MONITORING SAFETY AND HEALTH CONDITIONS IN THE WORKPLACE: A PILOT SURVEY IN A REGIONAL CONTEXT, THE VENETO REGION

Vol. 4, n. 1, 37-56 MONITORING SAFETY AND HEALTH CONDITIONS IN THE WORKPLACE: A PILOT SURVEY IN A REGIONAL CONTEXT, THE VENETO REGION Giuseppe Mastrangelo 1, Gianluca Marangi 3, Patrizia Carassai 8, Sergio Perticaroli 13, Giuseppe Campo 2, Danilo Bontadi 4, Alberto Baldasseroni 5, Michele Bertani 7, Eugenio Capodicasa 4, Claudia Carletti 9, Federico Cattani 9, Vittorio Cenci 6, Diego de Merich 2, Lia De Zorzi 10, Giuseppe Di Loreto 10, Massimo Dini 11, Emanuela Fadda 1, Antonio Leva 2, Elisabetta Maier 5, Vita Marzia 4, Giulio Mattioni 11, Maddalena Mazzi 4, Pietro Mazzoccoli 3, Carlo Melegari 7, Antonietta Mundo 11, Roberto Noceta 9, Gianfranco Ortolani 12, Pietro Antonio Patané 4, Massimo Piccioni 10, Gianfranco Priolo 1, Angela Sartori 9, Luca Scoizzato 1, Antonella Sereno 9, Luisa Silva 12, Paola Torri 4,Giorgia Tornieri 7, Luciano Marchiori 3 1 University of Padua, Department of Environmental Medicine and Public Health, Padua, Italy 2 Italian National Institute for Occupational Safety and Prevention (ISPESL), Department of Organization Processes, Rome, Italy 3 Local Health and Social Services Authority (ULSS) 20, Workplace Prevention, Hygiene and Safety Department, Verona 4 Studio GOMI, Industrial medicine specialists, Padua, Italy 5 Tuscan Regional Centre for Occupational Accidents and Diseases (CeRIMP), Italy 6 San Bonifacio Hospital, Accident and Emergency Department, Verona, Italy 7 Study Centre on Immigration (Cestim) -, Verona, Italy 8 Italian National Social Security Institute (INPS), Office of Regional Forensic Coordination for the Veneto Region, Venice, Italy 9 Italian National Social Security Institute (INPS), Central Directorate for Information and Telecommunication Systems, Rome, Italy 10 Italian National Social Security Institute (INPS), Office of General Forensic Coordination, Rome, Italy 11 Italian National Social Security Institute (INPS), Office of General Statistical and Actuarial Coordination, Rome, Italy 12 Italian National Institute for Insurance against Occupational Accidents (INAIL), Rome, Italy 13 Italian National Social Security Institute (INPS), former Department of Documentation, Information and Training, Rome, Italy (Key words: monitoring, working conditions, stress, health, safety) Prevention Today January - March 2008 This article is an original summary of the results of the research reported in the paper, Indagine pilota conoscitiva sulle condizioni di salute e sicurezza negli ambienti di lavoro relativa ad una realtà regionale: Veneto (Pilot cognitive survey on health and safety condition in the workplace) published in full (in Italian only) in the supplement to ISPESL s magazine, Fogli d informazione issue n. 2, 2006 which is also available online at: http://www.ispesl.it/ informazione/argomenti/rapportoveneto.pdf <http://www.ispesl.it/informazione/argomenti/ rapportoveneto.pdf>. This paper was also published in more detail (in Italian only) in the supplement to issue no. 1, 2008 of the journal, La Medicina del Lavoro. ABSTRACT The implementation of an occupational safety and health monitoring system immediately raises some fundamental questions about the object of the monitoring, how the survey is to be conducted, what type of information is expected to be gathered and communication methods. In the European Union there is a wide variety of approaches for such monitoring systems BOW PO/base indexing: EUOSHA - OSH: Ill health and accidents [OSH: 46401A] CIS: Occupational safety and health [CIS: A] NACE - ATECO: Public administration and defence; compulsory social security [ATECO: 75]; Activities of membership organizations n.e.c. [ATECO: 91] 37

whose purpose is to provide a description of occupational safety and health conditions at various levels, from the company to the national levels. An overview of the systems adopted in Europe has shown that a single data source alone cannot provide a complete and adequate description of occupational health and safety (OHS). The present study was promoted by the Italian National Institute for Occupational Safety and Prevention (ISPESL) in collaboration with the Prevention Department of the Veneto Region and with the contribution of national organizations and institutes, including the University of Padua, the Italian National Social Security Institute (INPS) and the Italian National Institute for Insurance against Occupational Accidents (INAIL). Its aim was to test a survey model that would provide a comprehensive picture of the occupational safety and health conditions in an Italian region, as a pilot study to create a nationwide monitoring system. The Veneto region was selected as the pilot region due to its broad range of occupational activities, high population density and extensive economic development. This research consists in testing a comprehensive methodological approach for analysing health and safety conditions in the workplace comprising five surveys on the following issues: Perception of occupational risks, health conditions and prevention measures adopted. The relationship between stress, occupational accidents and sickness absence. A qualitative approach to accidents among non-eu illegal workers. Sickness absence. Trends in occupational accidents, inability, and sickness absence. INTRODUCTION Prevention Today January - March 2008 The implementation of an occupational safety and health monitoring system immediately raises some fundamental questions about the object of the monitoring, how the survey is conducted, what type of information is expected to be gathered and communication methods. In the European Union (EU) there is a wide variety of approaches for such monitoring systems whose purpose is to provide a description of occupational safety and health conditions at various levels, from the company to the national levels. An overview of the systems adopted in Europe has shown that a single data source alone cannot provide a complete and adequate description of occupational health and safety (OHS). The differences between the various European monitoring systems relate to the choice of health indicators, the description of work environments and the analysis of the level of prevention measures. In certain cases, the traditional data-gathering methods, based primarily on occupational diseases and accidents, have been complemented by new initiatives seeking to combine data from various sources in order to have as complete a picture as possible and, at the same time, one that is effective in the timely identification of early warnings and of the possible solutions. It is along this same line that The European Agency for Safety and Health at Work, which analyses the main health problems of workers, has set up a Risk Observatory [1]. The Observatory complements the available data to provide a broader view of the topics treated through the archives and surveys conducted in EU countries. In addition, the European Foundation for the Improvement of Living and Working Conditions (Eurofound) conducts a specific periodic survey by questionnaire among workers - the European survey on working conditions (ESWC) - to assess workers health condition [2]. The present study was promoted by the Italian National Institute for Occupational Safety and Prevention (ISPESL) in collaboration with the Prevention Department of the Veneto Region and with the contribution of national organizations and institutes, including the University of Padua, the Italian National Social Security Institute (INPS) and the Italian National Institute for 38

