Published in: Chu, C. & Simpson, R. (1994) (eds.), The ecological public health. From vision to practice. Toronto/Brisbane (Centre for Health Promotion, University Toronto/ Institute of Applied Environmental Research, Griffith University), 172-181
In industrialized societies, it has become clear that the technological development increasingly threatens the ecological system and, thus, mankind itself. Catastrophies in Harrisburg, Bhopal and Chernobyl affecting relatively few have demonstrated the risks of industrialization, while the increase of daily health hazards in the working and living conditions of many people is rarely perceived in a similar manner. However, risks induced by technology have changed societies in a wide range of areas and have had several consequences:
At every point, these technological developments are mediated by social power and domination, by irrational fantasies of omnipotence, by legitimating notions of progress, and by the contradictions rooted in the technological projects themselves and the social relations of production (Noble 1986, 324).
The belief in technological rationality as being the rationality per se seems to be one of the key principles of societies of the northern hemisphere at least. It has led to a de-humanization of the working world; it has become a system of functions (work process) consisting of elements (human beings) which have to be controlled constantly regarding the quality of the interaction between elements and functions in relation to set targets (management). Human beings have become raw material and cost factors.
The working and living conditions of the people are subject of rapid technological changes which are brought about by microelectronics, information technology, bio- and gentechnology among others. These changes bear the potential of sound progress but also of several hazards related to the health condition of every person. On the one hand, the work organization controlled by computers and robots may offer new options in carrying out the work process, on the other hand, they contribute, for example, to the decline of workplaces and thus, to the increase of the number of unemployed individuals; they also contribute to the segmentation of the work process and to the increase of single activities to be carried out per hour, i.e., the density of the work process (Zuboff 1988). In effect, so-called new technologies may also contain the old health hazards of the workplace such as work-stress, noise, radiation, back pain, etc.
This changes in working conditions also happens in developing countries. In many cases, the development process is only based on economic parameters, not taking account of the vulnerability of human beings. As long as the labor force seems to be inexhaustible in a short-term perspective, it seems to be difficult to create awareness and stimulate action related to the improvement of working conditions. In those countries, however, already facing a shortage of the labor face and looking for migrant workers (e.g., Singapore, Malaysia, Taiwan) the quality of working conditions becomes an increasingly relevant issue.
There are many different ways to improve working conditions; many regard the safety of the machinery and the working process itself; others are related to occupational health and safety measures like providing health-protective devices. A rather comprehensive approach towards the enhancement of the health-related quality of working conditions and processes refers to worksite health promotion.
The purpose of this paper is to describe some of the conceptual backgrounds guiding worksite health promotion and to present its key areas of action. Reference is made to research studies and reports which indicate scientific activities. Insofar, most of the paper refers to knowledge gained in industrialized countries. However, it is emphasized that the principles of worksite health promotion are valid in every setting involving industrialization, irrespective from where the setting may be. Thus, readers from developing countries may identify a way of progress including its successes and failures which their countries will probably face in the near future. By raising the issue of worksite health promotion, it is underscored that the developmental process does not have to become as health-hazardous as it still is in many cases.
Worksite health promotion and occupational health and safety
Worksite health promotion has only become a major issue recently. Occupational Health and Safety (OHS), are still governing the minds and activities of many health and non-health personnel in the factories who are responsible for the prevention of accidents and the emission of toxic substances at the workplace. The technological development of industry during the past century has always created the difficulties and problems which OHS have to deal with. However, it is not, as some of the conservative representatives of the industrialized system feel, the imperfectness of the individual which causes the troubles but the defectiveness of the system itself (Berman 1979, Brod 1984, Douglas 1986, Kinnersley 1973, Stellman & Daum 1973, Stellman & Henifin 1989).
Traditional OHS re-acts with regard to problems that arise in industrial, administrative and service processes. Mainly these reactions aim at the improvement of bio-chemical, physical and physiological factors which are interpreted as indicators for certain health-hazards. The strategies of occupational prevention are oriented towards the individual case. The reason for this is the medical orientation of OHS and such disciplines like industrial or occupational medicine, ergonomics, etc. (Dixon & Price 1984, Levy & Wegman 1983, Rom 1983, Ward Gardner 1982, Watterson 1986, Weindling 1985).
