Work and Health: Risk Groups and Trends Scenario Report Commissioned by the Steering Committee on Future Health Scenarios

Work and Health: risk groups and trends

Research team of TNO Institute of Preventive Health Care Researchers: A. Bloemhoff, M.Sc. Dr. P.G.W. Smulders Scenario Committee on Work and Health Chairman: Dr. P.A. van Wely

Work and Health risk groups and trends Scenario report commissioned by the Steering Committee on Future Health Scenarios

1994 Kluwer Academic Publishers Dordrecht - Boston - London

Distributors for the United States and Canada: Kluwer Acadennic Publishers, P.O. Box 358, Accord Station, Hingham, MA 02018-0358, USA for all other countries: Kluwer Academic Publishers Group, Distribution Center, P.O. Box 322, 3300 AH Dordrecht, The Netherlands Steering Committee on Future Health Scenarios P.O. Box 5406 2280 HK Rijswijk The Netherlands Telephone (31-70) 3407205 Translation of the Dutch original 'Arbeid, gezondheid en welzijn in de toekomst' by E.W. Bergsma, M.A.

ISBN 0-7923-2733-0 © 1994 STG, Rijswijk All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, photocopying, recording, or othenA/ise, without the prior written permission of the publishers. Kluwer Academic Publishers, P.O. Box 17, 3300 AA Dordrecht, The Netherlands. PRINTED IN THE NETHERLANDS

TABLE OF CONTENTS

Page

Preface Summary

1

1 1.1 1.2 1.3 1.4

5 5 7 8

1.4.1 1.4.2 1.5

Introduction Why examine the future of work and health? How should the future be studied? Aim of this study First phase: description of the recent past and present situation Data sources used The social security system in the Netherlands Second phase: exploration of the future

9 9 11 14

2 2.1 2.2

How to define 'work' and 'health' What do we mean by 'work'? What do we mean by 'health'?

17 17 18

3

Theory: the quality of working life, work capacity and health The relevance of work for health The macro-determinants of the quality of working life The quality of working life: stressors at work Work capacity: the coping ability of working people The effects of work on health and well-being Working life, work capacity and health combined in a model

23 23 26 27 27 28 30

3.1 3.2 3.3 3.4 3.5 3.6 4 4.1 4.2 4.3 4.4 4.5 4.6

The macro-determinants of the quality of working life Introduction The economy as a determinant of the quality of working life Technology as a detemiinant Occupational health care as a detenninant Dutch government policy as a determinant of working conditions Summary and conclusions

33 33 33 35 39 42 45

Page 5 5.1 5.2 5.2.1 5.2.2 5.2.3 5.3 5.3.1 5.3.2 5.3.3 5.3.4 5.3.5 5.3.6 5.3.7 5.3.8 5.3.9 5.4 5.5 5.5.1 5.5.2 5.5.3 5.5.4 5.6 6 6.1 6.2 6.3 6.4 6.5 6.6 6.7

The quality of working life in the Netherlands Introduction Job content Monotonous work/short cycled work Training and experience in relation to the actual job content Work pace Working conditions Heavy physical work Noise at work Vibrations and shocks Climate and the Sick Building Syndrome Radiation Chemical agents and working conditions Biological agents and working conditions Dirty work Unsafe working conditions/dangerous work Labour relations Employment conditions Promotion possibilities/prospects Length of working hours New work patterns/work contracts Shift work Summary and conclusions Characteristics of the working population in the Netherlands Introduction The population and the labour force in the Netherlands Age Sex Education Norms and values about work Summary and conclusion

47 47 49 49 51 52 52 52 54 56 57 58 58 60 61 62 63 64 64 66 68 68 70 73 73 73 74 76 76 77 78

Page 7 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8

The health of the working population Introduction Opinions of working people about their own health Visits to GP's and the use of medicines by working people Sickness absence Prolonged employment disability Occupational diseases and disorders related to work Occupational accidents Summary and conclusions

8

The future of work and health: introduction and methodology The Delphi method in general The seven scenarios of the Delphi study Work and Health The selection of four industrial branches The experts consulted (members of the panel) The questionnaires used The questionnaire for the first Delphi round The questionnaire for the second Delphi round Method of analysis of the answers to the questionnaires The quality of the results of the Delphi study The homogeneity of the answers of the experts Impact of the feedback from the first round on the answers in the second round Influence of experts' occupation on the responses Influence of self-selection of the expert and the degree of expertise on the answers Summary

8.1 8.2 8.3 8.4 8.5 8.5.1 8.5.2 8.6 8.7 8.7.1 8.7.2 8.7.3 8.7.4 8.8 9 9.1 9.2 9.3 9.4 9.5 9.6

Results: the six exploratory scenarios Introduction The six exploratory scenarios compared Favourable and unfavourable developments in the quality of working life 1983/1986 - 2010 Favourable and unfavourable developments in health 1983/1986 - 2010 The differences in work and health between the four industrial branches 1983/1986 - 2010 Summary

79 79 79 83 84 87 92 97 98 101 101 102 104 104 106 106 110 111 112 112 113 113 114 116 119 119 119 121 129 132 134

Page 10 10.1 10.2 10.3 10.4 10.5

Results: the goal-oriented scenario Introduction Setting priorities in the nine policy areas Concrete measures in the three most important areas The costs of the proposed measures Summary

11

Future projections of sickness absence and work disability Introduction Influence of economic developments on sickness absence and employment disability until the year 2010 Influence of the demographic distribution of the working population on sickness absence and employment disability until the year 2010 Summary, discussion and conclusions

11.1 11.2 11.3 11.4 12 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 12.9

Summary and final reflections Aim and relevance Recent developments in the area of work and health Differences between age groups and between men and women Differences between industrial branches today and in the future What do the scenarios have in common? Influence of the state of the economy on the future of work Influence of policy measures on the future of work and health How should sickness absence and employment disability be tackled? Policy recommendations

137 137 137 139 141 142 145 145 146 150 153 157 157 158 161 163 166 169 171 173 177

Literature

181

Abbreviations

197

PREFACE

This book is an edited and updated version of the report 'Arbeid, gezondheid en welzijn in de toekomst; toekomstscenario's arbeid en gezondheid 1990-2010' commissioned by the Steering Committe on Future Health Scenarios and published by Bohn, Stafleu and Van Loghum, Houten/Antwerp in 1991. The authors wish to express their grateful thanks for the constructive comments they received from many people during the writing of this book. The following persons, however, deserve to be mentioned by name: E.W. Bergsma M.A., Prof. F.J.H. van Dijk, Dr. C.L. Ekkers, Prof. F. Huygen, Dr. M.A.J. Kompier, Prof. J.P. Mackenbach, Dr. P.A. van Wely and Dr. J.H.B.M. Willems.

SUMMARY

Aim and scope of the study The main aim of this book is to show how the field of work and health will develop until the year 2010 under certain economic and other conditions. This is done on the basis of a Delphi study carried out with the cooperation of 120 leading experts in the Netherlands. A secondary aim was to investigate the present state of work and health in the Netherlands with the aid of available statistical sources. We think that this book is relevant to policy-makers in government and in industry. The book will also provide material for discussion and policymaking, not only for personnel managers, occupational hygienists, company doctors, insurance physicians, safety officers, and ergonomists, but also for managers and members of works councils at company level. The book focuses on that part of labour that is involved in paid employment. A broad definition of health has been chosen, similar to that which is generally used in industry. Both physical and mental health (described for example in terms of back complaints and stress,) and health behaviour (described in terms of visits to GPs, use of medication, sickness absence and long-term employment disability,) wiU be discussed. The book assumes a 'classic' model in which the quality of working life (job content, working conditions, labour relations and employment conditions) is considered the main determinant of the health and welfare of the working population. The present A number of developments in the quality of working life in the 1970s and 1980s can be easily recognized. These relate to the unfavourable aspects of working conditions. Exposure to vibration and shocks has decreased in time, as have dangerous work, noise, dirty work and unpleasant smells at work. Labour relations ('human relations') appear to have improved in the last two decades, and the workload has been lessened by a decrease in working hours. The following trends may be considered negative: educa-

tion is less well related to job content, the work pace has risen and there is more heavy physical work. In short, we have seen an improvement in the 'classic' working conditions but a worsening of the 'work-stressors' in the past 15 years. In the past 10 to 15 years there has been a small increase in the number of working people who state that their own health can be described as good or very good. This does not go together with a corresponding decrease in backache and fatigue. The percentage of working people who sometimes suffer from headaches has fallen significantly. The number of visits to GPs has remained the same, while contact with specialists has decreased, as has the use of medication. Trend data on sickness absence and employment disability relating to the last 15 years show that the rate of sickness absence in manufacturing fell from about 9% to 6%; the percentage of people being declared disabled for work (per 100 insured per year) fell from 2.3% to 1.4%. The available data seem to indicate that the health of the working population in the Netherlands has improved somewhat in the recent past. This is probably due to selection and outflow mechanisms, and to improvements in the quality of working life. The future The future developments in the area of work and health have been explored by means of a so-called Delphi study carried out with a panel of 120 experts in the first round and 88 experts in the second. They were presented with questions about the possible future of work and health given some six scenarios: high, medium and low economic growth, improvement in working conditions, extension of occupational health care, and intemationalisation of economic life. The results may be summed up as follows. The quality of working life will develop to a certain extent independently of the economic developments and policy interventions in the coming 20 years. On the whole it will improve. Economic developments and policy measures, however, accelerate or decelerate these more or less autonomous developments, sometimes rapidly. In general the favourable future trends are concerned with physical working conditions (noise, dangerous work, exposure to toxic materials.

vibration and shocks, heavy physical work) and with labour relations and employment conditions. The unfavourable trends are mainly related to stress factors, (work pace, time pressure, working in shifts, lack of close correspondence between level of education and job content, mentally demanding work). For the future we therefore see on the whole a continuation of the developments that have been taking place in the past 15 years. What are the implications of these findings? Policy, health care and research will have to concentrate on the weU-being and mental health of the working population instead of on physical health. And as for the approach to be followed: an improvement in working conditions and occupational health-for-all have clearly the best effects on all fronts from the policy point of view. They will have a limiting effect on the psychological stressors at work, as well as on ergonomic and toxicological problems. Influencing the favourable development of the Dutch economy by appropriate economic policy measures will have less direct influence on the quality of working life than the above measures. It appears, however, that high economic growth has a more favourable effect in general on the quality of working life than low economic growth: growth has a favourable effect on physical workload, employment conditions and labour relations. On the other hand, high economic growth leads to more time pressure and mentally demanding work. What is there then to say about future health developments in the working population? The policy scenarios are favourable for all health indicators and especially so for bringing down back complaints, sickness absence and employment disability. With extensive policy intervention the rate of sickness absence could fall from 7.5% in recent years to 5.5-6% in the year 2010. The rate at which people become disabled for work could be diminished by a third in the policy scenarios. According to the experts consulted, low economic growth leads to a small increase in health problems linked to the work situation, although to a decrease in the rate of sickness absence. With high economic growth they expect this rate to increase.

How can the rate of sickness absence and employment disability be halved by the year 2010? Taking as a goal the halving of the rate of sickness absence and employment disability in the period till 2010, the study carried out with Dutch experts suggests that an improvement in working conditions and occupational health-for-all have great importance. But there is a set of measures which the experts consulted find even more important in reaching this goal. These are measures related to social security legislation and regulation. In practical terms this means introducing more premium differentiation between employers and between employees in the Sickness Benefits and Disability Insurance Acts, reward/punishment systems, own riskbearing for employees and employers, stricter assessment of the degree of employment disability of employees and stricter administration of the Sickness Benefit Act, etc. In short, improvements in the quality of working life and in the corresponding state of health of the working population do not happen by themselves. Intensifying and expanding policy-making in the area of improvement of working conditions, occupational health care and social security regulation is to be recommended.

INTRODUCTION

1.1

Why examine the future of work and health?

From the beginning of time humankind has tried to see into the future. Attempts have been made to predict the outcome of wars, harvests and distant travels. In ancient times the Oracle of Delphi was consulted. The need for insight into possible future developments is as great now as it has ever been, although nowadays we are more interested in traffic problems, the environment and the construction of cities, etc. In the field of work and health, a vigorous social and political debate broke out in the Netherlands at the end of the 1980s and early 1990s concerning the level of sickness absence and employment disability, which were widely considered far too high. In 1990 the rate of sickness absence was 8.1% of all available working days (SVr, 1991), and nearly 900,000 people were declared disabled for work (out of a working population of around 6.5 million). Some contend that this is due to the poor quality of working life in certain branches of industry. The high pressure of work and the great technological changes are often blamed for this. Others point to the large demographic changes which are taking place in industry, such as the ageing of the working population and the fact that more and more women turn to the labour market and do not find suitable jobs there. Finally some people consider that the social security regulations in the Netherlands are so favourable (employment disability benefits are higher than unemployment benefits) that they are open to abuse and misuse. Many people wonder how the quality of working life will develop in the next decades. Will the adverse health effects of working with toxic materials be eliminated by the year 2010? Will the assembly line continue to exist? Where will the advances in automation lead to? All things considered, there is more than enough reason to concern ourselves with the future of work, health and well-being.

In the past years a great many Dutch prospective studies have been carried out in the field of health and health care, on such varied topics as ageing, cancer, cardio-vascular diseases, accidents and mental health, to mention but a few. Some of these topics, such as the ageing of the population, industrial accidents and employment disability due to mental disorders (STG, 1985, 1989, 1992), touch on our theme 'Work and Health'. Research on the future of work has also been carried out in the Netherlands and abroad. Future studies on the theme of work in the Netherlands have been mainly centred on the supply and demand of labour, in both a quantitative and qualitative sense: for example, 'Information technology and employment' (SoZaWe, 1986) and 'The labour market by educational category 1975-2000' (CPB, 1987). Studies have also been made on the future orientation of work, such as the report 'Some aspects of work in the future' (Becker & Vink, 1986), and labour relations in 'Contemplations about the future of the social partners' (Reynaerts, Fase & De Boer, 1985). The most important factors influencing the future of work and the workforce are demographic, economic, technological, social and cultural developments (WRR, 1988). These topics are also discussed in international studies about the future of work. Examples include 'Work in America; the decade ahead' (Kerr & Rosow, 1979), 'The changing composition of the workforce: implications for future research and its applications' (Glickman, 1982), 'Sleepers, wake! Technology and the future of work' (Jones, 1982), 'Education, unemployment and the future of work' (Watts, 1983), 'The future of work' (Handy, 1985), 'Fabrik 2000; alternative Entwicklungspfade in die Zukunft der Fabrik' (Brodner, 1985), 'Work in Europe, five possible scenarios' (Van der Werf, 1987), 'Projections 2000' (Bureau of Labor Statistics, 1987), 'Quitting time: the end of work' (Macarov, 1988), 'The changing workplace' (McDaniels, 1989) and 'Future Work, seven critical forces reshaping work and the work force in North America' (Coates et al, 1990). In the field of work and health in the future, the only publication that has appeared in the American literature is, as far as we know, the book 'The future of work and health' (Bezold et al, 1986). Future developments in work are examined by these authors in terms of demographic, economic, technological, social and cultural developments. Future developments in health and health care are also examined, but are not explicitly related to work.

