relevance of OH&S hazards between the industrialized and developing countries. This is evident from the following priority lists generated at ILO (Takala 2000). Priorities of industrialized countries: -

Stress, overload and pace of work, psychological factors, workplace relations and management Problems caused by aging workforce, maintaining ability to work Right-to-know, right to be informed, hazard communication Chemical substances, carcinogens, asbestos

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-

Ergonomics, repetitive work and musculoskeletal problems Organizational issues and safety and health (quality) management issues Preventive occupational health services, health promotion New technologies.

Priorities of developing countries: -

Agricultural work accounts for 2/3 of manpower and work-related problems Other hazardous sectors, such as mining, construction, fishery, logging, and particularly dangerous occupations Major industrial accidents and fires Traditional accident and safety problems, housekeeping and productivity Occupational diseases, Global Programme on the Elimination of Silicosis Vulnerable groups, in particular, child labour Transfer of technology.

Most of the indicators described in the present document relate to the priorities of the industrialized countries, such as psychosocial, ergonomic and chemical factors, as well as work ability, management issues of OH&S, and occupational health services. The priorities of developing countries gave rise to the indicator on the consumption of pesticides. Also traditional indicators on work accidents and occupational diseases are included among the core indicators. The European Agency for Safety and Health at Work has published a document on priorities and strategies in OH&S policy in the EU countries (EASHW, 1998). In this report the national authorities in OH&S described their views on the present state and future plans concerning the following important national issues: legislation, enforcement/inspection, campaigns, financial incentives, certification, training, risks and risk groups, research, management, strategies, and developments in the labour market. We tried to include most of these areas in our indicators, provided that valid quantitative measures were available. Some of these issues are included in the proposed country profiles as descriptive figures or text. The priority list of hazards by EASHW also influenced our selection of specific core indicators among many alternative hazards. At least four of the 15 EU countries had paid particular attention to the following occupational safety or health hazards: Physical agents - noise - ionizing radiation - vibration Chemical agents - asbestos - chemical agents (general) - lead - carcinogens Safety - machine safety - risk of falling - electrical risks

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Psychosocial risks - stress Ergonomic risks - physical strain/manual handling Also many national bodies have set priorities for OH&S. One of the largest efforts is the NORA (National Occupational Research Agenda) project in the United States where the experts of the National Institute for Occupational Safety and Health (NIOSH) with their partner organizations prioritized 21 research areas. The results of this on-going project are well documented and freely available through the Internet (www.cdc.gov/niosh/ norhmpg.html). Conceptual frameworks for environmental indicators have been developed by OECD, UN Environment Programme, US Environmental Protection Agency and WHO (Corvalan et al. 1998). The WHO model which addresses the driving forces, pressures, state of the environment, exposures, effects and actions (DPSEEA), is rather well applicable also to the area of OH&S. Driving forces (D) in the DPSEEA model refer to demographic, economic and technological factors which influence the occurrence of potential hazards and outcomes. Some examples of them include a decreasing agricultural population, economic growth of telecommunication services and the automation of industrial processes. The driving forces may increase or decrease pressures (P) on working conditions, e.g., production and consumption of chemicals, and their waste releases change. Pressures influence the state (S) of the work environment, e.g., the occurrence of air pollutants, or of stress factors at work change. The changes in the state of the work environment may increase or decrease occupational exposure (E) or strain, which may be measured or assessed as external or internal dose. Exposure may lead to various effects (E) ranging from fatalities to changes in perceived well-being. Action (A) is a wide category of activities which may affect all other parts of the driving forceeffect chain. It includes political measures (e.g., banning of asbestos), introduction of clean technologies (e.g., closed processes), hazard management (e.g., lifting aids), monitoring (e.g., exposure measurements), education (e.g., safety training), awareness raising (e.g., information campaigns) and treatment of health outcomes (e.g., rehabilitation). For the purposes of our project, we present a more simplified model (Figure 4) which describes the domains of our indicators. We include in the OH&S indicators both indicators for known hazardous working conditions and indicators for their known health effects. The third group of indicators consists of measures of the state of OH&S legislation and occupational safety and health management systems. Even though we do not include socio-economic indicators in our indicator set, we are aware that it is important to pay attention also to socio-economic factors, such as the proportion of agriculture in the economy and the degree of automation in industrial processes. Differences as regards to these factors may lead to the need to classify countries into groups according to their socio-economic structure in order to maintain adequacy of the comparisons.

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Socio-economic structure - demography - industries - technologies

Working conditions OH&S policy and infrastructure

Exposure, work load and stress

Health outcomes Figure 4. Conceptual model for OH&S indicators We call indicators, that describe working conditions, exposure indicators . They refer to working conditions and cover the major determinants of OH&S outcomes. Indicators that describe health outcomes we call effect indicators . They refer to all OH&S outcomes in the wide sense of the word. Examples of these classes of indicators are given in Annex 2 of this document. We call indicators that describe OH&S policy and infrastructure prerequisite indicators as they describe the state of the most important factors required for successful performance of national OH&S systems. They concern, e.g., the quality of legislation, coverage of OH&S, characteristics of the occupational health service system and safety inspection system, etc. The state of OH&S policy and infrastructure also has an effect on the availability and quality of exposure indicators and effect indicators. It is possible to construct also ‘hybrids’, i.e., exposure-effect indicators which combine information on the outcomes and their determinants. Examples of such are ‘incidence of work accidents due to falling’ and ‘incidence of occupational diseases due to exposure to asbestos’. These kinds of indicators have been proposed in the area of environmental health (Corvalan et al. 1998). The construction of environmental health indicators requires that a causal relationship is established between exposure and effect. When this relationship is unknown, or one wants to survey all effects of a given exposure or a specific effect of all exposures, ‘pure’ exposure indicators and effect indicators are the only option. The value of exposure-effect indicators is in their ability to indicate also the causal exposure, if preventive measures are needed to reduce the incidence of a harmful outcome. However, ‘pure’ exposure indicators enable also proactive action if the effects of the exposure are known. Our core set of indicators does not include any exposure-effect indicators, although such indicators are often available in national statistics on work accidents and occupational disease. 2.1.2 Validity and comparability Validity refers to the ability of an indicator to describe accurately and precisely the phenomena of concern. The validity of an indicator depends on the completeness of the data and the reliability of its source. Validity aspects of different types of data sources

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are described in more detail in the next chapter on data sources. Briefly, administrative data may lack validity because of incomplete coverage. Interview surveys produce ‘subjective’ data of varying validity depending on the formulation of the questions. Expert assessment systems are often based on measured data and professional judgement. Although the measurements may be accurate and ‘objective’, they may also be selective and unrepresentative of the phenomena in question. Professional judgements are always ‘subjective’ and of varying validity. Sometimes validity can be tested by contrasting information from different sources, or studying a smaller sample carefully (‘golden standard’). Because of the difficulties of measuring validity in surveillance, it has been described merely as a goal which should be reached by defining the studied phenomena and indicators accurately, and by using tested methods whenever possible (Tüchsen 1998). A detailed checklist of validity criteria for environmental health indicators has been published by WHO (Corvalan et al. 1998). The criteria are: -

based on a known linkage between the environment and health sensitive to changes in the conditions of interest consistent and comparable over time and space robust and unaffected by minor changes in methodology/scale unbiased and representative of the conditions of concern scientifically credible, not easily challenged based on data of a known and acceptable quality.

This list is a useful guideline also in the construction of OH&S indicators. Many items of the list can be condensed to the requirement that an indicator should be relevant, valid and feasible. Because this document proposes an indicator set for international use, one component of validity, the comparability of data, is of special interest. Three kinds of comparisons are possible: -

between countries (external reference) between regions within a country (internal reference) within a country or region over time (country/region itself as a reference).

Comparability is generally poor across countries unless the data collection methods and definitions used are the same. The most problematic indicators in this respect are those which are derived by using administrative data, e.g., occupational diseases (see section 2.3.1). The pilot study on the State of Occupational Safety and Health in the European Union (EASHW 2000) looked for the availability and comparability of national data with jointly collected data from the Second European Survey on Working Conditions (ESWC)(see section 2.3.2). National data on 21 different OH&S exposures and outcomes were available in 58% of the cases. National data were in accordance with ESCW data in 20% of the cases. National data could either not be compared with ESWC data (24%), or they were different (14%). This suggests that comparable data from national surveys are available only in the minority of cases. The reasons for incomparability are many. The contents and answering alternatives in two surveys may differ. The sample size and structure, as well as the survey methods (telephone interview vs. personal interview vs. postal inquiry) may influence the results. If surveys are carried out in two countries, also language differences may be of concern. Based on these findings, we consider international surveys preferable to national ones as data

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sources, when the results are compared across countries. National surveys are very valuable in the surveillance of the situation and trends within a country, but their results are rarely applicable to international comparisons. Expert assessment systems, such as CAREX (see section 2.3.3), are usually based on systematic definitions, uniform methodology and standardization by economic structure; this tends to improve comparability across countries. However, also expert assessment systems include a ‘subjective’ component: different experts are likely to come up with different estimates due to varying competence, interpretation of data, and amount of work spent on the assessment. Comparisons between regions within a country are usually easier than between countries, provided that the same definitions and methodology are used to survey all regions. The reference in regional comparisons may be either the mean of the country, or the best (benchmark) and worst regions. If the economic structure of a region differs significantly from that of other regions, the data can usually also be standardized by economic structure. Comparisons over time within a country or region are usually quite well comparable, if the definitions and methodology have remained the same over time. The reference in these comparisons is the country or region itself at an earlier date. The economic structure may have changed, but the change is usually so slow that standardization is not needed.

2.2 Constructing indicators Constructing an indicator means operationalizing the indicator, i.e., defining how to measure the concept behind the indicator. 2.2.1 Types of indicators Indicators may be grouped according to several aspects. For example, they differ in their composition. A simple (non-composite) indicator summarizes information only on one aspect of the phenomena under study. A composite indicator summarizes information on related simple indicators describing the same phenomena. It is usually presented as an index by summing over single indicators which may have similar or different weighting factors (as multipliers). By condensing the data it provides an overall summary of the state of OH&S or one of its sub-areas. The disadvantages of composite indicators are that they cannot be calculated if data on one or more of their components (simple indicators) are missing, and that their construction is judgement- and value-dependent (Briggs 1998). The construction of a composite indicator requires that somebody selects the components to be included and sets weights to them. Both of these processes are subjective, making composite indicators debatable. Some composite indicators are in limited use in OH&S, e.g., work ability index (WAI). Because of their subjective nature, we avoided proposing any composite indicators to be included in our core set of OH&S indicators. Indicators may be divided also by their level of subjectivity into: - objective indicators

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-

subjective indicators.

Objective indicators represent facts that are independent of personal evaluations. Subjective indicators are based on an individual’s perception and evaluation of conditions (Noll 2000b). According to these definitions, most administrative statistics (e.g., statistics on occupational diseases) could be called objective, and data from interview and questionnaire-based surveys subjective. The borderline between objective and subjective is often not clear. Administrative statistics may be based on information observed and interpreted by an individual. Before being recorded in an administrative register, the data may be collected and transferred in several phases involving subjective elements, such as decision on inclusion/exclusion and coding. This makes administrative data ‘semi-objective’. On the other hand, information from interview surveys, although based on the perception of individuals, may also have ‘semi-objective’ features. This is the case especially when a question is simple and the response independent of a person’s opinion. E.g., Were you at work last Sunday? If the questions concern concepts which are complex and may be perceived very differently by the respondents, it is advisable to ‘standardize’ the concept by providing a brief definition to harmonize the responses. Therefore it is better to avoid asking about exposure to noise, cold, vibration, stress, etc., as such, without defining in the question what is meant by these concepts, and what is the minimum level of exposure to be noted. In our core set of indicators we have included both objective and subjective indicators. In the selection of subjective indicators, we have preferred ones which define briefly the concept, if it is suspected to be interpreted variably by the respondents. The object of interest of an indicator may be the whole population or a specific fraction of it. Therefore indicators may also be classified as - total population indicators - risk group indicators. The total population indicators are typically expressed as mean values. They are important because they indicate the total burden of a disease or of an exposure in the population. The distribution of exposure or effect in the population is often uneven in the occupational context. The subgroups which have the highest exposure or incidence of a harmful outcome are of special interest from the point of view of prevention. Therefore indicators may also be tailored to address groups at high risk instead of total population, total employed population, or total exposed population. Most of our proposed indicators address the total (employed/exposed) population. The only exception is the indicator of working hours. Instead of the average working hours of the employed (in hours/week), we propose using the proportion (%) of the employed who work for more than 50 hours/week. The reason for this is that the mean working time is in most countries about the same, and not predictive of any specific hazard. Instead, a very long working time is predictive of burnout, which is one of the priority hazards in post- industrialized countries. Subgroup-specific indicators are closely related to the previous classification (total population/risk group). These indicators may also be called stratified indicators. Data may be stratified, e.g., by industry or occupation, resulting in

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-

industry-specific indicators (sector-specific indicators) occupation-specific indicators gender-specific indicators agent-specific indicators, etc.

Subgroup-specific indicators are usually constructed to identify subgroups at high risk. Therefore they are indispensable in all statistics and other surveillance information in the area of OH&S. They also have another important use: they can be used to standardize data to improve comparability across countries/regions (or over time). If the economic structure of two countries differs greatly, the comparison of indicator data is not informative. Comparability can be improved by comparing only countries with a rather similar economic structure, or by standardizing data by economic structure. One example of this kind of standardization is the CAREX system (see section 2.3.3), where the preliminary estimates of the numbers of workers exposed to carcinogens were first standardized by economic structure of the country and then adjusted by national exposure patterns by experts. It is possible to standardize indicators also in multinational surveys, such as the European Survey of Working Conditions (see section 2.3.2). By first calculating an expected value for a country on the basis of industry-specific mean values of all participating countries, one can then compare countries and see if the indicator value is different from the expected value. We have not included any stratified indicators in our core set. The reason for this is that our proposal is meant to serve simply as the first approach to evaluate the general state of OH&S in a country as regards other countries. However, it is evident that stratified indicators are a necessity in every serious surveillance system of OH&S. 2.2.2 Feasibility The construction of OH&S indicators requires good quality data. These data should be available from international or national sources, or there should a procedure to obtain missing data at a reasonable cost. The availability and quality of European OH&S data have been studied (Nossent et al. 1996). Sixteen countries, including all EU countries and Norway, provided information on the availability of data and on actual data in 1996. There was more data on OH&S outcomes than on working conditions. Data on work accidents were best available (15 countries) followed by general mortality and occupational diseases (12 countries). National data were available for physical exposures (10 countries) and to lesser extent for other working conditions. The report tabulates figures on the availability of data by sex, age, occupation, economic sectors and some other variables. The comparability of data was also crudely assessed and discussed. Since that study, several projects have provided data on the working conditions (ESWC 1997), carcinogen exposure (Kauppinen et al. 2000), work accidents (Eurostat 1997) and occupational diseases (Karjalainen and Virtanen 1998) of 15 EU countries. Probably less data for OH&S indicators are available from countries outside the European Union. Data on OH&S legislation and work accidents worldwide have been collected by ILO (ILO 1999, www.ilo.org). Also WHO has collected information on work accidents, reported occupational diseases and selected exposures from all European countries in the context of Health for All by the Year 2000 programme (WHO 1994). The United States, Canada and many other non-European countries also have administrative recording systems on accidents, occupational diseases, sickness absenteeism and

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mortality. However, comparability of data with the European sources may be questionable. The same is true also as regards non-European surveys: definitions (questions) and methodologies (sample, data collection, coding) are different from the European practice. If OH&S indicator data are missing, there are in principle several ways to try to collect them. Administrative sources (registers, databases) often have their own history and established usage. Their modification to produce data in the form required is difficult and may even require legal changes. Observational surveys on hazards are slow and very resource-demanding, and carrying out such surveys has turned out to be feasible in only a few countries. Questionnaire-based surveys on working conditions have been conducted in most industrialized countries, and they are feasible if the infrastructure of a country allows the sampling of individuals and contacting them personally, by telephone or by mail. Their feasibility in developing countries, however, may be lower due to the lack of accurate population registers, limited number of telephones, illiteracy, and other obstacles. The questions and survey methods should be as well harmonized with the requirements of the indicators as possible. Another feasible approach to collect missing data is the expert assessment system. If no data are available, and surveys and other data collection methods are not applicable, a team of national or international experts could estimate the prevalence of the exposure or burden of the OH&S outcome on the basis of a suitable reference country which has complete good quality data available. An industry-specific approach allows also standardization of data according to the economic structure of the country, and this improves comparability with other countries. The experts can also modify their estimates by taking into account specific exposure or disease patterns prevalent in their countries. Although this procedure produces only estimates, their validity and comparability may be reasonable, especially in regard to the rather limited effort needed to produce them.