With health promotion entering the working world, the situation will be changing basically. Individualization in terms of OHS and traditional prevention will be reduced; structural changes of production and administration will have to be taken on the agenda. In the European region, the structural conditions of work play a far more prominent role in worksite health promotion than it seems to be in North America and elsewhere. Reports from the latter regions mainly deal with rather classical approaches of prevention, even if they contain the title health promotion (O'Donnell & Ainsworth 1984, Parkinson & Associates 1982, Cataldo & Coates 1986). What Europeans call humanization of work, a concept which has been adopted as governmental policy in the Scandinavian countries and which plays an important role in other European countries, is the interplay between trade unions and employers in order to improve the working conditions of the employees (Aguren & Edgren 1980, Bagnara et al. 1985, Emery & Thorsrud 1976, Gevers 1985, Lindholm 1975, Reich & Goldman 1984, Revans 1981, Zwerdling 1980). The concept focuses on the structural rather than the individual dimensions of work.
The development of worksite health promotion
Willis B. Goldbeck, Executive Director of the Washington Business Group on Health, distinguishes between four generations of worksite health promotion programs:
Programs of the first generation were initiated for a variety of reasons, most unrelated to health. Smoking policies, for example, have been in place for more than a century, long before there was indisputable evidence of the ill effects of smoking (...)
The second generation emerged when risk factor identification and intervention technology could be transported to the worksite. These programs were characterized by a narrow focus on one method of delivery, a single illness or risk factor, or programs offered to only one population (...)
Third-generation wellness programs are those that attempt to offer a spectrum of methods for delivering a more comprehensive range of interventions for a variety of risk factors to all employees (...)
In the fourth generation wellness becomes both a component of and the guiding principle for a corporate health strategy (...) A wellness health strategy incorporates all activities, policies, and decisions that affect the health of employees, their families, the communities in which the company is located, and the consumers whose purchasing decisions determine the companies relative success in the marketplace (O'Donnell & Ainsworth 1984, vi-vii).
The development of health promotion programs in the USA is hereby described - both in terms of its history and presence. However, the fourth generation represents an approach which is only seldom realized - whether in North America, Europe, or anywhere else in the world. Programs of the first till the third generation follow an individualistic approach, i.e., they are oriented towards individual behavior without taking too much into account which of the implications of the working condition may be effective in damaging workers' health. In their study Occupational Health Promotion, Everly & Feldman (1985) only state in one paragraph that health promotion may be concerned with structural working conditions; it reads:
Personal health behavior is due to a complex set of factors and individuals are not to blame for their unhealthy life-styles. In addition, health professionals involved in work settings need to be especially aware of work hazards in order to ensure that employees work in a safe and healthy environment. For example, a smoking cessation program for asbestos workers would have minimum impact if at the same time exposure to asbestos fibers were not reduced to a safe level (Everly & Feldman 1985, 301).
Shain et al. go one step further, however, without presenting a program of worksite health promotion related to working conditions. In their analysis of worksite health promotion, they conclude:
1. The individual intervention approach holds individuals responsible for their health while downplaying environmental sources of disease, thereby blaming individuals for sources of illness that are presently beyond their control.
2. Following this, the approach encourages a myopic self-centered view of disease and health, deflecting attention away from the possibility of collective, political and social action in health-related issues.
3. The approach is strongly middle-class-biased with little attention paid to the concerns and realities of those who are not.
4. The approach focuses exclusively on the individual, as opposed to any social special interest groups (Shain et al. 1986, 48).
With regard to worksite health promotion, one can conclude that changes demanded in health-related behavior have also to be described in terms of changes concerning working conditions, i.e., which quality and structure of workplaces and work-processes are prerequisite to stimulate and stabilize health-promotive physical, mental and social well-being of employees. As Sloan et al. (1987, 54) put it:
By supporting risk-related behavior change, incidence of disease will be reduced over time; but disease-related absenteeism and insurance claims account for only part of the overall corporate health costs. Organizational factors influencing illness behavior clearly are responsible for another large portion of the total cost of health care. It is critical that practicioners understand the reciprocal relationship between the organization and the individuals who compose it. For workplace health promotion to have its fullest impact, programs will have to address both the organization and the individuals.