'Work and Health' as an interrelated topic has never before been the theme for an exploration of the future. The present future scenario study, carried out at the request of the Steering Committee on Future Health Scenarios in the Netherlands (STG), is the first study in the Netherlands on that subject and may also be so internationally. We have, we hope, given enough arguments for the relevance of such a study. 1,2

Hov»^ should the future be studied?

The methods used to gain an insight into the future have changed considerably since the Oracle of Delphi; modem research on the future adopts a scientific approach (Becker & Dewulf, 1990). This modem approach was developed during and after World War II and was directed primarily to military strategy. In the 1960s and 1970s long-range research was carried out by government and industry. Dutch government bodies that are or have been concerned with such research include the Central Planning Office (CPB) (for economic predictions), the Social and Cultural Plarming Office (SCPB) (for explorations in the social and cultural sphere), the Central Bureau of Statistics (CBS) (for population projections) and the Scientific Council for Government Policy (WRR) (for general and policyoriented explorations on the future). In industry. Shell and Philips are examples of companies that have conducted future studies. The predictive value of various future studies was evaluated at the end of the 1970. The general conclusion was that their predictive value was too limited, and that uncertainties were not sufficiently taken into account. As a result, research on the future took a new course. Instead of one future, a number of possible altematives were sketched, and the so-called scenario method was bom (STG, 1986). Scenarios may be defined as: 'descriptions of the current situation in society (or part thereof), of potential and desirable future situations and of series of events which could lead from the former to the latter, with the purpose of obtaining a better insight into the underlying mechanisms and the possibilities of influencing them' (STG, 1986). In a scenario study a number of possible representations of the future are developed with the aid of scenarios. In short, a scenario study does not forecast, but explores possible futures.

In the literature on this subject, distinctions are made between various types of scenario. These are classified and named differently by various authors (see, for example, STG, 1986 and Bezold, 1991). In this report we distinguish between different sorts of scenarios. Firstly there are exploratory scenarios, which, starting from a consideration of the present situation, hypothesize a number of possible future developments. These scenarios can be further subdivided into autonomous scenarios, which examine the influence of more or less autonomous factors, and policy scenarios, which describe the future situations that may result from policy intervention. Secondly, there are scenarios that set targets. In these scenarios, effective strategies are sought for achieving a desirable future situation. Future developments can be explored on the basis of the expectations of experts and on the basis of extrapolations. Both methods are used in this scenario study. 1.3

Aim of this study

The ultimate aim of the future scenario study Work and Health is to stimulate public discussion about the future of work and health and to give a better foundation for policy proposals. In the light of this, two questions are formulated which need to be answered in this study: 1. What are the present factors in the work situation that can adversely affect the health, safety and well-being of the workforce, and what is the prevalence of those factors (for the groups at risk) in the working population of the Netherlands? 2. How wiU the prevalence of the relevant risk factors in the work situation (together with the accompanying health effects) change in the period up to the year 2010, as a consequence of both 'autonomous' developments and policy measures? The first question will be answered in Chapters 2 -7 of this report, in which a description is provided of the developments in the recent past and present in the field of work and health. The second question is dealt with in Chapters 8 - 1 1 , where the second phase of the research, directed to the future of health and work, is described. A summary and some final reflections on the future of work and health will be given in Chapter 12.

1.4

First phase: description of the recent past and present situation

First the scope of the field of work and health will be demarcated and the concepts defined. At the same time a simple model will be constructed, incorporating the most important elements and their interrelations, namely 'the macro-determinants of the quality of working life', 'the quality of working life', 'the working capacity of the workforce' and 'the health and well-being of the workforce'. The framework of the scenario study is set up on this basis. The review then describes trends in these elements from the past to the present and also examines the groups of employees at risk. The review can be considered as the starting point from which the future can be explored. 1.4.1 Data sources used A great many data sources were used for the description of the field of work and health from the past to the present. These do not, however, give a complete picture of the situation in the Netherlands. Zielhuis and Van Dijk (1989) name as limiting factors the fact that information on occupation is lacking in hospital and death records and that the present registration of occupational diseases is incomplete in quality and coverage. In order to give the most accurate possible picture of the present situation, numerous statistical sources, including those of the Central Bureau of Statistics (CBS) and the social security authorities, were consulted and relevant quantitative data gathered from the literature. The main criteria for selection of these data were that they should relate to different moments in time, be reasonably representative samples of the working population and be collected in a standardized way. The most important sources will be briefly discussed below. Life Situation Surveys (LSS) of the CBS During the period 1974-1986 the Central Bureau of Statistics commissioned a life situation survey every three years on a representative sample of about 4,000 people drawn from the Dutch population of 18 years and older. Each reference year a new cross-sectional sample was drawn, so that the data always relate to different people. The survey is based on interviews conducted in people's own homes. Table 5.1 in Chapter 5 shows the size of each sample, and the proportion of working people of 18 years and older within each sample. On average

this was 49% per year. All the data to be presented relate to this group. For the sake of completeness it should be mentioned that comparisons with other CBS data show that the sample of working people aged 18 years and over may be regarded as representative of the working population in the Netherlands (Bloemhoff Si Smulders, 1991). The Life Situation Survey gives information about the opinions of working people on certain aspects of their work and health. Data on the composition of the Dutch working population The Labour Force Sample Survey (in Dutch AKT) of the CBS gives information about the size and composition of the Dutch labour force and general population. These surveys (for which the data were also collected on the basis of interviews) were held every two years in the period 19731985. Before that period a population census was conducted by the CBS in 1960 and 1971, which also contained information about the (working) population. The definitions used in the population census with respect to the total labour force, the people actually employed and the levels of education differ somewhat from those used in the Labour Force Sample Survey. This is also the case with the Labour Force Survey (in Dutch EBB), the yearly enumerations which were conducted by the CBS from 1987 onwards as a replacement for the Labour Force Sample Surveys. General trends and developments in the size and composition of the labour force in the Netherlands in the period 1960-1987 can be illustrated, however, by a combination of the data from the population census, the Labour Force Sample Survey and the Labour Force Survey. Data on sickness absence and long-term employment disability Several institutions provide data on sickness absence in the Netherlands. - Within the context of the Sickness Benefit Act to be described below, the Social Security Council (SVr) reports on sickness absence in all firms that are members of an industrial association (i.e. roughly 90% of all employees, excluding civil servants). The data are published in their yearly report approximately two years after the reporting period. - The TNO Institute of Preventive Health Care (NIPG/TNO) regularly publishes information about the participants in its own statistics on sickness absence (200 firms with approximately 200,000 employees) via the CBS and its own publications. This survey mainly covers large firms and not all industries are equally as well represented. - The Netherlands Institute for Working Conditions (NIA) reports yearly about the participants in its own information system on sickness absence (with a working population of circa 80,000). Not all industrial 10

branches are equally represented in this sample and medium-sized firms are overrepresented. As a result there are no statistics in the Netherlands which are completely representative of sickness absence in the country as a whole. The data from the Social Security Council (SVr) provides the most representative picture, although neither civil servants nor self-employed persons are included in the survey. Unfortunately these statistics have a long lag-time in comparison with the others. In this study, therefore, statistics will be used from all three sources mentioned above. The Joint Medical Service (GMD) and the Disability Insurance Funds (AAf/Aof) publish statistical information about long-term employment disability. The data from the Disability Insurance Funds relate to all benefits, divided into four population categories, namely: (1) wage earners (insured via the WAO), (2) civil servants, members of the armed forces and the employees of the Dutch railways (insured by the ABP), (3) the self-employed and members of their family who participate in their work (insured via the AAW only) and (4) persons handicapped before starting work and others (also only insured through the AAW). The second category (civil servants, forces and employees of the Dutch railways) is not included in the statistics of the Joint Medical Service (GMD). Both sets of statistics (GMD and AAf/Aof) go back as far as 1967, when the Disability Insurance Act came into force. The AAW came into force in 1976, and the number of long-term disabled consequently increased considerably in that year. In this report statistics will be cited from both sources. 1.4.2 The social security system in the Netherlands For a proper understanding of the situation in the Netherlands a short explanation of the Sickness Benefit Act (ZW) and the Disability Insurance Act (WAO) will be given. The passage below has been adapted from the article 'Health care facilities and work incapacity: a comparison of the situafion in the Netherlands with that in six other West European Countries' by Soeters and Prins (1985) and from the dissertafion 'Economic aspects of disability behaviour' by Aarts & De Jong (1990).

11

Since 1967, no important distinctions have been drawn between the causes of employment disability within the social security system in the Netherlands; the same Sickness Benefit and Disability Insurance Act apply, irrespective of the causes of temporary or permanent incapacity. The Sickness Benefit Act provides income replacement in cases of temporary incapacity for work lasting up to a maximum of 12 months. The level of benefits currently comprises 70% of gross pay, with a fixed maximum. Most collective labour agreements provide a 100% replacement. The authenticity of work incapacity is assessed by a social insurance physician. Non-medical employees of the industrial associations may visit the sick person in the first few days of absence, to act as a deterrent against malingering and to make selections for medical control. General practitioners play no role in sickness certification in the Netherlands. Sickness absence is a complex phenomenon, whose operational definition includes any (accepted) claim under the Sickness Benefit Act. In practice, this means that almost any case of reported incapacity for work due to ill health may be considered as sickness absence. The scope of this definition is very wide and includes both illness and less serious conditions, as well as industrial accidents and maternity leave (12 weeks; since 1990, 16 weeks). The differentiation between certified and uncertified sickness absence, which is made in various countries, does not exist in the Netherlands. Whereas the maximum duration of a spell of sickness absence is one calendar year, the definition of employment disability in the Netherlands includes permanent incapacity for work (after one year of sickness absence), again irrespective of cause. After the mandatory waiting period of 12 months under the Sickness Benefit Act, one can apply for Disability Insurance benefits (Dl-benefits, in Dutch AAW/WAO). The risk covered by the Dl-programme, however, is more stringently defined as the income lost due to an individual's incapacity to perform his or her current work. Dutch law provides the following definition of employment disability: 'A person is partly or fully disabled for work if, as a consequence of illness or injury, he is no longer able to earn with his own labour that which healthy people with the same education and experience working in the same place (or in the close vicinity) usually earn.' As a consequence, qualification for disablement

12

status depends not only on physical and mental health status but also on education, work experience, previous income and other factors. The degree of disability is determined by measuring an applicant's 'earning capacity', i.e. the income a disabled person would be able to earn in commensurate work, expressed as a percentage of the income earned by healthy, but otherwise similar, persons. The degree of disability is, therefore, the complement of earning capacity. The first slice of Dl-benefits is provided under the General Disability Benefit Act (in Dutch A AW) enacted in 1976. The AAW-programme covers all residents, aged 18-64, whether employed in the private or public sector or self-employed. The level of AAW-benefit size is based on the social minimum. As well as AAW-coverage, privately employed workers enjoy supplementary coverage through the WAO-programme, which provides the second slice of Dl-benefits. Disability assessments are made by an independent body, the Joint Medical Service (JMS, in Dutch GMD). The relevant insurance boards are obliged to consult the JMS on matters of disability (AAW or WAO) insurance claims, whether for benefits or provisions in kind. The administration of work-related social insurance (Sickness Benefits, Disability Insurance) is delegated to 23 insurance boards, representing different branches of industry. These industrial insurance boards are managed by representatives of employer organizadons and trade unions. They have the discretion to develop autonomous benefit award policies. Collective strategies are set up through directives of the Federation of Industrial Insurance Boards. The Industrial Insurance Boards are supervised by the Social Security Council (SVR). Trade unions, employer organizations, and independent government appointees have equal representation in the membership of the Social Security Council. The Council carries out its supervisory responsibilities by issuing direcUves to the Industrial Insurance Boards. The Council also supervises the boards of the Disability Insurance Funds (in Dutch AAf/Aof). These boards make twice-yearly calculations of the payroll tax rates necessary to cover programme expenditures. As well as supervision, the Council also has advisory tasks. The government is obliged to consult the Council on certain matters of social security policy, one of which is the twice-yearly assessment of social insurance 13

premiums. The government, however, is not obliged to act on the Council's recommendations. Moreover, the Minister of Social Affairs and Employment determines independently how the burden of social insurance contributions will be distributed between employers and employees. 1.5

Second phase: exploration of the future

In the second phase of the scenario study (Chapters 8 to 11) an attempt will be made to gain a greater insight into future developments in the field of work and health by means of six scenarios. Delphi study The predictions of experts about possible future developments in the quality of working life and the health of the workforce have been collected by means of the Delphi method. This method is used in order to allow experts to form opinions on a number of topics (which need to be quantified) in the field of work and health by means of an exchange of expectations and ideas. This method differs from other group processes, in that there is no direct communication between the participants in the discussion; instead use is made of a number of sequenfial questionnaires drawn up by the researchers. The experts, who remain anonymous to each other, receive with each successive questionnaire a summary of the results of the previous round, including a statistical feedback on the answers of the group as a whole and the degree of mutual agreement. On the basis of this feedback, experts may wish to adjust their views or stick to their original opinion. The Delphi method was initially used to reach a consensus about the answers given by the experts. In recent years, however, the ultimate goal has shifted from consensus to 'a certain degree of stability' of the answers over time. If the experts' opinions scarcely alter after a few rounds, irrespective of whether a certain degree of consensus has been reached or not, the reiterative process can then be ended. Practice has shown that three rounds are usually sufficient to arrive at a stable group opinion. Furthermore extra rounds can lead to 'fiUing-in fatigue' on the part of the panel of experts. A number of eariier scenario studies carried out at the request of the Steering Committee on Future Health Scenarios in the Netheriands also used the Delphi method. In those studies two written questionnaires were used, followed by a third, oral round or workshop

14

(STG, 1989, 1992). The main reason for this third round was to discuss the consistency and plausibility of the final scenarios. In our scenario study two written rounds were held in the period between December 1989 and September 1990. Seven scenarios were examined, six exploratory and one target-setting. The idea of a third oral round was dropped because the possible extra returns from such an exercise were not deemed sufficient to justify the amount of time that would have to be spent on it. Extrapolations The second method used to explore future developments in the health of the workforce consisted of two different types of extrapolations into the future, namely: extrapolations from the sickness absence rates and the risk of employment disability in relation to the economic situation in the past, and extrapolations of these two indicators in relation to a changing composition of the labour force by age and gender. These extrapolations take into account different influencing factors and also lead to different future representations of the health of the workforce. The principle that several future possibilities need to be outlined (rather than just one version of the future) has been justified by these alternative extrapolations.