2.3 Sources of indicator data This chapter discusses the major sources of indicator data from the point of view of validity and comparability. Illustrative examples of strengths and weaknesses are presented. The main emphasis is on international data sources and harmonization projects, because our view is that they provide more comparable data than national sources. Readers who are interested in national data sources are referred to the European database on OH&S information systems (HASTE 1995, http://www.occuphealth.fi/e/eu /haste). 2.3.1 Administrative registers and statistics Administrative registers maintained by governmental agencies, insurance companies or research institutes typically provide data on the numbers of work accidents and occupational diseases. Their basic purpose is not surveillance. Often they are constructed to support compensation and prevention activities stated in the national legislation. Data on the numbers of accidents or diseases are a by-product of these registers and depend significantly on national regulations, their coverage and recording praxis. On rare occa-

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sions, standard statistics provides also information on production, export and import of hazardous agents (e.g., asbestos, pesticides) which may be useful in the construction of crude national exposure indicators. Some advantages and disadvantages of administrative registers and other similar sources providing standard statistics: Advantages • systematic data collection, often nationwide and based on legal obligation • continuous data collection and production (continuity and stability) • internal comparisons within data often valid and informative for preventive purposes

Disadvantages • coverage often incomplete in spite of obligatory nature of data collection (under-reporting) • restricted to fixed (case) definitions of administrative nature (inflexibility) • comparability across countries often poor • data production often slow

An example: Pilot project on European Occupational Disease Statistics (EODS) A Pilot Project on European Occupational Disease Statistics (EODS) was launched in 1991 to assess the comparability of the data drawn from the existing systems (Karjalainen and Virtanen 1998). Eurostat collected data on recognized occupational diseases in the 15 Member States for 31 selected items of the European Schedule of Occupational Disease for the year 1995. The data did not cover the entire working population for some member states, and for some member states it did not represent recognized cases. A questionnaire was used to clarify the inclusion criteria of mild diseases in general, coding of the medical diagnosis and specific recognition and inclusion criteria of six selected items. Labour Force Survey data were used to build reference populations that would correspond to the total workforce and the workforce that was covered by the recognition/compensation scheme (filtered workforce). The incidence of occupational diseases (31 items) in 1995, as calculated on the basis of total workforce and filtered workforce is presented in the following figure.

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Cases / total workforce

Lu S xe pa m in bo urg Ire lan d Gr ee ce

Cases / filtered workforce

Ita Un l ite Port y d K ug ing al do m

Fin lan Be d lgi De um nm Ge ark rm an Sw y ed en Au str ia Fra nc e

Incidence / 1000 employed

2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0

Figure 5. Incidence of 31 occupational diseases in the member states of the European Union in 1995 (Karjalainen and Virtanen 1998) The main factors restricting comparability were: (1) definition of the reference population, (2) varying inclusion criteria, (3) the coding of the medical diagnosis, and (4) differences in the recognition of mild cases. Definition of the reference population. Self-employed, family workers and workers in certain sectors were not covered or were only partly covered by national recognition systems. The proportion of the filtered workforce and the total workforce is a crude measure of the coverage of the occupational disease statistics. If the coverage is good, incidence is not affected by the selection of the reference population. However, the effect of coverage is not very dramatic because in all EU countries the recognition system covers most of the employed persons. Inclusion criteria. There was variation in the inclusion of specific diseases in the 31 items studied, e.g., the inclusion of asthma, rhinitis and alveolitis in respiratory allergies or pulmonary fibrosis, and the various pleural abnormalities in asbestosis. Coding of the medical diagnosis. Coding by diagnosis in the 31 items studied varied by country. A draft list was proposed according to the ICD classification of WHO. Recognition of mild cases. Some countries recognized occupational diseases at an early stage when they did not yet cause any disability in medical terms, while some member states recognized only cases with a certain minimum level of disability. It was not possible to directly compare the total incidence rates for most of the occupational diseases. This concerned, e.g., noise-induced hearing loss. The authors (Karjalainen and Virtanen 1998) summarize the strengths and weaknesses of the data:

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Strengths of the data. The data on recognized cases of occupational disease represent a high degree of causality. They also provide detailed information on exposure and on medical and social consequences. Such data can be used in the prevention and evaluation of the impact of the problem. Finally most systems offer these data on a continuous and more or less nationwide basis. If the effect of the varying inclusion criteria for severity and type of disease is eliminated by comparing the industry-specific incidence rates after adjustment for the national incidence rate in the pilot data, one can conclude that the risk industries identified by the national systems and the incidence rate ratios are similar in the member states for items in which the number of cases allows statistical comparison. Weaknesses of the data. After the above improvements, two general restrictions remain: (A) The data on recognized occupational diseases reflect not only the occurrence of such diseases, but inevitably also the way in which the concept of an occupational disease has been integrated into the social security system. Questionnaire data on the national recognition criteria of specific items proved to be informative in this regard. (B) The EODS pilot data indicate that underreporting is probable even for some classical occupational diseases, while it is quite clear that statistics on recognized cases do not rapidly identify new health problems. 2.3.2 Questionnaire-based surveys Interview surveys and other questionnaire-based surveys on working conditions are carried out in many countries and areas. They provide valuable information on the prevalence of perceived exposure to some physical agents, ergonomic factors, physiological factors, psychosocial factors, life-style factors, on work ability, and on the occurrence of work-related symptoms. Some advantages and disadvantages of questionnaire-based surveys: Advantages • contents flexible, can be tailored to address issues of current interest • based on a representative sample of population • repeated data collection and production (rather continuous) • comparability rather good across countries, if questions and methods similar • sensitive to changes in working conditions • rather rapid and inexpensive to carry out

Disadvantages • based on subjective perception of working conditions (indirect nature of information) • validity of questions may be unknown • questions may be imprecise and variably understood by respondents (imprecision) and results difficult to interpret • sensitive to context (e.g., economic recession may influence responding)

An example: Second European Survey of Working Conditions (ESWC) The European Foundation for the Improvement of Living and Working Conditions has conducted EU-wide surveys on working conditions in 1991 and 1996. These two surveys produced harmonized and original data on situations and trends in the European Union. The second survey took place in January 1996 and collated the views of 15,800 workers from all over the EU. One thousand workers in 15 Member States of the Euro-

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pean Union were questioned simultaneously about topics relevant to their working conditions. The sample was representative of the working population. This questionnairebased survey involved face-to-face interviews and was conducted outside the workplace. The third survey is in progress. Although the ESWC survey questions were uniform and the data were collected in a similar fashion in every country, comparability of the results was not good for each question. Linguistic issues and responding culture may have influenced the comparability across countries. An illustrative example is exposure to cold (ESWC 1977). The question posed was: How often are you exposed at work to low temperatures either outdoors or indoors. The highest prevalences were reported by Greek (44%) and Portuguese (33%) respondents, whereas, for example, Finnish (19%), Swedish (22%) and Italian (19%) respondents reported less exposure. The reason for these striking differences against the expected result may be linguistic, or due to a different perception of cold, different responding culture, or different clothing against cold. The formulation of the question is so vague as regards ‘low temperatures’ that it may lead to different interpretations of the concept ‘cold’. The linguistic and interpretative contexts in different countries may also influence the responding to questions on psychosocial/ work organizational items. The ‘socioeconomic’ approach (predominant, e.g., in France) focuses on aspects of work organization and functioning of enterprises, whereas the ‘psycho-social’ approach (predominant, e.g., in Scandinavian countries) focuses on the consequences to the workers’ health and wellbeing. Because varying thinking patterns prevail, the same question may be translated by researchers and interpreted by respondents in different ways in two countries (Affichard et al. 1998). The questions in ESWC were developed partly on the basis of questions used in Nordic surveys. The validity of Nordic questions has been comprehensively tested in Sweden (Wikman 1991). The answers of workers to survey questions were compared to the actual conditions at workplaces. The actual conditions were assessed by experts based on measurements (e.g., noise, temperature), observations (e.g., ergonomic factors, outdoor work) and interviews/professional judgements (e.g., psycho-social factors). The questions were divided first into three groups based on their ‘subjectivity’. The first group included questions which were thought to be precise, uniformly interpreted by respondents (concrete) and easy to respond to, based on the experience and observations of the respondents. Typical questions in this group concerned outdoor/indoor work, sitting/standing work, and well-specified questions on ergonomic and physical factors. The second group included more ‘subjective’ questions which were less precisely specified and utilized more abstract concepts. These questions required more complex evaluation by the respondent, but concerned still the concrete work environment or work organization. The third group included ‘subjective’ questions on personal experience and reactions. Typical questions in this group concerned harm or inconvenience perceived by the respondent. The correlation between the answers and actual situation (validation criteria) was higher for the less subjective questions on physical conditions of work. The correlation coefficients for groups 1, 2 and 3 were 0.75, 0.64 and 0.53, respectively. The corresponding correlation coefficients for psychosocial factors were 0.54, 0.41 and 0.24. The best accordance was found for simple questions on indoor work and sitting work, where only 1% of the answers were false positives or negatives.

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Specific questions gave less ‘false’ answers than did the general ones. For example, alternative questions on exposure to high level noise specified by examples provided 6– 17%, but a general question on noisiness 25% and a subjective question on harm due to noise 29% of answers which departed from the actual situation assessed by the experts. The conclusion of the study was that valid questions are simple and based on observations on the work environment or on physical reactions. If the question includes concepts which can be interpreted in different ways by the respondents, it is advisable to illustrate them with examples (e.g., noise, cold, heat, heavy lifting) or to show pictures (e.g., difficult positions). The response scales should also be as specific as possible. For example, it is better to ask for a proportion of time exposed than for a simple answer ‘yes/no’, or ‘always/often/rarely/never’. ESWC data have been used to construct indicators for the work environment in the Member States of EU (Dhondt and Houtman 1997). Most of the EU countries have carried out also their own national surveys, but their methodologies differ so much that the results are not comparable across countries. The long preparatory work on ESWC questions including relevance and validity considerations and the same methods used to collect data in all countries makes ESWC a preferable source for indicator data. On the basis of ESWC and other available data, 56 indicators were defined covering physical exposure, musculoskeletal job demands, information on working conditions, gender equality, and safety and health output. Most of these indicators are based on one or several questions in ESWC. The state of the work environment is indicated usually by the percentage of respondents reporting exposure to an agent or factor for at least ¼ or half of the time. Some indicators are of the sum score type, e.g., percentage of workers exposed to at least two musculoskeletal demands. The indicators were constructed using the methodology of the social indicators project of the European Union. Indicator data are proposed to be included in the HASTE database of the European Foundation for the Improvement of Living and Working Conditions. 2.3.3 Expert assessment systems When administrative sources and questionnaire-based surveys fail to provide reliable information on the prevalence of exposure or on the occurrence of a health outcome, an expert assessment project can be a feasible approach. Such an approach has proven to be useful when estimating specific chemical exposures, which are too numerous to be inquired in questionnaires and difficult to identify by the respondents. The idea is that one expert or a team of experts familiar with national exposure patterns and workforce characteristics estimates the numbers of exposed persons (and their exposure levels) for a country. If the national data are comprehensive and valid, they can be used as reference data for another country having invalid data or lack of data to generate preliminary estimates of numbers of the exposed workers in that country. The experts of that country can then refine these preliminary estimates based on their knowledge of differences between exposure patterns in their own country and the reference country. This approach can also be applied to generate alternative estimates for work accidents and occupational diseases if these are reported incompletely to the administrative sources.