Workstyles conducive to health
If the assumption is correct that there is a constant interplay between working conditions and work-/health-related patterns of behavior and action, it seems to be reasonable to integrate this argument into the conceptualization of worksite health promotion. I suggest that this context is named workstyles. The main objective of health promotion programs for the working world is the development of workstyles conducive to health.
By individual workstyles, I refer to the occupational and organizational patterns of behavior and action of a person, by which normative expectations regarding workplace- and occupation-related efficiency are met. Individual workstyles are subjectively developed potentials of action and concrete behaviors; they are demanded independently from a person by the work organization in terms of work-descriptions and in terms of the design of the workplace. Through individual workstyles a person demonstrates his or her capability to participate in the work-process pragmatically. In other words, individual workstyles represent what one could call work-related or occupational identity.
The (socio-) psychological competencies and the occupational qualifications of a person are set on the level of individual workstyles. It is the same level, individual coping strategies are settled on. Individual workstyles represent the subjective competence, a person has developed through his or her biography in order to become and stay a member of the labor-system.
Individual workstyles represent a complex system of mutually determining variables, the change of which will only be achieved, if their interdependencies are taken into account. Purely behavior-related measures, which aim at one or two aspects of individual workstyles will not be very successful in terms of worksite health promotion.
By collective workstyles, I refer to socially, culturally, historically, technologically, politically and economically developed patterns of action, which are related to specific occupations and which are developed during vocational training and the first years of occupational socialization. They form a reservoir of shared values and normative orientations towards his/her own professional group as well as to other professional groups. By collective workstyles, the person gains his/her professional identity, which enables the individual to form professional and political relations to his/her colleagues, i.e., to achieve the capabilities for solidarity. It is the level of collective workstyles, the expectations regarding (health-related) working conditions and workplaces are combined with, while dealing with certain health-related behaviors is a matter of individual workstyles.
The analytical distinction between individual and collective workstyles - which pragmatically complement each other - indicates that worksite health promotion is not only a matter of OHS but goes deeply into the biographical structure of an individual and his/her occupational and professional identity. Health promotion also always affects the organization of work and work-processes. Thus, one has to be aware of the long-term time-perspective that worksite health promotion bears.
To be employed is a fact which contains more than just fulfilling the expectations of the employers efficiently. It is not just a matter of spending some 8 hours at the work-place. The time-budget concerning all work-related activities can go up to almost 12 hours a day. It is a principle question of worksite health promotion whether or not employees can be asked to further intensify their work-related activities and health-related behaviors. This issue is discussed under the label of ethics of worksite health promotion (Allegrante & Sloan 1986, Roman & Blum 1987, Warner 1987, Watterson 1984). However, I feel that the ethical dimension is only one aspect while time-organization, access to public transport, housing, work-intensity, quality of workplaces, participation in work organization etc. are others strongly affecting the employee's willingness and capability to participate in health-related activities (Mergler 1987, Webb et al. 1986, Carlstein 1982, Fraser 1978, Grazia 1964, Rifkin 1989, Szalai et al. 1972, UNESCO 1976).
It seems to be necessary to consider the basic principles of worksite health promotion in the light of the Ottawa-Charter and the outlined concept of individual and collective workstyles. The behavioral implications of health promotion in general, i.e., the development of lifestyles and workstyles conducive to health, are always linked to structural changes of the environment, which have to be carried out simultaneously. It is nearly impossible for the individual and social groups to develop health-promotive patterns of behavior and action in an ecological system which destroys the health of the population by toxic and radioactive substances, health-hazardous workplaces and products, over-crowded housing areas, air and water pollution, etc. Health is an issue which cannot be divided into a rating scale; it is a similar concept like peace. It is a contradiction per se to develop lifestyles conducive to health in a society which produces unhealthy products and environments. This must not be interpreted that the attainment of these lifestyles is impossible; it rather emphasizes that their development is partly inhibited by the prevailing conditions; and it stresses the more the notion that there is no reason at all to blame individuals and groups if they are not capable to meet behavioral standards set by medical professionals and other influential and powerful groups of society.