Insurance against Occupational Accidents (INAIL). Its aim was to test a survey model that would provide a comprehensive picture of the occupational safety and health conditions in an Italian region, as a pilot study to create a nationwide monitoring system. The Veneto region was selected as the pilot region due to its broad range of occupational activities, high population density and extensive economic development as shown in figure 1 and in table 1. Figure 1 - Occupational distribution by broad economic activity in the European Union and in the Veneto region European union, year 2000 survey 5% Veneto, year 2005 survey 3% 65% 30% agriculture industry services Sources - EU: Third European survey on working conditions 2000 (European Foundation for the Improvement of Living and Working Conditions) - Veneto: authors calculations Table 1 - Industry and Services - Occupational distribution by economic sector in the Veneto region Economic sector 1991 2001 Agriculture and fisheries * 11 230 14 325 Mining and quarrying 1 982 2 302 Manufacturing 621 665 647 483 Electricity, gas and water 3 567 4 320 Construction 131 361 149 843 Trade and repair 284 000 306 457 Hotels and shops 72 132 87 106 Transport and communications 51 207 69 459 Credit e insurance 31 367 48 365 Other services 150 792 251 184 Total 1 359 303 1 580 844 60% 37% agriculture industry services Monitoring safety and health conditions in the workplace: a pilot survey in a regional context, the Veneto region * includes: service activities related to agriculture and animal husbandry that were not within the scope of the Agricultural Census; hunting and capture of animals for breeding and game repopulation and related services; farms that use forests and woods, forestation and reforestation associations and related services; fisheries, fish farming and related services. Source: 7 th and 8 th General Census on Industry and Services by the Italian National Institute of Statistics (ISTAT). 39

The OHS monitoring system in the Veneto region was developed based on five survey topics complementing each other according to a strategy focusing more in depth on certain issues from a preliminary general overview. This would be achieved by simultaneously using two ad hoc surveys (one of a general nature and another focussed on an emerging risk factor); a qualitative analysis on a specific issue, with a view to reassess the results of official statistics; and a review of administrative archives containing data useful for the monitoring activity. The point of departure was the Third European survey on working conditions 2000 conducted by Eurofound in the 15 Member States of the EU. It was decided to conduct a similar survey for workers in the Veneto region to obtain an overview of occupational risks, health conditions and prevention measures adopted. A second survey was then conducted, using an ad hoc questionnaire to achieve a better understanding of one of the major risk factors that emerged from the preliminary general survey: work-related stress. A third study consisted in the qualitative analysis of accidents among non-eu illegal workers to confirm the official statistics on this issue. The last two studies allowed INPS and INAIL data to be reused, thus contributing further to the existing databases, particularly in relation to sickness absence statistics. These five survey topics constituted the model for the OHS monitoring system tested in the Veneto region. The following presentation, therefore, has a double significance: first, for the results of each study taken individually, and second, for the well-articulated vision of the issues related to occupational health that emerges from the integrated approach of the surveys within a single monitoring system. THE FIVE SURVEYS SURVEY 1: Perception of occupational risks, health conditions and prevention measures adopted Prevention Today January - March 2008 INTRODUCTION This study began with the objective to obtain an overview of the occupational risks, health conditions and prevention measures adopted in the Veneto region. We based this survey on the methodology of the Third European survey on working conditions conducted by Eurofound in the 15 Member States of the EU in 2000. 1. METHODS The sample was drawn from the regional list of telephone numbers using a two-stage sampling method. In the first stage, a random sample of individuals was selected for the interview: employees or self-employed workers between 15 and 64 years old whose next birthday was closest to the interview date. As with the Eurofound survey, subjects such as retired and unemployed persons, disabled people, housewives, and students, were excluded from the survey. Non-EU workers were included on condition that they could be interviewed in Italian. In the second stage, after interviewing the first 2 858 subjects, the criterion for selecting the household members was modified to balance the sample composition by age and gender: the member of the gender and age group of interest was then interviewed. If the respondent was temporarily absent, a callback appointment for the interview was arranged, or the responded was contacted by cell phone. Four attempts were made to call the telephone number drawn from the list before it would be retired. The structure of the whole Eurofound questionnaire used for the ESWC [4] was unsuitable for 40