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Some advantages and disadvantages of expert assessment systems: Advantages • based on uniform definitions and methodology • systematic, can be extended to issues and countries where data are missing or unreliable • comparability rather good across countries • rather rapid and inexpensive to carry out

Disadvantages • definitions may be difficult to follow in practice • based partly on degree of knowledge and subjective views of experts • validity of results may remain unknown

An example: International information system on occupational exposure to carcinogens (CAREX) CAREX is an international information system on occupational exposure to known and suspected carcinogens (Kauppinen et al. 2000). The CAREX (CARcinogen EXposure) database, constructed in the mid-1990s with support from the Europe Against Cancer program of the EU, provides selected exposure data and documented estimates on the numbers of exposed workers by country, carcinogen, and industry. CAREX includes data on 139 agents evaluated by the International Agency for Research on Cancer (all agents in Groups 1 and 2A, and selected agents in Group 2B), displayed across the 55 industrial classes of the United Nations system (ISIC Revision 2). The 1990–93 occupational exposure to these carcinogens was estimated for the 15 countries of the EU in two phases. First, estimates were generated automatically by the CAREX system on the basis of national workforce data and exposure prevalence estimates from two reference countries (the United States and Finland). These estimates were then refined by national experts in view of similarity/dissimilarity to the perceived exposure patterns in selected countries. CAREX was recently extended to include estimates also for exposure in Estonia, Latvia, Lithuania and the Czech Republic (see www.occuphealth.fi/list/data /CAREX). The strengths of the CAREX system are its systematic nature, wide coverage and ease of use. CAREX tries to apply basically the same definitions and procedures to each country, which tends to improve the comparability and consistency of the results across countries. It covers all industries in an international classification of industries, and is able to provide both national and industry-specific estimates. CAREX is easy to use in personal computers. The validity of the CAREX estimates was extensively discussed by the planning team before the construction of CAREX, and several measures to improve validity were adopted. First, all estimates were standardized according to the labour force structure of the individual countries. Second, uniform definitions of agents and of occupational exposure, with inclusions and exclusions, were used to improve consistency. Third, preliminary estimates were checked and modified by national experts familiar with the exposure situation in their own country. Fourth, exposures in the reference countries were documented and estimated as specifically (at the sub-industrial level) as possible to provide a sufficient knowledge base for the estimations in other countries. Fifth, industrial hygiene data and descriptive information on exposures were included in the database to support the estimation efforts. Sixth, estimates suspected to represent a low level of occupational exposure were marked to allow their inclusion or exclusion, since low exposures may have a strong effect on the estimated numbers of exposed. Seventh, preliminary estimates for non-reference countries were selected by professional judgement to

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be the most valid out of alternative estimates (alternatives: value based on Finnish prevalence, value based on US prevalence, value based on their mean, own national estimate, no exposure). In spite of these precautions and the aids included in the CAREX system, there were still many validity issues of concern, such as differences in countryspecific use patterns for carcinogens, in the concept of exposure, in national survey protocols, in time frames, in national industrial coding systems (conversion difficulties), and in the assessment of multiple exposures. Omission of country-specific exposure patterns may bias results seriously. One such example is exposure to radon from the ground which is higher in Finland than in most EU countries, possibly resulting in overestimation in other countries if not adequately checked by national experts. Different legislation may lead to great variation in exposure patterns between countries, as in the case of asbestos or passive smoking at work. The adjustment of default estimates to correspond to the national situation turned out to be problematic. The national adjustment resulted in an increase of the total number of workers exposed to CAREX agents in Denmark (+15%) and France (+4%), but a decrease in Italy (-7%) and the Netherlands (-17%). The impact of the adjustment was also agent-specific extending from nil to substantial (e.g., radon). Although national experts were able to adjust the figures to correspond better to the exposure patterns of their countries, it is likely that the adjustments were sensitive to the definition of exposure (e.g., inclusion/exclusion of potential and low exposures) in the survey data and other exposure information used by the experts. The concept of exposure in the reference countries differed. The Finnish protocol required in most cases that non-occupational exposure, measured as annual dose, had to be exceeded, whereas the US protocol addressed potential exposure. The Finnish approach sets the minimum exposure generally at a higher level than the US approach, and therefore results in lower proportions of exposed workers. The survey protocols varied by country. The US data were based on an observational field survey (NOES, see section 2.3.4) and the Finnish data on professional judgement. Both methods have their advantages and disadvantages. The NOES survey was sensitive in identifying exposures, whereas the Finnish procedure often neglected small exposed groups and atypical exposures. However, sometimes the case was the opposite. The time frame of the assessments was not the same for all countries. The reference data from the United States came from a field survey performed in 1981–83. Exposure patterns have probably changed after that in the United States and elsewhere. The Finnish estimates were for the assessment period 1990–93. However, the reference values may have been outdated and their application to the present situation in another country is therefore questionable. Conversions between different industrial coding systems were used in the processing of labour force statistics and US exposure data. The major part of the labour force statistics came from OECD directly in the UN ISIC Revision 2 coding system. However, the OECD data are not coded originally according to UN ISIC but according to national classifications, which are then converted to UN ISIC. Conversions, different definitions of the employed populations included, and estimations of missing values brought some inaccuracy and incomparability to the labour force statistics used in CAREX. The CAREX system applied Finnish values to other EU countries in estimating the degree of multiple exposure. National modifications of multiple exposure multipliers would have been preferable, especially if the exposure patterns were likely to differ significantly from the Finnish one.

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Overall, an approach based on expert assessments, is worthwhile if data from other sources are very unreliable. It can generate rather valid preliminary estimates on the prevalence of exposure or on the occurrence of health outcomes across countries with reasonable effort. However, uniform definitions and procedures need to be applied to improve comparability of data across countries. 2.3.4 Observational surveys Observational surveys at the national level are rare. They are usually very extensive because the variability of working conditions requires large numbers of workplaces to be studied to allow generalizations on the whole labour force. Therefore they also require a substantial amount of organization, expert work and travelling. Their strength is thought to be the reliability of the results because they are based on observations and data interpreted by experts. Some advantages and disadvantages of observational surveys: Advantages • based on uniform definitions and methodology • systematic, based on a representative sample • based on observations of experts and visits to actual workplaces (reliability)

Disadvantages • conceptual definitions may be difficult to apply in practice • based partly on subjective observations • validity may remain unknown • exposure levels difficult to assess • comparability poor across countries • slow and very expensive to carry out

An example: National Occupational Exposure Survey (NOES) The National Occupational Exposure Survey (NOES) was conducted by the US National Institute for Occupational Safety and Health (NIOSH). NOES was a nation-wide observational survey conducted in a sample of 4,490 establishments in 1981–83. The target population was defined as employees working in establishments or job sites in the US employing eight or more workers in a defined list of Standard Industrial Classifications. Generally, these classifications emphasized coverage of construction, manufacturing, transportation, private and business service, and hospital industries. The NOES had little or no sampling activity in agriculture, mining, wholesale/retail trade, finance/real estate, or government operations. NOES addressed recordable potential exposure. A potential exposure had to meet two criteria to be recorded: (1) A chemical, physical or biological agent or a trade name product had to be observed in sufficient proximity to an employee so that one or more physical phases of that agent or product were likely to enter or contact the body of the employee; and (2) The duration of the potential exposure had to meet the minimum duration guidelines (at least 30 minutes/week on an annual average, or at least once per week for 90% of the weeks of the work year). NOES did not address the level of exposure at all. NOES covered about 12,000 different hazards in 523 industrial and 410 occupational classes. Field work was carried out by 15 surveyors between January 1981 and May 1983 (Seta et al. 1988, Greife et al. 1995). The strength of field surveys is that they are based on representative, stratified samples of workplaces, and the resulting data can therefore be used to estimate the numbers of

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exposed workers at the national level. A weakness of field studies is that they usually provide no information on exposure levels, which makes risk assessment and targeting of preventive measures difficult. Subjectivity may also be a problem, especially when low or infrequent exposures are recorded. Field surveys are also laborious, slow and expensive to carry out (Kauppinen and Toikkanen 1999).

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3. Indicators of prerequisites of occupational health and safety 3.1 Occupational health and safety legislation and its coverage Determining the quality of national OH&S legislation with indicators is complicated. However, a country profile should at least describe the relevant legislation. International organizations, such as the ILO and the EU, have set standards for national legislation in their conventions and directives. The most important ILO standards are ILO Convention No. 155 on Occupational Safety and Health (1981) and No. 161 on Occupational Health Services (1985). In Europe also the implementation of EU Council Directive 89/391 /EEC and other related directives could be used as a proxy indicator for the quality and completeness of national legislation. ILO collects information on the ratification of its OH&S conventions in the member countries. Countries which have ratified most of the about 20 ILO Conventions concerning safety and health tend to have the highest legal coverage of OH&S laws and policies (Takala 1999b). The coverage influences the performance of enforcement (e.g., safety inspection system), of the employment injury compensation system (e.g., recording of injuries and diseases), of the OH&S activities at workplaces (e.g., safety committees), and of the occupational health services. While the enforcement of occupational safety and health legislation covers practically 100% in the Nordic countries, the figure for many developing countries is close to 10% or less, leaving major hazardous sectors and occupations uncovered, such as agriculture, small-scale enterprises and the informal sector. The same applies to basic compensation and recording systems in cases of occupational accidents and diseases, and to the coverage of occupational health service systems.

3.2 Coverage of occupational health service system The coverage of occupational health (OH) service may refer to two things: the proportion of employed legally covered by OH services and the proportion of employed having access to the services. Both the extent of the legal coverage of the working population and the actual accessibility to OH services vary greatly worldwide. Over 80% of the workforce in Finland are covered by occupational health services, while 80–90% of the countries in the world have neither ratified the ILO Convention on Occupational Health Services, nor established other mechanisms to provide such services. The WHO estimates that this inaccessibility can be as high as 50% even in industrialized countries (Takala 1999b). Information on the legal coverage of compulsory OH services by industrial sectors can be obtained from the national authorities. This list can be complemented by industrial sectors and occupations, which can obtain voluntary services. It is more difficult to estimate the accessibility of the services. There are countries in which compulsory OH services are restricted to companies employing a certain number of employees, e.g. over 300. It is also possible to limit compulsory services to particular OH services. An exam-

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ple is the United Kingdom, where health examinations in only specific hazardous jobs are compulsory. These exceptions must be noted. Public statistics, expert panels and surveys can be used when estimations are made. We prefer to use accessibility instead of legal coverage as an indicator of the coverage of OH services. Comparable data across countries on the accessibility of OH services can be collected by questionnairebased surveys among the employed. The accessibility, however, does not in itself guarantee that the OH service efficiently provides the appropriate services needed by the customers. Therefore it would be advantageous to have also indicators which describe the performance of OH services, and more widely, the performance of the whole OH&S system.

3.3 Performance and resources of the occupational health and safety system The performance of the OH&S system depends on many factors such as legal base, client needs, adequate financial and human resources, efficient organization and management of service, competence and quality of the services. Again, the inter-country variation is great. For instance, while in Germany a detailed description of the processes and tasks of OH personnel are included in the regulations, in Sweden, most of the services are based on client needs subject to contract negotiations between the OH service providers and the enterprises. Some of the services are more common than others. In a review of multidiciplinary health services in the EU Member States, the two most commonly performed tasks were medical health examinations and risk assessment (Reviews of Multidisciplinary Services in the EU Member States 1996). Curative services that are usually voluntary are included in the services in most of the EU countries, including France, where the OH service is by law strictly preventive. Each service has a different delivery process requiring one or more actors. A list of processes common in OH&S is given in Table 1. Safety inspections refer to inspections at workplaces performed by any kind of labour, factory or safety inspectors. Only one indicator of the management of OH services is listed in Table 1, i.e., quality assurance. Table 1. Key processes in OH&S. A model table for the evaluation of the performance of a national/regional OH&S system. Alternative terms are presented (the most commonly used in bold). Process

Yes/ No

Compulsory / Voluntary

Workplace surveys , workplace visits, exposure assessment, risk assessment and management Health examinations, health surveillance (general & risk-based) Workplace health promotion, health education, counselling

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Actors

No. of actions/ actor

No. of actions / 1000 employed

Assessment of work ability, rehabilitation Curative services First aid, accident management Education, training, information campaigns Quality assurance of OH processes, audits Safety inspections Initiatives and advice for management of workplace safety and health; safe workplace design

Several problems exist in how the listed processes are understood and who is the principal actor in each process. The problem with terms and definitions is illustrated in the table by listing several terms with approximately the same meaning and bolding the terms used most in the English literature on the topic. The capacity ratios are suggested to be used as performance indicators to measure how well employees are actually covered by the services (the number of actions per 1000 employed) and how effectively the services are functioning (the number of actions per actor). The actual content and relevance of actions is not known without further investigation at the national level. These performance indicators of the OH&S system outlined in the two right-side columns of Table 1 are too many to be included in our core set of indicators. The collection of data for them is also complex and would require unambiguous definitions and procedures to guarantee at least reasonable comparability across countries. Instead, it is somewhat easier to indicate the human resources (actors) available to perform these tasks, although the composition of the team of professionals providing the services varies. For example, in the United Kingdom, an occupational health physician or a specialized nurse can act solo. Experts from technical and psychosocial fields are called in when needed. In Denmark, the tasks of the OH teams are directed more towards consulting and assisting the management on technical and organizational aspects of work safety and health. Consequently, the number of OH physicians in the team is low. The services both in Denmark and UK may be called multidisciplinary. The principal actors who perform the tasks listed in Table 1 include occupational health physicians, occupational health nurses, safety inspectors and workplace safety personnel (e.g., safety managers and safety representatives of workers). It is reasonable to count in also actors who do this work part-time instead of including only a limited number of specialists working full-time. As far as possible, the numbers of actors should be presented as full-time equivalents (person years) per 1000 employed. These figures may be available from national registers, by using expert panels, or from national surveys. Sectorial analyses are also possible. The underlining idea and limitation of this approach is that the human resources available reflect the level of activities, regardless of what they are.

3.4 Recommended core indicators of an occupational health and safety system The definitions of core indicators in the domain of the prerequisites of OH&S and the basic reasons to include them are summarized in Table 2. This set represents indicators

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which in our opinion are relevant, valid and feasible. They also have potential for crosscountry comparisons, although data from most countries are missing, with the exception of the ratification of ILO conventions. The sources of data to construct them and methods to generate the missing data are described in section 7 (Recommendations). Table 2. Recommended core indicators of prerequisites of occupational safety and health Indicator

Definition

Ratification rate of relevant ILO key conventions on OH&S (% ratified) Human resources in labour safety inspection (inspectors/ 1000 employed) Human resources in labour safety at workplaces (safety representatives and managers/ 1000 employed) Human resources in occupational health services (physicians and nurses/ 1000 employed) Coverage of occupational health services (% of the employed)

Proportion of ILO conventions relevant to OH&S (N=20) which a country has ratified thus far

Reason for inclusion, comments Indicates the state and coverage of OH&S legislation

Number of all types of labour safety inspectors per 1000 employed workers

Indicates the state of OH&S enforcement

Number of safety representatives of workers and safety managers at workplaces per 1000 employed workers

Indicates the state of OH&S activities of the personnel at workplaces

Number of physicians and nurses (full-time equivalents) in occupational health services per 1000 employed workers Proportion of employed who have access to occupational health services based on a questionnaire-based survey

Indicates the state of occupational health services

Indicates the accessibility of occupational health services

In addition to these core indicators, there are indicators on, e.g., the coverage of the enforcement, of the compensation system and of the OH services, as well as the performance indicators in Table 1, which can be used for the surveillance of prerequisites of OH&S at the national or regional level (see Annex 2).

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4. Indicators of working conditions The text in this section is partly based on a review article by two of the authors (Kauppinen and Toikkanen 1999).

4.1 Physicochemical and ergonomic factors Physicochemical exposures are numerous. Physical agents of occupational importance include noise, hand-arm vibration, whole-body vibration, heat, cold, draught, ionizing radiation and non- ionizing radiation. Thousands of chemical agents may have adverse health effects. These include inorganic dusts (e.g., asbestos), organic dusts (e.g., flour dust), metals (e.g., lead), organic solvents (e.g., benzene) and other organic agents (e.g., many pesticides). Examples of indicators of physicochemical exposures are presented in Annex 2. Microbiological hazards include viruses, bacteria, spores and other micro-organisms. Their exposure indicators are rare. It is more common to survey them through the incidence of infections or communicable diseases. Ergonomic factors relevant to work include inconvenient and difficult work postures, manual handling of burdens (e.g., lifting), repetitive work movements, sedentary work and standing work. Perceived physical work load and work with video display units may also be included among factors which may have physiological effects on workers. Examples of indicators of ergonomic exposures are presented in Annex 2. The next sections describe briefly data sources which are used to construct physicochemical and ergonomic indicators. The major sources are questionnaire-based surveys, occupational hygiene measurement and biomonitoring databases, observational surveys, registers of exposed workers, expert assessment systems, and statistics on consumption. Questionnaire-based surveys Questionnaire-based surveys are a rather common way to collect information on physical, chemical and ergonomic factors at work. Examples of these are the NHANES Survey in the USA, the ESWC Survey in the EU, and national surveys in the Nordic countries. One such survey, the Second European Survey on Working Conditions, has been described earlier (see section 2.3.2). They are a valuable source of information for the surveillance of physical and ergonomic factors, provided that they specify clearly what is meant by exposure. For chemical exposures, they tend to be unspecific and variably interpreted by the respondents by lumping together many chemicals with different effects (e.g., ‘breathing in vapours’ or ‘handling dangerous chemicals’). Some widespread chemical exposures can, however, be reliably identified by the respondents. These include environmental tobacco smoke, engine exhaust, detergents, welding fumes and solvents. The level of exposure cannot be reliably reported by the respondents, but the proportion of working time exposed can be used to distinguish those who are exposed continuously from those who are exposed temporarily. Indicators of exposure to noise, of handling dangerous chemicals, and of handling heavy loads, are based on interview surveys.