Issues in worksite health promotion
The changing working world
The working world is the key sector of our social system because it produces the fundamental contributions to keep the system functioning. Labor organization, the distribution of power and influence, the relationships between employers and employees plus other aspects reflect the overall social structure of a society. On the other side, their shaping contributes to the further development of the society. While the societal level represents values, belief systems, economic, social and cultural dimensions of a society, the labor system presents the application of these system elements in a rather materialistic way. The key element of the labor sector, i.e., the alienation from oneself, one's work and one's individual and collective actions, distinguishes this sector from other sectors of the social system. Alienation may take place there, but it is not incorporated by them per definitionem.
The human body is no more a relevant issue in the working world, which is build on the fundaments of high-tech. It is reduced to its mental efficiency. Within this structure, well-being does not mean more than the adaptation of workers to the work organization. It is requested that employees feel comfortable with their workplaces, however their well-being is not a prerequisite for the efficiency of the work organization as such. Work is dangerous to your health - this is the precise formula which Jeanne Stellman & Susan Daum (1973) used as the title of their analysis of occupational hazards. Shoshana Zuboff states:
In diminishing the role of the worker's body in the labor process, industrial technology has also tended to diminish the importance of the worker. In creating jobs that require less human effort, industrial technology has also been used to create jobs that require less human talent. In creating jobs that demand less of the body, industrial production has also tended to create jobs that give less to the body, in terms of opportunities to accrue knowledge on the production process (Zuboff 1988, 22).
Parallel to the computerization of work-processes, automatization of the workplace is implemented, the ultimate effect of which is the decrease of human interventions into the production process. On the other side, middle- and top-management face a fundamental change in their work-processes as well: through the implementation of information management, both, density and control of the work-load and work-processes are enhanced, while the individual control over the work-process decreases.
Right now a combination of twentieth-century technology and nineteenth-century scientific management is turning the Office of the Future into the factory of the past. At first this affected clerks and switchboard operators, then secretaries, bank tellers and service workers. The primary targets now are professionals and managers (Garson 1988, 10).
And she concludes:
Computers are only tools with many uses. But the battle for control turns tools into weapons (Garson 1988, 154).
WHO's health promotion concept is based upon several principles, one of the most important one is called participation. People are requested to participate in the development, implementation and evaluation of health promotion programs directly affecting their living and working conditions. The strengthening of community action with regard to health promotion represents one of the major goals of the Ottawa-Charter and the Call for Action. In practice, the issue of participation refers to the involvement of the people into the organization of community life. Participation, i.e., the right to decide jointly about common issues, means that the people are able to decide whether or not which kind of health promotion program is carried out in their social, cultural and ecological environment.
The key question concerning participation is: who participates in what and who has defined which "what" is (Brizziarelli 1989)? Basically, participation is regulated by legislation, i.e., it refers to certain rights and duties. It does not necessarily cover activities which are initiated spontaneously by individuals and/or social groups. Such activities may be considered as social action which lie outside of the frame of reference of participation. At least in the welfare states of Western Europe and Scandinavia, legislation concerning so-called co-determination of employees clearly defines those issues which can be dealt with within the co-determination process. Other issues not mentioned, cannot become subject of co-determination except by changes in legislation. Therefore, the participatory approach of co-determination finds its limits within given legislation.
Current legislation in the Federal Republic of Germany, for example, defines co-determination as an approach which is linked to the elected representatives of the employees of a given company. There is no possibility for individual workers to get involved in co-determination, but only through the election of their representatives. In this case, all kinds of issues related to the design of workplaces, work organization and work-processes are dealt with by the employees' committee; only this committee can put the issues on the agenda of its negotiations with the management. Within this frame of reference, participation is defined collectively and according to the principles of representative democracy. In a certain way, participation is centralized.
Taking into account WHO's concept of health promotion, participation would go one step further. Here, it is also related to the single person who should have the opportunity to participate in the development, implementation and evaluation of such programs. It seems to be obvious that this kind of participation is quite different from current approaches. In practice, it has to be clarified how individual participation is to be realized. Which regulations have to be implemented that individual participation becomes possible? Which kind of committees would form the arena in which participatory action is carried out? Which rights and duties of these committees are installed?
