T h e G l o b a l O c c u p a t i o n a l H e a l t h N e t w o r k �

Message from the Editor:

Dear Reader,We start this year’s edition of GOHNET with the topic of psycho-social factors and mental health at work. You will enjoy reading this issue, even though you may not be a psychologist or a psychiatrist, but are nevertheless working in the area of occupational health and safety. Therefore, the psychosocial and mental aspects of health are most rel-evant to you! You are certainly familiar with the WHO constitution which defines health in a holistic manner. It encompasses the physical, mental and social aspects of well-being:

“Health is a state of COMPLETE physical, mental and so-cial well-being and not merely the ABSENCE of disease or infirmity.”

It is a fact that for many working people it is all too frequent that the work environment is where they spend most of their waking hours. According to surveys, many perform activities that they perceive as demanding, constraining, and otherwise stressful. Mental health prob-lems and other stress-related disorders are recognized to be among the leading causes of early retirement from work, high absence rates, over-all health impairment, and low organizational productivity.

You may ask yourself how the different approaches of mental health and occupational health relate. In fact, the two areas can inform each other in the development of viable strategies to avoid any further in-crease in mental health problems and disorders, since mental health strategies and actions focus on treatment and rehabilitation. However, they also address awareness-raising and prevention. The occupational health approach focuses primarily on awareness-raising and preven-tion, but does address intervention and care issues.

On the one hand, mental disorders include mood disorders, substance use disorders, schizophrenia, anxiety and personality disorders. On the other hand, emotional experiences and behaviours associated with psychosocial hazards include mobbing, stress, drug & alcohol abuse, and depression. These experiences can eventually result in mental health problems without diagnosis of any disorder.

‘The term mental health problem or issue is often used to describe con-ditions associated with some of the characteristics of a mental disorder, but are not of sufficient severity to be diagnosed as a mental disorder. For example, stress results in a number of symptoms associated with mental disorders including distress and feelings of not coping. How-ever, these are not usually of such severity that a mental disorder can be diagnosed’1. Some research points directly at the relationship between work-related psychosocial hazards and mental disorder: ‘In both men and women, high job demands comprised of measures of work pace and conflicting demands, were associated with increased risk of psy-chiatric disorder’2.

Therefore, psychosocial factors need attention, since adverse psycho-logical and social factors may play a role (besides biological factors)

in leading to mental disorders. The focus of mental health experts at WHO on the workplace is relatively recent, whereas psychosocial fac-tors have been studied for many years within the working context and environment.

As you can see from the table of contents below, the choice of articles is varied, because it is a vast and international topic. You can read about research in Spain, the UK, Italy, Canada and Finland. We also report on the psychosocial risk management toolkit - or PRIMAT - which is being developed within the WHO Network of Collaborating Centres in Occupational Health and led by the Institute of Work, Health and Organizations in Nottingham. This is a truly international project because it is being developed by international experts for workplaces worldwide, with a particular focus on small and medium enterprises. In the GOHNET Newsletter No 7 we already reported on the Chem-ical Toolkit and we mentioned that a number of toolkits to address various workplace hazards are in development. The aim is to establish an Occupational Risk Management Toolbox that can claim to trans-late research and knowledge into action via creative solutions. For references please visit our website.Should you have any comments after your reading, please do not hesi-tate to send them to us.Evelyn Kortum, EditorKati Bozsoki, Co-Editor World Health Organization Occupational & Environmental Health Programme Department of Protection of the Human Environment20 Avenue Appia; CH - 1211 Geneva 27Fax: +41.22.791 13 83 - ochmail@who.intwww.who.int/occupational_health

Impact of Flexible Employment on Mental Health and Choice of Living Arrangements 2

Towards the Development of a Psychosocial Risk Management Toolkit (PRIMAT) 3

Psychosocial Factors and Mental Health at Work: A Canadian Perspective 6

Occupational Health Psychology Education and Training 8

Managing Mental Health at Finnish Workplaces 9

Work-related Post Traumatic Stress Disorder: an Italian Preliminary Study of Bank Employee Victims of Robbery 10

Publications 12

GOHNET News 12

How to join GOHNET 16

The Global Occupational Health Network ISSUE No. 10 - 2006 GOHNET NEWSLETTER

GOHNETGOHNET

IN THIS ISSUE

PSYCHOSOCIAL FACTORS AND MENTAL HEALTH AT WORK

T h e G l o b a l O c c u p a t i o n a l H e a l t h N e t w o r k2

Impact of Flexible Employment on Mental Health and Choice of Living ArrangementsLucía Artazcoz (lartazco@aspb.es),1 2 3 Joan Benach, Imma Cortès 1 2 1,

3 4 Carme Borrell,1 2 3 Agència de Salut Pública, Barcelona;A WHO Collaborating Centre in Occupational Health

2 Red de Investigación Temática de Salud y Género3 Red de Centros de Investigación de Epidemiología y Salud Pública

4 Universitat Pompeu Fabra, Barcelona

Summary

Th e objectives of this study are: 1) To analyse the impact of fl exible employment on mental health and job dissatisfaction; and 2) to examine the constraints imposed by fl exible em-ployment on men’s and women’s partnership formation and people’s decision to become parents. For the two objectives the potentially diff erent patterns by sex and social class are ex-plored.Th e data were derived from the 2002 Catalonian Health Sur-vey. Four types of contractual arrangements have been consid-ered: permanent, fi xed-term temporary contract (independent of the contract duration), non-fi xed term temporary contract and no contract. Th e population analysed were salaried work-ers with no long-standing limiting illness, who were between 16-64 years old (1474 men and 998 women).Fixed-term temporary contracts were not associated with poor mental health status. Th e impact of other forms of fl exible em-ployment on mental health depended on the type of contrac-tual arrangement, gender and social class and it was restricted to less privileged workers, women and manual male workers. Th e impact of fl exible employment on living arrangements was higher in men. Among both manual and non-manual male workers, those with fi xed-term temporary contracts were less likely to have children when married or cohabiting and, addi-tionally, among non-manual males they also were more likely to remain single.

Introduction

In recent years employers and policy makers have considered labour market fl exibility as a means of improving workers’ per-formance and adaptability to technical change and increasing globalisation (1). Alongside these changes within production, employment conditions have become less stable. However, very little research has been conducted to analyse the impact of fl exible employment on individuals’ health and living con-ditions. Th is knowledge is likely to provide some insights into equity considerations. Many studies have been based on one physical or psychologi-cal health indicator but the eff ect of fl exible employment can diff er depending on the well-being indicator used. For exam-ple, besides its impact on physical and mental health, fl exible employment can aff ect workers’ social health by limiting part-nership formation or the decision of being a parent. It has been shown that holding a job is an important predictor for union formation and parenthood (2). However, the lack of contrac-tual security can be an additional limitation for assuming fam-ily responsibilities. Employees expect their contract to fi nish

within a given time period and it is diffi cult to foresee their future labour market career and, therefore, also to plan ahead. At this stage of research it is also important to determine whether certain social groups are more or less vulnerable to the damaging eff ects of fl exible employment. For instance, criticism about the gender imbalance in the existing literature about health and contingent work has been raised (3). More-over, despite that it has been reported that social class modifi es the eff ect of unemployment on mental health (4), as far as we know, this issue has not been explored in the research on fl ex-ible employment. Less qualifi ed workers could be more vul-nerable to fl exible employment because of lower employability and less power to negotiate their employment conditions.Th e objectives of this study are 1) to analyse the impact of fl exible employment on mental health; and 2) to examine the constraints imposed by fl exible contractual arrangements on men’s and women’s partnership formation and people’s deci-sion to become parents. For the two objectives the potentially diff erent patterns by sex and social class will be explored.

Methods

Th e data for this study were derived from the 2002 Catalonian Health Survey, a cross-sectional study based on a representative sample of 8400 members of the non-institutionalised popula-tion of Catalonia, a region in North-Eastern Spain with about seven million inhabitants. Th e population analysed were sala-ried workers with no long standing limiting illness, aged 16-64 (1474 men and 998 women). Th e outcome showed poor mental health status and limitations in partnership formation and parenthood.Flexible employment was assessed through the type of con-tract. Th e question had four categories: permanent, fi xed-term temporary contract (independent of the contract duration), non-fi xed term temporary contract, and working with no contract. Th e three latter types of contracts were considered as objective fl exible employment.