a telephone interview because it was too long. A shorter, 30-question version of the questionnaire was therefore drafted and administered by specifically trained interviewers using the computer-assisted telephone interviewing method. The survey began in January- February 2005 and ended in July 2005. The duration of each interview was about 10 minutes. A total of 5 108 subjects were interviewed. 2. RESULTS The symptoms reported, in descending order of frequency, were: stress (27%), backache (18%), general fatigue (12%), upper limb pain (7%), headaches (6%), vision problems (5%), anxiety (5%), lower limb pain (4%), irritability (4%), hearing problems (2%), sleeping problems (2%), respiratory difficulties (1%), skin problems (1%), allergies (1%), stomach ache (1%), traumas (0.5%), heart disease (0.3%). With the exception of stress, all the other negative health indicators were two to three times lower in the Veneto region when compared with the 2000 Eurofound survey. My work improves my health, was the response of 251 workers (5%). The associated occupational factors are the following: opportunities to gain qualifications, control over the organization of work, support from colleagues, and satisfaction with the work carried out. Despite a lower prevalence of sickness, however, the prevalence of sickness absence was higher in the Veneto region when compared with the Eurofound survey. These differences are four times as high for short absences of less than 5 days. Regarding the perceived risk factors (Table 2), workers reported that for over 25% of their working time they are exposed to vibrations (20%); noise (19%); inhalation of vapours, fumes, dusts, hazardous substances (18%); repetitive movements (50%); painful or tiring positions (46%); working at very high speeds and working to tight deadlines (60%). Exposure to physical risk factors is markedly lower in the Veneto region than in the EU, while the differences between both are minimal as regards working at very high speeds. Table 2 - Exposure to physical, chemical and organizational factors in the work environment. Percentage of respondents who reported being exposed to the risk factor for over one quarter of their working time Risk factors EU Veneto region 2000 % 2005 % Working to tight deadlines 60 58 Working at very high speeds 56 59 Painful or tiring positions 47 46 Repetitive hand/arm movements 31 50 Noise so loud that you would have to raise your voice to talk to people 29 19 Vibrations from hand tools, machinery, etc. 24 20 High temperatures which make you perspire even when not working 23 13 Breathing in vapours, fumes, dust, or dangerous substances such as chemicals, infectious materials. 22 18 Low temperatures whether indoors or outdoors 21 9 Contact with or handling of hazardous products or substances 16 12 Radiation such as X-rays, radioactive radiation, welding light, laser beams 6 6 Monitoring safety and health conditions in the workplace: a pilot survey in a regional context, the Veneto region Source: - EU: Third European survey on working conditions 2000 (European Foundation for the Improvement of Living and Working Conditions); - Veneto: authors calculations. 41

The analysis by work sector reveals that: traditional occupational risks (noise, vibrations, high or low temperatures, inhalation and handling of hazardous substances, and radiation) are common in agriculture, in almost all industrial sectors and only in two sectors of the service industry, health and other social services; ergonomic risk factors are reported in almost all industrial sectors and in agriculture, but also in the service sector, including health and other social services; working at very high speeds, working to tight deadlines and job demands exceeding workers capabilities are more frequent in the service sector than in industry and agriculture; weekly working hours are longer in industry and agriculture than in the service sector, however shift work (at night, on Saturday or Sunday) is more common in the service sector; regarding prevention measures, information on risks and provision of personal protective equipment are the two most frequent prevention measures adopted in industry, while in the service sector training courses are more common; the average percentage of respondents who are satisfied with their work is 87% - it is higher in the service sector and lower in industry. Among the workers interviewed for the survey, 78% reported that they are very/fairly well informed on the risks, 29% use personal protective equipment, and 88% that they are very/fairly satisfied with their work. Prevention Today January - March 2008 3. DISCUSSION In addition to the traditional occupational risks, the survey also revealed other aspects of working conditions such as posture, handling of loads, repetitive movements, shifts and workloads which were excessively heavy on a psychic and cognitive level. These factors are difficult to examine since they are more widespread in the service sector (in which workers are scattered throughout the territory) than in industry (where workers are concentrated in factories), and they are more difficult to asses compared to risk factors of a chemical and physical nature. Furthermore, these risk factors are associated with psychopathological disorders, which are nonspecific diseases from the clinical and aetiological view and are much more difficult to identify when compared with disorders of an organic nature. All of these complications may have hindered a more in-depth examination or even acknowledgement of these problems. The aim of the survey was to provide an overview of the situation and of the problems facing the working population of the Veneto region, with the main objective of providing information on the need for more in-depth studies on specific topics, Therefore, in order to obtain a more comprehensive picture of the situation, the research was complemented by further surveys and other information sources, which will be described below. SURVEY 2: The relationship between stress, occupational accidents and sickness absence INTRODUCTION Perceived work stress is a common health problem - both in the present survey and in the one conducted by Eurofound in 2000 (28%) - and according to Karasek [5], it is correlated to a high psychological commitment (workloads, pressure, work pace, monotony, work efforts: job demand, JD) and a low decision latitude (DL). No studies have been conducted in the Veneto 42