Representatives of the trade unions would argue that individual participation would undermine the power of trade unions and also perhaps the solidarity among employees. The collective representation of employees' interests by the trade unions would guarantee the influence of the employees concerning the design of workplaces, work organizations etc., while individual participation would only be in a position to take care of the interests of one specific employee. The collective aspects of work processes in a factory are obvious:
... a production process with a technology that demands the exercise of skill simultaneously grants workers a measure of control over the production process and gives them a work-based reason to form the groups and develop cultures centered around the maintenance and extension of their control. Workers in such a process simply find that their job gives them a lot of reasons to talk to each other about the work. To put it another way, their involvement in work leads them to become involved with one another (Grzyb 1981, 467).
It seems, however, that the production process tends to become less skill-demanding; trained workers will be replaced either by robots or by unskilled workers. This may affect the capacities of the labor force to take care of the quality of working conditions; it may also affect the motivation to get organized in trade unions resulting probably in rather weak solidarity among the workers and, ultimately in reduced participation. In the age of the smart machine (Zuboff), the exercise of skills is only demanded from those who control the production process using more or less complex computer systems. And even the process of control becomes subject of computer systems:
Whether such computerized monitoring systems are used to discipline particular individuals is, finally, beside the point. It is enough that they exist, a kind of software sword of Damocles suspended over people's heads, ready to be brought into play at management's discretion. Worse, this fundamental arbitrariness is disguised by the seeming objectivity of the data. To the degree that the unambiguous measurements of the computer are scientific, they have the appearance of rationality. They serve to obscure the very relationship of unequal power that they reinforce (...) In a sense, control becomes automatic, just like work it-self. And the reality of power disappears behind the impersonality of the machine (Howard 1985, 65).
It seems to become rather difficult to find ways and means of participation in a working world which becomes increasingly controlled by computerized monitoring systems demanding and leaving few opportunities for individual and collective involvement into the work process.
Examples of worksite health promotion programs
Reviewing the current state of worksite health promotion in the USA, four different areas of activities have been identified (Fielding & Piserchia 1989, Pender 1989):
Programs undertaken in these areas mainly focus on individual behavior. Workers are targeted to change their behavior according to the set of objectives of the respective (preventive) program. Of course, the individual behavior can only be one facet of the working world. Working conditions, i.e. the quality of work, plus the general lifestyles and living conditions of workers play an even more important role to bring about health-promotive changes at the workplace.
As an illustration for an integrated approach to worksite health promotion, two different programs come to mind. First, the Swedish work reform initiative, and secondly the worksite health promotion program in Queensland (Australia).
The Swedish work reform initiative
In Sweden, legislation regarding occupational health and safety and worksite health promotion is very much elaborated. The industrial relations between employers and employees are subject of national legislation. The participation of the employees and the trade unions with regard to work- and health-related issues is guaranteed. Occupational health and safety standards in Sweden are rather high; the involvement of the employees into health-related aspects of working conditions and workplaces is still increasing. The issue of health promotion is integrated into the occupational health and safety departments. At first glance, this might look rather traditional; however, the Swedish approach of OHS has been broadened during the past years so that health promotion at the worksite has become an integrated part of it.
The design of workplaces and work processes has been a prominent task of OHS in Sweden. The example of Volvo has become quite familiar to experts of the field. I will not refer to it in this paper (Aguren et al. 1976), but briefly describe a training manual on Safety-Health and Working Conditions which is published by the Joint Industrial Safety Council of Sweden (1987). The target group of the manual are shop stewards as well as other employees, company doctors, nurses, safety engineers, management - whoever wants to get involved into the subject. In the introduction, it says:
This manual is designed to help you start discussing safety, health and working conditions of all the workers at your workplace.
The manual is divided into 7 chapters, covering the following issues:
The attached checklist provides a subject-related comprehensive questionnaire, which can be used by the employees themselves to analyze the specific quality of their workplaces and working conditions.
The manual is used in training sessions with groups of employees. The group approach should guarantee that different perspectives on the subject as well as a variety of possible solutions to particular problems can be carried out. It also reflects the aspect of solidarity among workers, i.e., the manual takes into account the individual and collective dimensions of workstyles.