15

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HOW TO DEFINE 'WORK' AND 'HEALTH'

2.1

What do we mean by 'work'?

Work structures the day, ensures social contacts, provides an income and gives status and identity. The importance of work for the individual, and perhaps for his health too, is summed up, concisely, in this statement. The report entitled 'Some aspects of work in the future' by the Netherlands' Social and Cultural Planning Office (Becker & Vink, 1986) states that all definitions of work, however else they may differ, start from a common assumption that work is directed to the satisfaction of wants. Work considered in this way covers a broad range of activities. Work has, however, come to mean paid work. According to the report of the Social and Cultural Planning Office, this is the result of a number of factors, such as the growth of the market economy, the development of legal regulations concerning work and the institutionalization of social security. For this reason this concept of work as a means of analysing society has become obsolete. In order to be able to pinpoint social developments, it is important, according to the above report, to distinguish between different kinds of work. The monetized economy is composed of the formal, counted economy and the informal uncounted economy. Official paid work is part of the formal counted economy and is registered in the national accounts. In the informal economy, two kinds of unofficial work can be distinguished, neither of which are included in the national accounts. First there are the unpaid activities which usually have an official counterpart, e.g. household work, child care, voluntary work and subsistence agriculture. Then there are the activities in the black economy, which are forbidden on legal or taxation grounds. These include work for which no income tax and premiums have been paid and work that is forbidden, e.g. theft or drug-dealing. According to the report of the Social and Cultural Planning Office, about 4,500,000 working years were spent on official work in the Netherlands in

17

1981 and between 7,500,000 and 9,500,000 working years on unofficial work. The information about work in the black economy is scarce, fragmentary and on the whole unreliable. The Central Bureau of Statistics tentatively estimated that such activities may amount to 10-15% of National Income. The various experts consulted believe that work in the black economy, on which no income tax is paid, may increase substantially in the future. Tfie Dutch Working Conditions Act (passed by Parliament in 1980) defines in great detail the words employer and employee, but does not give a definition of work. From Section 2 we may deduce that the Working Conditions Act can be applied to all industrial organizations, including government services and small firms. All work that does not fall into the category of official paid work, however, lies outside the scope of the Working Conditions Act. Having looked at the definitions and the different forms of work in general, it is now necessary to indicate how the concept of work will be treated in the present scenario study. For a number of mainly practical reasons the definition of the working population chosen is a limited one, namely the official (i.e. paid) working population. Those doing unpaid work therefore faU outside the scope of this study, as do people who have dropped out of the labour force: the unemployed and employment disability benefit claimants. 2.2

What do we mean by 'health'?

From the time of Ancient Greece to the present day very different views have been held as to what constitutes health. The definition most often cited, and also most often criticized, is that of the World Health Organization: 'Health is a state of complete physical, mental and social weU-being, rather than merely the absence of disease and handicaps'. Health is here a state of well-being which can be interpreted and used in any number of different ways. In 1978, when the concept 'Health for all by the year 2000' was introduced, the WHO stated that health was meant to be 'a personal state of well-being... that enables a person to lead a socially and economically productive life...'.

18

Various authors have pointed out that objective criteria for establishing health cannot be given. The Memorandum Health 2000 ('Nota 2000') issued by the Dutch Ministry of Welfare, Health and Cultural Affairs (WVC, 1986, 10-11) states that health is not an absolute concept. The Memorandum further says: 'Health can be seen as an equilibrium situation which is determined by the circumstances in which people find themselves and by the capacity which they themselves possess, or which they acquire with the help of others, to resist disturbances. These disturbances can have their origin either in the body of the person (endogenous) or outside it (exogenous). In order to prevent disease, either the exogenous or environmental factors and/or the individual (endogenous) capacity for adjustment or self-care can be manipulated. Perceptions about health vary between people and may also vary with time. This is seen, for example, when one looks at the human life-cycle. Every age has its own threats and possibilities for defence.' The American medical sociologist Mechanic (1986) has pointed out that physicians and patients tend to use very different definitions of health. Physicians speak in terms of specific illnesses. Padents use more general terms with the accent on well-being, not being able to function well, etc. Susser et al. (1985) wrote that health can be defined in (1) organic, (2) functional and (3) social terms. In this context they discuss such concepts as disease, illness, sickness, impairment, disability and handicap. These authors further add that someone can be 'organically ill' without feeling ill. Various factory workers, for example, continue to work when suffering from severe bronchitis. The reverse is also true: there are examples of people who declare themselves, or are declared, disabled, when no illness can be established in the organic sense. It is necessary to look into some other health concepts relevant to the field of work and health. The terms safety, health and well-being are often mentioned in one breath, thereby implying that all three are outcome-measures by which work situations can be judged. But safety does not belong to this threesome, because one can only refer to safe or unsafe machinery or work situations which may or may not lead to occupational accidents. Safety can therefore be a characteristic of a work situation, but the outcome-measure is the

19

number or kind of industrial accidents. In this scenario study these concepts will be used in this way. While the concept of well-being is interpreted very differently, the Netherlands' Ministry of Social Affairs provides the following interpretation of 'well-being in relation to work': 'The concept of well-being in relation to work is not the same as the well-being of every employee, but contains only objective criteria of aspects of work which make it possible to come to a situation of well-being.' The Dutch Working Conditions Act is limited to 'well-being in relation to work'. The regulations concerning well-being in Section 3 of the Working Conditions Act can be traced back to objective criteria concerning the organization of work, the design of workplaces and the establishment of production and work methods. One can conclude that 'well-being in relation to work', as interpreted in the Working Conditions Act, is, like safety, a characteristic of the work situation rather than an outcome-measure. By contrast the concept of well-being which we use in this study is meant to be a measure of effects, and lies very close to well-being in terms of work satisfaction. Finally we need to discuss two very common concepts, namely physical and mental health. Clark (1981) says that there is scarcely any concept more difficult to define than mental health. Not only is the division between mental and physical health unclear; that between health and illness is also far from clear. We can also conclude that physical and mental health are definitely not defined by the same concepts. To cite Susser et al. (1985): on the whole physical health is defined more in organic tenns, and mental health more in functional and social terms. In the present study the words health and illness will be used in a broad sense, in contrast to Bezold et al. (1986) in their future study about work and health. The reason for this, as argued above, is that there is no need for a more precise definition. Industry as a whole uses a broad concept of health, where health complaints, sickness absence and long-term employment disability are usually the central issues, and where health is often considered analogous with 'being able to be productive at work'. Our broad definition is therefore necessary in order to be relevant to Dutch industry. Furthermore, empirical data would not be available in sufficient quantity if a narrow definition of health were to be used. By adopting a broad definifion we can make use of such data as the diagnoses of illnes20

ses established by physicians (as, for example, in the case of sickness absence and/or employment disability), opinions of employees about their own health in broad or more specific terms and reported behaviour due to illness in terms of absence from work, visits to the G.P. and hospital admissions. Central to our study will be the health aspects/indicators which are relevant for the workforce and industry in general: back complaints, stress reactions, sickness absence and more permanent employment disability.

21

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THEORY: THE QUALITY OF WORKING LIFE, WORK CAPACITY AND HEALTH

3,1

The relevance of work for health

In the previous chapter both work and health were separately defined. It is now necessary to ask ourselves whether work is really relevant for health. This question can be divided up into three parts: (a) is working healthier or unhealthier than being unemployed or disabled? (b) which healthpromoting and health-threatening effects emanate from work, and how do these effects compare with other environmental factors, such as the physical environment, traffic, life-style, housing etc.? (c) Which healthpromoting and health-threatening effects emanate from different aspects of work? The empirical chapter 5 will be devoted to answering this last question. Various authors have taken up the first question, i.e. what are the relative states of health of working people, the unemployed and those unable to work because of disability? Philipsen and Halfens (1983) compared married working men with nonworking men, matched in pairs by age, social class and degree of urbanisation of the locality and region. It turned out that people disabled for work were less healthy in terms of all health indicators. It also turned out that there were no significant health differences between working people and people who had been unemployed for more than six months. At the same time it is worth mentioning that on the basis of Dutch statistical material. Van Houwelingen et al. (1984) concluded that there was no relationship in the Netherlands at macro-level between unemployment on the one hand and death as a consequence of (for example) suicide, alcohol abuse and heart disease on the other. On the basis of a life situation survey conducted in 1982, Becker and Vink (1986) concluded that there were few differences in the health of the unemployed and employed; only the stress scores of the unemployed were higher than those of the employed. The subjective judgement of health differed little between the two groups. People who were disabled for work however, 23

appeared to be distinctly unhealthier than working people, both physically and mentally. They also used more medication. One might conclude from these findings that working is healthier than not working, but this conclusion would be premature. Many of the aforementioned (unhealthy) people who were disabled for work were until recently part of the workforce. They left it for health reasons. Or to put it differently: working people form a group that is continuously being selected on health grounds. A cross-sectional comparison between working and non-working people does not, therefore, give a proper insight into the question as to whether working is healthier or unhealthier than not working. In order to research this, a longitudinal (cohort) study would have to be carried out on a group of working people and a group of nonworking people over several decades. Such studies are not available. The second question posed at the beginning of this section was concerned with the relative influence of work in relation to other environmental factors. Sturmans et al. (1982; pp.5-9) also considered this question. They contended that there is little prospect of a satisfactory answer, and that the influences due to interactive processes (for example, between the work and home situation) cannot be unravelled. An important study relating to the question put above is that of Schellart (1989). He analysed the files of 380 people who had been declared disabled for work, and concluded that in 37% of cases the cause of disability was completely or partly linked to work; in 49% of cases the cause lay outside of work and in 14% of cases no conclusive statement could be made. Grtindemann et al. (1991) repeated this study with similar results. In a recent Dutch study (Dijkstra, 1990) a thousand Dutch people, ranging in age from 15 to 95, were asked which factors they considered the most threatening to their health. In a sequence ranging from most to least threatening the following were cited: the environment, cancer, an accident, violence, a nuclear disaster, heart disease and, in eighth place, stress. Working conditions came in twelfth place. The working people interrogated gave stress and working conditions a higher priority, namely fourth and fifth place respectively. Approximately one third of the working population sees work as a possible threat to its own health. A similar study was carried out in the United States in the 1970s which concentrated on life-enhancing rather than health-threatening factors 24

(Campbell et al, 1976). These authors distinguished 17 'domains of life experience' in their nation-wide research project. Around 2000 people reported their personal satisfaction in these 17 domains. The authors calculated the contribution of these 17 scores to the total variance in a general well-being index. Work satisfaction was placed fourth, after sparetime activities, family life and standard of living, but before satisfaction related to marriage,finances,friendship, place of residence, housing, etc. In the literature on stress one body of research has concentrated on 'lifeevents' and their influence on illness. Holmes and Rahe (1967) made a list of stressful life-events using the medical files of American naval personnel. 43 events were listed in order or importance. The highest scores were for 'death of spouse' and 'divorce'. Six life-events connected with work were listed, namely dismissal (8th place), reorganization of firm (15th), change of job (18th), change in responsibilities at work (22nd), difficulties with the boss (30th) and change in working hours or conditions (31st). These six life-events show something of the relationship between work and mental health. French et al. (1982) reported that occupational factors explain between 14% and 45% of the variance in 'strain' (mental health or stress reactions). If the term 'occupational title' is replaced by the term 'occupational factors', the age of the variance explained drops to between 2% and 6%. Karasek et al. (1987) used material from questionnaires on 8,700 Swedish employees to throw light on the present query. They concluded that work factors (such as workload, role conflicts, own control of tasks, etc) explain more variance in the reported bodily and mental health factors than nonwork factors (such as travel time, spouse working or not, children at home, problems at home). The problem with this and other studies is the biased selection of the work and non-work variables used. The relationship between working conditions and life-style factors and mortality among the working population has been researched by Fox and Adelstein (1978) on the basis of official British data. They concluded that work plays a role in 18% of all cases. With cancer this would be true in 12% of cases, with accidents 23%, with respiratory diseases 28% and with circulatory diseases 32%. Peto (1985) explored in greater detail what the groups of factors to which cancer deaths may be attributed. Peto estimated that 3-10% of all cancer 25

deaths in the United States and the UK can be attributed to 'occupation' and 'industrial products'. Heederik (1990) estimates that in 10-30% of cases of chronic non-specific lung diseases (CNSLD) work and occupational aspects are a contributory factor. Reviewing the three questions posed at the start of this section, we can now draw the following conclusions: (a) at first sight, working appears to be healthier than not working (see also Figure 3.1), but it is difficult to compare working and non-working people because the former are constantly being selected on health grounds; (b) work, together with other causal factors, has a significant effect on health; (c) factors which are threatening to physical and mental health are certainly present in work (see also Chapter 5). This indicates that research on the future of work and health can certainly be regarded as worthwhile. 3.2

The macro-determinants of the quality of working life

If we glance through the pages of the 'Manual of Occupational Diseases' by the Dutch physician Heijermans (1908), the text and the photos dating from the tum of the century tell us much about what working conditions were like at that time and how much has changed since then. Although there are a number of negative aspects to working life in the year 1990, the changes since the tum of the century represent improvements in many areas: much less work is carried out in deplorable conditions, wages are better and working hours have been reduced, as will appear from Chapter 5. These changes in the quality of working life are an effect of relatively autonomous developments in the fields of technology and economics, as well as of conscious policy decisions on the part of government, management, trade unions and medical and non-medical consultants and providers of care and advice. In handbooks about industrial and/or organizational psychology attention has consistently been devoted in recent decades to the influence of the work environment on the functioning of organizations and their employ26

ees. Katz and Kahn (1978) distinguish five work-environment aspects: (1) the information and technology aspect; (2) the economic aspect: competition, market relationships, raw materials and labour; (3) the political aspect: laws and regulations; (4) the societal aspect: norms, values, culture; and (5) the physical aspect: geography, natural resources and climate. Having placed work-environment aspects in some sort of context, we should mention that the following environmental characteristics (or determinants of the quality of working life) will be examined in Chapter 4: -

financial and economic developments (§ 4.2); technological developments (§ 4.3); developments in the field of health care for people at work (§ 4.4); developments in government policy with respect to the workforce and to the quality of work (§ 4.5).