region to evaluate the extent and effects of stress in the workplace. The present study aims to analyze the level of occupational stress in firms of different sizes operating in various sectors, and its association to injuries, sickness absence and redeployment for medical reasons. 1. METHODS In all, 2 174 subjects were studied from 30 firms of various sizes operating in the most common industry and service sectors of the Veneto region. Karasek s questionnaire [6] was administered by the company s occupational physician during health surveillance checks. Before the interview, the subject was categorized by the physician on the basis of events which occurred in the previous 12 months: occupational accidents, sickness absence for ten consecutive days or more, or redeployment for medical reasons. Where an event occurred, the worker was invited to focus his/her attention on any psychosocial aspect of the work environment perceived prior to the event; otherwise the worker was invited to detail the circumstances of his/her current work. Therefore, even if the study design was transversal, it was possible to examine the temporal succession between psychosocial stress and occupational accidents, prolonged sickness absence and redeployment for medical reasons. In view of the uncertainty on which diseases today can be classified as being of occupational origin, the illness was not defined in more detail. The survey was conducted from May 2004 to June 2005. In order to characterize the exposure-response relation between each of the two dimensions that characterize the psychosocial work environment (JD and DL) and the risk of accident or sickness absence (Figure 2), the terziles of JD and DL were found, in respect of which the population examined was subdivided into three equal groups with the corresponding indicators showing increasing values. Dummy variables were then created to express the risk trend for occupational accidents and sickness absences in relation to the two aspects of increasing psychosocial distress. In order to have complete control over the confounding variables, all the other risk indicators that were studied were forced into the multiple logistic regression model through which the odds ratio (OR) was estimated (95% confidence interval, CI). Figure 2 - Karasek s Job strain model (1979) high Decision latitude (Control) low low Psychological demands high Learning motivation Risk of psychological strain and physical illness Monitoring safety and health conditions in the workplace: a pilot survey in a regional context, the Veneto region Source: Stress and Burnout: a Growing Problem for Non-Manual Workers, International Metalworkers Federation, 2002 43

2. RESULTS The results showed that high job strain was reported by 27% of the sample of 2 174 workers. The risk of job strain is greater in women than in men, in subjects using psychotropic drugs (habitually or occasionally) compared with those not using them, and in non-smokers compared with smokers; while there were no differences in age, educational level, country of origin and alcohol consumption. The highest risks of stress were reported by employees in trade and in the social/health sector, and especially by shop assistants and cashiers, nurses and health technicians, fabric dyers and printers. The risk of job strain was higher in respondents who suffered an accident at work or reported sickness absence. Controlling the possible confounding factors by using the multiple logistic regression analysis, the risk of occupational accident grew with the increase of JD: OR = 1.00, 1.42 (CI 0.85-2.37), and 2.29 (CI 1.35-3.89) in the first, second and third terzile, respectively). It then increases, albeit less so, with the reduction of DL: OR = 1.00, 1.08 (CI 0.65-1.78) and 1.62 (CI 1.02-2.58) in the third, second and first terzile, respectively. The risk of sickness absence grew with the increase of JD - OR = 1.00, 1.07 (CI 0.75-1.53), and 1.49 (CI 1.02-2.17) in the first, second and third terzile - and, especially, with the reduction of DL - OR = 1.00, 1.27 (CI 0.89-1.80) and 1.57 (CI 1.11-2.21) in the third, second and first terzile, respectively. Assuming that the overall risk factors for sickness absence was equal to 100%, then 9% was attributable to high psychological commitment, 14% to low DL, 8% to smoking, 6% to the habitual consumption of psychotropic drugs, and 37% to all of these factors together. Assuming that the overall risk factors for occupational accidents was equal to 100%, then 22% was attributable to high psychological commitment, 15% to low DL, 28% to smoking, and 22% to alcohol consumption. The risk attributable to smoking and alcohol consumption was 50% (= 22+28), the risk attributable to stress was 38% (= 23+15), the risk attributable to all of these factors was 88% (= 50+38). Prevention Today January - March 2008 3. DISCUSSION The Karasek model introduces another innovative element in addition to the possibility of predicting the negative consequences from exposure to stress (job strain) on the health of workers (e.g., occupational accidents, sickness absence): the advantages gained in terms of positive organizational behaviours (motivation towards organizational learning and innovation) following a design of working conditions in the active mode. The model is in fact very applicable, precisely because it is geared towards the implementation of job redesign measures. Therefore, in a number of firms where the presence and effects of psychosocial distress have been reported, improving the work organization should be promoted through the focus group strategy involving representatives of the firm and of the workers, occupational physicians, psychologists and other researchers. An increase of the risk of occupational accidents with age and smoking was observed in the Maastricht Cohort Study of Fatigue at Work, a prospective study based on a cohort of 7 051 workers employed in 45 companies and organizations in Holland [7]. In this study, moreover, the risk associated with occupational accidents was 1.91 (CI 1.21-3.02) in the subgroup with a higher level of JD, while the influence of DL was no longer statistically significant after adjustment for confounding factors. In the same study, the risk associated with long-term sickness absence was 1.69 (CI 1.22-2.38) in the group with a lower level of DL [8]. 44

SURVEY 3: A qualitative approach to accidents among non-eu illegal workers INTRODUCTION Only 2% of the 5 000 workers interviewed in Survey 1 responded that they were not born in Italy. The low response percentage could create an optimistic bias if these workers had worse working conditions than the other workers. The aim of this study was to provide greater visibility to a phenomenon which is difficult to identify and analyze. Given the problematic and sensitive nature of the subject matter of interest, an exploratory qualitative survey was conducted [9]. 1. METHODS The 2004 records of the accident and emergency department (A&E) of San Bonifacio Hospital (VR) were examined regarding non-italians who reported the event in the other accidental category (i.e., it did not occur in the workplace) in the hospital s patient form. The forms with suspect cases were those that had: a) a case history inconsistent with the nature of the accidental event (the forms contained the name of the injured worker s company); b) a case history inconsistent with the nature of the accidental event (the forms contained no information about the company); c) incomplete or partial diagnoses because the patient left the A&E. Furthermore, the testimony of privileged observers was collected - trade union representatives of the sectors where the risk of accidents is higher: construction and metal and mechanical engineering - as well as the life stories of a number of immigrant workers who suffered occupational accidents. 2. RESULTS In all the forms referring to foreign patient and nature of accidental event (records from the A&E), the most frequent diagnoses were the following: traumas and wounds (over 200 cases); fractures and contusions (over 50); low back pain and sprains (31); eye injuries (54), including eye injuries with diagnoses associated with activities such as construction work or the use of tools such as welding and milling machines without proper protection (actinic conjunctivitis, corneal abrasions, foreign bodies, conjunctivitis caused by lime). During the meetings with trade union representatives and with the injured workers who declared that the accident did not occur at work, it was possible to trace the different paths followed by foreign workers when they suffer an accident (Figure 3). In some accident cases, with the collaboration of lawyers and operators of the Workplace Prevention, Hygiene and Safety Department (SPISAL), it was also possible to reconstruct how the accident occurred. Monitoring safety and health conditions in the workplace: a pilot survey in a regional context, the Veneto region 45