The training program aims at two different objectives:
Workplace health promotion in Queensland (Australia)
Acknowledging the shortcomings of an individual-oriented approach, Chu & Forrester (1992, 13) state that workplace health promotion "does not simply (examine) health behaviour but also includes the workplace environment and the organization of work itself". In their report to the Minister of Health, Housing, and Community Services of the State of Queensland (Australia) they recommend the following key issues of workplace health promotion (WHP):
These recommendations have been applied meanwhile to different projects in Queensland. They are currently in their planning and implementation stage. Since the Queensland approach seems to be by far the most comprehensive one described in the literature, it is of utmost interest to monitor the processes of change at the worksite and to evaluate the outcomes of the projects. It would certainly provide a much needed insight into structures and mechanisms of comprehensive workplace health promotion. This would be particularly useful regarding the transfer of the approach to other countries.
Steps of planning worksite health promotion
It should have become clear that health promotion programs for the working world have to be designed more comprehensively than it has been done so far. Taking into account WHO's concept of health promotion, worksite health promotion is just one element of programs addressing the entire community. Thus, worksite health promotion is also a public affair although in many parts of the world, the economic system is mainly organized as private enterprises.
Therefore, before starting any planning activities, it is inevitable to bring together all people, groups, and organizations which are affected by such programs in order to discuss whether or not they would participate in the program, and whether or not they would support its objectives and activities. I feel that many projects have difficulties to implement their activities into the working world because the relevance of their issue is not recognized by those who should be concerned with the problems (Felix et al. 1985).
The first step of planning is to create awareness of the need for health promotion at the work place among all of the possible participants, particularly among the organizations to be involved into the program. This process may last several months.
If there is an agreement upon what to do, the second step, the planning process can be started by involving representatives of all groups concerned in order to carry out a program which reflects the interests of all participants. This process, again, may last several months because the program has to be discussed among all participants and their organizations involved; there will be suggestions what should be done in a different way etc. The political debate upon the project among trade unions, employers' association, etc. will influence the planning process quite a lot. Public discussion in the community about the planned program may also affect program planning, particularly if the company in question plays a major economic and political role in the community.
By pointing out to these facts, I want to create awareness among health planners and health promoters regarding the difficult political, social, and economic aspects that are linked to worksite health promotion. One cannot neglect them, but has to keep them in mind during the entire duration of planning and implementation of such programs.
If there is an agreement found upon the concrete program, the third step, its implementation requires careful activities regarding the information of all employees and those of the community who are affected by the measures of the program (families, neighborhood, social services, etc.). This step aims at the necessary support to the program given by all individuals, groups, and organizations in the community.
The implementation requires a detailed analysis of the time-schedule of the employees at work in order to find out their capabilities to carry out the activities the program intends them to do. The time-analysis provides insight into the structural possibilities of the employees to become involved into the program (Rifkin 1989, Moore-Ede 1993, Burns 1993).
The implementation of the program depends upon the working conditions of the employees, i.e., the degree of flexibility at the workplace which allows for the involvement into certain program activities. It is this particular aspect which decides upon success and failure of the program, because if the employees feel that the program interferes with their working process too much, they will not participate in it as wanted. Thus, the implementation of worksite health promotion always requires the willingness of employers to provide time and flexibility regarding the realization of the program; and it is this issue which usually interferes with the demands of the production process.
Public policies increasingly address the issue of developing lifestyles and living conditions conducive to health in order to contribute to an improvement of the quality of life of all people regardless of social class, gender, race or any other indicator. Health promotion has become the key word in this respect. Health has become a human rights issue. At least, it has become a concept through which those population groups which are deprived of living conditions conducive to health are able to communicate the lack of meeting their basic needs. Health as well as ecology are terms of the public discourse of concerned people who feel the need that the developed countries have to make basic changes in their structure and functions. If these societies will be able to switch to ways of sustainable development, depends heavily on their capability to restructure their economy as well as their entire value systems and subsequently, their ways of life.
Worksite health promotion is happening in one social sector. It has to be linked to similar activities in other sectors in order to accomplish what it intends to achieve: health for all. As other sections in this book demonstrate, these links are about to be developed. It would be, however, fairly naive if we would think that health promotors were the ones who would bring about the necessary changes. Health promotors are facilitators at best. If the people do not see the advantages of restructuring their lifestyles and living conditions, no substantial change will happen. Social changes always implicate changes in the economy; more often than not, they depend on economic changes. As Saul B. Alinsky (1969, 219) put it so rightly:
Our world has always had two kinds of changers, the social changers and the money changers.
I am afraid to say that health promotors at the worksite need to be both.
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