Results

Working with temporary contracts was more frequent among less privileged groups, such as manual workers and women (fi gure 1). Moreover, more than 8% of female manual work-ers were employed with no contract. Working with fi xed-term contracts was not associated with poor mental health status in any gender and social class combination. Among non-manual female workers and manual male workers, non-fi xed term temporary contracts were positively associated with poor mental health. Figure 1. Type of contract by gender and social class.

Among manual workers, both male and female, those with no contract were more likely to report poor mental health status (fi gure 2).

Type of contract

T h e G l o b a l O c c u p a t i o n a l H e a l t h N e t w o r k 3

Figure 2. Prevalence of poor mental health status by type of con-tract, gender and social class.

In all groups, except manual female workers, all forms of non permanent jobs were associated with non-partnership forma-tion although few associations were statistically signifi cant. Limitations in parenthood were only observed among men, both manual and non manual, with fi xed-term temporary contracts.

Discussion

Our study produced three main fi ndings: 1) Whereas non-fi xed term contracts and working with no contract were as-sociated with poor mental health status, no association with fi xed-term temporary contracts was observed; 2) the eff ect of fl exible contractual arrangements, other than fi xed-term temporary contracts, on mental health was higher among less privileged groups (women and male manual workers); and 3) the impact of fl exible employment, either fi xed-term or non-fi xed term contracts, on family formation was more pronounced among men.Th e most frequent type of non-permanent contract was fi xed-term temporary contracts. In both sexes, fl exible employment increased among manual workers. It is important to note that 8% of female manual workers had no contract. Most of them (63%) worked as cleaners or carers of dependent people in domestic settings. Th ese fi ndings emphasise the need for more research into traditional female jobs as well as the impact of fl exible employment in such jobs.We have found some evidence of poor health outcomes in those forms of fl exible employment more likely to be associ-ated with poor employment conditions, such as working with non-fi xed term temporary contracts and being employed with no contract. Moreover, we have also examined the role of so-cial inequalities and we have additionally shown that the nega-tive impact of these forms of contractual arrangements have a higher impact among less privileged workers (women and male manual workers). Th ese results challenge the view that the health eff ects of fl exible employment emerge in a univer-salistic manner through individual perceptions that bear little relation to social structure (5).In our study, 63% of manual males with non-fi xed term con-tracts were employed in the construction sector. A signifi cant proportion of persons worked more than 40 hours a week (46% versus 26% in persons with permanent contracts). It is likely that people with contracts of unknown duration accept hard working conditions and diff erent forms of exploitation, such as long hours, in order to keep their job. In this context, evidence shows that employees with temporary contracts are less likely to have sickness absences (6). Th is can be even more

Poor mental health status

frequent in the Spanish labour market with a high unemploy-ment and growing rates of immigrant workers. Th ese results suggest that it is not only the uncertainty about job future that relates to poor mental health status but also the poor working conditions associated with some temporary contracts. How-ever, this is just a speculation that deserves further attention in future research.Workers with temporary contracts, either fi xed-term or non-fi xed term, were less likely to decide for partnership formation and parenthood. However, this association was more pro-nounced among men. Among women, an association between not being married and working with a non-fi xed term tempo-rary contract was only observed among non-manual workers. Th is fi nding could be explained, among other reasons, by the higher attachment of women of higher education levels to the labour market (7). Besides the impact of fl exible employment in shaping the capacity of both women and men to realise their potential for health, these results illustrate their contribution to the low birth rate in Spain, which is the lowest in the EU-15 after Ireland (8). Th e results further emphasise the need for political interventions to reduce the abuses of temporary forms of employment arrangements.

Conclusions

Th e results of this study have signifi cant policy implications. Th ey emphasize the need that labour policies in Spain increase their eff orts to reduce the high rates of fl exible contractual ar-rangements, the highest in the EU, taken into account the existence of social inequalities. Additionally, psychosocial risk assessments at the workplace should specifi cally analyse the situation of workers with temporary contracts. Finally, consid-ering the increasing liberalisation of the labour market, health and working condition surveys should be more sensitive to situations related to fl exible employment and eff ectively moni-tor them.Note: Further details of this study are published in “Artazcoz L, Benach J, Borrell C, Cortès I. Social inequalities in the impact of fl exible employment on diff erent domains of psychosocial health.J Epidemiol Community Health 2005; 59: 761-767.”

Towards the Development of aPsychosocial Risk ManagementToolkit (PRIMAT)

Stavroula Leka, Institute of Work, Health &Organisations (I-WHO), University of Nottingham,

UK (Stavroula.leka@nottingham.ac.uk),A WHO Collaborating Centre in Occupational Health

Over the years, a need has been identifi ed through the work of the WHO Network of Collaborating Centres (CCs) in Oc-cupational Health for practical procedures and tools for the management of occupational health and safety at work. Ide-ally, these should be capable of dealing with the diff erences that exist between countries, sectors and enterprises. It is clear that such procedures and tools should be suitable for use in developing countries and also in countries in transition as well as in small and medium-sized enterprises (SMEs). It is widely acknowledged that their conditions and needs diff er mark-edly from those of developed countries or larger organisations (19).

T h e G l o b a l O c c u p a t i o n a l H e a l t h N e t w o r k�

In addition, emphasis has been placed on the changing nature of work and new forms of risks that could negatively affect employee health and safety (3, 9). Issues such as work-related stress, bullying and harassment are now receiving attention on a global basis and efforts have been made to address them at the workplace level (1). Task Force 7 on Psychosocial Factors at Work of the WHO Network of CCs in Occupational Health has been particularly active in this respect (20). However, the complexity of the aetiology of such issues and their context-specificity have made it difficult until now for practical, pre-vention-oriented tools to be developed that could be adaptable and usable to a wide range of enterprises, sectors and coun-tries.This paper presents a framework for action to address this challenge; it discusses the development of a Psychosocial Risk Management Toolkit (PRIMAT), which could form part of a wider Occupational Risk Management Toolbox that would address health and safety issues at work in a comprehensive manner.

Basic rationale

Psychosocial hazards

The International Labour Office (17) defined psychosocial hazards in terms of the interactions among job content, work organisation and management, and other environmental and organisational conditions, on the one hand, and the employ-ees’ competencies and needs on the other. Those interactions that prove to be hazardous influence employees’ health through their perceptions and experience (17). A simpler definition of psychosocial hazards might be ‘those aspects of the design and management of work, and its social and organisational contexts, that have the potential for causing psychological or physical harm’ (4). Psychosocial hazards concern both the content of work, and its context. These hazards are summarised, together with exam-ples, in Table 1 below. There is a reasonable consensus in the literature of the nature of psychosocial hazards, but it should be noted that new forms of work give rise to new hazards – not all of which will yet be represented in scientific publications. Any assessment of a particular working group’s problems needs to be alert to the existence of new psychosocial factors, and to incorporate a process that allows for their discovery. Such taxonomies need to be kept under review, given the changing nature of work, and are offered largely as a guide to thinking.Table 1: Psychosocial Hazards (adapted from 18)

Exposure to different types of hazard can contribute to dif-ferent forms of harm. Psychosocial and organisational hazards affect health largely - but not exclusively - through psycho-physiological pathways. For example, violence, as a psychoso-cial hazard, may have a direct physical effect on its victim in addition to any psychological trauma or social distress that it causes. Both physical and psychosocial and organisational haz-ards have the potential for detrimentally effecting social and psychological health as well as physical health. One should not make the mistake of thinking about psychosocial and or-ganisational hazards solely as risks to psychological health (2). Furthermore, significant interactions can occur both between hazards and in their effects on health.