Figure 3 - Analysis of an immigrant s possible courses of action after an occupational accident Event Occupational accident suffered by a non-italian worker Has a residence permit and an employment contract May attend Has a resident permit but does not have an employment contract May attend Does not have a residence permit May attend A general practitioner files INAIL claim or reports it as a home accident claims sickness absence or attends An emergency general practitioner files INAIL claim or reports it as a home accident claims sickness absence or attends An accident and emergency department files INAIL claim or reports it as a home accident claims sickness absence A general practitioner reports it as a home accident or attends An emergency general practitioner reports it as a home accident or attends An accident and emergency department reports it as a home accident An emergency general practitioner reports it as a home accident uses a Temporary Residence card (STP) or reports it as a home accident and under false identification or attends An accident and emergency department reports it as a home accident uses a Temporary Residence card (STP) or reports it as a home accident and under false identification 3. DISCUSSION Prevention Today January - March 2008 In the course of this research, the hypothesis that not all of the occupational accidents suffered by non-eu workers emerge in INAIL s statistics, became plausible (Figure 4). The Veneto Observatory on the black economy indicates that during the 2000-2003 period, over 14 000 irregular immigrant workers were identified in inspections by the INPS and the Ministry for Labour in the Veneto provinces. If the accident rate were similar to that of legal immigrant workers - at about 65 accidents reported per 1000 insured workers, according to INAIL data - the number of accidents among irregular immigrant workers would be over 900 per year; further, it can be assumed that these workers are more concentrated in the building and metal and mechanical engineering industries, which have high accident rates. 46

Figure 4 - Patient forms from an accident and emergency department concerning injured foreigners who were classified in the other accidental event category (ie., it did not occur in the workplace) 11% 3% 65% patient forms that were in order 21% name of company was indicated although reported as a home accident Source: Authors calculations based on data from the records of the Accident and Emergency Department of San Bonifacio Hospital (Varese), 2004 SURVEY 4: Sickness absence INTRODUCTION In Study 1, the percentage of respondents reporting not having taken sickness absence over the last 12 months was 45% while the percentage of the 2000 ESWC was almost double, (80%): specifically, in respect of absences of less than 5 days it was four times greater; for absences of 5 to 20 days, three times greater; whereas it was similar for absences of over 20 days. Thus, surprisingly, sickness absences showed a reverse trend from that of health conditions, which were better in the Veneto 2005 study compared to the ones in Europe. In light of this, a further investigation was needed; it was more likely that in many cases the true cause of sickness absence was not in fact sickness. To this end, a study was conducted where the INPS data on sickness absence are described by broad areas (agriculture, crafts, industry, services), production sector, professional qualification (blue-collar and white-collar workers), age group, gender and calendar year (1997-2002). 1. METHODS inconsistent case histories (no references to the company) patients who left the A&E without fully completing the patient form To conduct this study it was first necessary to define the database of employees registered with INPS and insured against illness - workers employed in agriculture, industry, crafts and services, but not civil servants who are insured with the Italian National Social Security Institute for Civil Servants (INPDAP) - and then identify which of these insured workers were absent on sick leave in the 1997-2002 reference period. Using the total number of the insured, events (sickness absences) and the sick (workers absent on sick leave), the following indicators were constructed: events/the insured, which is an incidence density rate; the sick/the insured, which is a cumulative incidence rate. Monitoring safety and health conditions in the workplace: a pilot survey in a regional context, the Veneto region 47

Only the sick/the insured rate was subject to statistical analysis, but not the events/the insured rate because for the latter, the numerator was greater than the denominator in some circumstances. The excessively large number in the numerator (the sick) when compared to the denominator (the insured) prompted the use of a binomial regression model in which the dependent variable was the number of sick persons and the independent variables were: the number of the insured; gender (dichotomous variable: M = 1; F = 0); age (the 6 age groups were recodified as 5 dummy variables using the age group 19 years as the conventional risk reference group = 1); the sector (the 27 sectors were recodified as 26 dummy variables using as reference group the sector manufacturing of metal products, machine installation and mechanical materials - in the broad area of crafts ); and the calendar years (the 6 calendar years from 1997 to 2002 were recodified as 5 dummy variables, using 1997 as reference year). Using binomial regression analysis the odds ratio (OR) and the confidence interval (CI) were estimated at 95%. In a second binomial regression model, only data relating to sectors employing blue-collar and white-collar workers were analysed. In this case the reference sector, (conventional risk value = 1), was transport and communications - broad area of industry and professional qualification of office workers, because in this sector the difference in the cumulative incidence rate between blue-collar and white-collar workers was minimal. Estimates of OR and CI in all the other sectors were obtained, separately for blue-collar and white-collar workers respectively, net of the influence of gender, age, and calendar year. 2. RESULTS Prevention Today January - March 2008 What first emerged from the data in this study, is that the temporal trend among the insured shows a significant increase in employment in the region. This trend represents a real increase since there were non regulatory changes during the observation period (1997-2002) to extend insurance coverage to other categories of workers previously not protected. In the time period observed, the population of workers insured with the INPS in the Veneto region changed qualitatively due to an increase of the share of women and to ageing. Moreover, there is a deindustrialization trend in the Veneto region that has shifted employment toward the service sector; younger workers are concentrated in this sector, whereas workers in industry and crafts are, on the average, older. The increase in employment registered in the agricultural sector, which also affects younger workers, is probably associated with the increase in insured workers from non-eu countries. In the observation period, the ratio between the number of the sick - with at least one episode per year of sickness absence - and the insured, was at 43% (45% in Survey 1). The results of the first model of binomial regression analysis (Table 3) indicate through the OR that sickness absence: was 16% lower in men than in women; reaches a peak in the age group 20 to 29 and then drops to a value lower than that of the reference group (19 and under) in the age group 60 and over; reached the highest value in 1999 and slowly dropped in subsequent years. The results of the second model confirm that in the 1997-2002 period, the rate of cumulative incidence (the sick/the insured ratio) decreased on average by 1.6% per year, reaching the lowest value in agriculture. Further, the ORs in the crafts sector are lower than in the industrial sector. When compared to equivalent sectors, in the crafts sector the cumulative incidence 48