3.3

The quality of working life: stressors at work

This chapter serves as a theoretical introduction to the main concepts used in this book, the most central of which is the quality of working life. Four dimensions are usually attributed to the quality of working life: job content, working conditions, labour relations and employment conditions. Zielhuis and van Dijk (1989) used this classification as a starting point for their discussion of stressors at work and of the corresponding health risks. Both these authors discussed the following stressors: chemicals, noise, vibration, climate, radiation, physically demanding work, shiftwork, mental workload, psychosocial demands and biological factors. In Chapter 5 the quality of working life will be discussed in greater depth, with special concentration on the developments in the quality of working life mentioned above, their health effects and the groups at risk. 3.4

Work capacity: the coping ability of working people

The concept of the quality of working life was discussed in the last secfion. This section deals with the concept of 'the coping ability of working people'. 27

Van Dljk et al. (1990) define the ability to cope as 'the totality of physical and mental capabilities of the worker at a given moment. This concerns the workers's actual and desired performance potential. Coping can also be described as the ability to achieve and to resist.' Coping ability will be examined in greater detail in Chapter 6. The focus will be on sex, age and level of education, as well as certain work values. 3.5

The effects of work on health and well-being

In discussions concerning the effects of work situations on the health, safety and well-being of working people, several indicators other than death and illness are often used. These include subjective health, health complaints, frequency of visits to a doctor, use of medicines, sickness absence and permanent employment disability. One reason why so many different indicators are used is that work does not generally sow 'death and decay' and that death and serious illness are not generally sufficiently sensitive indicators to measure the effects of work on the physical and mental well-being of working people. Another reason is that when a death is registered in the Netherlands, no record is kept of the employment or occupation of the deceased person. The relationship between work and death is therefore unknown in the Netherlands. Furthermore, several studies indicate that working people are a relatively healthy sample of the total Dutch population, as is shown in Figure 3.1 (based on the data from the Life Situation Survey of the CBS). One might conclude that our workforce is in fact overly healthy, given the numerous threats to health. This can be explained by the fact that a high proportion of adverse health effects manifest themslves among the nonworking population. Nearly 900,000 people were declared disabled for work in the Netherlands in 1990, representing one out of every 11 potential workers. This is the result of a 20-year 'weeding-out' process during which the sick, the less healthy and those who, for a number of reasons, are less able to cope were pushed out of working life. The process leads to a working population which is selected for health and working capacity: this can be traced back in the results of the Life Situation Survey presented.

28

Figure 3.1

Percentage of working and non-working people who do not consider themselves to be in good health. Source: CBS/Life Situation Survey, 1986

percentage

80 H

60 H

working people

housewives/ men

unemployed

disabled for work

There is a growing interest in government circles and among employers' and employees' organisations in policies aimed at lowering the drop-out rate from the workforce. This interest is mainly due to cost considerations. As Figure 3.2 shows, 10.1 billion guilders (approximately US $ 5 billion) were spent on sickness benefits and 21.0 billion guilders (approximately US $ 10.5 billion) on disability payments in 1990 for a working population of 6,000,000. These cost figures show the relevance of thinking about the future of work and health. Not included in these figures are the costs of the administration of benefits, the costs of medical consumption, and the indirect costs incurred by employers because of sickness absence, i.e. productivity losses and/or the costs of using temporary replacements. In Chapter 7 a detailed account will be provided of the way in which the various health indicators of the Dutch working population have developed in the last decades.

29

Figure 3*2

Payments made for sickness absence and employment disability (1970-1990), in billions of Dutch guilders. Source: CBS, 1971, 1981, 1988, 1990

billions Dutch guilders

1970 1980 1988 1975 1985 1990

1970 1980 1988 1975 1985 1990

H sickness benefits EH disability payments

3.6

Working life, work capacity and health combined in a model

In the last four sections four questions were discussed. These were: (1) What are the macro-detemiinants of the quality of working life? (2) How is the quality of working life defined? (3) What is meant by work capacity or coping ability of working people? (4) What are the health effects of work? The elements discussed can be combined in a simple model, as shown in Figure 3.3. On the left-hand side of the model are the four macro-determinants which are assumed to determine the quality of working life. In the centre are the four aspects or elements of the quality of working life discussed above. On the right-hand side are seven indicators of health and well-being which are often used. In the lower part of the model are three aspects of work capacity or coping ability, and three determinants of coping ability.

30

Figure 3.3

Model of Working Life, Health and Work Capacity

macro-determinants of the quality of working life

quality of working life

health and well-being

- economics - technology - policy -health - provison for working people

- job content - working conditions - labour relations - employment attitude

- illnesses - death - complaints - visits to physician - sickness absence - employment disability

- ^

- demography - education - social and cultural developments macro- determinants of wor Ic capacity

—•

^

W

-age - sex - education

indicators of work capacity

The arrows show the supposed directions of causality. Little further explanation is required, though something should be said about the indicators of (physical and mental) work capacity. Depending on age, sex and education, certain stressors may or may not affect health. For instance, young people are generally capable of lifting and carrying greater weights than their elders, and people with a high level of education are likely to be more resilient to certain mental stressors and to have more coping abilities at their disposal than those less well educated. The model described above can serve the reader as a guide to the rest of this book. There is no intention, however, of attempting to verify the model with empirical material. The block 'macro-determinants of the quality of working life' is discussed in Chapter 4, the block 'quality of working life' in Chapter 5, the blocks 'macro-determinants of work capacity' and 'indicators of work capacity' in Chapter 6, and finally the block 'health and well-being' in Chapter 7.

31

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THE MACRO-DETERMINANTS OF THE QUALITY OF WORKING LIFE

4.1

Introduction

In their book 'The future of work and health' Bezold et al. (1986) conclude that there are four 'key trends' (also called macro or environmental factors) that determine the future of working life: economic developments, technological developments, developments in the norms and values of people, countries and/or societies and, finally, changes in the work and the work situation itself. Bezold et al. (1986) then distinguish three key trends that determine the future of health and health care: demographic developments, changes in the financing and organization of care, and changes in attitudes towards health and health care. Bezold's key trends are employed below, although here and there the particular stress may differ. In this chapter four topics will be reviewed, namely economics (section 4.2), technology (section 4.3), health care activities (secUon 4.4) and policy directed at work and health (section 4.5). Demography and norms/values will be treated in Chapter 6 in the section about the working or coping capacity of the workforce. 4.2

The economy as a determinant of the quality of working life

The assumption here is that in an economic boom the corporate sector and institutions wiU invest not only in buildings, machines and materials, but also in a better quality of working life. The latter may be prompted only by the wish to remain competitive in the labour market, in that good staff can be lured by the good working conditions. Figure 4.1 shows changes in the rate of unemployment rate (as an indicator of the economy) in the Netherlands since the 1950s.

33

Figure 4.1

Unemployment in the Netherlands (1952-1990) (in percentages of the working population). Source: CBS

percentage unemployed

The rate of unemployment was relatively stable until the early 1970s. Thereafter there was a steady rise, reaching a peak in 1983-1984. From these figures it may be concluded that the economic situation in the Netherlands in the 1980s did not favour investment in the quality of working life. Since the beginning of the century (see Figure 4.2), there have been important shifts in the structure of employment. Employment in agriculture fell continuously - from 30% to 5% of the total working population - while employment in industry began to fall in the second half of the 1960s. Employment in the service industries steadily increased in the period 1899-1987, especially since 1971, while employment in the building industry has remained relatively constant, accounting for 6-8% of the working population. From these trends it may be tentatively concluded that the quality of working life has improved in the last decades.

34

Figure 4.2

Percentage of the working population in four branches of industry (1899 - 1987). Source: CBS, 1989

percentage of the total working population

1899

4.3

1909

1920

1930

1947

1960

1971

Agrjc. & fisheries

—^ Manufacturing ind.

Construction ind.

-3-

1981

1987

Services

Technology as a determinant

As in the case of the economy, the assumption here is that technological developments (i.e. developments in production techniques in industry and administration) can have both positive and negative effects on the quality of working life. Experts still disagree about the nature of these effects (see for example, Huijgen, 1989). Technology is concerned with the way a firm or institution operates. One can talk about industrial technology, training technology, insurance technology, transport technology, agricultural technology, etc. Most studies and publications refer to production technology in manufacturing. Woodward (1965) distinguished three types: process-production (of, for example, rubber or oil), mass-production or production of large batches (of, for example, cigars) and unit-production (as with aeroplanes). Woodward established that each of these three types of production technology went together with a specific pattern of management and organization.

35

Mass-production often involves short-cycled work (for example, in food, tobacco, timber, furniture and metal industries). Brouwers et al. (1988) estimate that 5% of the Dutch working population carry out short-cycled work (with short cycles of no more than one and a half minutes). The authors do not expect automation to replace short-cycled work in the future, but expect, for example, that 'operator-functions' will be created in which short-cycled work will take place. Developments in computer and communication technology in the industrial and administrative environment are discussed below. In the industrial automation of batch production (as, for example, in the metal and electrotechnical industries), technological development is characterised by the application of computer-aided design, computer-aided processing machinery (CNC) and industrial robots (for welding, spraying, painting, grinding and loading). The number of industrial robots has increased greatly since the beginning of the 1908s, both in the Netherlands and elsewhere. In the Netherlands the number rose from 40 to nearly 800 in the period 19821989. Almost a quarter of the robots are to be found at the sole car manufacturer in the Netherlands. The most important use of robots is in welding. In comparison with other countries, the spread of robots has been hmited. In the process industry the most important technological development has been the control technology applied to the production process. In the early 1950s computer and communication technology was introduced into the administrative sector. Large administrative processes are now automated, and many routine operations formerly done by people are performed by machines. Around 1970 developments in the computer and communication industry gave rise to what is now termed information technology. Figure 4.3 shows the increase in the number of computers, terminals and word processors during the period 1979-1989 in the Netherlands. According to the automation statistics of the Central Bureau of Statistics, there were around 240,000 computers in use in the private sector in the Netherlands in 1988 and around 250,000 in the government sector, each with a minimal purchase value of 2,0(X) guilders (approximately US $1,000). Word processing hardware and computers for industrial automation (e.g. hardware for computer-aided design, computer-aided manufacturing) were not included in those figures.

36

Figure 4.3

Growth in the number of computers, terminals and word processors, 1979-1989, in the private sector in the Netherlands (1987=100). Source: CBS, 1985 - 1989

computers 11979

^^1981

terminals [II]l983

^1985

word processors (10101987

^1989

The degree of automation was not evenly spread throughout the various branches of industry in 1986; the figures show for instance that trade and service industries had a higher than average degree of automation, while the building industry had the lowest. The use of computers and telecommunication makes the place where and the time when work is carried out relatively unimportant. One of the consequences of this is so-called telework. Geographical divisions between firm and employees can be bridged by telecommunication and microelectronics. Most telework, like traditional home-based work, is carried out by women, and offers a quality of working life that is not optimal. The work is mainly administrative: inputting data, typing and processing reports on a word processor. There are some highly skilled teleworkers, such as programmers, project managers and computer analysts and these are mostly men. The leading employers of teleworkers are those involved in banking, insurance services, the computer and software industry and the graphic industry. It is estimated that, given the present state of technology, 2 million out of a workforce of 6.5 million would potentially be employed

37

as teleworkers in the Netherlands. In the mid-1980s there were only a few hundred (Weijers & Weijers, 1986). Koopman and Algera (1989) studied the effects of automation on employment and the quality of working life. They conclude that in both cases experts' forecasts differ widely. With regard to the quality of working life, they quote research that suggests that automation has a positive influence on working conditions. There is less optimism about job content. Some authors foresee a polarization in labour qualifications. 'On the one hand, a relatively small elite of specialists will emerge who will be forced to increase their knowledge continually, while on the other a large number of routine tasks will be carried out by semi-skilled people who have little knowledge of the systems with which they work.' (Koopman & Algera, 1989). They add: 'Automation can have both a positive effect (the elimination of dirty and dangerous work through remote control) and a negative one (the erosion of tasks through the integration of decisions in the software programmes).' The consequences of working with display screens have been researched by Pot et al. (1986). They conclude that continuous work with display screens (in combination with high pressure of work) can lead to headaches, stress, back trouble and fatigue. Finally a few words about chemical or process technology. In 1987 there were more than 100,000 chemical substances on the market in the EEC. According to the criteria of the Hazardous Substances Directive, it is estimated that at least 20,000 substances are a danger to health. Approximately 700 substances in the Netherlands have a Maximum Accepted Concentration in the air, a limit value set by the government. A large amount of empirical material has been collected about different forms of technology in the last decades. From this two main conclusions can be drawn about the quality of working life: (a) Physical demands will drop through the mechanization and automation of industrial processes, but mental demands may increase, for example through task erosion. (b) the automation of administrative production processes will lead to a reduction in routine administrative work and to an increase in work with display screens, which will make heavy mental demands for prolonged periods of time. 38

4.4

Occupational health care as a determinant

The reason for including occupational health care among the determinants for the quality of work is that this type of care aims to improve the quality of working life, as well as helping individual employees who have suffered illnesses or accidents. It needs to be understood that occupational health care practitioners have an advisory function and no line responsibility for the quality of working life, a fact which limits their influence. Some facts and figures on Occupational Health Care (OHC) in the Netherlands will be given here. It should be borne in mind that the working population in the Netherlands consists of some 6.5 million people out of a total population of 15 million people (see also Chapter 6). The scope of OHC is shown in Table 4.1.

Table 4.1

Number of occupational health services, organizations served and workers covered, by three types of services in the Netherlands in 1989

Type of occupational health services

Number of occupational health services

Joint OHS (privately organized)

49

4,000

950,000

Single OHS (privately organized)

70

155

525,000

OHS departments (of public agencies)

66

3,300

550,000

185

7.455

2,025,000

All

Organizations served

Workers served

Three types of services are distinguished. Joint services (BGDs) are nonprofit making bodies, working for a number of enterprises at once and administered by management and labour representatives from these firms. 39

Each service has its own management. In 1989 there were 49 of these services, offering care to some 4,000 firms with a total of nearly 1 million employees. Single services are founded by one firm and work for that firm only. There were 70 of these services in 1989 serving 155 companies and over half a million employees. A third type of service is formed by OHC departments of the central government and local authorities, delivering care to their own staff. Nearly all of these services are joint in the sense mentioned before. There were 66 such services, serving some 3,300 organizations/agencies and over half a million employees. In total, therefore, more than 2 million employees are served (30-35% of the Dutch work force). All care is paid for by employers. The care required is laid down in the Health and Safety at Work Act. If a firm is mainly of an industrial nature and has more than 500 employees (or bears some specific risks such as the handling of lead), OHC is compulsory under the Health and Safety at Work Act. The firm is obliged to found its own single OHS or engage an existing joint OHS. The OHC given to that firm must be certified by the Labour Inspectorate. In other cases OHC is voluntary. Where care is compulsory the Act specifies 22 tasks that a service must perform. The main tasks are: - medical examinations when workers are recruited - periodic medical examinations of workers exposed to certain risks - to stay informed of the conditions of work and to advise on these - to provide first aid (treatment other than first aid is not allowed in principle) - to report suspected cases of occupational disease - to help restrict sickness absence. Certification of sickness absence can be done by the OHS. In the private sector, certification is usually done by the Industrial Insurance Board of the industry in quesfion. In some large firms, however, certification is delegated to the occupational health service. The certification is done by the occupational physician himself or by a specially appointed physician in the service. In the public sector, certification of sickness absence of all civil servants is a task solely for the occupational doctor.