Work-related stress

European data from a variety of national and transnational surveys of those in work, or who have recently worked, have identified stress-related problems as among the most commonly reported sources of work-related ill-health (3). For example, the European Foundation 1996 survey of Working Condi-tions in the European Union revealed that 57% of the workers questioned believed that their work affected their health. The work-related health problems most frequently mentioned were musculo-skeletal complaints (30%) and stress (28%). Survey data such as that referred to above is available from a variety of European (and other) countries across at least a ten-year window and gathered using a variety of instruments. These data are supplemented by at least two other sources: empirical data from more focussed studies on particular work groups and occupations, again across a wide variety of countries and sectors using an equal variety of approaches and instruments, and practice data from both occupational and primary health care specialists. Taking such studies and surveys together, the weight of evidence provided can tell a reliable enough story to support action (6, 8, 11). Doing this, it becomes obvious that work-related stress now presents one of the major challenges to the health of working people.Translation of knowledge into practice – risk management

The adaptation of the traditional risk management paradigm e adaptation of the traditional risk management paradigm to deal with work-related stress does not have to aim at an exhaustive, precisely measured account of all possible stressors for all individuals and all health outcomes. The over-riding objective is to produce a reasoned account of the most impor-tant stress-related hazards for a particular and defined work-ing group grounded in evidence (8, 15). The account simply needs to be ‘good enough’ to enable employers and employees to move forward in solving the associated problems and com-ply with their legal duty of care. The notion of ‘good enough’ is used here to mean fit and sufficient for purpose. In other words, this is not an activity carried out for the benefit of re-searchers, but one pursued with the aim of making a differ-ence to working conditions within organisations (16). At the heart of most risk management models are two distinct but intimately related cycles of activity: risk assessment and risk reduction. It is argued here that the risk management paradigm could provide the basis for the development of the psychosocial risk management toolkit. This could be achieved by refining the stages involved and providing/developing practical tools that can be readily used by companies and supported by appropri-ate expertise. These need to be carefully validated through a series of empirical studies focusing on different types of enter-prises and sectors of employment in different countries where relevant expertise might or might not be readily available. A

PSYCHOSOCIAL HAZARDS

Job content Lack of variety or short work cycles, fragmented or meaningless work, under use of skills, high uncer-tainty, continuous exposure to people through work

Workload & work pace Work overload or under load, machine pacing, high levels of time pressure, continually subject to deadlines

Work schedule Shift working, night shifts, inflexible work sched-ules, unpredictable hours, long or unsociable hours

Control Low participation in decision making, lack of con-trol over workload, pacing, shift working, etc.

Environment & equipment Inadequate equipment availability, suitability or maintenance; poor environmental conditions such as lack of space, poor lighting, excessive noise

Organisational culture & function Poor communication, low levels of support for problem solving and personal development, lack of definition of, or agreement on, organisational objectives

Interpersonal relationships at work

Social or physical isolation, poor relationships with superiors, interpersonal conflict, lack of social support

T h e G l o b a l O c c u p a t i o n a l H e a l t h N e t w o r k �

set of clear aims and objectives that should be addressed are described below. Aims and objectives

The proposed Psychosocial Risk Management Toolkit (PRI-MAT) could form part of a wider Occupational Risk Man-agement Toolbox. Such a Toolbox would address health and safety issues at work in a comprehensive manner. PRIMAT will aim at the effective management of psychosocial risks and will address context-specific factors (such as employment sec-tor, type of enterprise, availability of expertise and country). The main objectives to be met are:

To develop a toolkit that will be readily usable and user-friendlyTo develop and refine the tools that it will consist ofTo develop appropriate expertise and support in relation to the toolkit, utilising e-learning technologyTo evaluate the toolkit in different contexts, including a cost-benefit analysis, through the WHO Network of CCs in Occupational HealthTo develop training packages for the toolkit deliverable through e-learning and face-to-faceTo integrate the toolkit in the provision of basic occupa-tional health servicesTo use the toolkit as an awareness raising mechanism, es-pecially in SMEs, developing countries and countries in transitionTo establish a global network of PRIMAT providers/ex-perts

Key issues

1. Awareness

There are certain key issues that need to be considered in the process of the toolkit development. The first concerns the level of awareness in relation to psychosocial hazards in different countries. This could relate to differences in perception, cul-tural factors, the availability of local expertise and education as well as involvement. Awareness issues should be taken into account early in the process. It is important that organisations from countries with marked differences in the experience of these issues participate in the development of the toolkit. These could be accessed through the WHO Network of CCs in Occupational Health. Limited awareness could also hinder the promotion of the toolkit in the longer term. Through the inclusion of PRIMAT in a wider, comprehensive Toolbox (consisting of toolkits ad-dressing different OHS issues) access and use could be en-hanced. As such, it is important that a systems approach is maintained throughout the development of PRIMAT that will view the toolkit as part of the extended OHS system. In the longer term, it is envisaged that the toolkit could serve as the basis for an awareness campaign in countries where expertise is lacking.2. Cost-benefit analysis

In addition, the toolkit could be promoted more effectively if a cost-benefit analysis is incorporated in its development and used in its evaluation. This will also facilitate access to organi-sations in developed countries and will make it especially at-tractive to SMEs.

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3. Access to expertise

Finally, access to expertise to support the use of the toolkit is a crucial issue and needs to be explored not only through more traditional avenues (for example, provision through occupa-tional health services, use of local expertise) but also through the utilisation of new technology and especially e-learning. If access to, and promotion of, the toolkit are addressed at dif-ferent levels and in different ways, a better response could be achieved even where resources and knowledge are limited.

Development framework

A staged approach will be followed for the development of PRIMAT that will address the main objectives and key issues discussed above. This could follow the model presented be-low.• Stage 1 : Development

This stage will focus on the development of the basic elements of the toolkit, including information and guidance sheets, as-sessment tools (for example, questionnaires), quick analysis tools, action plans, referral to expert systems, expert support systems (including e-learning), cost-benefit analysis tools.This stage will require adequate time for development and it is expected that it will be completed within a period of 2-3 years. Companies from different employment sectors, of dif-ferent sizes and in different countries will participate in the development of the toolkit as will a number of experts from the WHO Network of CCs in Occupational Health. The In-stitute of Work, Health & Organisations will co-ordinate the development stage and will be responsible for the development of the toolkit while collaborating with the experts that will participate in the programme as advisors.• Stage 2 : Evaluation

This stage will evaluate the toolkit in further companies and will identify best practice standards and examples. These will be compiled in a PRIMAT guide that will include experiences from companies on a global basis. The Institute will work with other WHO CCs to evaluate the toolkit. At the same time, the expert support network will be expanded. This stage will last approximately a year.• Stage 3 : Training & Promotion

During this stage a training package will be developed for both companies and trainers/experts. This package will be used to promote the toolkit through occupational health services and other relevant local organizations on a global basis. A WHO-supported awareness campaign will be organized globally. This campaign will aim at promoting awareness of the toolkit (and Toolbox), making the toolkit available to as many companies as possible, training as many experts as possible on the use of the toolkit and further expanding and crystallizing the ex-pert support network through a Global Network of PRIMAT Providers. E-learning could be used both for training and for promotion purposes. This stage will last 1-2 years.

Actions

A PRIMAT Working Group has been established. This in-cludes experts from the Institute of Work, Health & Organisa-tions (UK), the WHO, the National Institute of Working Life (Sweden), ISPESL (Italy), TNO (Netherlands), the Finnish In-stitute of Occupational Health (Finland), and BAuA (Germa-ny) with input from experts from NIOSH (USA). A one-year project has been funded by SALTSA that is a joint undertaking by three Swedish confederations of employees and the Swedish

T h e G l o b a l O c c u p a t i o n a l H e a l t h N e t w o r k6

National Institute for Working Life. Th e main objectives to be met at this fi rst stage of PRIMAT development are:

To provide a review of the current situation in relation to the changing nature of work and psychosocial risksTo agree on the guiding principles that will drive the review of psychosocial risk management approaches throughout Europe To review existing practical approaches and tools to psy-chosocial risk management in EuropeTo develop a European inventory of best practice exam-ples, underpinned by sound theory and a business case, that have proven eff ective in addressing the needs of or-ganisations of diff erent sizes and employment sectorsTo recognise experts in psychosocial risk management in diff erent European countriesTo develop best practice principles that will serve as the basis for the development of PRIMATTo produce a publication that will provide an overview of this fi rst stage and will form the basis towards the devel-opment of a major grant proposal that will facilitate the next stages of PRIMAT development

Th e PRIMAT Working Group is committed to the facilitation of the management of psychosocial risks at the workplace. It views psychosocial issues as priorities that need to be addressed on a global basis and aims at developing a practical approach by use of a toolkit that will be eff ective in diff erent contexts (such as employment sectors, types of enterprises, countries). Th e Group aims at raising awareness in relation to psycho-social hazards, responding to the needs of SMEs, developing countries and countries in transition and establishing a global expert network that will promote the toolkit and will facilitate access through the use of e-learning technology. Th is network will involve occupational health services and local expertise.