rate is always lower than that of industry (with deficits varying between -25 and -61%, depending on the sector), and the OR is always lower in blue-collar workers compared to that in white-collar workers, (with deficits varying between -7 and -37%). From the analysis of the temporal trend, it emerges that the rate of the sick/the insured, having peaked in 1999, tends to decrease. Table 3 - Subjects who went on sick leave - Binomial regression model Odds Confidence interval ratio (p = 0.05) Gender Gender (M = 1) 0.84 0.84 0.84 Age 20-29 years 1.72 1.70 1.74 30-39 years 1.64 1.62 1.65 40-49 years 1.39 1.37 1.40 50-59 years 1.35 1.34 1.37 60 years and over 0.98 0.96 1.00 Economic macro sector Agriculture 0.47 0.46 0.47 Disaggregation, industry Manufacturing vehicles, means of transportation, tools, etc. 2.08 2.05 2.12 Manufacturing, installation and repair of computers and similar products 2.19 2.16 2.22 Manufacturing metal products, installation of machines 1.99 1.97 2.01 Construction and plant engineering 1.21 1.19 1.23 Energy, mining, chemical and fibre industry 1.80 1.79 1.82 Wood, furniture, paper, rubber, other 1.75 1.73 1.77 Food products, sugar, beverages and tobacco 1.24 1.22 1.26 Repair of consumer goods and vehicles 1.56 1.51 1.60 Textiles, leather, hide, shoes, clothing 1.46 1.44 1.48 Transport and connected activities, communications 0.99 0.98 1.00 Disaggregation, Crafts Manufacturing vehicles, means of transportation, tools, etc. 0.82 0.79 0.85 Manufacturing, installation and repair of computers and similar products 1.03 1.00 1.05 Construction and plant engineering 0.91 0.90 0.92 Energy, mining, chemical and fibre industry 1.07 1.04 1.09 Wood, furniture, paper, rubber, other 0.95 0.94 0.96 Food products, sugar, beverages and tobacco 0.55 0.54 0.56 Repair of consumer goods and vehicles 0.91 0.89 0.93 Textiles, leather, hide, shoes, clothing 0.79 0.78 0.80 Education, health and other services 0.66 0.65 0.68 Monitoring safety and health conditions in the workplace: a pilot survey in a regional context, the Veneto region (Table continued on next page) 49

Table 3 (continued) Disaggregation, Services Education, health and other services 1.02 1.01 1.04 Financial aids and other services for enterprises 1.02 1.01 1.04 Retail trade 1.00 0.98 1.01 Wholesale trade and brokers 1.10 1.08 1.12 Shops and hotels 0.45 0.44 0.45 Year 1998 1.05 1.05 1.06 1999 1.19 1.18 1.19 2000 1.04 1.03 1.04 2001 0.98 0.97 0.98 2002 0.97 0.96 0.97 3. DISCUSSION The results confirm the percentages of sickness absence among workers of the region that were already shown in Survey 1. In the industrial sector, the overall number of episodes of sickness absence exceeds the number of the insured in the age group 20 to 39; each worker from the most productive age group had one or more episodes of sickness absence per year. Women show a greater tendency to take sick leave than their male colleagues. The incidence rate (events/the insured) in the economic sectors, shows a clear difference, in relation to sickness absence among women and also between the two genders. No recent studies, however, report data to allow a comparison to be made and there are no international agreements for constructing indicators in order to investigate this phenomenon [10]. SURVEY 5: Trends in occupational accidents, disability, and sickness absence INTRODUCTION Prevention Today January - March 2008 In the first study, maintaining good health was positively correlated with job satisfaction (p-trend = 0.0073), the possibility of maintaining friendly relationships with co-workers, the opportunity provided by the job to increase their own professionalism (p-trend = 0.0001), the possibility of adapting the work to their own needs (p-trend 0.0000). Information on risks, however, was not correlated (p-trend 0.0926); whereas training (p-trend = 0.0317) and the use of personal protective equipment (p-trend 0.0008) were negatively correlated. It must be remembered that the last three elements - information, training, and use of PPE, are required by law (Legislative Decree 626/94 for the prevention of occupational accidents and diseases). Italian legislation provides for benefit payments to be made to workers in case of accidents at work, sickness absence, disability (cases where the ability to carry out work tasks has been reduced by at least one third due to non-occupational causes), and inability (cases where there is a total inability to work due to non-occupational causes). Where accidents are workrelated, the indemnity is paid to workers by the INAIL. All other benefits are paid by the INPS, from the contributions paid by the employer for each employed worker. Therefore the INPS archives contain information on workers concerning their history of employment (the various employers, specified by category), and of pathologies (sickness absence, disability and inability); accidents at work are due to occupational causes, cases of disability and inability to non-occupational causes, and sickness absence may be partly due to occupational causes and partly to non-occupational ones. 50

