Work-related asthma symptoms and attitudes to the workplace
Correspondence to: David Fishwick, Medical Unit, The Centre for Workplace Health, Health and Safety Laboratory, Harpur Hill, Buxton, Derbyshire SK17 9JN, UK. Tel: 01298218445; fax: 01298218471; e-mail: david.fishwick{at}hsl.gov.uk
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Abstract |
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Background The Health & Safety Executive estimate that between 1500–3000 UK workers develop asthma through potentially avoidable workplace exposures each year.
Aims To assess the perception of health, safety and the work environment by workers with symptoms suggestive of occupational asthma.
Methods A total of 97 workers referred to hospital specialists with symptoms suggestive of occupational asthma were studied in order to investigate their attitudes to the workplace, safety and health. A qualitative study design using semi-structured telephone interviews at 2 months and 12 months following enrolment was used at 6 national UK centres with a special interest in occupational asthma.
Results Many workers in the study felt let down by the workplace and management and perceived that a lack of health and safety measures had contributed to the development of their asthma symptoms. Many workers felt that their employers were ‘uncaring’ and were pursuing or considering medico-legal cases against them.
Conclusions Workers' perception of risk influences their behaviour in the workplace, and their own health beliefs potentially create barriers to changing this. It is essential to consider workers' perceptions when developing strategies to effect change within the workplace.
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Introduction |
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Work-related ill-health is a significant financial and social burden for the UK. The UK Health & Safety Executive (HSE) estimates that in 2001/2002, 2 328 000 individuals believed that they were suffering from a condition caused, or made worse, by work [1]. This is equivalent to 5.3% of those who have ever worked. Occupational asthma is the most frequently reported occupational respiratory disease in the UK and costs society up to £1.1 billion over a 10-year period. It is thought that
10% of adult onset asthma is attributable to occupational exposures [2]. The prompt diagnosis of occupational asthma depends on workers reporting work-related respiratory symptoms quickly, possibly as part of a health surveillance programme, and subsequent referral to an occupational or respiratory physician for diagnosis [3]. There is reasonable evidence to support an improved outcome for those workers removed earlier from harmful exposures [4,5,6].
Despite a recent approved code of practice relating to occupational asthma prevention [7], confusion still exists among workers and employers about their best actions to comply with current legislation. In addition, there are significant barriers to identifying new possible cases of occupational asthma. Previous work suggests, for example, that patients with asthma are reluctant to discuss work and lifestyle restrictions with health care personnel [8]. Other data suggest that workers are concerned about economic consequences, particularly if they report work-related asthma symptoms, even when being screened within an annual health surveillance programme [9].
This paper describes the findings of a national multicentre study, designed to assess the perception of health, safety and the work environment by workers with symptoms suggestive of occupational asthma.
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Methods |
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Six centres were recruited into the study using purposive sampling (this is a type of non-random sampling in which respondents are specifically sought out because they meet the criteria required for the study). Each centre employed a hospital physician with a particular interest in occupational asthma. During the recruitment phase, the centre enrolled all consenting patients referred with a suspected diagnosis of occupational asthma. All subjects gave written informed consent. The study was given ethical permission to proceed by the Trent Multi-region Ethics Committee of the UK.
One trained respiratory nurse administered a semi-structured telephone interview, 2 months following the subject's initial consultation with the respiratory physician. The interviews collected both qualitative and quantitative data that were transcribed immediately onto a specifically designed interview schedule sheet.
A follow-up telephone interview was carried out 1 year after initial inclusion into the study. Again, this collected both qualitative and quantitative data.
All qualitative data were retranscribed before data analysis commenced. Two experienced researchers, one from a medical and one from a nursing background (DF and LMB) coded the data independently to increase the reliability of the study. Data were organized into codes from which themes and categories were identified. All quantitative data were entered into SPSS for windows, release 11.0.1. The analysis consisted mainly of descriptive statistics, rather than tests of inference. Chi square analysis was used to detect differences between proportions.