Psychosocial Factors and Mental Health at Work: A CanadianPerspective

Joan Burton, Manager, Health Strategy for the Industrial Accident Prevention Association (IAPA), Toronto, Cana-da (jburton@iapa.ca); A WHO Collaborating Centre for

Workplace Injury and Illness Prevention(www.iapa.ca)

Martin Shain , Senior Scientist at the Centre for Addic-tion and Mental Health, cross-appointed with the Depart-ment of Public Health Sciences, Faculty of Medicine, Uni-

versity of Toronto (Martin_Shain@camh.net); A WHO Collaborating Centre for Addiction

and Mental Health(www.camh.net)

A Model for a Healthy Workplace

From the late 1970’s to the early 1990’s, Health Canada and other organizations interested in workplace health, such as Canada’s National Quality Institute (NQI), developed and re-fi ned a model of a healthy workplace that includes principles and tools to help Canadian organizations develop healthy workplaces (1,2). A key component of this model is a defi ni-

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IAPA Model of aHealthy Workplace

tion of three “avenues” by which employers could infl uence the health and well-being of their employees. Th ese avenues have been slightly modifi ed by the Industrial Accident Preven-tion Association (IAPA), and can be described as follows:

Physical Environment – the physical surroundings, con-ditions or circumstances that aff ect employee health, in-cluding air quality, noise, lighting conditions, the quality and safety of workspaces and machinery or equipment. Psychosocial Environment – the design and organization of work, including hours, responsibilities, relations with supervisors and co-workers, demands of the job, decision latitude, balance between eff ort and reward, employer support for work-family balance, etc. Health Practices – those aspects of a person’s lifestyle that aff ect health, such as physical activity, smoking, drinking, eating habits, sleep, use of medication or other drugs.

IAPA recognizes that these factors are not entirely separate or distinct, and overlap considerably. Th erefore, they are represented graphically as in Figure 1 (3).

What are psychosocial factors?

Th e literature abounds with models related to psychosocial factors at work. Two of the most well known and used are Karasek’s Demand-Control model (4), and Siegrist’s Eff ort-Reward Imbalance model (5). Examples of psychosocial haz-ards in the workplace might include:

Work overload and time pressureLack of infl uence or control over how day-to-day work is doneLack of social support from supervisors or coworkersLack of training or preparation to do the jobToo little or too much responsibilityAmbiguity in job responsibilityLack of status rewards (appreciation)Discrimination or harassmentPoor communicationLack of support for work/family balanceLack of respect for employees and the work they do

How Psychosocial Factors Infl uence Health

Th ese factors, alone or in combination, have been found to have a profound eff ect on various aspects of an individual’s physical and mental health. Shain has summarized much of the literature on this subject in one graphic, which indicates estimated ranges of increased risk for various indicators of health, as seen in Figure 2 (6):

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While the research that generated these data looked at in-dividual outcomes, the extent to which they influence each other has not been well documented. The rapidly developing field of research into mind-body interactions (psychoneuro-immunology) is documenting the effects that mental health problems have on cardiovascular disease, a variety of immune system, gastrointestinal and pulmonary disorders, as well as certain types of injury involving musculoskeletal and soft tis-sue damage.

How Psychosocial Factors Influence Mental Health

Sometimes psychosocial hazards in the workplace are referred to as “mental health hazards” because their first impact is on the thoughts and emotions – or mental processes – of workers. Research clearly shows that these hazards increase, by two to three times, the risk of various mental disorders, especially de-pression, anxiety and substance abuse, in addition to decreased mental functions, such as innovation and creativity (6,7).Bill Wilkerson, President of Canada’s Global Business and Economic Roundtable on Addiction and Mental Health, and the Honourable Michael Wilson, a former Canadian federal finance minister and honorary chair of the Roundtable, have repeatedly stated that the costs of mental illness to Canadian workplaces are staggering. The Roundtable’s Scientific Advi-sory Committee has stated that the direct costs of productiv-ity loss from clinically diagnosed mental illness is in excess of CAN$11 billion per year in Canada, and that this number would triple if the indirect costs of health and social services, and of sub-clinical conditions, were counted (7). While “stress leave” taken by workers likely will not affect a company’s work-ers compensation costs in most jurisdictions, the costs will be reflected in increased short and long-term disability, increased absenteeism and decreased productivity, creativity and initia-tive.When we consider mental health problems among workers, the first question that comes to mind is, “To what extent are these problems imported into the workplace by individual employees and to what extent are they created by the work-place itself?” Research over the past 25 years has sought to answer this. Currently, organizational factors are seen as play-ing a catalytic if not causal role in the precipitation of mental health and addiction problems at work (8). It is now known that measurable changes in working conditions produce mea-surable changes in mental health outcomes (9). In addition, there are also suggestions that certain types of organizational practices can lead to changes in brain neurochemicals that af-fect mental health, such as noradrenalin, serotonin, and dopa-mine, among others (10). The two predominant theories of how these conditions affect health are the demand/control and effort/reward concepts mentioned above. The research summarized in Figure 2 indi-

cates that when these factors are out of balance, they place em-ployees at significantly higher risk of depression and anxiety. More current research in this area indicates when imbalances of this sort arise not by chance, but rather as a result of choices made by managers and supervisors, the result is often percep-tions of unfairness among employees. This sense of unfairness has been implicated as an additive effect that acts like a chill factor upon already unhealthy working conditions: it makes bad situations worse.

Legal Liabilities for Employers in Canada related to Mental Health

The law in Canada related to workplace stress is fragmented and generally very non-specific. While all provinces have com-prehensive state-run workers compensation systems, mental or emotional harm that results from chronic workplace stress is rarely accepted as grounds for workers compensation.The province of Québec is unique in that it has legislation that came into effect June 1, 2004, making psychological harass-ment in workplaces illegal. Amendments to Québec’s Labour Standards Act give employees the right to a work environment free from psychological harassment and oblige employers to prevent psychological harassment and put a stop to it whenev-er they become aware of it. The Act defines psychological ha-rassment as “any vexatious behaviour in the form of repeated and hostile or unwanted conduct, verbal comments, actions or gestures that affects an employee’s dignity or psychological or physical integrity and that results in a harmful work envi-ronment for the employee.” A single serious incidence of such behaviour that has a lasting, harmful effect on an employee also constitutes psychological harassment (11). Other provinces in Canada have no such legislation, and is-sues related to harm to the health of employees due to psy-chosocial factors in the workplace are dealt with in a variety of ways. The past five years have seen an escalation of litigation with ever-growing settlements in favour of employees, when the psychosocial characteristics of the workplace are found to be harmful to mental or emotional health. Shain notes that science, law and emerging best practices in human resource management all point to the ascendance of a duty of care to avoid reasonably foreseeable harm to the emotional or mental health of others within our spheres of interest at work. He notes, “The strength of the evidence is such that the duty to avoid reasonably foreseeable harm can be considered to have the weight of law behind it, the foundations of science beneath it and the beacon of common sense ahead of it” (12).In Canada, there is movement afoot to bring the matter of measurement and evaluation of psychosocial hazards within the parameters of a workplace standard that can be discussed and debated among industry and business leaders. Specifically, The Global Business and Economic Roundtable on Addiction and Mental Health has included the rationale for measure-ment of psychosocial hazards in their groundbreaking char-ter for the advancement of mental health in the workplace to which several prominent Canadian and multinational compa-nies are signatories.

The Employer’s Responsibility

The bulk of the evidence suggests that psychosocial factors in workplaces do have an impact on mental health and mental illnesses, and in turn, mental illnesses or health have an impact on workplaces in terms of innovation, creativity and produc-tivity (or lack thereof). There are broadly three avenues where employers have a role to play:

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1. Prevention: Employers should strive to create environ-ments or cultures that promote good mental health by measuring, evaluating and then controlling psychosocial hazards that negatively impact mental and emotional health. Th is may reduce stressful workplace conditions that lead to or exacerbate mental illness rather than health.

2. Recognition and Treatment: Because of the amount of time employees spend at work, the workplace is an ideal place to recognize symptoms of mental illness among em-ployees, and encourage them to seek treatment. Manag-ers and supervisors should be trained to recognize signs of mental illness, and coached on how to deal with employ-ees they may have concerns about. Employers may also provide employees with access to Employee Assistance Programs and Health Promotion Programs that may as-sist employees to strengthen their mental health.

3. Accommodation: Workplaces have a critical role in assist-ing employees who have experienced, or are experiencing a mental illness to return to the workplace or continue to work productively at their jobs. Th is includes learning how to accommodate those who have not fully recovered, as well as eliminating any stigma that may exist in the workplace related to mental illness.

Th e degree to which the workplace contributes to mental ill-ness or health will determine the employer’s level of respon-sibility for dealing with the problem. If the workplace were merely a place where an individual’s mental health problems are expressed, then an enlightened employer’s responsibility would be limited to items 2 and 3 above. However, if it is demonstrated, as a growing amount of evidence indicates, that the workplace can actually contribute to causing or ex-acerbating mental illness or addictions, then the employer’s responsibility goes much further, into the realm of preven-tion.