Over time, there has been a reduction of accidents, a stable trend of disability and an oscillating one of sickness absence, which are probably all due to the application of Legislative Decree 626/94. The aim of this study is therefore to investigate - through the temporal trend of three standardized incidence rates in industry - the effectiveness of the legislation that governs safety management in the workplace. 1. METHODS The numerators of the rate of accidents at work, disaggregated by sex, age and calendar years, were provided by the INAIL and refer to the accidents suffered by workers in the industrial sector of the Veneto region between 1994 and 2002. The INAIL archive does not contain data on the employees, who are the denominators of the rates of accidents. Thus, these denominators and also the numerators and denominators of the pensionable disability rates and of the sickness absence rates, were provided by the INPS. The available data on accidents and inability/disability covered the period from 1994 to 2002, and the sickness absence data, the period from 1997 to 2002. The rates were age- and sex-standardized for each year, from 1994 to 2002, using the direct method and considering as the standard population the 1994-2002 means by sex and age group of the industrial employees of the Veneto region. The year-specific rates, age- and sex-standardized and expressed as incidence rates per 1 000 employees, were analyzed using the Joinpoint Regression Program [11], which enables to test whether an apparent change over time of a standardized rate is statistically significant. The program also provides the graphs and the Annual Percent Change (APC) estimate; if the regression is expressed by a broken line, the APC is calculated for each line segment. 2. RESULTS The results of the Joinpoint Regression analysis (Figures 5, 6 and 7) demonstrate that for accidents at work, the significant model is that with zero joinpoints, represented by a line with an increasing trend over time. The APC value indicates that the age- and sex-standardized rate of occupational accidents in the industrial sector of the Veneto region, increased by 0.4% per year in the period of interest (1994 to 2002). Also for the rate of inability/disability, the significant model was that with zero joinpoints and the APC value indicates an average annual reduction of 2.6%. In conclusion, the significant model for the rate of sickness absences, showed three joinpoints, with four segments. After an increase up to 1999, the rate showed a decreasing trend in more recent years. Monitoring safety and health conditions in the workplace: a pilot survey in a regional context, the Veneto region 51

Figure 5 - Accidents at work (Industry, Veneto region) - age -and sex-standardized rates, Joinpoint regression All: 0 Joinpoint Rate 0,061 0,061 0,060 0,060 0,059 0,059 0,058 0,058 0,057 0,057 Observed APC - 0,43 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year Figure 6 - Disability or inability (Industry, Veneto region) - age -and sex- standardized rates Joinpoint regression All: 0 Joinpoint Prevention Today January - March 2008 Rate 0,002 0,002 0,001 0,001 0,001 0,001 0,001 0,001 Observed APC - 2,56 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year 52

Figure 7 - Sickness absence (Industry, Veneto Region) age -and sex- standardized rate Joinpoint regression All: 0 Joinpoint Rate 0,555 0,550 0,545 0,540 0,535 0,530 0,525 0,520 0,515 0,510 0,505 1997 1998 1999 2000 2001 2002 3. DISCUSSION Year Observed APC 1-2,98 APC 2-6,83 APC 3-7,15 APC 4-1,03 There are no data to compare with the data on the standardized trend neither for accidents, nor for the other two indicators, (disability/inability and sickness absence); the scarcity of research on this issue was one of the reasons for the present study. Indeed, this is the first study in Italy that reports the age- and sex-standardized rates for accidents at work, sickness absences and disability/inability among industrial workers. The results reveal an epidemiological situation that is difficult to explain. The increase in occupational accidents in the observation period may be explained by the increase of non-eu industrial workers and by the recognition of accidents occurring during travel to and from work due to regulatory amendments introduced in 2000. Both these factors could have contributed to increase a rate that would have been otherwise decreasing, as observed since 2002. Finally, this situation could lead to considerations on the insufficient efficacy of the legislation on this issue although it is impossible to know what the trend would have been in the context of the previous legislation. Regarding prevention in the workplace, today the methodological approach is based on controls of a technical/engineering nature and on formal aspects, to the detriment of planned intervention measures to combat the principal risk factors and to check the effectiveness of the safety management system within the enterprise. According to a recent study [12], an effective program to reduce accidents in industry must go beyond the application of traditional methods (job-related ergonomic risk factors) and include personal lifestyle factors such as smoking, overweight and alcohol abuse. Therefore, it would be advisable that technical and inspection interventions be supported by multi-disciplinary interventions, centred on the specific characteristics of individuals and of the firm. Indeed, it has been shown that the risk of accidents, sickness absence, disability and inability are all reduced in workplaces where health-promotion initiatives are encouraged (among these, quit smoking campaigns seem to have the greatest success) [13, 14]. Monitoring safety and health conditions in the workplace: a pilot survey in a regional context, the Veneto region 53