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Databases on occupational hygiene measurements and biomonitoring Occupational hygiene measurement databases are maintained in many countries by research institutes, labour safety authorities, or companies (see e.g., Smith and Glass 1993). These databases provide an overview of exposure levels and their trends. However, the information is often based on compliance measurements from a selected sample of workplaces which usually varies from year to year, making the results unrepresentative and difficult to interpret. Large measurement databases are laborious to maintain because of their comprehensive coding requirements. The potential of measurement registers to aid in the identification of work tasks entailing high exposure levels may be insufficiently utilized. This type of ‘alarm’ information is essential for prevention, and its dissemination to workplaces should be promoted. Workplaces also need information on feasible preventive measures to control excessive exposures. Although they are valuable for risk identification and prevention, databases on occupational hygiene and biomonitoring measurements can rarely be used directly in the construction of national exposure indicators. Indicators such as the proportion of measurements exceeding the exposure limit value have been constructed and used, but their interpretation is difficult if the workplace sample is not representative and varies over time. None of the indicators in our proposed core set is based on data from these kinds of registers. Observational surveys Examples of observational field surveys on the occurrence of exposure are the US National Occupational Hazard Survey (NOHS) in 1972–74, the US National Occupational Exposure Survey (NOES) in 1981–83 (Seta et al. 1988, Greife et al. 1995), the SUMER survey in France (Heran Le Roy and Sandret 1996), exposure surveys in Denmark (Brandorf et al. 1995, Seedorf and Olsen 1990) and an on-going survey in Israel. The NOES Survey has been discussed in more detail previously (see section 2.3.4). NOES provides estimates of the numbers of workers potentially exposed by industry, occupation and gender in the United States in 1981–83. However, these estimates are influenced by the definition of potential exposure and its interpretation among field surveyors. Field surveys also require much expert work, and they are difficult to repeat in other countries according to uniform methodology which would improve comparability of the data. The core set of proposed indicators does not include indicators which would require observational surveys. Registers of exposed workers Registers of exposed workers are rare. Some countries have a special register on workers exposed to ionizing radiation, but there is a lack of national or international registers of workers exposed to other hazards. One example of such a register is the Finnish Register on Occupational Exposure to Carcinogens (ASA) (Kauppinen et al. 1992). The objectives of ASA were to stimulate identification, assessment and prevention of carcinogenic exposures at workplaces, to target safety inspections, to enable targeted training and dissemination of information, and to enable national follow-up of occupational cancer risks. The employers are obligated to notify exposed workers annually to a national register. ASA does not focus on true high-risk groups, because the minimum level of exposure is low and inaccurately defined. It is also likely that all exposed workers are not notified. In this sense ASA resembles other administrative registers and

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shares their problems, such as strong dependence on national legislation and notification practices, and incomplete coverage (see section 2.3.1). Expert information systems One international expert information system (CAREX) has been described previously (see section 2.3.3). CAREX utilized data from questionnaire-based surveys (e.g., environmental tobacco smoke), observational field surveys (e.g., NOES and SUMER), an exposure register (ASA) and national expert information systems (e.g., FINJEM). All these data were reviewed and assessed by a team of experts and modified by national experts to generate carcinogen- and industry-specific exposure estimates for the EU countries. Selected CAREX data and figures are shown in Annex 2. Our core set of indicators includes only one indicator on exposure to carcinogens, i.e. the consumption of asbestos per capita. An example of a national expert information system is the Finnish Job-Exposure Matrix (FINJEM Exposure Information System) (Kauppinen et al. 1998). This system provides quantitative information on exposure prevalences, levels, and numbers of exposed workers by period, agent and occupation. FINJEM covers the major chemical, physical, microbiological, ergonomic and psychosocial factors occurring in Finland. It was constructed with the help of about 20 experts who entered relevant background data on the labour force and on exposures to a database, and assessed accurately defined exposures according to a uniform procedure. This database has been used for surveillance purposes, in large epidemiological studies (e.g., in register-linkage studies) and as a general multipurpose databank on exposures. Consumption statistics Statistics on production and trade (export, import) statistics can in some cases provide data for indirect exposure indicators. If annual production, export and import figures are known, domestic consumption can be estimated. One example is the use of asbestos. In 1996 asbestos was produced in more than 16 countries and the production of the 8 main producers varied between 57,000 and 700,000 tons, and asbestos was consumed in about 100 countries (Tossavainen and Takahashi 2000). The annual consumption per capita ranged from zero to 3.4 kg. This indicator has been shown to predict rather well the incidence of asbestos-induced mesothelioma 20–30 years after the consumption (Takahashi et al. 1999). Another example is the annual consumption of pesticides which is a relevant surrogate exposure indicator, especially for developing countries where pesticide poisonings are common. The Food and Agriculture Organization of the United Nations (FAO) collects national data on pesticide use annually by a questionnaire. The data are maintained in a database, but there are some limitations, such as the high rate of non-response (only 50– 60 countries provide data) and unknown comparability (some countries may report the weight of the formulation instead of the active ingredient) (www.fao.org/waicent/ FAOINFO/economic/pesticid.htm). In spite of these limitations we propose the indicator ‘annual pesticide consumption per agricultural worker’ to be included for the moment in the core indicator set. An alternative would be to use an effect indicator instead of exposure indicator. However, official statistics on fatalities and poisonings due to exposure to pesticides are known to be unreliable due to notorious underreporting. Agri-

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cultural workers in many countries are not covered by any employment injury benefit or insurance schemes. The World Health Organization (WHO) has estimated that the total number of cases of pesticide poisonings is 2–5 million, out of which 40,000 are fatal (Forastieri 1999).

4.2 Psychosocial factors Stress and other psychosocial factors are one of the top priorities of OH&S in industrialized countries. They cover, e.g., challenges, social climate, control possibilities, social demands and supervisor support at work. Questionnaire-based surveys are the major source of information on psychosocial factors. The Second European Survey on Working Conditions has been described in the previous chapters (see section 2.3.2). Data for Finland from the EU survey and from national surveys are presented in Annex 2. Psychosocial factors are a challenging area of surveillance where indicators, survey methods and interpretation of results still require research to provide more practical and valid information. The theories and concepts in this area are not yet established, although the validity of different questions has been studied. Psychosocial factors can be classified into two mutually overlapping classes (Tüchsen 1998): 1) workload factors, such as haste at work, difficult decisions, and threat of violence 2) factors which modify the relationship between workload and health outcomes, such as control possibilities and social support at work. Modifying factors may weaken or strengthen the effect of workload factors. The effects of psychosocial stress at work, such as burnout and psychosomatic symptoms, are classified as outcome indicators, and are therefore not covered in this section. We selected ‘working at very high speed’ as the indicator of psychosocial stress at work. This indicator can be derived from one question in the ESWC Survey. Data in Annex 2 suggest that it correlates strongly, e.g., with ‘working to tight deadlines’. An additional advantage of this question is that it is measured as a proportion of working time, which is more uniformly understood by respondents than less specific categories, such as often, sometimes, etc. (see e.g., Wikman 1991).

4.3 Working time arrangements Also working time arrangements (total working time, shift-work, work at night, work on Sundays, flexitime, etc.) may influence the health or social relationships of employees. Data on working time arrangements are usually collected in questionnaire-based surveys on working conditions or in labour force surveys. The general issues related to the validity of one survey, the Second European Survey on Working Conditions, have been discussed previously (see section 2.3.2). Example definitions and data on working time arrangements are presented in Annex 2. We propose one indicator on working arrangements to be included in the core set of OH&S indicators: proportion of the employed working regularly over 50 h/week. There is evidence that regular long workdays increase the risk of exhaustion and burnout (Kalimo and Toppinen 1997) which is one of the OH&S priorities in industrialized coun-

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tries. Especially if a high value for this indicator is combined with a high value for the indicator ‘high-speed work’, burnout may be expected to be a serious problem.

4.4 Life-style of the employed A holistic view of OH&S considers the health of employees to be determined not only by their working conditions, but also by life-style factors. The most relevant lifestyle factors with health effects are tobacco smoking, alcohol consumption, diet and physical activity. Data on these factors usually come from questionnaire-based surveys. Example data for Finnish workers are presented in Annex 2. Some internationally comparable data are also available, but they are not presented in this document (EC 2000). Although life-style factors are relevant to health, we considered them to be outside the scope of the present document. Life-style factors are more important as public health indicators than as OH&S indicators, and we preferred indicators which address directly occupational issues.

4.5 Recommended core indicators of working conditions The definitions of core indicators in the domain of working conditions and the basic reason to include them are summarized in Table 3. This set represents indicators which in our opinion are relevant, valid and feasible. They also have sufficient potential for cross-country comparisons. The sources of data to construct them and the methods to generate missing data are described in section 7 (Recommendations).

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Table 3. Recommended core indicators of working conditions Indicator

Definition

High level noise (% of employed)

Question in survey: How often are you exposed at work to each of the following? (all of the time, almost all of the time, around ¾ of the time, around half of the time, around 1/4 of the time, almost never, never, don't know) • Noise so loud that you would have to raise your voice to talk to people Included if at least around ¼ of the time

Handling dangerous substances (% of employed)

Question in survey: How often are you exposed at work to each of the following? (all of the time, almost all of the time, around ¾ of the time, around half of the time, around 1/4 of the time, almost never, never, don't know) • Handling or touching dangerous products or substances Included if at least around ¼ of the time Reported consumption of asbestos in 1996 per capita

Indicates overall chemical exposure

Consumption of pesticides in 1998 per agricultural worker as reported to FAO

Important toxic group of agents

Question in survey: How often does your main paid job involve each of the following? (all of the time, almost all of the time, around ¾ of the time, around half of the time, around 1/4 of the time, almost never, never, don't know) • Carrying or moving heavy loads Included if at least around ¼ of the time Question in survey: How often does your main paid job involve each of the following? (all of the time, almost all of the time, around ¾ of the time, around half of the time, around 1/4 of the time, almost never, never, don't know) • Working at very high speed Included if at least ¼ of the time Question in survey: How many hours do you usually work per week, in your main job? Included if at least 50 h/week

Important ergonomic factor

Asbestos consumption (kg/capita/y) Pesticide consumption (kg/agricultural worker/y) Heavy loads (% of employed)

Working at very high speed (% of employed)

Working at least 50h/week (% of employed)

Reason for inclusion, comments Important physical hazard

Important carcinogen

Important psychosocial factor

Indicates burnout and workload

In addition to these core indicators, there are many other indicators in this domain which can be used for the surveillance of working conditions at the national or regional level (see Annex 2).

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5. Indicators of occupational health and safety outcomes The text in this section is partly based on a review article by two of the authors (Kauppinen and Toikkanen 1999).

5.1 Accidents at work Accidents at work receive a high priority worldwide, but especially in developing countries. Statistics on occupational injuries and accidents are collected in almost all countries for purposes of worker compensation and prevention. Definitions and notification practices are often based on regulations, and statistics are published annually. The coverage of statistics may be a problem especially when an accident causes only a minor injury leading to a short absence from work or no absence. ILO collects information on fatal and non-fatal work accidents worldwide. A resolution on statistics of occupational injuries was adopted at the 13th International Conference of Labour Statisticians in Geneva in 1982. It defines work accidents as accidents occurring at or in the course of work which may result in death, personal injury or disease (ILO 1999). However, the national definitions may vary. The numbers of work accidents may represent reported or compensated accidents depending on the source of data. The numbers may include also commuting accidents (on the way to or from work), and even occupational diseases. The coverage of data may be limited to certain types of workers (employees, insured persons, full-time workers, etc.), or specific economic activities. The numbers are very much affected by the minimum number of days of absence from work (3 days vs. 1 day vs. no limit). Cross-country comparisons require calculation of incidences (accident rates). They are usually expressed as rates per 1000 or 100 000 employees or persons insured, but they may also be given as rates per million hours worked or per 1000 years of 300 days each. The most commonly available incidence rates are expressed as accidents per 100 000 employees. Fatal accidents are not reported to ILO from all countries of the world. Global figures and rates for fatal accidents have been estimated by ILO (Takala 1999a). In 1994, the estimated total number of fatal occupational accidents was 335,000 and the average incidence was 14.0/100,000 workers. These figures include fatal accidents and traffic accidents at work, but not commuting accidents or fatal health problems at work (e.g., asbestos-induced deaths). The annual incidences ranged between 1 and 44 per 100,000 employees. We propose this indicator to be included in the core set, although comparability across countries is slightly hampered by national differences in definitions, coverage and reporting. Comparability problems of non-fatal accidents are partly the same as for fatal accidents, but an additional problem is related to the seriousness of the accident. It is usually measured as the number of days of absence from work. ILO collects global statistics on

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work accidents, but as for fatal accidents, national definitions and practices vary, resulting in questionable comparability (ILO 1999). The EU has prompted a project which aims at harmonizing European statistics on accidents at work (ESAW)(Eurostat 1997). An accident at work is defined in this project as such that the person is unfit for work for more than 3 calendar days apart from the day of the accident. An accident should occur in the course of work. This includes road traffic accidents at work but not accidents when commuting to or from work. Also deliberate self-inflicted injuries and injuries emanating from strictly natural causes are excluded. Data for ESAW came from insurance-based systems with 100% reporting of compensated cases (except in one country), or from compulsory notification systems with varying reporting levels of notified cases. In some EU countries the reporting systems did not cover some types of professional status (e.g., self-employed, working family members), some branches (e.g., the public sector, parts of the transport sector), or road traffic accidents during work. The ESAW project has produced national incidence rates of accidents at work with more than 3 days of absence per 100,000 employees in 8–9 branches in 15 EU countries in 1994–96. The incidence ranged from 1200 to 7200 per 100,000 employed in 1996 (Eurostat 1997). In spite of limitations and comparability problems, we propose for the moment that the incidence of work accidents as defined by the ESAW project will be included in the core set of OH&S outcome indicators. It is evident that such data are not directly available outside the EU countries, and require an expert estimation approach or standardized data collection effort. An alternative to the collection of harmonized statistics on occupational injuries is to collect questionnaire-based survey data. The Labour Force Survey of the European Union included in 1999 an ad hoc module on accidents at work and occupational diseases. The questions on accidents refer to accidents which caused injuries during the past 12 months at work or in the course of work. Also the type of injury and the time elapsed from the accident to restarting of work are inquired. The results of this study are expected to be published in 2001, and they may provide data for the construction of a valid indicator on work accidents which would be comparable across countries.