40

Figure 4.4 shows the increase in the extent of occupational health care in the Netherlands in the period 1973-1988. While there was only a small increase in the number of occupational health services, from 151 to 173, the number of occupational health physicians nearly doubled from 514 to 981. Approximately 80% of them work full-time. The number of occupational health nurses increased from 435 to 532, and the number of employees who have access to occupational health care increased from about 1 million to about 2 million in the period 1973-1988. Figure 4.4 Number of occupational health care services, physicians, nurses and other staff in the Netherlands (1973-1988). Source: Jonkers and Lindeman-Clocquet, 1989

physicians

services

Il973

ESl976

[ZIil979

employees (x 10000)

11962

GII0]l985

^^1988

The degree of occupational health care is highest in the building industry, where 100% of employees have access; for industry as a whole the figure is 40% and in services it is approximately 30%. Not only physicians and nurses but other staff, such as occupational hygienists, work in the occupational health services. In the study by Meerman and Middendorp (1990) an overview is given of the staff categories responsible for the 'well-being problem' at work (in the interpretation of the Dutch Health and Safety at Work Act). In half the 41

cases this turns out to be the concern of personnel staff. The remainder are members of special commissions, line managers, company and organization consultants and (to a small extent) occupational health physicians. Around 100 full-time and 150 part-time occupational therapists are also employed in companies and institutions in the Netherlands (estimate by the professional association of occupational therapists) and some 1,400 safety experts (estimate by the professional association). Finally it should be mentioned that there are some 1,000 insurance doctors who are consulted about the Sickness Benefit and Disability Insurance Acts. At present advising fimis and institutions on the quality of working life is a marginal activity for this professional group. The future integration with occupational health care is advocated by many insurance physicians, as the relationship between insurance doctors and the quality of working life would then become clearer. In conclusion it can be said that occupational health care is available to only one third of the working population of the Netherlands, mainly employees of large and well equipped firms. There is, however, a slow but steady increase in this type of health provision. 4.5

Dutch government policy as a determinant of working conditions

It goes without saying that the policies of governmental authorities, employers and employees can play a role in improving the quality of working life in factories and offices. Although employers' and employees' organizations have for many years regularly given their opinions about questions of work and health, we feel that to report and analyse these opinions here would be going beyond the scope of this overview. We shall therefore limit ourselves to developments in domestic legislation which, while formulated by many sections of society, is heavily influenced by employers and employees. Social and technological reform and innovation in the 1970s brought about much criticism of the laws which regulate the protection of work. The following three elements played an especially important role:

42

- nationally and internationally more attention was paid to the quality of working life and to safety, health and well-being; - the right of worker participation received social acceptance; - sickness absence and employment disability, as well as the costs of the benefits, increased steadily during the 1970s. This led to the insight that completely new legislation was needed for the protection of work. The Health and Safety at Work Act came into force in November 1980. The main points of this new Act are as follows: - the law assumes a different relationship between government and industry and sets up rules which are directed less to health policies and more to the organization of the firm (e.g. structures for the consultation between the different parties). - the law compels the employer to carry out measures with respect to safety, health and well-being, which must be integrated into the general policies of the company. - the purpose is to let the employee share responsibility for company policy with respect to the quality of working life by improving mutual consultation. - the concept of well-being has been incorporated in the law as the key concept for the humanizing of working life. This is worked out in such (objective) aspects as: (1) the work situation must be ergonomically suited to the individual characteristics of the employee, (2) work must contribute to the professional competence of the employee, (3) there must be room for manoeuvre in the execution of the task, as well as (4) the possibility for social and functional contacts with others and (5) for information about the purpose and products of the work, together with the demands involved, while (6) short-cycled work and a work pace which has been set by a machine need to be avoided or interspersed with periods of rest or other work. - the policies and the powers of the Labour Inspectorate must be adapted to the new law. The Inspectorate now has the power to issue a ruling. This is intended as a coercive measure to be used when job consultation within a firm has come to a standstill. At the same time the way the Inspectorate relates to the representatives of employees has been revised. As a result a member of the Works Council has the right to accompany the Inspector on his round of the firm and to speak to him privately. The Labour Inspector is legally bound to report to the Works Council all the information given to the employer. The Council in turn has the right to ask further questions related to this.

43

- under the Act firms are now required to appoint a safety team or safety expert, in order to build up expertise in this area. The Health and Safety at Work Act came into force in all its component parts in 1990. After the first phase of the law was introduced, the Ministry of Social Affairs commissioned an evaluation study. This study examined the extent to which the new law had promoted attention to working conditions in companies (Reubsaet et al., 1988). Some results of this study are given below: - the Health and Safety at Work Act has encouraged improvements in working conditions. - working conditions are a contentious issue in only a few companies. Many managing boards and works councils have delegated their tasks in the area of working conditions. - in many firms the responsibility for working conditions appears to lie formally or informally - with middle management. The way middle management carries out these responsibilities is not, however, entirely satisfactory. The underlying problems are an insufficient familiarity with the law, a shortage of specific training, lack of insight into the cost-benefit relation of working conditions and an absence of the necessary resources and powers to carry out the tasks of the Health and Safety at Work Act. - the role played by other employees in the introduction of the Health and Safety at Work Act has been small. The factors responsible are a lack of knowledge of the Health and Safety at Work Act and its consequences, combined with and a lack of interest in the subject of working conditions. - Safety officers are instrumental in structuring (and stimulating attention in) working conditions. - the Occupational Health Services do not appear to be greatly involved in the improvement of working conditions, and in most companies have no policy influence. A number of laws apart from the Health and Safety at Work Act affect working conditions and the quality of working life. One of these is the first Works Councils Act, which came into force in 1950. Since then the scope of this law has repeatedly been extended. At the present moment it is compulsory for companies with 35 or more employees to set up a Works Council. Companies with 10-35 employees are not compelled to do so, but the law does provide for a limited participation on the part of all

44

employees. The participation of employees in a firm with fewer than 10 employees is not regulated by law. The Sickness Benefit and Disability Insurance Acts and the way in which these two Acts are applied have a great influence on the extent of sickness absence and employment disability in the Netherlands, and so are relevant to the discussion of working conditions. In his international comparison Prins (1990) came to the conclusion that rules and procedures concerning illness and employment disability are not only more liberal in the Netherlands, but are applied more flexibly than in Belgium or Germany. Comments on the two Acts vary. On the one hand, it is said that they allow employees to recover fully from illness or accident because they do not have to work while unwell. On the other hand, it is pointed out that these two Acts do not encourage employers to carry out active policies concerning work and health, sickness absence and employment disability: nor do they encourage employees to carry on working or return to work quickly in situations where this would be possible. In 1990 the Government initiated a public debate to review the Sickness Benefit and Disability Insurance regulations. At the heart of the debate was the question of whether the responsibility for financial risks should be shouldered directly by employers and employees. 4.6

Summary and conclusions

In this chapter four (external) determinants of the quality of working life have been discussed. The first of these concerned the economy. We saw that the economy was relatively healthy in the 1950s and 1960s. In the 1970s it deteriorated, reaching its lowest point at the beginning of the 1980s, with numerous bankruptcies and high unemployment. Since that time the economy has been recovering, and investment has increased not only in buildings, machines and materials, but also in the quality of working life. This recovery has coincided with a large increase in the number of people working in the service industries and a corresponding decrease in the number working in manufacturing, construction and agriculture. The second determinant of the quality of working life was technology. Two conclusions may be drawn with respect to the impact of technological developments on the quality of working life in firms and offices: 45

(a)

(b)

through the mechanization and automation of industrial production processes (manufacturing and assembly), the physical workload will on average have lessened, although the mental load may well have increased in certain occupations; Through the automation of administrative production processes routine administrative work will be reduced and working with display screens will increase, possibly making heavy mental demands on those performing such work for extended periods of time.

The third factor discussed was occupational health care. We found that the following groups of professionals are concerned with the care and advising of people in employment: personnel managers (in terms of the Health and Safety at Work Act they can be better described as 'well-being experts'), occupational therapists, occupational health physicians, safety officers and insurance company doctors. Employees in the Netherlands who are faced with problems in the area of (mental) health and well-being usually have to deal with personnel managers in terms of receiving care. Occupational health care is limited to one third of the working population, mainly employees of the larger, better equipped firms, although there has been a gradual expansion in occupational health care in the 1970s and 1980s. The fourth determinant of the quality of working life considered was government policy. Central to this is the Dutch Health and Safety at Work Act, which was passed in 1980 but only came into force in all its component parts in 1990. From evaluadon studies it appears that the Dutch Health and Safety at Work Act has brought about an improvement in working conditions. A second important point of policy is concerned with the legisladon on sickness benefits and employment disability. Both acts have been under attack for many years, because many consider that the regulations and administrative procedures provide too few incentives for limiting sickness absence and employment disability in the Netheriands. At the end of the 1980s/eariy 1990s a growing consensus for change in these areas appears to be emerging.

46

5

THE QUALITY OF WORKING LIFE IN THE NETHERLANDS

5.1

Introduction

The quality of working life in the Netherlands can - as was said in section 3.3 - be divided into four main dimensions, namely the job content, working conditions, labour relations and employment conditions. These four dimensions may be further subdivided into a number of concrete aspects of the work situation that can affect health both physically and psychologically. In this chapter each of these four dimensions will be discussed in a separate section, in which the concrete aspects relating to each particular dimension will be described. The following points will be looked at for each aspect: (1) the developments in its occurrence, (2) its occurrence in the Dutch working population by industrial branch, age and sex, and (3) the health risks established in research. Apart from a large amount of quantitative material from the research literature, the main source for this chapter is the Life Situation Survey of the Central Bureau of Statistics (CBSA-SS). Table 5.1 shows the size of each sample from 1974 until 1986 and the number of working people between the age of 18 and 65 included in each sample. All the data presented relate, of course, to the employed people in the survey. The Life Situation Survey for 1989 has been published in the meantime, but it was not possible to adapt these data to the form required for this report, for which reason the time-series cover the 1974-1986 period only. It should be noted that in this chapter, as well as in Chapter 7, conclusions will be drawn about differences between time periods and differences between groups of working people. In research such differences are usually tested for significance. This is discussed in detail in the article by Bloemhoff and Smulders (1991). As a general rule a difference of 3-4% between the groups studied here can be considered significant (with a 5% probability). 47

Table 5.1

Size of samples in Life Situation Surveys for 1974, 1977, 1980, 1983 and 1986

year of survey

size of total sample (LSS)

size of sample for analysis (working; 18-65 years)

percentage

1974 1977 1980 1983 1986

4806 4159 2865 3987 4040

2376 1973 1556 1995 1897

49 47 54 50 47

Total

19857

9797

49

Readers may ask why the observed differences have not been 'controlled' for cross-cutting variables such as age and sex. In principle this would have been possible. We decided, however, not to make such corrections, as we were chiefly interested in finding out the real, 'rough' and uncorrected differences in time or between the numbers of working people in the different categories. For example if we wish to show the differences in the quality of working life between the construction industry and service industries it may be noted that in the construction industry a lot of men and in service industries a lot of women are employed. If the data were to be controlled for this or 'standardized', the results obtained would then be free of possible gender effects. In the comparison with service industries, the many men in the construction industry (with their physically heavy workload) would be weighted in the same way as the few women in that industry (with their light administrative work). The same would be true of men and women in the service industries. This did not strike us as a sensible way of making comparisons. In this and later chapters the term 'potential working population' will occur many times. It should be pointed out that this category consists of the working population and unemployed people who are officially registered as looking for work. The category 'working population' consists entirely of people who are actually in employment and therefore excludes those who are looking for work. 48

Table 5.2

Percentage of working people with complaints about aspects of work in the period 1974 - 1986. Source: CBS/LSS

1974

1977

1980

1983

1986

carrying out a lot of monotonous work

_

14

13

13

12

actual work not properly related to training and experience

.

.

28

33

34

working at a high pace

-

38

36

42

47

carrying out a lot of heavy physical work

-

20

21

22

24

working in a noisy environment

26

-

24

23

22

carrying out dirty work

28

-

28

26

25

sometimes carrying out dangerous work

-

11

10

9

8

no good prospects of advancement

-

-

68

74

70

working shifts

9

10

9

11

10

'-' : no data available

5.2

Job content

5.2.1 Monotonous work/short-cycled work In Table 5.2 (which uses data from the Life Situation Surveys of the CBS), we see that complaints about monotonous work fell slightly from 1974 to 1986. In 1977 14% carried out monotonous work, but in 1986 this was 12%. Monotonous work was most frequent in the transport sector 49

(22%) and in manufacturing as a whole (18%). Monotonous work was also carried out more often by women and young people than by men and older workers (see Figure 5.1).

Figure 5.1

Carrying out a lot of monotonous work: differences between industrial branches, men and women and age categories (n=5757). Source: CBS/LSS, 1977, 1983 and 1986 (aggregated)

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 35-64 36-64 >• 66 >" 66

years years years years years years

total working population. 10 20 30 40 60 60 70 percentage of affirmative answers

80

Short-cycled work, characterised by repetitive, monotonous and routine tasks which are carried out in a very short period of time and are bound by place and time, is considered to lead to stress reactions. An important factor favourable to health is autonomy or the extent to which a person is free to use his own judgement in carrying out his work (Karasek & Theorell, 1990). Links have been established between job content and sickness absence. Variety in the work situation, a high measure of autonomy and responsibility and a high degree of training go together with a low level of sickness absence (Smulders, 1984).