Prevention Today January - March 2008 CONCLUSIONS ON THE PROJECT AS A WHOLE Changes in the organization of work - especially more flexible methods for organizing work schedules and a more individual human resources management also focussed more on results - have a profound impact on the problems associated with occupational health and, more generally, on workers wellbeing. An occupational safety and health monitoring system should combine data from various sources in order to have as complete a picture as possible and, at the same time, one that is effective in the timely identification of early warnings and of the possible solutions. The aim of the research was to test a monitoring model - which would be used for a nationwide ad hoc survey - that would provide a comprehensive picture of the occupational safety and health conditions in an Italian region; Veneto was chosen as the pilot region. Thus the research intended to provide the know-how for the nationwide survey that will have to determine the priority measures concerning economic sectors, professional activities, groups at risk etc. It will also have to identify and assess the parameters to measure the adequacy and quality of prevention measures taken by the local health units and other institutions and operators in the field. To this end, the research examined the following themes in depth: the perception of risks (from exposure to physical, chemical, biological and ergonomic factors); psychosocial and organizational factors, and emergent risks deriving from new forms of work, health conditions and the prevention measures adopted (health surveillance, training of workers, etc); safety conditions at work, (through currently available data on occupational accidents and diseases, with particular attention to musculoskeletal disorders and injuries from noise); other diseases correlated with work (data from the Italian Workplace Prevention, Hygiene and Safety Services, SPISAL ); sickness absences (INPS data); and safety issues in relation to non-eu workers in the labour force. The research showed that the main health problems suffered by workers of the Veneto region were stress (27%), followed by backache (18%) and by pain of the limbs (11%). Stress, second only to back ache, was also one of the main health problems reported in the 2000 Eurofound survey conducted in Europe. In relation to the perceived risk factors, in addition to traditional physical and chemical risk factors (vibrations, noise, inhalation of fumes, smoke, dusts and hazardous substances), other aspects related to working conditions emerged, such as posture, handling of loads, repetitive movements, work shifts and excessive psychological and cognitive demands. The Karasek questionnaire was administered to investigate the extent and effects of stress in the workplace: 27% of the sample reported high job strain (i.e., working conditions perceived to be high in psychological demands and low in decision latitude). The risk of exposure to high job strain was greater in women, in subjects taking psychotropic drugs, and in nonsmokers; whereas there were no differences in age, educational level, country of origin and alcohol consumption. The highest risks of stress were reported by employees in trade and in the social/health sector, among subjects with over 10 years of service and among workers who suffered an accident at work or reported sickness absence. In regard to the safety at work of foreign workers, the study was developed along three lines: the records of the accident and emergency department of a hospital in the province of Verona, the testimony of a number of trade union representatives (who were privileged observers), and a selected collection of cases of injured workers. In its effort to provide greater visibility to a phenomenon which is relatively well known but difficult to analyze, the study 54

strengthened the original hypothesis that not all work-related accidents suffered by non-eu nationals emerge in INAIL s statistics. The analysis of the INPS data on sickness absence for the 1997-2002 period indicates a proportionally lower percentage of absences in the crafts sector among blue-collar workers, showing a peak in the 20-29 age group. Females show a greater tendency to take sick leave: the incidence rate (events/the insured) examined, indicates a clear difference between the two genders, especially in industry. The analysis of the 1994-2002 INPS rates of occupational inability/disability indicated a significantly greater risk of disability among employees of the crafts, industrial and service sectors than among the self-employed. The greatest risk of disability was found in the construction and plant engineering sectors (both industrial and crafts), followed by the textile sector (as an industrial activity). In addition, the analysis of the 1994-2002 age- and sex-standardized rates, indicated a reduction in the rate of inability/disability and, in more recent years, of the rate of sickness absence; the analysis also indicates an increase in the rate of occupational accidents, which may be explained by an increase of non-eu industrial workers and by the recognition of accidents occurring during travel to and from work due to INAIL regulatory amendments. In conclusion, the results of the data collected by the occupational safety and health monitoring system tested in the Veneto region has shed new light on aspects that failed to emerge with sufficient clarity from each source of information alone; it emphasized the criticality of official data sources concerning phenomena associated with the evolution of the job market, and it detailed issues concerning certain emerging risks based on a general overview. Monitoring on a regular basis, as well as integrated information gathering, constitute the minimal references for the timeliness and effectiveness of the system itself. REFERENCES 1. European Risk Observatory - Anticipating ch ange. [online]. Available from: URL:http://risk observatory.osha.europa.eu/osm 2. European survey on working conditions (ESWC). [online]. Available from: URL:http://www. eurofound.eu.int/working/surveys 3. Paoli P, Merllié D. Third european survey of working conditions, European Foundation for the Improvement of Living and Working Conditions. 2000 4. Development of the Working Conditions Survey Questionnaire). [online]. Available from: URL:http://www.eurofound.europa.eu/docs/ewco/4EWCS/evolution_questionnaire.pdf 5. Karasek R. Job demands, job decision latitude and mental strain: Implications for job redesign. Administrative Science Quarterly 1979;24:285-308 6. Karasek R, Brisson C, Kawakami N, Houtman I, Bongers P, Amick B. The Job Content Questionnaire (JCQ): an instrument for internationally comparative assessments of psychosocial job characteristics. J Occup Health Psychol 1998;3(4): 322-55 7. Swaen GM, van Amelsvoort LP, Bultmann U, Slangen JJ, Kant IJ. Psychosocial work characteristics as risk factors for being injured in an occupational accident. J Occup Environ Med 2004;46(6):521-7 8. Andrea H, Beurskens AJHM, Metsemakers JFM, van Amelsvoort LGPM, van den Brandt PA, van Schayck CP. Health problems and psychosocial work environment as predictors of long term sickness absence in employees who visited the occupational physician and/or general practitioner in relation to work: a prospective study. Occup Environ Med 2003;60:295-300 Monitoring safety and health conditions in the workplace: a pilot survey in a regional context, the Veneto region 55

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