Current Canadian Initiatives Related to Mental Health at Work

Awareness of the importance of mental health at work, and the relationship of workplace practices in either increasing or decreasing the likelihood of mental illness among employees, is growing rapidly in Canada. Some initiatives are as follows:

Université Laval recently published a series of compre-hensive booklets called Mental Health at Work: From Defi ning to Solving the Problem (13).Th e National Quality Institute (NQI) declared 2005 Th e Year of Mental Health and Excellence at Work in Canada.Th e Workplace Safety and Insurance Board in Ontario is considering ongoing funding for a Centre for Re-search Expertise in Work-related Interventions in Mental Health.Th e Canadian Institutes for Health Research recently dedicated $3.2 million Canadian Dollars for a ten-year research project entitled Mental Health and the Workplace: Delivering Evidence for Action.In 2005–2006 Harvard Medical School will survey more than 100,000 Canadian employees to document the cost benefi ts of early and eff ective treatment of depression in the labour force.

Both of these latter two research initiatives are aimed at deter-mining, among other things, management practices that lead

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to or exacerbate depression and mental illness among employ-ees.

Conclusion

While there are many questions left to answer before we have fully defi ned the relationship between work practices and men-tal health, it is clear that factors in the psychosocial environ-ment can have an impact, for better or worse, on the mental health of employees. As more and more evidence is gathered, and the picture becomes clearer, it will become more incum-bent upon employers to ensure that they are doing everything reasonable to provide not only a physically safe workplace, but one that is emotionally safe as well. In Canada, a growing awareness among conscientious employers is resulting in in-creased interest and attention to the psychosocial work envi-ronment; while a growing awareness among workers is result-ing in increased litigation.

Occupational Health Psychology Education and Training

Tom Cox & Stavroula Leka (stavroula.leka@nottingham.ac.uk), Institute of Work, Health & Organisations (I-WHO), University of Nottingham, UK;

A WHO Collaborating Centre in Occupational Health

Occupational health psychology is a ‘young’ scientifi c disci-pline having emerged over the past decade. Since its ‘birth’ it has been, quite intentionally, developed on an international basis. Occupational health psychology concerns the applica-tion of principles and practices of applied psychology to oc-cupational health issues, with the objective of enhancing un-derstanding of psychological, social and organisational aspects of the dynamic relationship between work and health. Oc-cupational health psychologists seek to promote healthy work environments that contain healthy people and healthy interac-tions between work and family/home environments. Where this does not exist, they design and implement preventative and therapeutic interventions that aim to bring this about. Increasingly, the services of occupational health psychologists have been sought by organisations that seek to prevent work-related ill-health and promote well-being through application of multi-disciplinary approaches.Th e Institute has played a key role in the consolidation of oc-cupational health psychology as a distinct scientifi c discipline and has been the world leader in the provision of postgradu-ate courses and training in this fi eld. Th ree recently developed educational and training programmes are presented below.

Postgraduate Education In Occupational HealthPsychology By E-Learning

January 2005 brought a historical development in educa-tion and training in occupational health psychology with the launch of an MSc/Diploma in occupational health psychology delivered by e-learning. Th e pioneering postgraduate qualifi -

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cation is the fi rst degree to be off ered through the Institute’s e-learning programme.Th e course represents an alternative route to the existing full-time face-to-face MSc. It is off ered on an international basis, both through the University of Nottingham and the Univer-sity of Nottingham in Malaysia, and seeks to meet the need for more fl exible, distance learning arrangements by prospective European and International students. In doing so, the quali-fi cation serves to widen access to education and training in the rapidly evolving discipline of occupational health psychol-ogy. In parallel, research is being conduced to identify learning points for the design, development and use of e-learning in this area of knowledge.

FOLIC: Competent Career Counselling For Older Workers

Th e Institute is participating in a training programme funded by the EC Leonardo da Vinci programme focussing on the development of competent career counselling and career de-velopment for older workers. Th is programme is conducted in collaboration with European partners and aims to design and test an on-line training model, which will provide a framework to facilitate the career development of older workers. Th is pro-gramme aims to create an innovative training model to be used by career counsellors within companies that provide guidance and consultation, with particular reference to their capacity for intervening when dealing with older workers. Th e training programme will be directed to ‘in-house’ consultants and will cover counselling methods and techniques for encouraging workplace health promotion and the development of human potential. Th e project aims to support the development of an innovative European approach for the distribution of counsel-ling and career development services in the workplace, with the purpose of helping older workers to defi ne their individual learning and career plans. Th e initiative will last 30 months and is collaborative with partners from Italy (IACP, ISPESL), France (CNAM), Spain (University of Valencia), Germany (BKK) and Malta (Ministry of Health).

Stress Prevention Activities

Th e Institute is also participating in another European project, funded by the EC Leonardo da Vinci programme, focussing on stress prevention. Th e main objectives of the project are to promote eff ective risk management and prevention of work-related stress in small and medium-sized enterprises and the maritime sector by developing transferable practices and re-sults. Th e main objectives of the project are to: 1. promote eff ective risk management and prevention of

work-related stress, 2. raise awareness on the importance of preventative ac-

tions, 3. involve key interested parties (social partners, owners,

managers, employees, experts) in the activities of the project, and

4. address the diversity of micro and small enterprises in Eu-rope by developing transferable practices and results.

Training packages are currently being developed and will be available for dissemination by September 2006. Th e project is collaborative with partners from the UK, Greece, Finland and the Czech Republic.

Managing Mental Health at Finnish Workplaces

Anna-Liisa Elo, Finnish Institute of Occupational Health (FIOH), University of Jyväskylä, Helsinki, Finland

(Anna-Liisa.Elo@ttl.fi );A WHO Collaborating Centre in Occupational Health

Trends in Mental Health and Work Disability

In recent years, the work disability pensions granted on the basis of mental disorders have become the largest group of all granted work disability pensions (35%) in Finland. Also sick-ness absenteeism due to mental disorders, particularly depres-sion has increased drastically. Reasons to this trend are not fully known. Th is may be associated with working life changes or inadequate or insuffi cient care. National surveys are useful in describing changes in working life and psychosocial working conditions. In Finland, population surveys are carried out ev-ery year by the Ministry of Labour, every three years by FIOH, and every seven years by Statistics Finland. New research proj-ects have been launched to investigate the work-related aetiol-ogy of mental disorders and to develop interventions.

Prevalence of Minor Mental Health Disorders and Ac-tions Taken

During the past 20 years the occurrence of minor mental health disturbances in the working population has not increased on the basis of national epidemiologic research results (1). Accord-ing to the working population surveys conducted by FIOH in 1997, 2000, and 2003 the stress symptoms did not increase in general, but they increased in the branches of whole-sale and retail, public administration, and training. Stress symptoms were most common in the branches of training (18%) and fi nancing (17%). Th e probability of occurrence of stress symp-toms increased by education (no education 12%, college or university education 18%), and by socioeconomic status. (2)According to the survey in 2003 interventions in work stress and psychosocial working conditions are common at Finnish workplaces. Th e branches with the most stress symptoms have been active in monitoring the psychosocial working condi-tions with questionnaires with a 70-85% response rate. Th ese branches are also active in carrying out psychosocial interven-tions (reported by 55-60% of the respondents). 57% of the whole working population reported that a psychosocial ques-tionnaire survey had been carried out during the past three years, and 44% reported that a psychosocial intervention had been carried out. Psychosocial questionnaire surveys were not associated with the quality of psychosocial working condi-tions or with the level of stress symptoms, but psychosocial interventions were associated with good psychosocial work-ing conditions and low level of stress symptoms irrespective of branch, number of employees at the workplace, and socio-economic status of the respondents. Best results were obtained by combining a survey and an intervention. It is also possible that healthy organizations more often invest in surveys and interventions.

National Programs for Promoting Mental Health and an Attractive Working Life

On the national level, governmental programmes fi nance pre-ventive projects with a focus on work organization. In 1998-2002, the National Programme on Ageing Workers aimed at

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reinforcing the position of the over 45’s in the job market. It focused on both unemployed and employed persons. In 2000-2003, the Well-being at Work programme aimed at promoting working capacity and maintaining well-being at the workplace. In 2003-2007, the ongoing National VETO Programme aims at increasing the attraction to working life. Th e measures are targeted at work and workplaces, and organizations that infl u-ence them in areas signifi cant for maintaining and promoting an individual’s ability to work.