5.2 Occupational diseases Occupational diseases are usually regulated in the same way as occupational injuries, and statistics are produced annually in most countries. National legislation, diagnostic practices and notification procedures strongly influence the statistics. Comparability of data across countries is often very poor (Laursen et al. 1992). This was clearly revealed in the pilot project aiming at standardized European Occupational Disease Statistics (see section 2.3.1). The incomparability of data across EU countries was obvious. It is likely that these pilot statistics measure more the coverage of compensation and notification systems than the true incidence of occupational diseases. The value of this kind of comparative statistics is in its ability to reveal gaps in the identification of occupational diseases and to stimulate discussion on the appropriateness of national legislation and practices. Although very difficult to compare across countries, statistics on occupational diseases are important at the national level. Annex 2 provides data on occupational diseases in Finland. Data can be compared between regions within a country, or over time quite accurately, provided that the national system is the same in all regions and remains the

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same over time. Because the risk of occupational diseases varies greatly by industry and occupation, more specific statistics identifying groups at high risk are essential for this kind of statistics. Because occupational diseases are traditionally a high priority outcome in OH&S, we propose including an indicator in our core set. As incidence figures cannot be compared at all across countries, we mention this fact in parentheses in the title of indicator to remind the users of the data. The proposed indicator is the annual incidence of 31 occupational diseases per 100 000 employed. It is evident that such data are not directly available outside the EU, and thus require an expert estimation approach (also within EU countries) or a standardized data collection effort. An alternative to an expert assessment project on occupational diseases would be to collect questionnaire-based survey data. The Labour Force Survey of the European Union in 1999 included an ad hoc module on accidents at work and occupational diseases. The questions on occupational diseases refer to illnesses, disabilities or other physical or mental health problems of the person during the past 12 months, which were caused or aggravated by the work. This definition is wider than the traditional definition of occupational disease which varies considerably by countries. Also the type of health problem, length of the sick leave and some characteristics of work are inquired. It is not yet possible to evaluate whether these questions in the survey could provide data for the construction of a valid indicator of occupational diseases which would be comparable across countries.

5.3 Occupational mortality The statistics on causes of death have been analysed by occupational title at least in the UK, USA, and the Nordic countries. Mortality patterns in different occupations are determined both by occupational and life-style factors. Only in rather rare cases are specific occupational risks so strong that they influence significantly the mortality of an occupational group. An example of such an occupation are insulators whose mortality to mesothelioma is substantially influenced by heavy exposure to asbestos. We do not propose any mortality indicators (except fatal work accidents) to be included in our core set of indicators.

5.4 Occupational disability Pension statistics have been analysed by occupation and diagnosis at least in the Nordic countries (Tüchsen 1998). The work-relatedness of back pain, mental disorders and heart diseases may be studied through work disability data. As with occupational diseases, the state and trends of work disability depend significantly on the national legislation and practices. Because the etiology of work disability is often multifactorial, with both non-occupational and work-related factors contributing to it, work disability addresses only indirectly the effects of work. We do not propose any indicators on work disability because of incomparability problems and the multifactorial nature of the outcomes.

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5.5 Occupational morbidity The concept of work-related diseases includes occupational diseases that are predominantly caused by occupational exposure, and other diseases to whose etiology or development work contributes. Such diseases include musculoskeletal diseases, mental disorders, cardiovascular diseases, respiratory diseases and cancer. The occurrence of workrelated diseases and their determinants (age, gender, occupation, etc.) can be studied by questionnaire-based surveys or from registers (disease-specific registers, hospital discharge registers). Particularly surveillance methods for musculoskeletal symptoms and diseases have been developed during the 1990s (Kuorinka and Forcier 1995). Work-related and occupational diseases may be surveyed in the same way as communicable diseases, through a network of individual health care providers. A system called Sentinel Event Notification System for Occupational Risks (SENSOR) was launched in the 1980s in some states of the USA (Baker 1989). Case reports of work-related conditions are analysed by a central state agency, which also coordinates follow-up and intervention activities to prevent occupational diseases. This approach has been applied, e.g., to silicosis, asthma, pesticide poisoning (Maizlich et al. 1995a), lead poisoning and carpal tunnel syndrome (Maizlish et al. 1995b). The SENSOR approach is an alternative and complementary method to study work-related and occupational diseases if registers and surveys are unsatisfactory. We considered that work-related diseases and occupational morbidity are issues which are still in the research mode, and not directly measurable with established methods to allow indicators to be constructed. Although the SENSOR approach and national register-linkage approaches are able to provide interesting information on work-related morbidity, these systems are at the moment applicable only in a few countries, and they cannot form a basis for indicator data which would be comparable across countries.

5.6 Work ability The mean age of the labour force is increasing in most industrialized countries, and therefore problems caused by aging of the workforce and activities to maintain workers’ ability to work have become a priority in OH&S. Work ability has become an important summarizing concept in the efforts to avoid early retirement of the aging labour force. Work ability may be considered to include not only physical health, psychosocial wellbeing and professional competence of individuals, but also an appropriate work environment and work organization which improve the performance of individuals at work (Ilmarinen 1997). The Work Ability Index (WAI), which is based on a person’s own opinion of his/her work ability, diseases diagnosed by a physician, and sick leave during the past year, has been found to predict future work disability and early retirement (Tuomi et al. 1998, Eskelinen et al. 1991). Work ability can be measured by several questions in surveys (see Annex 2). However, the validity of WAI has not been sufficiently tested yet. There may also be other measures of work ability in preparation. Because of its high priority in OH&S, we propose for the moment that one simple survey question (the most predictive component question) of WAI would be used to indicate the state of the work ability of the employed. Data are probably available only from a limited number of countries which have used the WAI approach or have included this specific question in their national surveys on working conditions. This question is, however, simple and easy to include in questionnaire-based surveys.

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5.7 Work-related health problems and absenteeism due to sickness Work-related symptoms and health problems cover such outcomes as perceived stress, backache, overall fatigue, headache, muscular pain, sleeping disorders, and irritability. Absenteeism from work due to health problems may also be work-related, although non-occupational reasons usually dominate. The Second European Survey on Working Conditions includes a set of questions on work-related health problems and absenteeism (see Annex 2). Analysis of the symptoms reported in questionnaire-based surveys may reveal new or existing risks at work. However, because also non-occupational symptoms are common, attention needs to be given to the collection of precise information on symptom frequency and severity to identify work-related symptoms (Wegman 1994). Due to this confounding by non-occupational factors, the indicators of work-related symptoms at the national level do not address directly OH&S hazards. Absenteeism depends both on work and on other factors, such as age, gender and life-style. Although work-related problems are a useful outcome to follow at the workplace level, we do not recommend any indicators to be included in the core set due to the complex relationship between work and these outcomes.

5.8 Recommended core indicators of occupational health and safety outcomes The definitions of core indicators in the domain of OH&S outcomes and the basic reason to include them are summarized in Table 4. This set represents indicators which in our opinion are relevant, valid and feasible. They also have sufficient potential for cross-country comparisons. The sources of data to construct them and methods to generate missing data are described in section 7 (Recommendations).

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Table 4. Recommended core indicators on occupational health and safety outcomes Indicator

Definition

Fatal work accidents

Cases of fatal accidents and traffic accidents at work per 100,000 employees; does not include commuting accidents and fatal health problems at work Cases of accidents and traffic accidents at work with more than 3 days absence per 100,000 employees; does not include commuting accidents, deliberate self-inflicted injuries or injuries emanating from strictly natural causes Cases of 31 occupational diseases as defined by EU per 100,000 employees

Work accidents

Occupational diseases (incomparable across countries) Perceived work ability (0–10 scale)

Question in survey: Assuming that your work ability at its best is worth 10 points, how many points would you give to your current work ability (scale 0–10)? 0 means that you are not able to work at all.

Reason for inclusion, comments High priority outcome

High priority outcome, data not comparable across countries outside EU

High priority outcome, data not comparable across countries

Basis for a Work Ability Index

In addition to these core indicators, there are many other indicators on this domain which can be used for the surveillance of working conditions at the national or regional level (see Annex 2).

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6. Presentation of indicators The advisory committee of WHO recommended in 1997 a method to visualize the general health status of a population. The method was called the Visual Health Information Profile (VHIP) method (WHO 1997). The core of the method is a multi-dimensional circular radar figure where each dimension represents one indicator. The scale of each dimension ranges from 1 to 10. Value 1 is in the outer circle and represents a situation where urgent improvements are needed. Value 10 is in the centre and represents a good situation. The values representing the health status of a population (national or regional) form a profile within the radar. There may be several profiles within the circle representing the situations between countries, between regions, between two dates, or between a specific region and the country. These profiles allow visual comparisons and evaluations to be made, and a database provides additional information if needed. We adopted the basic idea of the VHIP method, and applied it to the field of occupational safety and health. We call the resulting profiles Work and Health Information Profiles (WHIP). WHIP data can be compared between countries, between the regions within one country, and over time within a country or region. Examples of radar figures which compare the index country (Finland) with other countries, or two periods within the index country, are presented in Annex 2. In cross-country comparisons we have adopted the benchmarking approach so that the best country (benchmark) is closest to the centre of the figure and the worst country closest to the circle. The ‘best’ and ‘worst’ countries vary by indicator and are based only on countries for which indicator data were available. The index country (=country of interest) is shown in the figures between the best and worst country. A commonly available spreadsheet programme (MS Excel) was used to generate figures. Several technical problems were encountered while constructing their visual presentations: -

directionality of indicators scaling of indicator values visualization of great differences between indicators visualization of small temporal changes of an indicator comparing indicators from different dates standardization of values by economic structure presenting missing information presenting incomparable information.

A high value of an indicator may represent a good or a bad state of affairs, depending on the indicator. A high value is good if the prerequisites of OH&S (coverage, resources, etc.) are considered, but bad if hazards or adverse health outcomes are considered. This directionality of indicators means that the benchmark would be variably close to the centre or outer circle of the radar figure if the figure includes indicators whose directionality is different. This would complicate the interpretation of the figure. In order to avoid this we turned the scale around. The visual message is now correct. The turning of the scale is indicated in parentheses in the title of the indicator (e.g., scale 100–0%).

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The scales of indicators may be absolute or proportional. Absolute scales have the advantage of providing information in easily comprehensible terms. For example, the prevalence of hazard in a population is expressed in terms of % of workers exposed. If all prevalences are, say between 5% and 10%, an absolute scale of 0–100% forces the figure close to the very centre of the radar figure, making visual comparisons difficult. If a proportional scale, e.g. 5–10% is used, the values of the best country, index country, and worst country are well spread between the centre and circle, but the values are no longer directly absolute prevalences. A further complication with scaling is that different indicators are expressed in variable units (%, hours per week, cases per 1000, 10,000 or 100,000 employed, or per million, etc.). We therefore compromised between absolute and proportional scales. We used absolute scales (0–100%) when the variability between countries was sufficient (see e.g., Annex 2, Figure on the prevalence of working time arrangements). If the variability was small, a proportional scale was used, as for the average working time, which was scaled between 30 and 50 h/week in the same figure. It was also convenient to cut the upper end of the scale if all indicator values were small. For example, if all figures were below 50%, we set the maximum to 50% to increase the visual spread between the best, index and worst countries (see e.g. Annex 2, Figure on prevalence of exposure to physical and chemical agents). In the incidence figures we also modified the units (e.g., from cases/million hours to cases/10 million hours) in order to have the values in the same absolute scale (see e.g. Annex 2, Figure on incidence of work accidents and occupational diseases). When the unit of the indicator is not %, it is shown in parentheses in the title of the indicator. A special case of scaling concerned situations where the prevalences of related indicators were widely distributed between high and low values (see e.g. Annex 2, Figure on exposure to carcinogens). A radar figure is not very informative in such cases because most values are too close to the centre. For these kinds of cases we recommend using alternative figures. The same information is more clearly presented as vertical (or horizontal) lines where the best and worst countries are at the lower and upper end of the line, and the position of the index country is marked on the line (see the alternative figure on exposure to carcinogens in Annex 2). This presentation visualizes better large differences between related indicators. Figures which describe changes over time (trends) within a country are sometimes also difficult to visualize in radar figures. This is the case when the changes are small but still significant (see e.g. Annex 2, Figure on changes in work ability). The small improvement in the mean value of perceived work ability of the employed is hardly visible in the Figure, even though it is significant. Temporal changes are often better presented by line diagrams. We have included as an example one line diagram on changes in the incidence of major types of occupational diseases over time. Another minor problem with radar figures on temporal trends is that data on different indicators may come from different years. In the figures we have simply omitted these slight inconsistencies of years and referred only to ‘earlier year’ and ‘later year’. Another alternative would have been to give the years in parentheses in the title of the indicator. The indicator figures presented in this document are not standardized by economic structure of the country. Therefore many differences between countries may have natural explanations. For example, the consumption of pesticides per capita is probably low

49

if agriculture is only a minor sector in a country. Sector differences in the risk can be presented, e.g., as horizontal bar figures (see Annex 2, Figure on allergic respiratory diseases by sector). When comparing countries, one could improve comparability by using as reference countries only such countries which have a rather similar economic structure. For example, comparing industrialized countries with developing countries may be inappropriate due to their different economic structure. The World Bank has classified countries to 6 groups by area and to 4 groups by income (gross national product, GNP) which may improve comparability of data when an indicator is significantly correlated with area or income of the country (for the classifications, see www.worldbank.org /data/databytopic/class.htm). Another option to improve comparability is to standardize indicator values by the economic structure of the employed. For example, the prevalence of high-level noise in the EU countries may be standardized by economic structure, and the observed prevalence can be compared with the prevalence expected on the basis of the economic structure of the country (see Annex 2, Figure on exposure to noise by country, from Marklund 2000). When data on an indicator of the index country is missing, we indicate this in parentheses in the title of the indicator. If reference data are missing, the index country is simultaneously the best and worst country. If the current data are essential but incomparable across countries, as for occupational diseases, the incomparability is indicated in parentheses in the title. For the core set of indicators we have presented two different profile figures: a multidimensional radar figure, and a proportional vertical bar figure. In the bar figure zero represents the worst country and 100 the best country.

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7. Recommendations 7.1 Proposed core set of indicators The criteria of a good core set of indicators to describe the state of OH&S in a country or region are the following (Noll 2000b, modified): -

consistency (indicators well-defined, valid and comparable) non-redundancy (each indicator addresses a different issue) comprehensiveness (indicators cover all relevant areas of OH&S) parsimoniousness (indicators are as simple as possible, and not too many).

Our selection of proposed core indicators is presented in Table 5. The reasons for inclusion of the indicator and its definition are described in the preceding, domain-specific chapters. We consider all proposed indicators as relevant for OH&S, and many of them address high priority issues predominantly in industrialized countries. Their validity is generally good in the defined form, and most of them provide rather comparable data across countries. Comparability is a serious problem for the indicator on occupational diseases, and problematic for indicators on prerequisites of OH&S (except ILO ratifications), pesticide consumption and work accidents. Our set was also planned to be nonredundant and parsimonious. The set contains only simple (non-composite) indicators and is limited to 16 key indicators. We decided to avoid composite indicators because they require complete data on component indicators which are usually not available, and judgment on the weights of component indicators which is subjective and therefore debatable. Our set therefore became incomprehensive. By selecting only the most relevant simple indicator from one area (e.g., high level noise to represent physical agents), our approach omits other indicators of the area which may be significant at the national level (e.g., cold, heat, etc.). Another implication of this approach is that countries cannot be directly ranked by the overall state and performance of the OH&S system according to this set of indicators. The ranking would require construction of an algorithm which summarizes information (and lack of information) from different indicators into one index. The core set proposed in this document is just a crude comparative tool to evaluate the state of OH&S in a country/region in regard to other countries/regions. Therefore more detailed indicator sets and surveillance methods should be used at the national/regional/ provincial level to identify risks and problems in OH&S aiming at effective prevention of adverse health outcomes and improvement of the health of workers. Therefore also the construction of more comprehensive country profiles including essential descriptions and indicator data is highly recommended.