50

Because of new technologies the area of application for short-cycled work has been extended from manufacturing to the services (offices, laboratories). It is expected that under the influence of new technologies shortcycled work will diminish but remain as a left-over function (e.g. packaging) or take on a more intensive, but simpler form. At the same time new functions arise, the so-called operator functions, some of which are monotonous (Brouwers et al., 1988). 5.22 Training and experience in relation to actual job content Table 5.2 shows that the percentage of working people who said that their work was not properly related to their education or past experience rose from 28% in 1980 to 34% in 1986. The transport sector had the greatest negative score on that point, and agriculture the least. Here again, as with monotonous work, women and young people form a risk-group (see Figure 5.2). Figure 5.2

Actual work is not properly related to level of training/ experience: differences between branches of industry, men and women and age categories (n=3826). Source: CBS/LSS, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 36-54 >• 66 >• 65

years years years years years years

total working population 10 20 30, 40 60 60 70 percentage of affirmative answers

51

The discrepancy between the level of work and the level of education has been studied for the wage-earning working population in the period 1960 1985 (Huijgen, 1989). The quality of working life, measured by the level of skill required, improved in the period 1960 -1985. The increase in the level of skill required, however, was not enough to compensate for the strong rise in the educational level of the Dutch working population. One can conclude that for the period 1960 - 1985 the discrepancy between level of education (training) and level of appointment has increased for the wage-earning population. The opportunities for women are clearly worse than those for men. 5.2.3 Work pace In the CBS Life Situation Surveys (see Table 5.2) 38% of employees in 1977 declared that they had to work at a high pace, while in 1986 this figure had risen to 47%. This is one of the most striking trends in the quality of working life in the past two decades. The work pace is highest in the transport sector (48% affirmative) and in services (44%). It is lowest in manufacturing, according to the employees who work there (37%). Men and women differ little in their perception of the work pace. Young people most frequently report that they have to work at a high pace (Figure 5.3). 5.3

Working conditions

5.3.1 Heavy physical work There are few reliable statistics on trends in working conditions. For a number of working conditions estimates can be made; for others only broad qualitative statements can be made or trends indicated on the basis of subjective statements from the working population. According to the three-yearly surveys of the CBS (see Table 5.2), the percentage of working people who stated that they had to carry out heavy physical work increased slightly, from 20% to 24% between 1977 and 1986. It is no surprise that the heaviest work was in agriculture and in the construction industry, and that young men did a lot of heavy physical work (see Figure 5.4).

52

Figure 5.3

Working at a high pace: differences between branches of industry, men and women and age categories (n=5742). Source: CBS/LSS, 1977, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 36-64 >• 66 >• 66

years years years years years years

I

total working population P 10 20 30 40 60 60 70 percentage of affirmative answers

Figure 5.4

Carrying out a lot of heavy physical work: differences between branches of industry, men and women and age categories (n=5758). Source: CBS/LSS, 1977, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 36-64 >• 66 >" 66

years years years years years years

total working population 10 20 30 40 60 60 70 percentage of affirmative answers

53

It is clear that heavy physical work has diminished since World War II as a result of mechanisation and automation in manufacturing, agriculture and horticulture. There does however appear to have been a shift from a dynamic to a more static form of work, while work pressure and work pace have increased (Den Dekker, 1988). Heavy physical work, i.e. work where a lot of physical exertion is demanded and/or where a fixed position has to be maintained for long periods of time, can lead to adverse effects on the circulatory and the musculoskeletal systems. Besides giving rise to symptoms of fatigue, heavy physical work can lead to back disorders, inflammations and the wearing down of joints (Den Dekker, 1988). In a recent survey the following risk factors for back disorders were mentioned: working in a sitting, standing, or forward leaning position, heavy physical exertion, lifting, bending over, prolonged walking, pulling and pushing. Other factors, such as vibration, long duration and fast pace of work contribute to back trouble, as do individual factors such as age, muscle weakness and earlier back complaints (Hildebrandt, 1987). Static work load is also linked to another disorder of the musculoskeletal system, namely Occupational Cervicobrachial Disorder. This disorder affects the neck, shoulders, back, arms and hands and is the result of a static load on muscles (in the neck and back), in combination with repeated movements of the hand, arm and shoulder. If pregnant women carry out heavy physical work, this may adversely affect the outcome of the pregnancy, e.g. in the form of a lower weight at birth, dysmaturity and premature birth (Slob, 1986). 5.3.2 Noise at work The percentage of people who said that they work in a noisy environment dropped from 26 to 22% during the period 1974 - 1986 (see Table 5.2). Figure 5.5 shows that the noisiest working environments are in manufacturing, agriculture and the transport sector. It appears that men and young people are more likely to work in a noisy environment than women and older workers (see Figure 5.5). Working people's perceptions of their own exposure to noise does not, however, correspond exactly with actual exposure (Van Dijk, 1984).

54

Figure 5.5 Working in a noisy environment: differences between branches of industry, men and women, age categories (n=3813). Source: CBS/LSS, 1983 and 1986 agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 35-54 36-54 >• 66 >• 66

years years years years years years

total working population! 10 20 30 40 60 60 70 percentage of affirmative answers

Statistics about trends in the actual occurrence of noise in the workplace are not available. With the help of data about the number of working people and estimates of the occurrence of noise in the various branches of industry (and assuming an equal level of exposure in all branches of industry) an overall trend can be indicated. Through shifts in the number of workers in each branch of industry, the estimated number of employees working with exposure levels of 80 dB(A) or higher fell from almost 490,000 in 1975 to 318,000 in 1984. This decrease is also due to a large reduction in the number of employees in the textile industry. In conclusion, it appears that the actual exposure to noise in manufacturing fell between 1975 and 1984 and that the perceived exposure to noise between 1974 and 1986 also fell, but less sharply. Exact data about levels of noise in each industry are not available, but some estimates have been made for manufacturing. It was estimated that 38% of employees in manufacturing work with a level of noise of more than 80 dB(A) (Passchier-Vermeer & Jurriens, 1985). The clothing and leattier industries appear to be the least noisy. The most noisy are the 55

timber and furniture industry, the various metal industries, the building materials industry and the textile industry. One of the most important consequences of exposure to noise is loss of hearing. It is accepted that regular exposure to noise of 80 dB(A) or above can lead to impaired hearing. According to the international standard ISO 1999 this possibility already exists at a level of 75 dB(A). It is estimated that in manufacturing alone 100,000 people suffer from impaired hearing as a result of working in a noisy environment. Van Dijk (1984) concluded that deafness is the most common occupational disease in the Netherlands. Exposure to noise also leads to difficulties with concentration, stress, hoarseness (due to raising the voice) and problems with balance (Van Dijk, 1984).

5.3.3

Vibration and shocks

Trends in the number of employees exposed at work to whole-body vibrations or hand-arm vibrations can be derived from the Labour Force Surveys. Oortman Gerlings et al. (1985) provide an overview for 1971 and 1981. The total number of people exposed to whole-body vibrations has fallen in the last 10 years. This decrease has mainly taken place in jobs in agriculture and manufacturing. The number of people exposed to wholebody vibrations in administrative functions and in jobs in the transport sector has increased slightly. The number of employees exposed to handarm vibrations has also fallen in this period. A large number of employees are exposed to whole-body vibrations at work: 4(X),000 who drive vehicles for a living and 75,000 who work in manufacturing. The number of employees exposed to hand-arm vibrations is smaller, i.e. about 140,000 people who work with hand tools that produce vibrations or knocks. Most of these employees work in agriculture, horticulture, manufacturing, construction or transport. Whole-body vibrations result from a weight-bearing part of the body, e.g. the feet or the seat, being subject to vibrations. In the long run exposure to whole-body vibrations can lead to complaints and disorders of the musculoskeletal system (Bongers & Boshuizen, 1990). At the same time complaints and disorders of the digestive tract, peripheral vascular system, female reproductive organs and peripheral nervous system are linked to

56

whole-body vibrations (Seidel & Heide, 1986). For these disorders, however, there are not enough data to confirm a causal relationship. Working with certain hand tools causes vibrations and shocks to move through the hand and the arm. A specific effect of these hand-arm vibrations is the syndrome called 'Vibration induced White Fingers'. Other disorders of the musculoskeletal system (especially shoulder, arm, hand and fingers) may also result (Koemeester, 1987). 5.3.4 Climate and the Sick Building Syndrome Employees who are exposed to extreme climatic influences are those working in the building industry and agriculture (outdoor work), the metal and glass industry (extreme heat), shops and public transport (draughts), and those whose jobs involve ovens (heat), cold storage (cold), or abattoirs (damp conditions) (Zielhuis & Van Dijk, 1989). The total number of these employees is unknown. We assume that the number has decreased in recent years with automation, mechanization and the drop of employment in agriculture. Demanding climatic influences can lead to respiratory and musculoskeletal disorders. This may in turn lead to undue strain on the cardio-vascular system (Zielhuis & Van Dijk, 1989). Another health effect related to climate is the so-called Sick Building (Syndrome, a complex of non-specific complaints such as complaints of the nose, eye, respiratory mucous membranes and skin, apathy, headaches and asthma-like symptoms) which affects workers in (new) office buildings. The causes of this set of complaints are not yet fiiUy clear. The number of office buildings responsible for the Sick Building Syndrome has increased in the past 10 to 15 years. Possible reasons are the increased use of VDUs, laser printers and copying machines, more mechanical ventilation, and an increase in work pace. It may also partly be explained by an increased interest in the problem. There are estimated to be around 2 million office workers in the Netherlands, of whom approximately half have complaints occasionally and around 40,000 regularly. It is expected that the Sick Building Syndrome will continue to demand attention in the coming years (Schalkoort, 1988). 57

5.3.5 Radiation Around 0.5% of the workforce (23,000 workers) run the risk of being exposed to ionizing radiation. Those who are most at risk are employees in hospitals, nuclear centres and various manufacturing industries (Gezondheidsraad, 1985). People who are exposed to non-ionizing radiation are welders, employees in metal and glass foundries and people working with ozone rays, lasers and microwave ovens (Zielhuis & Van Dijk, 1989). The harmful effects of ionizing radiation include an increased likelihood of cancer and hereditary malformations. If pregnant women are exposed, there are risks for the unborn child, with the possibility of spontaneous abortion, retardation of growth, mental retardation and infantile cancer (Slob, 1986). Possible risks of non-ionizing radiation are 'welders' eyes' (UV-radiation), burning of the cornea (laser beams), cataracts (UV, infra-red), eye infection (UV) and ageing, burning and cancer of the skin (UV) (Zielhuis 8L Van Dijk, 1989). Visual display units emit electro-magnetic radiation. It has however been shown that working with VDUs carries no risk of radiation for the employee, or for possible offspring (Pot et al., 1986). Epidemiological studies and experiments carried out on animals show no evidence of the opposite (McDonald et al., 1988). 5.3.6 Chemical agents and working conditions In 1987 there were over 100,000 chemical substances on the market in the EEC. An estimated 20,000 substances are harmful to health according to governmental criteria. About 700 substances have a MAC-value (Maximum Accepted Concentration in the air, comparable with Threshold Limit Values), a limit value set by the government. As a consequence of new technologies, e.g. the long-distance handling of processes, exposure to chemicals has also diminished. Every year many new substances and applications come onto the market. By way of illustration a number of developments related to three chemical substances (organic solvents, asbestos and pesticides) of importance from the health point of view are discussed below.

58

Around the turn of the century only a dozen or so different organic solvents were widely used. Apart from being used in the rubber industry, the solvents were also used in the making of such products as glue. The discovery of all kinds of plastics gave a new impulse to the manufacturing of these materials in the period 1930-1960. The present production of organic solvents is several million tonnes per year (1978: 4.3 million ton). There are many very different materials and applications: 'surface coaters' (paint, etc.), cleaning materials, gluing materials, household and pharmaceutical products (Hogstedt and Axelson, 1986). New materials and applications are constantly being introduced onto the market. Because of their lipid-solving capacity, organic solvents can cause skin disorders and have an irritating effect on mucous membranes and respiratory organs. These solvents are also known to have effects on the nervous system. These effects can be acute, such as fainting, or chronic, such as fatigue and disorders in mental functioning (Hogstedt & Lundberg, 1992). Asbestos is used frequently as an insulating material and for the production of brake linings. Although the health risks of asbestos (mesothelioma, a form of cancer) have been known for decades (Swtiste et al., 1988), the Asbestos Decree only came into force in the Netherlands in 1978. Around that time a search began for replacement materials. Although exposure to asbestos is now strictly regulated, asbestos is still being used, for example in brake and friction materials. No complete prohibition is likely in the short term. The risks of exposure to asbestos will probably remain for a long time, for example in garages. Since 1945 the production and use of pesticides in horticulture and agriculture have greatly increased. The number of different active ingredients is also increasing as some products can no longer be used because of resistance or environmental problems. Exposure to pesticides can occur in production companies during transport and storage and during the application of pesticides in agriculture and horticulture. Professions and branches of industry where there is an increased risk of cancer as a result of working with toxic materials are listed in Saracci (1985). There are cancer risks involved in viniculture, mining, asbestos production and shipbuilding as well as in the construction, metal, chemical, gas, rubber, leather, and timber and paper industries. The health risks of chemicals at work are many. The effects can be classified into acute effects, such as poisoning, and chronic effects, such as 59

cancer, respiratory disorders and reproduction risks. The cancers that occur are those of the bladder, the prostate, the scrotum, the skin, the bone, the stomach, the liver, the nose and the lungs (Doll & Peto, 1981). 5.3.7 Biological agents and working conditions The most important biological agents that may endanger health are microorganisms (viruses, bacteria, fungi), allergens and toxic material from plants (e.g. pollen, but also wood dust or coffee beans) and allergens from animals (e.g. those present in faeces, hairs or in dust particles). These agents can cause infection, allergic reaction, poisoning or even cancer. The respiratory organs and the skin are the part of the body most seriously affected. (Dutkiewicz et al., 1988). For a long time the dangers of working with risky biological agents had been recognized only in the health care sector and in work with animals. Since the beginning of the 1960s, however, more and more biological agents have been discovered as a result of advanced immunological and microbiological research methods, and a greater proportion of the working population has become exposed to the dangers. The working population potentially at risk in the Netherlands is made up of employees in the food, tobacco, animal foodstuffs, meat processing, textile, leather, timber and paper industries, in agriculture, forestry, horticulture, fishing, veterinary services, health care, biotechnology, mining and catering (Dutkiewicz et al., 1988). In the health care sector, the infection risks that have had the most attention in the past years are viral infections with Hepatitis-B, AIDS, cytomegalio virus and a number of bacterial infections (Smulders et al., 1985). The infection risks at work are a hundred times smaller for AIDS patients than Hepatitis-B patients. Measures taken for the prevention of AIDS infection are sufficient to prevent infection by HIV, the virus responsible for AIDS (Rijssen-Moll et al., 1988). Exposure of pregnant women to biological agents, especially the infectious agents, can lead to an increased health risk for the unborn child (Slob, 1986).

60

5.3.8 Dirty work 'Dirty work' is a layman's term for work that involves exposure to dangerous substances - including chemical and biological exposure. But 'dirty work' may also have a connotation of 'unpleasant work', without a direct adverse health effect.

Figure 5.6

Carrying out dirty work: differences between branches of industry, men and women and age categories (n= 3828). Source: CBS/LSS, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 36-64 >• 66 >• 66

years years years years years years

total working population 10 20 30 40 50 60 70 80 percentage of affirmative answers

There was a slight decrease in the amount of dirty work performed in the period 1973 - 1986 (see Table 5.2). In 1974 and 1980 28% of the workforce performed dirty work; in 1986 this was 25%. Older workers do less dirty work than younger workers (see Figure 5.6). It occurs mainly in agriculture and fisheries, the construction industry and in manufacturing. One third of working men and one tenth of working women report that they carry out dirty work, i.e. work which involves getting dirty hands, clothes or hair or inhaling 'dirty substances'.