Legislation to Boost Employers’ Action

Th e amended Act on Occupational Health Services (2001) obligates employers to monitor the possible risks causing mental and physical overload, and to take action to balance the individual resources and work demands. Th e amended legislation on occupational safety and health care services has boosted developmental activities. Th e Act on Occupational Safety at Work (2002) stipulates that the employer has to take action to prevent mental health risks, mental load, violence, and harassment. Solitary work and working hours must be or-ganized properly. Th e Act on Occupational Health Care Ser-vices (2001) obliges the employer and/or occupational health personnel to monitor the working conditions including men-tal load and psychosocial working conditions, and to take ac-tion when risks are observed. Promotion of the work ability of personnel is emphasized and supporting actions on individual level have to be taken when needed.

Monitoring Methods and Implementation of Good Practices

New monitoring methods have been developed in FIOH as a response to the amended legislation. A risk monitoring method based on modern information technology enables simultaneous monitoring, data entry, and reporting by hand microphone at the workplace. An observation method for monitoring loads at work is also available for safety and health specialists and other informed users (3). Th e last mentioned method takes into account the 1) physical load, 2) psycho-logical load (clarity of work goals, time pressure, employees’ control and learning opportunities, interruptions, reasonable responsibility, and feedback and appreciation at work), 3) so-cial load (working alone, social interactions and collaboration, information and predictability, leadership practices, equality and appreciation of diversity, bullying and harassment, and client work evoking negative emotions), 4) safety risks, and 5) working hours (number of hours, shift systems, and irregular working hours specifi ed in more detail). Th e monitoring must be carried out every time the working conditions are changed. When needed a more specifi c psychosocial monitoring is con-ducted by occupational health care psychologists. Future challenges for national prevention of mental disabil-ity have been discussed in diff erent fora. Constructive imple-mentation of legislation, monitoring of risks, targeted actions for risk groups, and developing eff ective interventions in pro-cesses conductive to mental disability have been emphasized. Improved training of health care personnel aims at better pre-vention, early detection of disorders, and adequate treatment. Supporting return to work after sick leave is a newly recognized challenge for employers and occupational health personnel.

International Collaboration for Promoting Mental Health

A new WHO Collaborating Centre for Mental Health Promo-tion, Prevention and Policy Implementation was established in Finland in 2005 as a network organization of the National

Research and Development Centre for Welfare and Health, National Public Health Insitute, and Finnish Institute of Oc-cupational Health.

Work-Related Post-Traumatic Stress Disorder: An Italian Preliminary Study of Bank-Employees Victims of Robbery

Giuseppe Paolo Fichera, Department of Occupational Health – “Clinica del Lavoro Luigi Devoto” –

University of Milan, Milan, Italy(giuseppepaolo.fi chera@unimi.it)

Renato Gilioli. ISPESL/ICP Consortium for the WHO Collaborating Centre for Occupational Health –“Clinica del Lavoro Luigi Devoto”, Milan, Italy

(omscons@unimi.it)

Post-traumatic Stress Disorder (PTSD)

Th e Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM IV) lists the Post-traumatic Stress Disorder (PTSD) in the section of anxiety dis-orders. Unlike the other anxiety disorders, PTSD is character-ized by a clear aetiology, that is one or more traumatic events experienced by the subject.Th e fi rst criterion (Criterion A) for PTSD diagnosis (DSM IV) is the detailed description of the features of the traumatic event: “the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or seri-ous injury, or a threat to the physical integrity of self or others” and “the person’s response involved fear, helplessness, or horror” (2).Th e following three criteria (criteria B,C, and D in DSM IV) refer to the main symptoms of PTSD. An essential characteris-tic is the presence of a wide set of typical symptoms identifi ed in the three groups:

re-experience of the traumatic event;avoidance symptoms;hyper-arousal.

Th e re-experience of the traumatic event consists of psycho-logical distress reported by the victims and related to persis-tent re-experiencing the trauma with thoughts, recollections, dreams, or fl ashbacks. Avoidance symptoms are made up of all the attempts of the victims to shun the stimuli associated with the trauma, for example, places, persons or conversations. Symptoms of hyper-arousal are diff erent manifestations such as diffi culty falling or staying asleep, outbursts of anger, hyper-vigilance or exaggerated startle responses.PTSD is a serious disorder, that can even be debilitating. If not promptly recognized and treated it could become chronic. PTSD has high co-morbidity with other psychiatric disorders. In fact, other studies point out that subjects with PTSD have other symptoms that meet the criteria for other psychiatric dis-orders. Among the disorders associated with PTSD, the Ma-jor Depressive Disorder is the most frequent (11), (15), (16),

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(9), (29). Chronic anxiety disorders (36), dissociative disorders (3), (7), (20), drugs, substance and alcohol abuse/addiction are also associated with PTSD (33), (24), (31), (21).

Relation between PTSD and Occupational Health: Accidents and Violence at Work

We believe that PTSD, just as depressive disorders and all the other post-traumatic psychiatric disorders, deserve the atten-tion of occupational health professionals.The worker, whatever his occupation and wherever the oc-cupation is performed, is always at risk of traumatic events of various types. Although occupations and workplaces exist that imply a special risk for the worker (armed forces, police and emergency personnel) (8), the possibility of occurrence of post-traumatic disorders should be taken into account also for the workplaces where the threat to physical integrity is not inherently bound to the occupation. Severe accidents such as caused by structural failure of sheds and planking are frequent and, especially if unexpected, can cause severe psychological distress (30), (26), (1). Moreover, attention should be paid to physical violence in the workplace both for its frequency and its pathogenic potential. According to the study of the U.S. Bureau of Justice Statistics (BJS), from 1993 to 1999, about 1.7 million persons were victims of an aggression at the workplace. In the same period, 800 persons have been killed at the workplace (www.cdc.gov/niosh/injury/traumaviolence.html). A recent study carried out in South Africa showed that about 80% of the persons inter-viewed had been victims of an aggression at the workplace. In France, the number of victims among the personnel of the public transportation system reached a peak of 2000 in 1998 (10). In many parts of the world, alarming data on the magnitude of violence at work are reported. In this context, the armed-rob-bery is included as one of the most frequent acts of violence at work, perpetrated in banks, post offices and retail shops (12).The amount of studies performed in this area is still small be-cause the interest of researchers towards the issue of the victims of traumatic events has always been devoted to particularly bloody and moving themes such as rape, war, concentration camp deportation, terrorism, war kidnapping, ransom kid-nappings, or great natural disasters (25), (6), (4), (9), (15), (14), (32), (34). Only recently have researchers directed their interest to daily workplace hazards such as those deriving from severe accidents or violent episodes (11), (18), (35), (28), (19), (30), (26), reaching unclear and contrasting results as to the severity of psychological distress (23), (17). Due to these gaps of knowledge, it is crucial to further address these issues, so as to be able to assess the psychological distress and the possible impairment of workability in victims of trau-matic events at their workplaces.

PTSD in a Group of Italian Bank-Employees: Victims of Robbery

Considering the frequency of assaults in banks in Italy, rob-bery has become a problem of current interest. In Italy, yearly, one in thirteen banks are robbed compared to a European av-erage of one in thirty. The Italian robbery rate is twenty-fold that of Switzerland, ten-fold that of Greece, six-fold that of Germany and the UK, and four-fold that of France. In spite of these data, up to 2002, no study was in progress to assess psychological distress in victims of robbery in the Italian bank employees.

In this context, a pilot study was promoted by the ISPESL/ICP Consortium for the WHO Collaborating Center and the University of Milan, to assess the presence of PTSD in a group of bank employees, victims of at least one robbery at the work-place. To this end, 22 bank employees residents in Lombardy (age range 24-51 years) were examined with the help of the main trade unions, according to the following procedure:

medical examination to assess the health conditions and to rule out possible confounding diseases;ad hoc interview to highlight the characteristics of rob-beries and how they were performed;battery of psychological tests to evaluate the personality and the robbery-related psychological distress to deter-mine the presence and the severity of PTSD symptoms;cortisol and urinary catecholamine as biological indica-tors of stress, measured in a 24-hour urine sample.From this investigation, it was found that:Twenty one subjects were in general condition and the physical examination did not show any sign of organic disorder, except for one subject that was diagnosed as my-asthenia gravis, a serious neuromuscular disease;all subjects had a well-balanced personality;two subjects (9%) met the criteria of a full and current PTSD, while three subjects met the criteria for a PTSD in remission. Five subject (23%) had a partial1 current PTSD and five other (23%) had a partial PTSD in remis-sion. For the remaining seven subjects (31%) who had shown clear signs of psychological distress, the symptoms did not meet the criteria for a psychiatric diagnosis;urinary cortisol was increased in all subjects. The urinary catecholamine was within normal limits in twenty sub-jects (91%).