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Table 5. Recommended core indicators on occupational health and safety DOMAIN/indicator OH&S SYSTEM Ratification of ILO OH&S conventions (% of conventions) Human resources in labour safety inspection (inspectors/ 1000 employed) Human resources in labour safety at workplaces (safety representatives and managers/ 1000 employed) Human resources in occupational health services (physicians and nurses/ 1000 employed) Coverage of occupational health services (% of the employed)

Source of information

Availability of data

Collection of missing data

ILO

most ILO countries limited

by ILO

national statistics or estimates

limited

by expert assessment

national statistics or estimates

limited

by expert assessment

national statistics or estimates

by expert assessment

national limited questionnaire-based surveys

by expert assessment or questionnairebased survey

EU surveys

15 EU countries

Handling dangerous substances (% of employed)

EU surveys

15 EU countries

Asbestos consumption (kg/capita/y) Pesticide consumption (kg/agricultural worker/y)

national statistics or estimates national statistics or estimates

Heavy loads (% of employed)

EU surveys

most countries around 60 FAO countries 15 EU countries

Working at very high speed (% of employed)

EU surveys

15 EU countries

Working at least 50h/week (% of employed)

EU surveys

15 EU countries

by questionnaire-based surveys by questionnaire-based surveys by expert assessment by FAO, or by expert assessment by questionnaire-based surveys by questionnaire-based surveys by questionnaire-based surveys

national statistics

most countries EU countries

WORKING CONDITIONS High-level noise (% of employed)

OH&S OUTCOMES Fatal work accidents Work accidents

national statistics or estimates

Occupational diseases (incomparable across countries)

national statistics or estimates

52

most countries

by ILO by ILO, by expert assessment, or by questionnairebased surveys by expert assessment, or by questionnaire-based

Perceived work ability (0–10 scale)

national surveys

53

very limited

surveys by questionnaire-based surveys

Table 6. Data for recommended core indicators on occupational health and safety, Finland as an example country DOMAIN/indicator

Best Index coun- country try

Worst Reference coun- countries try

Remarks

90

80

0

scale 100–0 %

Human resources in labour safety inspection (inspectors/ 1000 employed) Human resources in labour safety at workplaces (safety representatives and safety managers/ 1000 employed) Human resources in occupational health services (physicians and nurses/ 1000 employed) Coverage of occupational health services (% of the employed) WORKING CONDITIONS High-level noise (% of employed) Handling dangerous substances (% of employed) Asbestos consumption (kg/capita/y) Pesticide consumption (kg/agricultural worker/y) Heavy loads (% of employed)

0.20

0.16

0.05

ILO member states (ca. 180) 7 European countries

-

11

0

Finland only

scale 15–0

1.2

1.2

0.1

7 European countries

scale 1.5–0

87

87

10

7 European countries

scale 100–0 %

21

39

39

scale 0–50 %

10

18

32

0

0

3.4

0

12

181

EU member states (N=15) EU member states (N=15) all countries (over 200) FAO (N=54)

24

38

40

scale 0–50 %

Working at very high speed (% of employed) Working at least 50h/week (% of employed) OH&S OUTCOMES Fatal work accidents (/100,000 employed)

37

71

71

8

13

38

EU member states (N=15) EU member states (N=15) EU member states (N=15)

1.4

3.2

43.7

scale 0–50/ 100,000

Work accidents (/1000 employees) Occupational diseases (/1000 employees, incomparable across countries) Perceived work ability (0–10 scale)

13

35

73

0.02

1.7

1.7

ILO member states (ca. 180) EU member states (N=15) EU member states (N=15)

-

8.0

-

Finland only

scale 9–7

OH&S SYSTEM Ratification of ILO OH&S conventions (% of conventions)

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scale 0.2–0

scale 0–50 % scale 0–4 kg scale 0–200 kg

scale 0–100 % scale 0–40 %

scale 0–100/ 1000 scale 0–2/1000

Two alternative WHIP figures based on the above data are shown on the following pages. Note that data are very scarce for some of the indicators (Table 6); these figures are shown only as illustrative examples of the core indicators of OH&S.

7.2 Other proposals Our analysis and proposal on core indicators is preliminary by nature. The feasibility of this indicator set and approach is unknown apart from Finland which was used as a test country in the preparation of this document. The process of constructing OH&S indicators and related data collection can be outlined to proceed through the following stages: 1) Preliminary analysis of sources of data for national OH&S indicators and country profiles (included in this document) 2) Preliminary proposal on national core OH&S indicators (included in this document) 3) Piloting of national core OH&S indicators in selected countries (test of feasibility) 4) Evaluation of national core OH&S indicators (relevance, validity) and of data collection procedures (feasibility) by group(s) of experts 5) Proposal on final national core OH&S indicators, and on data collection procedures by group(s) of experts.

The proposed set of key indicators should first be discussed and, if appropriate, modified by interested parties. The next step could be testing of the feasibility of the core set of OH&S indicators in some countries. The piloting could take place, for example, in one EU country, in one EU candidate country, in one newly industrialized country, and possibly in one developing country. It is already known that the availability of indicator data varies from very good to very limited (see Table 5). Our aim was to include relevant and valid indicators, for which data are either available, or can be made available with reasonable effort. A substantial part of the missing data can be collected by adding a simple question (as defined in this document) in national questionnaire-based surveys. This may be rather easy in countries where questionnaire-based surveys are established, but difficult in countries without a tradition and sufficient infrastructure for carrying out such surveys. Another major approach to collect missing data is expert assessment (see section 2.3.3). This method requires a team of experts which plans a suitable estimation procedure and contacts national focal points which can provide national information needed in the estimation. National experts can also check the results of the estimation, modify them, and interpret them together with the international expert team. Expert assessment projects could be organized, e.g., by WHO/EURO, EU/Bilbao, EU/Dublin, WHO or ILO which all have networks of national focal points. If piloting and evaluation suggest that this kind of an indicator set is useful and feasible, the project could continue by construction of an international database, data collection for indicators from focal points, expert assessment efforts to generate missing data, organization of questionnaire-based surveys in selected countries, and reporting and dissemination of information through the Internet.

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ANNEX 1. Compiled concepts and terms coverage: A measure of the extent to which the services rendered covered the potential need for these services in a community. It is expressed as a proportion in which the numerator is the number of services rendered, and the denominator is the number of instances in which the service should have been rendered. (see Last 1988) criterion: A criterion is a standard by which something is judged, and may be technical or social. A technical criterion for the safety of drinking-water would be a certain technical standard for water purity; a social criterion for the suitability of drinking-water would be the acceptance of its taste by the people for whom it is intended. (WHO 1984) demography : The study of populations, especially with reference to size and density, fertility, mortality, growth, age distribution, migration, and vital statistics, and the interaction of all these with social and economic conditions. (see Last 1988) health: Is defined in the Preamble of the Constitution of the WHO as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. In 1978, WHO-EURO referred to health as a dynamic process which depends largely on the individual capacity to adapt to the environment; to be healthy means to maintain an intellectual and social activity despite any disorders or handicaps. (see ILO 1997) health care: Those services provided to individuals or communities by agents of the health services or professions, for the purpose of promoting, maintaining, monitoring, or restoring health. Health care is broader than, and not limited to medical care, which implies therapeutic action by or under the supervision of a physician. The term is sometimes extended to include self-care. (see Last 1988) health indicator: A variable, susceptible to direct measurement, that reflects the state of health of persons in a community. Examples include infant mortality rates, incidence rates based on notified cases of disease, disability days, etc. These measures may be used as components in the calculation of a health index. (see Last 1988) health services: Services that are performed by health care professionals, or by others under their direction, for the purpose of promoting, maintaining, or restoring health. In addition to personal health care, health services include measures for health protection and health education. (see Last 1988) health statistics : Aggregated data describing and enumerating attributes, events, behaviours, services, resources, outcomes, or costs related to health, disease, and health services. The data may be derived from survey instruments, medical records, and administrative documents. Vital statistics are a subset of health statistics. (see Last 1988) indicator: A thing that serves to give an indication or suggestion of something else; A device which indicates the condition of a machine etc.; which draws attention or gives warning, Something used in a scientific experiment to indicate some quality, change, etc. (see Oxford 1993)

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If the aim of the programme is to train a number of auxiliary workers annually, the number of workers trained each year is a direct – or output – indicator. If the aim is to improve child health, several indicators could be used, such as nutritional status, psychosocial development, the immunization rate, or the morbidity and mortality rates. While efforts are normally made to quantify indicators , this is not always possible. Moreover, evaluations cannot always be made by aggregating numerical values alone. Qualitative indicators are therefore often used, for example, to assess people's involvement and their perception of their health status. WHO has proposed four categories of indicators: health policy indicators ; social and economic indicators ; indicators of health care delivery; and indicators of health status , including quality of life. It should be emphasized that, while indicators help to measure the attainment of targets, they are not in themselves targets. Indicators have to be selected carefully to make sure that they are responsive to current trends of development and that they are useable for the analysis of ongoing activities. When selecting indicators, full account has to be taken of the extent to which they are valid, objective, sensitive and specific. Validity implies that the indicator actually measures what it is supposed to measure. Objectivity implies that even if the indicator is used by different people at different times and under different circumstances, the results will be the same. Sensitivity means that the indicator should be sensitive to changes in the situation or phenomenon concerned. However, indicators should be sensitive to more than one situation or phenomenon. Specificity means that the indicator reflects changes only in the situation or phenomenon concerned. Another important attribute of an indicator is its availability, namely that it should be possible to obtain the data required without undue difficulty. (see WHO 1978) medical data: Are those data collected for medical purposes, i.e., for the purpose of practising medicine; such data are those collected by a physician or by a health professional (for instance, a nurse or a paramedic) working under a physician's responsibility and should only be used for medical purposes. (see ILO 1997) monitor: Something that serves to remind or give warning; to oversee, supervise, or regulate; to watch closely for purposes of control, surveillance, etc.; keep track of; check continually. (see Webster 1996) notifiable disease: A disease that, by statutory requirements, must be reported to the public health authority in the pertinent jurisdiction when the diagnosis is made. (see Last 1988) occupational health: Since 1950, the ILO and WHO have had a common definition of occupational health, revised in 1995: Occupational health should aim at: the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities; and, to summarize, the adaptation of work to man and of each man to his job.

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The main focus in occupational health is on three different objectives: (i) the maintenance and promotion of workers' health and working capacity; (ii) the improvement of working environment and work to become conducive to safety and health; and (iii) development of work organizations and working cultures in a direction which supports health and safety at work and in doing so also promotes a positive social climate and smooth operation and may enhance productivity of the undertakings. The concept of working culture is intended in this context to mean a reflection of the essential value systems adopted by the undertaking concerned. Such a culture is reflected in practice in the managerial systems, personnel policy, principles for participation, training policies and quality management of the undertaking. (see ILO 1997) occupational health care: Refers to the care of the health of workers. It includes preventive health care, health promotion, curative health care, first aid, rehabilitation and compensation, where appropriate, as well as strategies for prompt recovery and return to work. (see ILO 1997) occupational health data: Are those data collected for occupational health purposes; such data are collected by an occupational health professional. Minimum requirements should be established with regard to sensitive health data which should be covered by medical confidentiality. (see ILO 1997) occupational health professionals: Are persons who have been accredited through appropriate procedures to practise a profession related to occupational health or who provide occupational health services according to the provisions of relevant regulations. Occupational health professionals include all those who by profession carry out occupational safety and health activities, provide occupational health services or who are involved in occupational health practice, even if only occasionally. They may be occupational health physicians, nurses, occupational safety and health inspectors, occupational hygienists, occupational psychologists and specialists involved in ergonomics, accident prevention and the improvement of the working environment, as well as in occupational health and safety research. Many others, in addition to occupational health and safety professionals, are involved in the protection and promotion of the health of workers, e.g. management and workers' representatives. (see ILO 1997) occupational health services: services entrusted with essentially preventive functions and responsible for advising the employer, the workers and their representatives in the undertaking on the requirements for establishing and maintaining a safe and healthy working environment which will facilitate optimal physical and mental health in relation to work and the adaptation of work to the capabilities of workers in the light of their state of physical and mental health. (ILO Convention No. 161, see Rantanen & Fedotov 1998) occupational health services, functions of: The ILO Convention No. 161 specifies that occupational health services should include those of the following functions that are adequate and appropriate to the occupational risks at the worksite: - identification and assessment of the risks from health hazards in the workplace; - surveillance of the factors in the working environment and working practices which may affect workers’ health, including sanitary installations, canteens and housing where these facilities are provided by the employer;

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- advice on planning and organization of work, including the design of workplaces, on the choice, maintenance and condition of machinery and other equipment and on substances used in work; - participation in the development of programmes for the improvement of working practices, as well as testing and evaluation of health aspects of new equipment; - advice on occupational health, safety and hygiene and on ergonomics and individual and collective protective equipment; - surveillance of workers’ health in relation to work; - promoting the adaptation of work to the worker; - contributing to measures of vocational rehabilitation; - collaborating in providing information, training and education in the fields of occupational health and hygiene and ergonomics; - organizing first aid and emergency treatment; - participating in analysis of occupational accidents and occupational diseases. (see Coppée 1998). occupational health practice: Consists not only of the activities performed by the occupational health service. It is multidisciplinary and multisectoral activity involving in addition to occupational health and safety professionals other specialists both in the enterprise and outside, as well as competent authorities, the employers, workers and their representatives. Such involvement requires a well-developed and well- coordinated system at the workplace. The necessary infrastructure should comprise all the administrative, organizational and operative systems that are needed to conduct the occupational health practice successfully and ensure its systematic development and continuous improvement. (see Rantanen & Fedotov 1998) occupational health surveillance: Is the ongoing systematic collection, analysis, interpretation, and dissemination of data for the purpose of prevention. Surveillance is essential to the planning, implementation and evaluation of occupational health programmes and control of work-related ill health and injuries and the protection and promotion of workers' health. Occupational health surveillance includes workers' health surveillance and working environment surveillance. (see ILO 1997) occupational health surveillance system: Is a system which includes a functional capacity for data collection, analysis and dissemination linked to occupational health programmes. It refers to all activities at individual, group, enterprise, community, regional and country levels to detect and assess any significant departure from health caused by working conditions and to monitor workers' general health. Occupational health surveillance programmes record instances of occupational exposures or work-related illness, injury or death and monitor trends in their occurrences across different types of economic activities, over time, and between geographical areas. (see ILO 1997) occupational health and safety: (Syn: occupational safety and health) Is the discipline dealing with the prevention of work-related injuries and diseases as well as the protection and promotion of the health of workers. It aims at the improvement of working conditions and environment. Members of many different professions (e.g., engineers, physicians, hygienists, nurses) contribute to occupational safety, occupational health, occupational hygiene and improvement of the working environment. (see ILO 1997)