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Results |
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The mean age of the 97 workers studied was 44 years (range 24–64) and 75% were male. Occupational breakdown by major category was as follows: service industry (10%), manufacturing/engineering (37%), paint/chemicals (18%), food (19%), health care (9%), building/joinery (5%) and office work (2%). No two workers came from the same workplace.
Most individuals (50%) had consulted their primary-care physician (family physician) between one and five times with work-related respiratory symptoms prior to referral to secondary care, and 32 (43%) had consulted their primary care physician on more than five occasions. The majority (72%) were referred from primary care, although others were referred from occupational health physicians, occupational health nurses, solicitors and following hospital admission.
Ninety-two individuals (95%) were successfully contacted for the second interview 12 months later, and 45 of the workers were given a final definitive diagnosis of occupational asthma.
There were no major differences seen in emergent themes and attitudes between those with and without occupational asthma.
It is notable that during the interviews, subjects made very few spontaneous supportive comments concerning the workplace. Workers were generally aggrieved by the fact that work may have contributed or caused their asthma symptoms, and illustrative comments from workers describing the working environment where they first developed respiratory symptoms are set out in Box 1.
| Box 1. Description of the workplace ID 544: It's a terrible place to work, there is chemical powder in the air continuously and there was no dust extraction prior to 2000 ID 512: The air is thick with flour dust; there was no ventilation from 1986–91 in the sieving area as the windows were screwed down. We still have no extraction system ID 219: The atmosphere is full of impurities, fans blow air around and oil in the air continuously. Known as the dirtiest shop in the plant ID 511: (I am) constantly covered in oil, hair full of oil after each shift ID 402: Only stopped smoking at benches in workplace in 2002
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Sixty-four per cent of respondents indicated that some form of workplace assessment had been carried out. Despite being required by law, only 43% of workers reported that a formal assessment under the Control Of Substances Hazardous to Health (COSHH) regulations had been carried out.
Box 2 illustrates comments made regarding workplace monitoring and risk assessment. It is clear that normal procedures for ensuring a safe workplace had failed or were absent in many cases.
| Box 2. Workplace monitoring and risk assessments ID 107: [The company] had an assessment for TIG and nickel spray welding, I had a monitor attached to my overalls for a short period ID 212: [The] company was very good at monitoring dust and noise doing risk assessments and implementing change ID 506: Independent assessments found grinding dust to be over the legal limit, there were 2 repair booths and only 1 had working extraction ID 513: [I have] never heard of COSHH ID 534: All requests to carry out risk assessments have been ignored
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Comments relating to occupational health provision and its value varied. For example, a number of workers were not reassured by the advice given (ID 206).
One-quarter of all worksites had no form of occupational health input and in some cases respondents had recognized that health surveillance was lacking, and requested this themselves. Box 3 illustrates the range of comments made regarding occupational health.
| Box 3. Occupational health provision ID 105: [I am] pleased with the medical care I have received and the changes my condition has brought about. The company have had to tighten up practises such and risk and COSHH assessments, this can only benefit all concerned. ID 110: [I have] no occupational health facility during the night (subject worked full time night shift) ID 111: [I] do not feel that the occupational health doctor or nurse have been very helpful ID 541: [I] told the company nurse I was asthmatic at induction week but I was still placed into paint shop despite the occupational health nurse advising that I shouldn't be put in that area ID 544: All staff demanded health checks and were seen at the local hospital because the company did not have an occupational health service
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The majority of workers felt that there was a lack of understanding from the management in their workplace. Many felt that their managers were more interested in profit and production than the respiratory health of their workers. Box 4 illustrates how these employees, suffering from respiratory symptoms, perceived the management in their workplace.