Conclusion and Future Challenges

Nearly all the study participants developed a condition of psy-chological distress following the robberies.Furthermore, the prevalence of PTSD may have been under-estimated because most subjects were examined only a few months after the robberies. In fact, it is known that the on-set of PTSD may occur also several months or years after the event (13).These data do not permit to draw conclusions as to the extent of psychological distress of robbery victims due to the small sample size. It is important to stress that further investigation should consist of two days of exams to follow-up the clinical

1 Many victims of traumatic events express a clear psychological distress but they do not fully meet the requisite criteria for a PTSD diagnosis. This type of reaction is called Partial PTSD (5).

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New Prevention Kit for Work-Related Mental Health Problems (October 200�)The Université Laval’s Chair in Occupational Health and Safety Management (Québec, Canada) launched a prevention kit for work-related mental health problems: “Mental Health at Work. From Defining to Solving the Problem”. The kit enables workers and organizations to effectively handle mental health stressors and issues in the workplace and is intended for anyone who wants to understand problems related to workplace stress and would like to become better equipped to prevent them. The kit includes three booklets in full colour. The first booklet defines the concept of occupation-al stress and describes the extent of the problem and its consequences for individuals and organizations. The second booklet presents the main sources of occupa-tional stress. It describes the personal factors that predispose certain individuals to such problems and proposes various methods that can help reduce the negative impacts of stress. The last booklet describes the three possible levels of pre-vention: (1) risk factor elimination or control, (2) the mechanisms that can help reduce the negative impacts of stress, and (3) treatment, the return to work, and fol-low-up of people. It also presents a strategic process for ef-fectively preventing work-related mental health problems and practical tools for facilitating the initiation of action. The kit is available at the following web-site: www.workand-stress.ca

GOHNET NewsFollow-up of the Global Strategy on Occupational Health for All

In 1996, the World Health Assembly endorsed the Global Strategy on Occupational Health for All and urged Member States to devise national programmes to provide occupational health services for all workers and particularly for the high risks sectors, vulnerable groups and underserved populations (Resolution WHA49.12). Furthermore, new political realities, initiatives and requests by the Member States call for renewed attention and global action by WHO on workers’ health. The World Summit on Sustainable Development, Johannesburg 2002, recommended strengthening and promoting the programmes of the ILO and WHO to “reduce occupational deaths, injuries and illnesses, and link occupational health with public health promotion as a means of promoting public health ...” A number of regional ministerial conferences have also requested specific action by WHO on occupational health.Taking into consideration these recent policy developments, the need to move from strategy to action in the area of occu-pational health, and to provide new impetus for action by the Member States in the area of workers’ health, in March 2005 WHO launched the development of a Global Plan of Action as a follow up to the WHO Global Strategy on Occupational Health for All to be presented to the World Health Assembly in 2007.WHO organized a country questionnaire study (April-July 2005) to evaluate the progress made in achieving the objec-tives of the Global Strategy and to solicit proposals for the fu-ture Global Plan of Action on Workers’ Health. The survey

cases six months after the first examination so as to include also the late onset of PTSD and to monitor its course.Therefore, it is necessary to continue the study on a larger sam-ple to obtain reliable epidemiologic data regarding the gravity of the psychological distress and the possible impairment of workability in victims of workplace psychological trauma. This represents a starting point to develop prevention strategies of chronic psychiatric syndromes. In fact the so-called “social sup-port” provided to the victims of traumatic events seems to play a key-role in the development of psychological disorders (27). The data obtained from victims of different types of trauma have shown that a higher number of support interventions was predictive of a lower development and faster disappearance of PTSD symptoms (21), (22).

PublicationsHealth Policies and Programmes in the Workplace (WHO, 200�) : Mental Health Policy and Service Guidance Package

This module is part of the WHO Mental Health Policy and Service Guidance Package which provides practical information aimed at helping countries to improve the mental health of their populations. The package provides guidance for policy-makers and planners on:- developing policies and comprehensive

strategies for improving the mental health of popula-tions;

- using existing resources to achieve the greatest possible benefits;

- providing effective services to persons in need;- helping people with mental disorders to reintegrate into

all aspects of community life, thus improving their overall quality of life.

Executive summary : Mental health problems, such as depres-sion, anxiety, substance abuse and stress, are common, affect-ing individuals, their families and co-workers, and the broader community. In addition, they have a direct impact on work-places through increased absenteeism, reduced productivity, and increased costs. Mental health problems are the result of a complex interplay between biological, psychological, social and environmental factors. There is increasing evidence that both the content and context of work can play a role in the development of mental health problems in the workplace.Key factors include:

workload (both excessive and insufficient work);lack of participation and control in the workplace;monotonous or unpleasant tasks;role ambiguity or conflict;lack of recognition at work;inequity;poor interpersonal relationships;poor working conditions;poor leadership and communication;conflicting home and work demands.

To find the document on-line go to: http://www.who.int/mental_health/policy/workplace_policy_programmes.pdf

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yielded responses from 104 Member States and a total of 1300 proposals for action at national, regional and global level, as well as specifi c actions to be taken by WHO and its Collabo-rating Centers (CCs). Based on the proposals of the Member States, the input of the Regional Offi ces and the contribution of the CCs, WHO developed a fi rst draft of the Global Plan of Action on Work-ers’ Health. It is foreseen to convene further consultations with other relevant programmes in WHO, the Member States, the WHO Collaborating Centres in Occupational Health, the In-ternational Labour Offi ce, the Commission on Social Deter-minants of Health, and special interest groups of employers, workers, and professional organizations.

WHO Country Survey on Occupational Health for All

A global survey was carried out by WHO in the period April-August 2005. It asked questions about social dialogue and political will regarding

occupational health and safety in the countries, capacities of the institutions dealing with occupational health, andthe infl uence of the WHO Global Strategy on Occupa-tional Health in the countries.

Responses were received from 104 out of the 192 Member States of WHO, mainly from the ministries responsible for health. In most cases the questionnaires were completed in consultation with the ministries of labour, the national insti-tutes for occupational health and other relevant national or-ganizations. Below are some highlights of the results of the survey. Highlights

Th e survey found that half (50%) of the countries with high level of development, 44% of those with medium level of de-velopment and only 25% of countries with low level of human development have endorsed a national political instrument for occupational health and safety. Such instruments were en-dorsed primarily by the ministries of health (77%) and minis-tries of labour (69%). In the majority of cases social partners were involved in the development of these documents. More than two thirds of the countries which have endorsed a na-tional political instrument on occupational health and safety have ensured funds for its implementation. Th e study also measured the division of responsibilities be-tween the health and labour sector with regards to occupa-tional health. Th e results show that the largest responsibilities of the ministries of health include health impact assessment, occupational health services, providing information, dealing with occupational diseases, workplace health promotion and training, while the ministries of labour are primarily respon-

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Strengthening of research in occupational health and safety

Establishment of appropriate support services foroccupational health

Strengthening occupational health services

Development of occupational health standards based onscientific risk assessment

Establishment of registration and data systems foroccupational diseases and work accidents

Development of human resources for occupational health

Developing a healthy work environment

Development of inter-sectoral collaboration in occupationalhealth

Strengthening national policy for health at work

Development of healthy work practices and promotion ofhealth at work

sible for developing legislation, policy formulation, inspection and work accidents. Th e responsibilities for risks assessment are shared between the health and labour ministries. Ministries of labour have devoted slightly more human resources to oc-cupational health and safety (72% full time and 7% part time staff ) compared to the ministries of health (60% full-time and 16% part-time). Th e WHO strategy has stimulated the development of national strategies, programmes or action plans on occupational health. One third of the countries, primarily those with medium level of human development said that infl uence to be “a lot”, 54% reported that the strategy has infl uenced their national policy to “a certain extent”, and only 15% of the countries reported no infl uence at all. For more information contact Dr. Ivan D. Ivanov at WHO ivanovi@who.int.

New Challenges and Avenues for Dr Maged Younes

Maged Younes, former Coordinator, Occupational and Environmental Health at WHO Geneva left WHO for

the 1 February 2006 to join the United NationsEnvironmental Programme (UNEP) as Head, Chemicals

Branch. In this function, he will be responsible forinter-agency relations with WHO.