61

5,3,9 Unsafe working conditions/dangerous work A description of occupational accidents in the Netherlands will be provided in Chapter 7 (section 7.7). In that section health effects are the subject, whereas in this section the causes will be discussed: unsafe and dangerous working conditions. The percentage of working people in the Netherlands who state that they carry out dangerous work fell slightly in the period 1977-1986, from 11% to 8% (see Table 5.2). In the construction industry and in the transport, storage and communications industry, between one fifth and one third of employees state that they carry out dangerous work (see Figure 5.7). Figure 5.7

Carrying out dangerous work occasionally: differences between branches of industry, men and women and age categories (n=5754). Source: CBS/LSS, 1977, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-54 36-64 >• 56 >• 56

years years years years years years

total working population

10 20 30 40 60 60 70 percentage of affirmative answers

80

Around 10% of working men and 4% of working women state that they sometimes have to carry out dangerous work. Older workers carry out dangerous work less often than younger people (see also Figure 5.7). No overview of unsafe working conditions exists. In order to arrive at an inventory of unsafe work situations, use can be made of the classification 62

of causes of accidents as registered in the accident records of the Netherlands' Central Bureau of Statistics (CBS, 1972-1991): mechanical objects in operation (e.g. tools and machines) and not in operation (e.g. ladders, falling objects), thermal contacts and radiation, chemicals, living agents, excessive load of parts of the body and traffic accidents. Mechanical objects cause around 93% of accidents at work. Accidents due to mechanical objects not in operation (e.g. falling objects) occur often in the construction industry and in agriculture and fisheries. Objects working functionally (tools, machines) cause a lot of accidents, especially in manufacturing and in agriculture and fisheries. Accidents due to thermal contact and radiation (e.g. welding tools, hot water) occur most often in the construction industry and in manufacturing. 5.4

Labour relations

The most commonly used indicators of labour relations are relations between employees and management, relations between colleagues, possibilities for consultation, participation, and management style. Relations with clients do not fall under the heading of labour relations but under aspects of job content. From a comparison of a few company characteristics of 85 comparable production companies in 1964/1965 and 1980/1981, it is evident that a number of changes took place in labour relations in that period: more delegation of responsibilities, less authoritative management of companies and more professional support of personnel (Smulders, 1984). On the other hand, research on the impact of micro-electronics in the service industries indicates that new - often not transparent - possibilities for supervising employees are made available by automation (Weggelaar & De Boer, 1984). Social relations (between colleagues and between different levels of the internal hierarchy of a firm) can lead to stress if the demands from the social environment cannot be satisfied or if the number of social contacts do not meet the expectations, needs and norms of the employee. Good social relations appear to correlate with job satisfaction and general well-being and poor social relations with complaints of a psychological 63

nature (Karasek & Theorell, 1990) and with sickness absence (Smulders, 1984). Social relations can also ease stress due to other causes: this has been coined social support in the literature on stress. Strong, personally experienced social support from the boss or colleagues goes together with greater job satisfaction, fewer complaints of a psychological nature and less concern about one's own functioning. Social isolation can therefore be considered a stress-inducing factor at work. Social isolation can occur when the work site is isolated, as with home-based work, or when communication is impeded by physical circumstances, as with noise (Karasek & Theorell, 1990). 5.5

Employment conditions

Employment conditions can be characterised as: pay, pension, working hours, education possibilities, job security, promotion prospects, child daycare facihties, personnel management and occupational health care. Empirical data on these aspects are very scarce in the Netherlands. In this section we shall therefore only discuss a few aspects. 5.5.1 Promotion possibilities/prospects Data from the Life Situation Survey of the CBS give an insight into how some career aspects are experienced by the working population in the Netherlands. Opinion about promotion possibilities has not changed much in the last few years: in 1980 68% of the working population were unsatisfied with promotion possibilities; the figure had risen to 70% by 1986 (see Table 5.2). As far as differences between particular branches of industry are concerned, opinions about promotion possibilities are most negative among people working in agriculture and in the construction industry, and most positive among those working in transport and in manufacturing (see Table 5.8).

64

Finally it can be seen in Figure 5.8 that women and older employees are more negative about their promotion possibilities than men and younger workers.

Figure 5.8

Absence of good promotion possibilities at work: differences between branches of industry, men and women and age categories (n=3681). Source: CBS/LSS, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 36-64 >• 66 >• 66

^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^

85

^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ 69

1 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^

^^^B

67

72

years years years years years years

totai worldng population

^ 10 20 30 40 50 60 70 80 90 100 percentage of affirmative answers

When promotion possibilities do not coincide with the needs, norms and expectations of employees, dissatisfaction at work results. It appears from many studies that satisfaction about promotion possibilities goes together with a low level of sickness absence. A more important employment condition, in relation to stress, is job security. Lack of clarity and uncertainty about the future (due to reorganizations, mergers, changes in job content due to automation) can give people the feeling that they no longer have the situation in their own hands. This is seen as a major cause of stress (Karasek & Theorell, 1990).

65

5.5^ Length of working hours The average number of working hours in the Netherlands has fallen by 50% in the last 80 years, from 60 hours per week in 1910 to 40 hours per week in 1987 (see Figure 5.9). Between 1910 and 1945 there was a sharp fall in the average number of working hours per week. After 1945 the average number of hours worked fell more gradually, but the number of working days decreased and part-time work increased, particularly in the last decade (De Neubourg & Kok, 1984). In 1971 11% of the total labour force worked for less than 35 hours per week. This percentage almost trebled over the next 16 years to 31% in 1987 (CBS/Labour Force Surveys). The number of holidays and other days off increased five-fold between 1910 and 1987 (from 8 to 44 days per year) in the Netherlands (see Figure 5.9).

Figure 5.9

1910

Development in the number of working hours per week and the number of holidays and other days off, per year (1910-1987). Number of working hours: average of adult employees in manufacturing, excluding overtime. Source: CBS, 1989

1960

1960

- * - working hours/week

66

1970

1980

- ^ days of vacation/yr

1987

In 1971 31% of women worked part-time (less than 35 hours per week), while in 1987 more than 60% of women did so. The number of men working part-time also increased over this period. Figure 5.10 shows that older workers are more likely to be employed part-time than younger workers, and that part-time work is most common in the service industries (25%) and least common in the construction industry (3%). Figure 5.10 Part-time work (less than 35 hours per week): differences between branches of industry, men and women and age categories (n=5721). Source: CBS/LSS, 1977, 1983 and 1986

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 35-54 35-64 >• 66 >• 66

years years years years years years

25

62

total working population 10 20 30 40 60 60 70 percentage of affirmative answers

80

Finally a few words about the effects of shorter working hours on health indicators. As part-time employees work fewer hours than 'normal', their workload is on the whole less and there is more spare time in which to recover. Research on differences in sickness absence between full-time and part-time workers does not confirm this: the way in which spare time is used is the important factor (Vrijhof, 1985). Furthermore part-time workers sometimes decide to work fewer hours because of health problems, which will change the relationship between the number of working hours and sickness absence. 67

5.5.3 New work patterns/work contracts As the working week becomes shorter interest in the 'compressed' working week (for example 36 hours in four days) becomes greater. Working hours have become ever more flexible, a trend reflected in a diversity of working patterns. The freedom of choice of employees with respect to working hours has led to more flexible labour contracts, temporary jobs, on-call contracts and home-based work. Some data on new work patterns in the Netherlands are provided below: - Around 15% of men and women under 25 have temporary jobs, while for men and women over 25 the figures are 4% and 8% respectively. In sectors such as services in old people's homes, hospitals and cleaning firms there are more part-time jobs than elsewhere (CBS/Labour Force Sample Survey, 1985). - On-call contracts are most common in the hotel and catering industry and in large shopping chains. Almost 70% of the on-call workers are married women; the rest are students, old age pensioners and unmarried women (Van Eijk & Derks, 1987). - It is estimated that at least 3% of the workforce did home-based work in 1985 (Vissers et al, 1986). The vast majority of home-based workers are women. The effects of flexible contracts on health and well-being are not clear. What is clear, however, is the lack of security that goes with these new contracts. Extreme examples are on-call contracts and home-based work. In the former case the employee has little or no say about working hours and working time, and his legal position in regard to social benefits (minimum wage, sickness and disability benefits, unemployment benefits) is weak. Home-based workers are left totally on their own; they have to organize their own working times and have no contacts with colleagues. This can lead to increasing social isolation (Van Eijk & Derks, 1987). 5.5.4 Shift work From the beginning of the 1960s to the present day there is no clear pattern to be discerned in the prevalence of shift work and irregular work in manufacturing (Jansen, 1987). In the period 1974-1986 the percentage of people doing shift work fiuctuated around 10% of the total labour force (see Table 5.2). In 1987 around 14% of men and 15% of women worked 68

irregular hours or in shifts. Men work more in shifts, women more at irregular times. Young people do a relatively large amount of shift work. Shift work is most common in manufacturing, transport, storage and communications firms. Irregular working times are found mainly in the hotel and catering sector, transport, storage and communication firms and 'other services'.

Table 5.3

Percentage of employees working at irregular times and in shifts, by branch of industry and sex in 1987. Source: CBS, 1990; salaried employees

Industrial

Percentage of employees working at irregular times

m

f

Percentage of employees working in shifts

m

Percentage of employees working at irregular times or in shifts m

f

f

Agriculture and fisheries

0

1

0

0

0

1

Mining and manufacturing industry

1

0

21

3

22

3

Public utilities

2

0

3

0

5

0

Construction industry

0

1

0

0

0

1

Retail and wholesale trade, hotels and restaurants, repair of consumer durables

1

2

1

0

2

2

36

32

45

35

Other services

10

23

0

0

10

23

All industry

7

14

7

1

14

15

Transport, storage and communications industry Banking and insurance, commercial services

69

Age is important with respect to the effects of shift work, as older people have more problems in adjusting to changes in sleeping and eating patterns. Working in shifts can lead to disturbances in sleeping patterns and eating habits. Because the 24-hour rhythm is not the normal one, disturbances can arise in the physiological functions of the body. The main health complaints related to shift work are sleeping problems, lack of appetite, chronic fatigue, disorders of the digestive and respiratory systems and cardiovascular disorders. Working in shifts also has important consequences for the social life of these workers and their families (Meijman et al., 1988, 1989). 5.6

Summary and conclusions

In this chapter some 20 key aspects related to the quality of working life were reviewed. For each of these aspects two questions were asked: what have been the developments in the recent past, and in which categories of the working force is the situation better or worse. The categories of the working force considered were branch of industry, age group and sex. The most important source of data was the Life Situation Surveys of the CBS for the years 1974-1986 (covering some 10,000 employees in total). Use was, of course, made of many other sources. First the longitudinal trends. The trends relate mostly to the 1977-1986 period because a number of data from 1974 were missing. In the case of some aspects it is not properly clear how the trends took place (e.g. radiation, chemical, climatic and biological working conditions). Favourable developments are the following. Exposure to vibrations and shocks has been reduced with time, as have dangerous work, noise, dirty work and nasty smells at work. Furthermore labour relations have improved in the last decades and working times have been shortened. Negative developments are the following: less correspondence between level of education and experience and level of skills required, a higher work pace and more heavy physical work. Finally there have been no major changes with respect to monotonous work, promotion possibilities and shift work.

70

It is important to establish next which groups are most at risk with respect to the quality of working life. Let us first look at the branches of industry. The transport sector scores negatively on many aspects. A lot of monotonous work is performed at a high pace, and there is poor agreement between the level of training/experience and the actual work done. Those working in the transport sector are exposed to considerable noise, vibration and shocks, dangerous work, shift work and long working hours. It is recommended that government, employers and employees, and those involved in health care and research, pay more attention to the transport sector than hitherto. When it comes to the branches of industry with the most groups at risk, manufacturing and construction are together in second place, after transport. In manufacturing there are many adverse diverse conditions - monotonous work, noise, vibrations/shocks, radiation, biological and chemical risks and labour relations - which could be improved. In the construction industry there are specific problems: limited possibilities for promotion, much heavy physical work, unfavourable climatic working condidons, chemical risks, unsafe and dirty work and long working hours. Agricultural workers perform a lot of heavy physical work and dirty work, are subject to biological risks and have few possibilities of promotion. Finally the service sector scores relatively favourably in almost all aspects. Most of the problems are to be found in the work pace, the mental load and the irregular working hours/shifts. It must be added, however, that the overall picture of the service sector is heavily dominated by banks and insurance companies. It should, however, be borne in mind that such categories as education, health care, police and prisons also fall under services. Let us now take a look at the differences in the work situation of men and women. Male work is characterised by a higher work pace, heavy physical work, noise, unsafe conditions and long working hours. Unfavourable aspects of female work are monotony, lack of promotion possibilities and a poor correspondence between training/experience and the actual work done.

71

Finally a few words about age categories. The conclusion - in as far as data are available - is that younger people work in much worse conditions than older workers. Younger people carry out more monotonous work and at a higher pace; their work is more physically taxing, more dangerous and is carried out in an environment with more noise. They woric more hours per week and work more in shifts. The only positive point is that younger people see more possibilities for promotion than older people - but then it would be odd if this were not the case. It is also true that many older people cannot keep up with the job and leave the labour force under the disability provisions. In other words their coping ability - most probably 'damaged' by years of work - can no longer match the workload.

72

CHARACTERISTICS OF THE WORKING POPULATION IN THE NETHERLANDS

6.1

Introduction

As explained in sections 3.4. and 3.6, we assume that the work capacity of the working population partly determines whether demanding factors at work will or will not lead to adverse health effects. Work capacity may be defined as the total physical and mental abilities of the worker in carrying out a particular task at a given moment. Physical work capacity, knowledge, skills and emotions are all contributory factors (Van Dijk et al., 1990). Important indicators of the work capacity of working people are age, sex, level of education and social and cultural norms and values in relation to work. These aspects and their development over time will be discussed in this chapter (from sections 6.3 to 6.6). But first a total picture will be given of the Dutch population and labour force in the past, present and future (section 6.2). 6.2

The population and the labour force in the Netherlands

The Dutch population has increased from 5 million at the beginning of this century to 15 million in 1990. The potential labour force (i.e. those people who are in employment together with those who are officially looking for jobs) as a proportion of the total population has decreased with respect to men and increased with respect to women (see Figure 6.1). In 1990 the total potenfial labour force came to almost 7 million people. Of these, almost 4 million men and 2.4 million women had jobs and 0.6 million people were unemployed (CBS/Labour Force Survey, 1991).