| Box 4. Perception of management ID 111: The management are not listening ID 208: [I] cannot trust them ID 218: [I] feel disappointed with the company's attitude; they are trying to blame my previous employment (as the cause of his respiratory problems) ID 405: The company are negligent, it's family run and profit is more important ID 507: Recently my manager produced a document containing a lot of untruths and this is distressing (in relation to medico-legal case) ID 509: [There is] lack of co-operation from the management, total disregard for health and safety from the MD, [he is] only concerned with production ID 401: [I] feel that my employers are uncaring ID 403: [I am] annoyed that their attitude is blasé, they do not take health and safety seriously
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Suffering from respiratory symptoms had a huge personal impact on the majority of subjects (Box 5). This often related to their current or perceived future employment prospects. Many workers were on long-term sick leave or had been dismissed from work on medical grounds. Others found it difficult to relocate to other workplaces. The balance of financial need and tolerating asthma symptoms is seen in many comments.
| Box 5. Personal impact ID 112: [I am] worried about future employment prospects [due to my] age and health problems ID 104: [I am] still exposed to wood, dust, resins .... but better than in previous workshops, I have a young family, I have to work. ID 109: [I] was told by the company to buy myself a mask if I needed one, I've left that job now and have taken a much lower salary, frustrated as to what is causing health problems ID 404: [I] may not be able to continue work as a spray painter as the workplace is small and there are not many other places I could move to ID 406: [I am] very depressed about the recent news that I can not work with flour, aware that [my] health is suffering, [I am] very worried about future employment ID 507: [I am] very anxious about my future, I don't want to retire but [I am] unable to work with cleaning agents and chlorine solutions, feel isolated at present ID 601: [I] have been advised to change jobs but cannot find another one, [I am] very concerned about this ID 212: [I] used to be fit and well, I'm finding it hard living with limitations due to ill health, I am on long term sick now ID 218: [I] was initially told to stay at home until a new placement was found for me, I moved briefly to office work, then to another plant before being dismissed for medical reasons
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Ninety-two workers (95%) were contacted again 12 months after their first interview at which time 90% had been given a firm diagnosis, of which 49% had confirmed occupational asthma. Eighty per cent of individuals were still symptomatic at follow-up (84% with a diagnosis of occupational asthma and 77% of those who did of those who did not have occupational asthma). The difference between these was not significant.
Of those diagnosed with occupational asthma, 36% were still working in the job where their symptoms began, although 62% of workplaces had made some form of adaptation. Of those individuals who had not been given a diagnosis of occupational asthma, 47% remained in the same job with significantly fewer (25%) of these workplaces subsequently being adapted, P < 0.001.
Box 6 illustrates the wide range of changes in the workplace, which had potentially affected individual exposures.
| Box 6. Changes in the workplace ID 204: Formaldehyde was only used during the foot and mouth crisis ID 210: [I am] not handling dried fish samples, refused fish sample preparation for the past 12 months with the backing of the occupational health department ID 501: Fumes are much less as much of the PVC work has gone overseas ID 511: [The company] closed down the section 3 months ago, now working in an area where machines are enclosed ID 105: [I have] moved to a new building where lots of improvements have been introduced ID 502: [I am] trying to avoid contact in the plant room until clerical work is found [for me]
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Many workers at follow-up felt aggrieved with their employers and were pursuing compensation claims.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConflicts of interestReferences |
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This is the first study to report the perception of workplace issues by workers with symptoms suggestive of occupational asthma. The semi-structured interview was designed to explore attitudes regarding the workplace and provision of health and safety. This method was adopted in order to allow triangulation between certain quantitative aspects of each case, such as the agents worked with and reported respiratory symptoms.
Potential criticisms of this study, and of qualitative design in general, include validity and generalization of these findings to all workers with work-related respiratory problems. We specifically adopted a sampling strategy thought valid for assessing qualitative aspects of health and safety in workers. As these patients were drawn from a standard referral system between primary-care physicians and hospital specialists, it is probable that the recruited population is externally valid, and that the study findings are reasonably applicable to all workers being investigated for occupational asthma. Again, a potential criticism of this work lies in the ‘common sense’ nature of the findings. We believe, however, that only by formally documenting these attitudes will we most likely achieve an eventual reduction in this condition. Any future work relating to occupational asthma must take into consideration the complex workplace dynamic, including workers' attitudes and beliefs.