Maged holds a MSc and a PhD degree in Biochemistry/Physi-ological Chemistry from the University of Tübingen, Germa-ny, and a DSc in Toxicology and Biochemical Pharmacology from the Medical University of Lübeck, Germany. Following an academic career, Maged joined WHO in 1991. In his time at WHO, he managed groups dealing with risk assessment, chemical safety, cross-cutting environmental health issues, and occupational health. He performed work on establish-ing linkages between science and environmental health poli-cies, on ensuring coordination with other international bodies and NGOs, and on providing policy advice to counterparts in Member States.Maged was responsible for Occupational and Environmental Health at WHO from 2003-2004, in addition to his function of Acting Director, Protection of the Human Environment, before taking on new duties as Director, Offi ce of the Assistant Deputy General/Sustainable Development in Healthy Envi-ronments.We look forward to continued collaboration with Maged from his new offi ce.

We welcome Dr María P. Neira as the newDirector of the Department of Public Health andEnvironment

Maria is a Spanish national with a Medical De-gree in Medicine and Surgery from the Uni-versity of Oviedo (Spain). She specialized in Endocrinology and Metabolic Diseases at the Université René Déscartes in Paris (France). She has a master’s degree in Public Health, a Special Diploma in Nutrition both in Paris,

and an International Diploma in Emergency Preparedness and Crisis Management from the University of Geneva, (Switzer-land).

T h e G l o b a l O c c u p a t i o n a l H e a l t h N e t w o r k��

In collaboration with:

- Istituto Superiore per la Prevenzione e la Sicurezza sul Lavoro (ISPESL)

- ISPESL/ICP Consortium for the WHO Collaborating Centre in Occupational Health

- Istituto dell’Approccio Centrato sulla persona (IACP)

Organising Secretariat : Laura BenettiScientifi c Secretariat : Anna Clara Fanetti;Francesca Metruccio

Phone: +39 02 3904 2845Fax: +39 02 3820 3163E-mail: whomeeting@icps.it

The Occupational Health Team inGeneva, Switzerland From left : Kati Bozsoki (Co-editor & Administrative Assis-tant) - Gerry Eijkemans (Scientist); Ivan Ivanov (Scientist); Evelyn Kortum (Editor & Technical Offi cer); Carlos Corvalan (Coordinator)

GOHNET Newsletter - Contributors’ Information

General

GOHNET is a vehicle for information distribution and communication for all who are involved, active and inter-ested in the subject areas of occupational health.Th e Editor reserves the right to edit all copy published. Contributors of all material off ered for publication are requested to provide full names, titles, Programmes or Departments, Institute names, and e-mail addresses.

Why write for GOHNET?

All experts have a professional responsibility to dissemi-nate their views and knowledge. Th e Network of occu-pational health experts is constantly growing, and the Newsletter can therefore help you to reach a large audi-ence in the occupational health community. Th is can help you to make new contacts, exchange views and expertise. What kinds of article do we publish in GOHNET? Our diverse audience means that articles should be not only informative but also engaging and accessible for the non-spe-cialist. We do not accept articles based on data that has not

•

••

Before heading the Department of the Protection of the Hu-man Environment in September 2002, Maria served as Presi-dent of the Spanish Food Safety Agency and Vice Minister of Health at the Ministry of Health and Consumers Aff airs in Spain between September 2002 and August 2005. Prior to that and since 1993, she had been working for the World Health Organization in Geneva in various positions, including that of Director of the Department of prevention, control and eradication of communicable diseases. From 1991 to 1993, Maria worked as Public Health Adviser in the Ministry of Health in Mozambique and before that she spent two years in Kigali, Rwanda for the United Nations Development Programme (UNDP). From 1987 to 1989 she served as Medical Coordinator in Salvador, Nicaragua and Honduras for Médecins sans Frontières.

Welcome to the Team, Susan Wilburn!

Susan Wilburn is a registered nurse and an in-ternational occupational health specialist, will work on a half-time basis with the Occupa-tional Health Team on occupational health for health care workers until June 2006. Susan worked as a nursing consultant to the Inter-national Council of Nursing coordinating the

joint WHO/ICN Needlestick Prevention Project in Tanzania, South Africa, and Vietnam. Together with the Occupational Health Team Susan created the WHO CD-ROM Preventing Needlestick Injuries (see GOHNET no. 9 for details). In Geneva, Susan will follow-up on the needlestick project in South Africa, Tanzania and Vietnam to support policy imple-mentation to protect health care workers including the im-plementation of hepatitis B immunization. She will expand the needlestick prevention work and implementation of the Preventing Needlestick Injuries toolkit throughout southern Africa (SADC region). Furthermore, Susan will develop a network of health care professionals (including WHO Col-laborating Centres) and unions involved in health care worker protection.

�th Global MeetingWHO Collaborating Centres

for Occupational HealthStresa, Italy

June 8-9, 2006Palazzo Congressi Stresa - Piazzale Europa, 3

I-28839 STRESA (VB) - ITALYPhone: +39 0323 30389, Fax: + 39 0323 33281

E-mail: info@stresacongressi.itWebsite: www.stresacongressi.it

Organised by:International Centre for Pesticide Safety

and Health Risk Prevention (ICPS)

OSPEDALE L. SACCOAZIENDA OSPEDALIERAPOLO UNIVERSITARIO

WORLD HEALTH ORGANIZATION

LOMBARDIA REGION

UNIVERSITY OF MILAN

T h e G l o b a l O c c u p a t i o n a l H e a l t h N e t w o r k ��

How do I submit my work?

Send your article as an attachment to ochmail@who.int.Evelyn Kortum, Editor of GOHNET, World Health Organi-zation, C/o SDE/PHE/OEH, office L.125, 20 Avenue Appia, 1211 Geneva 27, SwitzerlandCounterpoint articles

If you have a view on an article we have published, your best route is an e-mail or a letter to the Editor. If you wish to add a substantial amount of evidence on a significantly different angle, we welcome commentary pieces of up to 1000 words, submitted within four months of the original piece. Conference or workshop reports

Brief reports on conferences or workshops of interest to a wider audience (any length up to 700 words) should be sent, within a month of the event, to the Editor. Focus on what is new and of general interest, rather than including a lot of background information about the conference.

been accepted for publication following peer review. Such articles are more appropriate for submission to a journal. Articles may provide a broad overview of a particular area; discuss theory; add a critical commentary on recent articles within a GOHNET Newsletter; or debate applied, practi-cal and professional issues. You can view examples of issued Newsletters, which are available at http://www.who.int/occu-pational_healthHow should I go about writing my article? Articles should be written as for an intelligent, educated but non-specialist audience, as the majority of readers will not necessarily be familiar with the topic of any individual article. Articles need to be written in clear, non-technical language, and aim to engage the interest of the membership at large. Sexist, racist and other discriminatory or devaluing language should be avoided. Articles can be of any length from 800 up to a maximum of 2000 words (excluding references), double spaced, with complete references and a precise word count (excluding references). Relevant high-quality scanned image materials is also welcome.

WHO headquarters (www.who.int/occupational_health)

Department of Protection of the Human Environ-ment Occupational and Environmental Health ProgrammeGeneva, SwitzerlandFax: (41) 22 791 1383e-mail: ochmail@who.int

WHO Regional Advisers in Occupational HealthRegional Office for Africa (AFRO) (www.whoafr.org/ )Brazzaville, Congo Fax: (242) 81 14 09 or 81 19 39Attention: Mr Thebe Pule e-mail: pulet@afro.who.int

Regional Office for the Americas (AMRO) (www.paho.org/ )Pan American Health Organization (PAHO)Washington DC, USAFax: (202) 974 36 63 Attention: Dr Luz Maritza Tennassee e-mail: tennassm@paho.org

Regional Office for the Eastern Mediterranean (EMRO) (www.who.sci.eg)Cairo, EgyptFax: (202) 670 24 92 or 670 24 94 Attention: Dr Said Arnaout e-mail: arnaouts@emro.who.int

WHO/EURO Centre for Environment and Healthwww.euro.who.intBonn, GermanyFax: +49 228 2094 201Attention: Dr Rokho Kim

Regional Office for South-East Asia (SEARO)(http://www.whosea.org/)New Delhi, IndiaFax: (91) 11 332 79 72

Regional Office for the Western Pacific (WPRO)(http://www.wpro.who.int/)Manila, PhilippinesFax: (63) 2 521 10 36 or 2 526 02 79Attention: Dr Hisashi Ogawa e-mail: ogawah@wpro.who.int

CONTACTS

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