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parameter: In mathematics, a constant in a formula or model; in statistics and epidemiology, a measureable characteristic of a population. (see Last 1988) periodic medical examinations : Assessment of health status conducted at predetermined intervals, e.g., annually or at specified milestones in life such as preemployment, or preretirement. This form of medical examination generally follows a formal protocol, e.g., employing a set of structured questions and/or a predetermined set of laboratory tests. (see Last 1988) primary health care: Health care that begins at the time of first encounter between a patient and a provider of health care; An alternative terms is primary medical care. The WHO definition of primary health care includes much more: Primary health care is essential health care made accessible at a cost the country and the community can afford, with methods that are practical, scientifically sound, and socially acceptable. Everyone in the community should have access to it, and everyone should be involved in it. Related sectors should also be involved in it in addition to the health sector. At the very least is should include education of the community on the health problems prevalent and on methods of preventing health problems from arising or of controlling them; the promotion of adequate supplies of food and of proper nutrition; sufficient safe water and basic sanitation; maternal and child health care including family planning; the prevention and control of locally endemic diseases; immunization against the main infectious diseases; appropriate treatment of common diseases and injuries; and the provision of essential drugs. (see Last 1988) profile: A verbal, arithmetical, or graphic summary or analysis of the history, status, etc., of a process, activity, relationship, or set of characteristics: a biochemical profile of a patient's blood; a profile of national consumer spending; a set of characteristics or qualities that identify a type or category of person or thing (see Webster 1996) public health: Public health is one of the efforts organized by society to protect, promote, and restore the people's health. It is the combination of sciences, skills, and beliefs that is directed to the maintenance and improvement of the health of all the people through collective or social actions. The programmes, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole. Public health activities change with changing technology and social values, but the goals remain the same; to reduce the amount of disease, premature death, and diseaseproduced discomfort and disability in the population. Public health is thus a social institution, a discipline, and a practice. (see Last 1988) qualitative data: Observations or information characterized by measurement on a categorical scale, i.e., a dichotomous or nominal scale, or, if the categories are ordered, as ordinal scale. Examples are sex, hair colour, death or survival, and nationality. (see Last 1988) register, registry: In epidemiology the term "register" is applied to the file of data concerning all cases of a particular disease or other health-relevant condition in a defined population such that the cases can be related to a population base. With this information incidence rates can be calculated. If the cases are regularly followed up, information on remission, exacerbation, prevalence, and survival can also be obtained. The register is

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the actual document, and the registry is the system of ongoing registration. (see Last 1988) risk: The probability that an event will occur, e.g., that an individual will become ill or die within a stated period of time or age. Also, a non technical term encompassing a variety of measures of the probability of a (generally) unfavourable outcome. (see Last 1988) Exposure to the chance of injury or loss. (see Webster 1996) risk assessment: The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. (see Last 1988) risk factor: An aspect of personal behaviour or lifestyle, an environmental exposure, or an inborn or inherited characteristic, which on the basis of epidemiological evidence is known to be associated with health-related condition(s) considered important to prevent. (see Last 1988) risk indicator: An attribute that is associated with an increased probability of occurrence of a disease or other specified outcome and that can be used as an indicator of this increased risk. Not necessarily a causal factor. (see Last 1988) risk management: The steps taken to alter, i.e., reduce, the levels of risk to which an individual or a population is subject. (see Last 1988) safety: The state of being safe; freedom from the occurrence of risk or injury, danger, or loss; the quality of averting or not causing injury, danger, or loss. (see Webster 1996) standard: Something that serves as a basis for comparison; a technical specification or written report drawn up by experts based on the consolidated results of scientific study, technology, and experience, aimed at optimum benefits and approved by a recognized and representative body. (see Last 1988) standardization: A set of techniques used to remove as far as possible the effects of differences in age or other confounding variables, when comparing two or more populations. (see Last 1988) survey: An investigation in which information is systematically collected but in which the experimental method is not used. (see Last 1988) surveillance of the working environment: A generic term which includes the identification and evaluation of environmental factors which may affect workers' health. It covers assessments of sanitary and occupational hygiene conditions, factors in the organization of work which may pose risks to the health of workers, collective and personal protective equipment, exposure of workers to hazardous agents and control systems designed to eliminate and reduce them. From the standpoint of workers' health, the surveillance of the working environment may focus on, but not be limited to, ergonomics, accident and disease prevention, occupational hygiene in the workplace, work organization, and psycho-social factors in the workplace. (see ILO 1997) validity: The property of being genuine, a true reflection of attitudes, behaviour, or characteristics. A measure (such as a question, series of questions, or test) is considered valid if it is thought to measure the concept or property which it claims to measure. (There are many different definitions of validity in the available literature. (see Marshall 1998)

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variable: Any attribute, phenomenon, or event that can have different values. (see Last 1988)

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List of sources: Coppée G. Occupational health services and practice. In: Encyclopaedia of Occupational Health and Safety. Fourth edition. Volume I. Ed. Jeanne Mager Stellman. International Labour Office, Geneva 1998:16.18–16.22. Development of health programme evaluation: Report by the Director-General. Geneva, World Health Organization, 1978 (document A31/10). Glossary of Terms used in the "Health for All" Series No. 1–8. Health for All Series, No. 9, World Health Organization, Geneva 1984, 36 p. Last John M (ed). A Dictionary of Epidemiology. Second edition. Oxford University Press, New York 1988, p. 141. Marshall, Gordon (ed). A Dictionary of Sociology. Oxford University Press, Oxford 1998. Rantanen J, Fedotov I. Standards, principles and approaches in occupational health services. In: Encyclopaedia of Occupational Health and Safety. Fourth edition. Volume I. Ed. Jeanne Mager Stellman. International Labour Office, Geneva 1998:16.2–16.18. Technical and Ethical Guidelines for Workers' Health Surveillance Report. International Labour Organisation, Geneva, 2–9 September 1997. http://www.ilo.org/public/english/protection/ safework/health/whsguide.htm. The New Shorter Oxford English Dictionary. Volumes 1–2. Brown, Lesley (ed). Clarendon Press, Oxford 1993, p. 3801. Webster's Third New International Dictionary: Unabridged. Gove, Philip Babcock (ed). Merriam-Webster Inc., Springfield 1986, p. 2662.

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ANNEX 2. An example of a country profile: Finland (draft) Basic information on Finland and its health system The basic country information of this annex is mainly from Leino et al. 2000.

Area and population

Finland has been an independent republic since 6 December 1917. The population of Finland is 5.1 million and the area 338 000 km2 (population density 15 per km2 ). 63% of the population live in urban areas. The capital city is Helsinki (540 000 habitants), and the official languages are Finnish (spoken by 93% of the population) and Swedish (6%). The country is divided into five provinces and 455 municipalities.

Table 1. Population statistics of Finland in 1998 Population (million) Men (%) Women (%) Labour force (million) Employed (million) Men (%) Women (%) Unemployed (million) Unemployment (%) Live births per 1000 population Deaths per 1000 population

5.160 2.516 2.644 2.507 2.222 52.8 47.2 0.285 11.4 11.1 9.6

SOURCE: Labour force survey 1998. Population statistics. Statistics Finland, Helsinki, 1999.

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Economy Table 2. Selected economic indicators of Finland FIN Gross national product (GNP) per capita (in USD) 1996 23240 Gross domestic product (GDP) per capita (purchasing power parity in 17417 USD) 1994 GDP produced by agriculture, hunting, forestry and fishing (%) 4.4 GDP produced by industry and construction (%) 35.4 GDP produced by services (%) 60.2 Export as % of GDP 37.7 Import as % of GDP 29.7 Inflation rate (%) 1.2

EUR-15 NA NA 2.3 30.7 67 29.8 27.6 1.7

SOURCES: Health in Europe 1997, WHO Regional Publications, European Series, No 83, annex 1. FINLAND: GDP (%) figures from Statistical Yearbook of Finland, Helsinki 1998 REMARKS: NA = data not available

The Finnish economy has improved continuously after an economic recession in the early 1990s. In 1997, Finland imported mainly mechanical appliances (15%), electrical machinery and equipment (14%), mineral fuels and oils (10%) and automobiles and bicycles (8%). The major export commodities were paper and paperboard (21%), electrical machinery and equipment (18%), mechanical appliances (14%) and wood and wood articles (6%).

Labour force Table 3. The employed by industry in Finland in 1997 Industry

N (1000) Agriculture, hunting and forestry 150 Fishing 2 Mining and quarrying 6 Manufacturing 436 Electricity, gas and water supply 22 Construction 130 Wholesale and retail trade; repair of motor vehicles, motorcycles and 263 personal and household goods Hotels and restaurants 66 Transport, storage and communication 164 Financial intermediation 48 Real estate, renting and business activities 192 Public administration 133 Education 146 Health and social work 310 Other community, social and personal service activities 116 Private households with employed persons 4 Extra-territorial organizations and bodies 7 Not classifiable 0 TOTAL 2195 SOURCES: ILO Yearbook of Labour Statistics 1998. REMARKS: NA = data not available

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% 7 0.1 0.3 20 1 6 12 3 7 2 9 6 7 14 5 0.2 0.3 0

According to the labour force data, forestry and logging, paper industry, recreational and cultural services, wood industry, water transport, manufacture of petroleum and coal products, welfare institutions, petroleum refineries and metal ore mining employed proportionally at least 50% more workers in Finland than in the EU on average. On the other hand, coal mining, production of petroleum and natural gas, pottery industry, footwear industry, leather industry, rubber industry, wearing apparel industry, textile industry, personal and household services and fishing employed only 50% or less of the mean in the EU. The average hourly labour costs in industry were ECU 20.3 million and indirect costs as % of total labour costs 26%.

Public health and health care system Table 4. Health statistics Life expectancy (years) at birth (1997) Men Women Infant mortality per 1000 live births, 1996 or latest available Maternal deaths per 100,000 live births (1993) Standardised death rate (SDR), cardiovascular diseases, 0–64 years /100,000 (1993) Standardised death rate (SDR), cancer, 0–64 years / 100,000 (1993) Standardised death rate (SDR), external causes of injury and poisoning, 0–64 years /100,000 (1993) Standardised death rate (SDR), suicide and self-inflicted injury, 0–64 years /100,000 (1993) Human development index, 1994 Total health expenditure (% of gross domestic product), 1996 Physicians per 1000 population Dentists per 1000 population Nurses per 1000 population

73.4 80.5 4.0 4.1 81.7 66.8 79.3 26.5 0.94 7.5 3.0 1.0 10.6

SOURCES: Health in Europe 1997, WHO Regional Publications, European Series, No 83, annex 1. Eurostat Life expectancy (1997) and numbers of registered physicians, dentists and nurses (1997) from Statistical Yearbook of Finland 1998, Helsinki 1998. REMARKS: The human development index measures the average achievements in a country in three basic dimensions of human development: longevity, knowledge, and a decent standard of living.

Table 5. Indicators of health system attainment and performance in WHO Member States in 1997 Measure

Indicator

Health level (DALE) Health distribution Level of responsiveness

Attainment of health level goals (rank among 191 WHO countries in 1997) Attainment of health distribution goals (rank among 191 WHO countries in 1997) Attainment of goals on level of responsiveness (rank among 191 WHO countries in 1997) Attainment of goals on distribution of responsiveness (rank among 191 WHO coun-

Distribution of responsiveness

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Definition of Unit indicator see source see source

-

see source

-

see source

-

Fairness in financial contribution Overall goal attainment Health expenditure Health system performance on level of health Overall health system performance

tries in 1997) Attainment of goals on fairness in financial contribution (rank among 191 WHO countries in 1997) Overall goal attainment (rank among 191 WHO countries in 1997) Health expenditure per capita in international dollars (rank among 191 WHO countries in 1997) Health system performance on level of health (rank among 191 WHO countries in 1997) Overall health system performance (rank among 191 WHO countries in 1997)

see source

-

see source

-

see source

-

see source

-

see source

-

SOURCE: World Health Report 2000 (www.who.int/whr/2000/en/report.htm)

Table 6. Data for health system attainment and performance in WHO Member States in 1997 Measure Health level (DALE)

Health distribution

Level of responsiveness

Distribution of responsiveness

Fairness in financial contribution

Overall goal attainment

Health expenditure

Health system performance on level of health

Overall health system performance

Country Index country: Finland Best WHO country: Japan Worst WHO country: Sierra Leone Index country: Finland Best WHO country: Chile Worst WHO country: Liberia Index country: Finland Best WHO country: United States of America Worst WHO country: Somalia Index country: Finland

Rank 20 1 191 27 1 191 19 1 191 20.5

Best WHO country: United Arab Emirates Worst WHO country: Central African Republic Index country: Finland

1 191 9.5

Best WHO country: Colombia Worst WHO country: Sierra Leone Index country: Finland Best WHO country: Japan Worst WHO country: Sierra Leone Index country: Finland Best WHO country: United States of America Worst WHO country: Somalia Index country: Finland

1 191 22 1 191 18 1 191 44

Best WHO country: Oman Worst WHO country: Zimbabwe Index country: Finland

1 191 31

Best WHO country: France Worst WHO country: Sierra Leone

1 191

SOURCE: World Health Report 2000 (www.who.int/whr/2000/en/report.htm)

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Indicators of prerequisites of occupational health and safety The information in this section of the annex is mainly from Leino et al. 2000. FIBELLC refers to the countries studied in the project (Finland, Italy, Belgium, Estonia, Latvia, Lithuania, the Czech Republic).

Infrastructure of OH&S OH&S system

OCCUPATIONAL HEALTH AND SAFETY AUTHORITIES Advisory committee on labour protection

Municipal boards of labour protection - Permit section

* Regulations * Enforcement * Inspection * Directions

Ministry of Social Affairs and Health Dept. for occupational safety and health

Social Insurance Institute

Dept. for promotion of health and welfare

Advisory committee on occupational health services

Occupational safety and health inspectorates - 11 districts * Guidelines * Statements * Consultations * Monitoring

* Training * Information * Registers * Funding

OTHER AUTHORITIES Safety Technology Authority Finnish Centre for Radiation and Nuclear Safety National Public Health Institute National Research and Development Centre for Welfare and Health National Product Control Agency for Welfare

Safety delegates

WORKPLACE

Occupational health care personnel

Safety representatives Occupational safety committee

LABOUR MARKET ACTIVITIES

* * * *

Consultations Training Information Register of occupational safety personnel

Occupational safety superviser

RESEARCH AND SERVICE UNITS

State advisory committee on occupational health and safety matters

Labour market organisations

Centre for Occupational Safety

Employer Employee

Finnish Institute of Occupational Health - 6 regional institutes

The Finnish Work Environment Fund

Technical Research Centre of Finland

* * * *

Institutions of higher education

Research grants Grant for applied research Scholarships State grant for occupational safety (State administration) * Agreements (State administration)

* * * *

Research Expert services Measurements Statements

Reference: Occupational health and safety organization of Finland (leaflet)

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Universities Private research institutes Federation of Accident Insurance Institutions * Education * Information * Statistics

OH service models The following five models were used for occupational health (OH) services until January 1996: (1) the municipal health care centre model, (2) companies’ in-plant services (integrated model), (3) group services for several small or medium-sized enterprises (joint model), (4) regional service units of the state (structure similar to that of group services), and (5) private medical centre model.