The main shortcoming of the study is that the interviews were not tape recorded. Our previous experience with this group of patients highlighted concerns about disclosure and confidentiality issues, particularly those anticipating compensation claims. It was therefore decided, a priori, that in order to increase response rates, immediate direct transcription and summary by the researcher would be used. These will inevitably have introduced certain bias into categorization of the data. The use of a semi-structured questionnaire may also have contributed to bias.
There were many specific adverse comments made in relation to the workplace, and in particular the perceived high level of harmful exposures, and the inability to alter these. Comments were mixed in relation to monitoring of exposures, and while some documented such measures, others felt that the results were not made available to the workers. Comments did not materially differ between those with or without a diagnosis of occupational asthma, suggesting that the suspicion itself, but not a confirmed diagnosis may have dictated various attitudes in workers.
The reaction to local occupational health provision was mixed. Some workers clearly thought these services, and health surveillance programmes, were useful. Others felt that the communication by these professionals with management was not appropriate. For example, one worker (ID 541) was placed in the spray paint shop despite clearly stating to the occupational health nurse that he had asthma, although an individual assessment may have been performed to agree this.
The majority of workers felt let down by their employers, and felt that lack of health and safety measures had contributed to the development of their asthma symptoms. Workers generally thought that workplace exposures had caused their asthma symptoms, irrespective of a final confirmed diagnosis of occupational asthma, and that the management and health and safety processes had failed them.
This study documented many comments relating to the personal impact made by asthma in the workplace. A significant proportion dealt with the difficult balance between persisting asthma symptoms in the workplace and fear of divulging these due to potential loss of earnings. Furthermore, some stated that they had not discussed these issues with their family physician for similar reasons. Most of these issues persisted at 12 months of follow-up, although workers started to talk more definitively about compensation. The follow-up data also highlighted two issues relevant to the continuing management. Firstly, the persistence of respiratory symptoms and the frustrations of having to change working practice, or even give up work because of ill-health, and secondly, the relevance of adaptations or improvements that had been made in the workplace. Many workers remained in the same job at 12 months, despite early removal dictating a better prognosis [10].
The personal impact following a diagnosis of occupational asthma is not well-understood. Previous studies have reported financial problems following loss of employment and reduced promotion prospects in workers diagnosed with occupational asthma [11,12,13]. It has also been reported that even in the absence of diagnosed occupational asthma, work-related asthma-like symptoms are associated with a considerable socio-economic impact [14]. The current study supports this conclusion, and confirms that the main issues of concern are personal health and financial status. One potential way forward would be to include occupational exposures as a possible trigger in personal action plans, recently confirmed using qualitative techniques to be popular with asthma patients [15].
This study suggests that workers with work-related asthma symptoms perceive many problems with their workplace and employers, irrespective of the final confirmed diagnosis of occupational asthma. Many clearly place financial gain ahead of their respiratory health. Workers appear to have largely negative views about employers, and occupational health provision, and are reluctant to seek medical advice as they risk losing their income.
It appears also that workers may choose to continue with work practices known to harmfully expose them, even when they are aware of the risks [16]. There are many potential reasons why workers and employers are not willing or able to change work practice. While financial constraints appear to hinder this process, workers' perception of risk will also dictate their behavioural choices [17] and their own health beliefs may create barriers to behaviour change [18,19].
There is even less known about the role of primary and secondary care in terms of the prevention of occupational asthma. In a recent editorial [20], action points associated with key programmes identified in the UK HSE's Securing Health Together document were emphasized [21]. One action point was to promote improved diagnosis of occupational asthma and better awareness among health professionals, workers and safety representatives; adding that practice nurses and primary-care physicians should be specifically targeted.
All of these issues are relevant to both early case findings [22], essential if the prognosis of occupational asthma is to be improved, and research studies in the workplace [23]. Such studies must take into account the complex communication between workers, their employers and their health care providers.
Key points
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Conflicts of interest |
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None declared.
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Acknowledgements |
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The authors would like to thank all participating workers and Chris Stenton, Sherwood Burge, Rob Niven, Christopher Warburton, Trevor Rogers, David Hendrick, Roger Rawbone and Nerys Williams for their time and expertise.
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References |
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