73

Figure 6.1

Trends in the Dutch male and female potential labour force (1899-1987) as a percentage of the total male and female population. Source: CBS, 1989

As a percentage of the total male and female population

||69 59

62 63 « 61

ei

il 57 fii

64

50

52

r

18 19 19 20

1899 1920 1947 1971 1987 1909 1930 1960 1981

22

1899 1920 1947 1971 1987 1909 1930 1960 1981

I women

6.3

Age

Table 6.1 shows the age development in the potential labour force in three age groups from 1899 to 1990, as weU as a forecast for 1990 to 2010. We see that in the past the proportion of young people steadily decreased and that the same pattern will hold in the future. The percentage of older people (50 and over) remains relatively stable throughout the 1899-2010 period. This percentage falls slightly in the period 1960-1988 but is expected to increase in the coming 20 years (1990-2010). Reasons for these developments are the greater participation in education of younger people and the retirement, early retirement and employment disability of the older workers. Figure 6.2 shows the expected changes in 5-year age groups for the period 1990-2010. We see a sharp decrease in the 20-34-year-old age groups and a sharp increase in the 45-64-year-old age groups. 74

Table 6.1

Trends in the potential labour force, by age and sex (1899-2010). Source: CBS, 1991; Op de Beke & Arts, 1987

25-50 year %

>50

women

men

total

year %

year %

%

%

%

34 34 34 33 29 27 28 23 20 13

45 46 47 48 50 50 51 60 66 64

21 20 19 19 21 23 21 17 14 23

23 24 23 24 24 22 26 31 39 41

77 76 77 76 76 78 74 69 61 59

100 100 100 100 100 100 100 100 100 100

- 55 >• 55

years years years years years years

total working population 10 20 30 40 50 60 70 percentage of affirmative answers

81

Figure 7.3

Often having a feeling of fatigue: differences between branches of industry, men and women and age categories (n=5758). Source: CBS/LSS, 1977, 1983 and 1986 combined aoriculture

manufacturing construction transport servicea

men women men women men women

18-34 18-34 35-54 35-64 >• 55 >• 56

years years years years years years

totai woricing popuiation 10 20 30 40 50 60 70 percentage of affirmative answers

Figure 7.4

Sometimes having a headache: differences between branches of industry, men and women and age categories (n= 5760). Source: CBS/LSS, 1977, 1983 and 1986 combined

agricuiture manufacturing construction transport services

men women men women men women

18-34 18-34 35-54 35-64 >• 66 >• 56

years years years years years years

total worthing population 10 20 30 40 50 60 70 percentage of affirmative answers

82

80

7.3

Visits to GPs and the use of medicines by working people

According to the data from die Life Situation Survey of die CBS, die number of visits to a GP made by the working population scarcely changed in die 1977 - 1986 period (Table 7.1). In addition, we see tiiat there were fewer contacts widi GPs in agriculture than in manufacturing and services (Figure 7.5). The figure also indicates that in general women make contact with a GP more often dian men, and that older people do so more often than younger people. The use of medicines by the working population appears to have been less in 1986 than in 1977 (see Table 7.1). It is also evident that fewer medicines were used by diose working in the construction industry and agriculture than elsewhere (see Figure 7.6). Figure 7.6 also shows that older people consume more medicines than younger ones and that women consume more than men, except in die older age group (55 and over). This last observation is also true of contacts widi the GP: female employees of 55 or over appear to be a relatively healthy group, widi fewer medical problems than their male colleagues. Figure 7.5 Contact with the GP in the last three months: differences between branches of industry, men and women and age categories (n= 5755). Source: CBS/LSS, 1977, 1983 and 1986 combined agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 35-54 35-54 >" 55 >• 55

years years years years years years

totai worthing population 10 20 30 40 50 60 70 percentage of affirmative answers

83

Figure 7,6

Medication in the last two weeks: differences between branches of industry, men and women and age categories (n= 5768). Source: CBS/LSS, 1977, 1983 and 1986 combined

agriculture manufacturing construction transport services

men women men women men women

18-34 18-34 36-64 35-64 >• 66 >• 66

years years years years years years

total wori(ing population 10 20 30 40 50 60 70 percentage of affirmative answers

7.4

Sickness absence

As noted in Chapter 1, there are two reporting systems in the Netherlands for sickness absence, in which fimis participate on a voluntary basis (NIPG and NIA). There is also a reporting system in which firms participate on a compulsory basis because of the sickness benefits to be paid (namely the data of the SVr). As is shown in Figure 7.7 below, the rate of sickness absence in manufacturing increased from 3.9% to 6.4% in the period 1952 - 1991. In 1978/1979 it reached a peak of 10%. The state of the economy has been a definite factor in this trend. One explanation for the increase is the changed composition of the labour force. Since the early 1960s more married, slightly older, women with children have been joining the labour force. Other possible explanations are that people report sick sooner than they used to (as a result of better health and changing norms and values regarding work and leisure) and

84

that there has been an increase in the total workload, which has not been accompanied by a sufficient increase in the time for recuperation (see previous chapter). Figure 7.7 Rate of sickness absence in the Netherlands 1952 - 1991 (for the most part in manufacturing). Source: NIPG/TNO, 1991 percentage 10 H

Among other things the recession and high rate of unemployment have been advanced as explanations for the fall in sickness absence after 1977/1978. Employees with a high rate of sickness absence are weeded out of the labour force on health grounds, via unemployment and employment disability rulings, and replaced with new employees with a low rate of absence (Kruidenier & Bakker, 1985). Another explanation for the fall may be the willingness to work extra hard, for fear of being made redundant. There are clear differences in sickness absence among men and women. The rate (see Figure 7.8) and frequency of absence in the Netherlands is higher for women than for men; the average duration of absence, however, is longer for men than for women. 85

The rate of sickness absence increases with age. Older people are on average sick for longer periods than younger people, but take sick leave less often (see Figure 7.8). Symptoms of 'wear and tear', both as a result of the ageing process and of many years spent in the labour force, are a factor. It appears from many statistical sources that manual laborers report sick more often and for longer periods than civil servants and that they therefore have a higher rate of absence. This difference is, of course, linked to differences in the quality of working life. Figure 7.8

Rate of sickness absence of men and women in the five age groups (averaged over 1988-1989). Source: calculations based on data from NIA (Klein Hesselink & Reuling, 1990)

I men

m women

Figure 7.9 provides an overview of the rate of sickness absence per industry (i.e. industrial insurance boards), averaged over two years (19881989). Branches of industry with a high rate of absence are 'government' (i.e. social work provision paid out of government funds), the textiles, stone, construction, metal, and clothing industries (11-14%). A low rate of absence is to be found in the following industrial associations: banks, agriculture, health care, shipping trade and bakers (5-6%). 86

Figure 7.9

Rate of sickness absence in the 25 branches of industry; average of the period 1972-1985. Source: SVr

work by handicapped-j construction industry butchers stone industry 4 textiles industry-f timber industry-{ health care 4 chemical Industry-{ metal industry-r graphic industry-{ metallurgy industry-{ food processing 4 hotels/restaurants -{ -others' dairy -i retail trade-{ tobacco industry transport -t harbours merchant navy agriculture-] bakers H banking -| national average

percentage

7.5

Prolonged employment disability

The Disability Insurance Act (known as WAO in the Netherlands; see Chapter 1 for more details) regulates the financial consequences of prolonged employment disability for people working for private companies, while the Public Sector Employees Pension Act (ABP) regulates these for civil servants and the General Disability Benefit Act (AAW) for the selfemployed and those who have been handicapped early in life. According to recent data the number of disablement benefit claimants stood at 882,000 at the end of 1990. Expressed in percentage terms, we have the following breakdown: 72% from private companies, 10% civil servants, 7% self-employed, 10% early-handicapped and 1% 'others'. For a proper interpretation of these data and these statistics it is important to distinguish between these categories. The early-handicapped category is best left out of consideration as work was not a factor in their becoming disabled.

87

In Figure 7.10 trends in the number of disabled persons (AAW/AOW) is given for the period 1968 - 1990 (exclusive of early-handicapped). It may be seen that the number of disabled persons increased from 163,000 in 1968 to 749,000 in 1990. But the total number in any year is of course determined by the inflow and outflow of disabled people. It appears that the increase in the inflow had almost stopped at the beginning of the 1980s. In 1986 the difference between the inflow and outflow was still only 15,000 people. But in 1989 - 1990 the inflow increased again while the outflow lagged behind: as a result, the total was increased by 34,000 people in 1990.

Figure 7.10 Total number of people disabled for work in the Netherlands 1968-1990 (WAO/AAW; exclusive of early-handicapped and 'others')- Source: AAf/Aof number of people disabled for work x 1000 785

800 H

727

626

662

690

582

600 H

514 402

400 H 313 261 215

200 H 1 6 3

y..wfi,,,^ I irn....,,.irn...., mn M|I i i m ,,,. tm,,.^,,,tm,,,^,,inrh,.^,,it-n,,

.,.jrri,,,M,

.irri....

1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990

The increase in the number of people newly disabled for work in the period 1968-1978 can be attributed in part to the economic developments in that period. Reorganizations, redundancies and high unemployment caused an increase in the inflow of disabled (Bijlsma & Koopmans, 1984; Van 't HuUenaar & Van Koningsveld, 1986). After 1978 fewer people were declared disabled in all age categories. This may be due to a changing age distribution in the working population, such

88

as a fall in the number of working people aged 60 - 65 years. This group has the highest probability of being declared disabled for work. It should be borne in mind that these numbers are absolute figures and that the total working population has increased by more than a million in the period 1968 - 1989. Taking the number of newly disabled persons per 1,000 insured persons in paid employment in Figure 7.11, we see that the rate increased between 1969 and 1978. It then fell sharply in the period 1980 - 1984, subsequently increasing again to 17 newly disabled persons per 1,000 insured persons per year in 1990. The sharp fall in the rate of new disablement between 1981 (23 per 1,000) and 1984 (13 per 1,000) has not been sufficiently explained and researched. This fall may be worth a separate study.

Figure 7.11 Number of people newly disabled for work, per year and per 1,000 persons insured. Source: GMD, 1970-1991 30-1

24 !2G Lea

25-J IS

20-J

17'17

15H 114 ^

ft

115

2S 2 3 ^ [23 LC7 1 1 F 7

\

'n

1( LEH7

14

|i2 /S7

M4^ 12 Ls7

ie

1

n

10-j

^1

M^M-Lpl MM MMM"MM

MU-MM

LpU' Ljl 11 uI t 1 Lpi 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1969

0-J

We shall now look at the sex and age aspects of being declared disabled for work.

89

Women nowadays have the same chance as men of being declared disabled. For both sexes the inflow in 1990 was 17 out of 1,000 insured. Women, however, after a long period of being ill, more frequently retire altogether from work than men and thus disappear from 'the books'. In these comparisons between men and women, the kind of work that people do should also be taken into account. It is therefore surprising that women and men have the same chance of being declared disabled: one would expect a lower chance for women. The risk of being declared disabled increases with age. Statistics show that about 29 disabled employees per 1,000 insured are aged between 45 and 55 and about 35 disabled per 1,000 insured are aged between 55 and 65. In other words, at least 3% of people over 45 years of age are declared disabled. Figure 7.12 shows the total number of disabled people per 100 people insured and receiving benefits, men and women by age category. We see that less than 1% of young people between the age of 15 to 24 is disabled, but that in the oldest age category 50% are disabled. Figure 7,12 Total number of people disabled for work (per 100 insured and receiving benefits), per age category and sex; average of five years (1986 - 1990). Source: GMD, 1991

16-64 years

men

90

Finally we may look at the relationship between industrial branch and employment disability. From a study by Schellart (1989) it appears that work-related factors were the cause of disability for 37% of the people disabled for work. In 49% of cases the cause lay outside of work and in 14% the cause was not directly attributable to either one or the other. Occupations with physical or mental stress factors or with a high level of unskilled work have a high risk of employment disability (Van 't HuUenaar & Koningsveld, 1986; Aarts & De Jong, 1990). The number of people disabled for work varies widely from industry to industry (see Figure 7.13). The average percentage of people disabled in all branches of industry is 14% of all insured persons. Industries associated with a high number of disabled are: mines, clothing, textiles, construction, stone and leather (24 - 41%). A low percentage of disabled people is to be found in banking, health care, retail trade and agriculture (8 - 10%) (Source: SVr, unpublished data 1984 - 1986). Figure 7.13 Total number of people disabled for work (per 100 people insured and receiving benefits) in the 25 branches of industry; averaged over three years (1984-1986). Source: SVr; unpublished data work by handicapped mining clothing industry textiles Industry construction Industry stone industry leather Industry ~| timber Industry A dairy -| harbours metal industry merchant navy tobacco industry food processing -l chemical industry-f metallurgy industry-{ hotels/restaurants • transport graphic industry < bakers butchers agriculture retail trade health care banking national average

91

1.6

Occupational diseases and disorders related to work

Occupational diseases Until the 1.1.1988 occupational diseases were defined in the Dutch Sickness Benefit Act as acute or chronic disorders which affect the insured (and for which the insured receive benefits) and which are the consequences of paid employment. From 1.1.1988 Section 9 of the Safety and Health at Work Act came into force. The definition of occupational disease has been broadened in such a way that disorders resulting from physical demands (such as musculoskeletal disorders) and mental demands (such as stress) can be now regarded as occupational diseases. It is impossible to estimate the true occurrence of occupational diseases in the Netherlands on the basis of the official figures. Willems (1987) estimates from international statistics that there may be an underestimate of 20%. This would mean in reality an additional 10,000 cases per year in the Netherlands. Occupational skin diseases caused by chemical and physical agents are the most common (98%) of reported occupational diseases, for both men and women (CBS, 1972-1991). A large number of the cases reported are linked to accidents or accidental events, such as bums, acid or alkaline bums of the skin and mucous membranes and the inhalation of chemicals causing lung oedema. On the basis of intemational literature Willems (1987) names the following industries as being responsible for important risk factors: metal, constmction, health care, timber and fumiture, catering, transport and food-processing. Because occupational diseases are underrepresented in the official Dutch statistics, it is impossible to present trends in occupational diseases on the basis of these data. Disorders related to work The World Health Organization (1985) names the following important work-related disorders: musculoskeletal disorders, mental disorders. Chronic Non-Specific Lung Disease (CNSLD), diseases of the circulatory system and certain forms of cancer. These disorders are common in the Netherlands as well, as can be seen from the statistics on sickness absence

92

and employment disability. In 1990 two stood out above the others: musculoskeletal and mental disorders (see Figure 7.14). The fact that these two disorders are predominant has led us to give them special attention in the rest of this study (see Chapter 8 and others).

Figure 7.14 Percentage distribution of people disabled for work, by diagnosis (1990). Source: based on GMD, 1991 (total= 100%; n=821,051) musculoskeletal dls. mental disorders vague complaints circulatory dis. neurological dis. injuries respiratory dis. neoplasms digestive dis. congenital anomalies endocr./metabolic infectious diseases diseases of the si