Enterprise

Enterprise

Self-employed Municipal health care centre Enterprises 65% Employees 40% OHS units 29%

Farmers

Enterprise

Enterprise Enterprises 2% Employees 28% OHS units 43%

OHS unit

Enterprise

Enterprise Enterprise Enterprises 4% Employees 6% OHS units 6%

Joint model OHS unit Enterprise

Enterprise Enterprise Enterprises 29% Employees 26% OHS units 22%

Private medical centre

Enterprise

Reference: Rantanen J. Role of occupational health services in the improvement of workers' health. Presentation held in New Trends and Developments in OHS, 3–6 October 1989. Also in: Rantanen J, Hyvä työterveyshuoltokäytäntö. Finnish Institute of Occupational Health, Helsinki 1997, and Räsänen K, et al. In Kauppinen et al. (Ed) Work and Health in Finland in 2000 (In Finnish), Finnish Institute of Occupational Health, Helsinki 2000.

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Legislation and coverage of OH&S Table 7. Indicators of legislation and coverage of OH&S Factor ILO ratification

Indicator Proportion of ILO conventions on OH&S ratified

Coverage of accident insurance

Proportion of the employed covered by accident insurance

Coverage of Proportion of the emoccupational ployed covered by health care occupational health services

Definition of indicator Proportion of ILO conventions relevant to OH&S (N=20) which a country has ratified until present (scale 0–1 where 1 corresponds to 100%) Proportion of the employed covered by compulsory or voluntary accident insurance including insurance against occupational diseases (scale 0–1 where 1 corresponds to 100%) Proportion of the employed covered by compulsory or voluntary occupational health services (scale 0–1 where 1 corresponds to 100%)

Unit -

-

-

Table 8. Statistics on legislation and coverage of OH&S (Takala 2000, Leino et al. 2000)

ILO ratification

Coverage of accident insurance

Coverage of occupational health care

Country

Year

N

Index country: Finland Best ILO country: Sweden Worst ILO country: many Index country: Finland

1999

16 18 0

Best FIBELLC country: Worst FIBELLC country: Index country: Finland

1998

1997

Best FIBELLC country: Finland Worst FIBELLC country: Estonia, Latvia and Lithuania

Value of indicator 0.8 0.9 0 0.905

Unit -

0.87

-

0.87

-

0.1

-

REMARKS: FIBELLC refers to Finland, Italy, Belgium, Estonia, Latvia, Lithuania, the Czech Republic.

Human resources in OH&S Table 9. Indicators of occupational health and safety personnel Occupational health physicians Occupational health nurses Occupational physiotherapists

Occupational health physicians / 1000 employed Occupational health nurses / 1000 employed Occupational physiotherapists / 1000 employed

Occupational health physicians (full-time equivalents) per 1000 employed

/1000 employed

Occupational health nurses (full-time equivalents) per 1000 employed

/1000 employed

Occupational physiotherapists (full-time equivalents) per 1000 employed

/1000 employed

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Occupational hygienists and hygiene assistants Labour safety inspectors Enterprise safety managers Safety representatives of employees

Occupational hygienists and hygiene assistants / 1000 employed Labour safety inspectors / 1000 employed Enterprise safety managers / 1000 employed Safety representatives of employees / 1000 employed

Occupational hygienists and hygiene assistants (full-time equivalents) per 1000 employed

/1000 employed

Labour safety inspectors (full-time equivalents) per 1000 employed

/1000 employed

Enterprise safety managers (full-time equivalents) per 1000 employed

/100 employed

Safety representatives of employees (fulltime equivalents) per 1000 employed

/100 employed

Table 10. Statistics on occupational health and safety personnel Occupational health Index country: Finland physicians Best FIBELLC country: Italy Worst FIBELLC country: Lithuania Occupational health Index country: Finland nurses Best FIBELLC country: Finland Worst FIBELLC country: The Czech Republic Occupational Index country: Finland physiotherapists Best FIBELLC country:

1998

1998

1998

Worst FIBELLC country: Occupational hygienists and hygiene assistants

Labour safety inspectors

Enterprise safety managers

Index country: Finland

1998

Best FIBELLC country: Lithuania Worst FIBELLC country: Latvia Index country: Finland Best FIBELLC country: Latvia Worst FIBELLC country: Belgium and The Czech Republic Index country: Finland Best FIBELLC country: Latvia

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1998

1998

8851

0.40

90001

0.45

34

0.02

16921

0.76

16921

0.76

1173

0.02

2991

0.13

-

-

-

-

1502

0.07

378

0.22

312

0.03

3603

0.16

162

0.2

180

0.05

102084

0.46

84001

0.81

/1000 employed /1000 employed /1000 employed /1000 employed /1000 employed /1000 employed /1000 employed /1000 employed /1000 employed /1000 employed /1000 employed /1000 employed /1000 employed /1000 employed /1000 employed /100 employed /100 employed

Safety representatives of employees

44176

0.26

135694

0.61

Best FIBELLC country:

-

-

Worst FIBELLC country:

-

-

Worst FIBELLC country: Lithuania Index country: Finland

1998

/100 employed /100 employed /100 employed /100 employed

SOURCES: Occupational health services in Finland 1997. Institute of Occupational Health. Ministry of Social Affairs and Health. Helsinki 1998. Annual report of the Occupational Safety and Health Administration 1998. REMARKS: NA = data not available (1) Full-time equivalents; The number of posts in occupational health services in 1998 was 1799 for occupational health physicians, 1930 for occupational health nurses, 589 for physiotherapists, 198 for psychologists and 849 for assisting personnel. (2) The figures for occupational hygienists and occupational hygiene technicians are estimates based on membership in the Finnish Occupational Hygiene Association. Safety engineers and technicians are not included. (3) Those directly involved in workplace safety inspections; Occupational Safety and Health Administration (OSHA) employs 540 persons, of whom 460 work in inspectorates. Some 90 experts work in the central administration. (4) The figures are from the statistics of the Register of Occupational Safety Personnel 1998. Registration is obligatory for private enterprises and for municipalities, but excludes public (state) administration. Data were not available from other FIBELLC countries. FIBELLC refers to Finland, Italy, Belgium, Estonia, Latvia, Lithuania, the Czech Republic.

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Indicators of working conditions

Physicochemical exposures Table 11. Indicators of physicochemical exposures (Second European Working Conditions Survey 1997) Agent High-level noise

Indicator Prevalence of exposure to high level noise among the employed

Vibration

Prevalence of exposure to vibration among the employed

Radiation

Prevalence of exposure to radiation among the employed

High temperatures

Prevalence of exposure to high temperatures among the employed

Low temperatures

Prevalence of exposure to low temperatures among the employed

Definition of indicator Question in survey: How often are you exposed at work to each of the following? (all of the time, almost all of the time, around ¾ of the time, around half of the time, around 1/4 of the time, almost never, never, don't know) • Noise so loud that you would have to raise your voice to talk to people Included if at least around ¼ of the time Question in survey: How often are you exposed at work to each of the following? (all of the time, almost all of the time, around ¾ of the time, around half of the time, around ¼ of the time, almost never, never, don't know) • Vibration from hand tools, machinery, etc. Included if at least around ¼ of the time Question in survey: How often are you exposed at work to each of the following? (all of the time, almost all of the time, around ¾ of the time, around half of the time, around 1/4 of the time, almost never, never, don't know) • Radiation such as X rays, radioactive radiation, welding light, laser beams Included if at least around ¼ of the time Question in survey: How often are you exposed at work to each of the following? (all of the time, almost all of the time, around ¾ of the time, around half of the time, around 1/4 of the time, almost never, never, don't know) • High temperature which makes you perspire even when not working Included if at least around ¼ of the time Question in survey: How often are you exposed at work to each of the following? (all of the time, almost all of the time, around ¾ of the time, around half of the time, around 1/4 of the time, almost never, never, don't know) • Low temperatures whether indoors or

77

Unit %

%

%

%

%

Breathing in vapours

Prevalence of breathing in vapours among the employed

Handling dangerous substances

Prevalence of handling dangerous goods among the employed

outdoors Included if at least around ¼ of the time Question in survey: How often are you exposed at work to each of the following? (all of the time, almost all of the time, around ¾ of the time, around half of the time, around 1/4 of the time, almost never, never, don't know) • Breathing in vapours, fumes, dust, or dangerous substances such as chemicals, infectious materials, etc. Included if at least around ¼ of the time Question in survey: How often are you exposed at work to each of the following? (all of the time, almost all of the time, around ¾ of the time, around half of the time, around ¼ of the time, almost never, never, don't know) • Handling or touching dangerous products or substances Included if at least around ¼ of the time

%

%

Table 12. Data for indicators of physicochemical exposures (Second European Working Conditions Survey 1997) Agent High-level noise

Vibration

Radiation

High temperatures

Low temperatures

Breathing in vapours

Handling dangerous substances

Country

Value of indicator Index country: Finland 39 Best EU country: Italy 21 Worst EU country: Finland 39 Index country: Finland 26 Best EU country: The Netherlands 13 Worst EU country: Greece 37 Index country: Finland 8 Best EU country: Portugal 3 Worst EU country: Austria 9 Index country: Finland 20 Best EU country: Sweden 14 Worst EU country: Greece 40 Index country: Finland 19 Best EU country: Germany, West 17 Worst EU country: Greece 44 Index country: Finland 34 Best EU country: Denmark 15 Worst EU country: Greece 47 Index country: Finland 18

Unit

Best EU country: Germany, East Worst EU country: Greece

% %

78

10 32

% % % % % % % % % % % % % % % % % % %

Table 13. Indicators of use of asbestos (Tossavainen and Takahashi 2000) and pesticides at work (FAO database on pesticide consumption) Agent Asbestos

Pesticides

Indicator Consumption of asbestos per capita per year Consumption of pesticides per agricultural worker per year

Definition of indicator Reported consumption of asbestos in 1996 per capita

Unit kg/capita/y

Consumption of pesticides in 1998 per agricultural worker as reported to FAO

kg/agricultural workers/y

Table 14. Data for indicators of use of asbestos (Tossavainen and Takahashi 2000) and of pesticides at work (FAO database on pesticide consumption) Agent

Country

Asbestos

Index country: Finland Best country: many Worst country: Russia Index country: Finland Best country: Laos? Worst country: Belgium-Lux

Pesticides

Value of indicator 0 0 3.4 12 0 181

Unit kg/capita/y kg/capita/y kg/capita/y kg/agr worker/y kg/agr worker/y kg/agr worker/y

Table 15. Indicators of harm due to physicochemical exposures (Finnish Work and Health Surveys 1997 and 2000, Piirainen et al. 1997 and 2000) Agent Noise

Vibration

Dust

Solvents

Indicator Prevalence of harm due to exposure to noise among the employed Prevalence of harm due to exposure to vibration among the employed Prevalence of harm due to exposure to dust among the employed Prevalence of harm due to exposure to solvents among the employed

Definition of indicator Question in survey: Does noise occur in your work? (yes, no) Is noise harmful in your work (no, to some extent, rather harmful, very harmful) Included if rather or very harmful Question in survey: Does vibration occur in your work? (yes, no) Is vibration harmful in your work (no, to some extent, rather harmful, very harmful) Included if rather or very harmful Question in survey: Does dust occur in your work? (yes, no) Is dust harmful in your work (no, to some extent, rather harmful, very harmful) Included if rather or very harmful Question in survey: Do solvents occur in your work? (yes, no) Are solvents harmful in your work (no, to some extent, rather harmful, very harmful) Included if rather or very harmful

79

Unit %

%

%

%

Detergents etc.

Gases, exhausts

Environmental tobacco smoke

Cold, heat or draught

Inadequate lighting

Mouldy smell

Prevalence of harm due to exposure to detergents etc. among the employed Prevalence of harm due to exposure to gases, exhausts among the employed Prevalence of harm due to exposure to environmental tobacco smoke among the employed Prevalence of harm due to exposure to cold, heat or draught among the employed Prevalence of harm due to inadequate lighting among the employed Prevalence of harm due to exposure to mouldy smell among the employed

Question in survey: Do detergents etc. occur in your work? (yes, no) Are detergents etc. harmful in your work (no, to some extent, rather harmful, very harmful) Included if rather or very harmful Question in survey: Do gases, exhausts occur in your work? (yes, no) Are gases, exhausts harmful in your work (no, to some extent, rather harmful, very harmful) Included if rather or very harmful Question in survey: Does environmental tobacco smoke occur in your work? (yes, no) Is environmental tobacco smoke harmful in your work (no, to some extent, rather harmful, very harmful) Included if rather or very harmful Question in survey: Does cold, heat or draught occur in your work? (yes, no) Is cold, heat or draught harmful in your work (no, to some extent, rather harmful, very harmful) Included if rather or very harmful Question in survey: Does inadequate lighting occur in your work? (yes, no) Is inadequate lighting harmful in your work (no, to some extent, rather harmful, very harmful) Included if rather or very harmful Question in survey: Does mouldy smell occur in your work? (yes, no) Is mouldy smell harmful in your work (no, to some extent, rather harmful, very harmful) Included if rather or very harmful

%

%

%

%

%

%

Table 16. Data for indicators of harm due to physicochemical exposures in Finland (Finnish Work and Health Surveys 1997 and 2000, Piirainen et al. 1997 and 2000) Agent Noise Vibration Dust Solvents Detergents, etc. Gases, exhausts Environmental tobacco smoke Cold, heat or draught Inadequate lighting Mouldy smell

1997 8.6 1.7 8.1 1.6 2.6 2.4 2.2 12.5 4 11.9

2000 10.4 2.1 10.4 2.3 2.6 2.2 2 16 4.5 10.8

80

Unit % % % % % % % % % %

Table 17. Indicators of occupational exposure to carcinogens (CAREX database of FIOH) Agent Solar radiation

Indicator Estimated prevalence of regular exposure to solar radiation among the employed

Tobacco smoke (environmental)

Estimated prevalence of regular exposure to environmental tobacco smoke among the employed

Silica, crystalline

Estimated prevalence of exposure to crystalline silica among the employed

Diesel engine exhaust

Estimated prevalence of exposure to diesel engine exhaust among the employed

Radon and its decay products

Estimated prevalence of exposure to radon and its decay products among the employed

Wood dust

Estimated prevalence of exposure to wood dust among the employed

Lead and lead compounds, inorganic

Estimated prevalence of exposure to lead and inorganic lead compounds among the employed

Definition Regular outdoor work (>75% of annual working time) is considered to entail exposure. The figures are not comparable from the point of view of UV radiation dose, because the intensity of radiation varies by country. Inhalatory exposure at work to environmental tobacco smoke (ETS) due to smoking of customers or coworkers. Inhaling ETS (as smoke or 'smell') at least 75% of working time is considered to entail exposure. Inhalatory exposure at work to crystalline silica (mainly as quartz, cristobalite, tridymite or tripoli) or minerals containing crystalline silica probably exceeding nonoccupational exposure originating from road dust, beach sand, etc. (long-term exposure level to respirable dust usually