Training of occupational physicians in The Netherlands with regard to occupational health services delivered to the population.

In the Netherlands, the need for a basically new approach to education and training in occupational medicine was felt by professionals, students, schools and occupational health services (OHS) in the early 1990s. After an inventory of the problems and shortcomings of the traditional curriculum, the Netherlands School of Occupational Health defined the framework for a new curriculum. In this article the background, principles and structure of the new curriculum are described. Three principles shape the curriculum: the needs of OHS; professional standards; and the state-of-the-art. The characteristics of the new curriculum are: interaction between theory and practice; students' self-management of the learning process; co-makership with OHS; and multidisciplinarity. The curriculum consists of a course/theory and a practical part. Most of the theoretical part is presented to so called core group of 12 students, which is to be maintained during the full course period of 4 years. The adage for the practical part to be spent in a certified OHS institution is: "the best teaching OHS are learning OHS". In 1999, the first group of students entered the renewed curriculum. First impressions of the experience gained are presented.

Questionnaire surveys on health and working conditions: development of an instrument for risk assessment in companies.

Periodic Occupational Health Surveys (POHS) are frequently used by occupational health and safety services in the Netherlands as a risk assessment instrument. These surveys include a questionnaire on work and health. Systematic attention is paid in this questionnaire to a broad range of working conditions and health complaints. In this article a method is presented to identify and evaluate work risks and health problems in groups of workers. Working conditions and health in any given company or department are assessed by comparing questionnaire data from its worker populations with data from one or more reference populations. Significant differences are interpreted as signals for both adverse working conditions and health problems. Considerations and choices with regard to the technical, operational and strategic quality of the method are elucidated. Probabilities of alpha- and beta-errors, choice of significance levels, and selection of reference populations are dealt with. Finally, a way of presentation of the results is shown. The method is considered to be part of a broader approach toward risk assessment. We recommend the combined use of questionnaire results and other available information, such as workplace surveys and sickness absence data. Questionnaires about work and health can be seen as one step in a multi-phase design: like in many diagnostic processes, the latter phases can enhance the precision of previous results. Recommendations are made for validating and evaluating this instrument.

Recent changes in occupational medicine in The Netherlands.

In some respects, the Dutch seem to be forerunners in Europe. Occupational health care for all workers can be considered as a substantial progress. Nonetheless, The Netherlands has taken the lead in Europe regarding high work pressure, sickness absence and disability for work. The resulting focus on sickness absence management in many companies is associated with changes in the tasks and position of the occupational physician. Quality of occupational health care is not always as high as it should be, partly as a result of the commercial approach occupational health services have to adopt nowadays. However, the post-academic education programme, with special attention for training of skills, is increasingly adapted to occupational physicians working in a commercial environment. Moreover, a basis has been laid for a better infrastructure and occupational physicians show an increase in professional enthusiasm. Furthermore, co-operation between different professionals has become increasingly common, resulting in a more comprehensive support for companies. Efforts are being made for better co-operation with general practitioners and medical specialists. Finally, the priorities for future research have been clearly outlined by a programming study. Experts are in demand for studies regarding implementation and evaluation of interventions, especially cost-benefit analysis. Furthermore, work stress and musculoskeletal disorders remain on the research agenda.

[The social security reform: wide-ranging effects on companies as well as occupational health services]. / Privatisering van de Ziektewet: uiteenlopende effecten bij zowel bedrijven als Arbo-diensten.

OBJECTIVE: To evaluate the reactions of companies and Occupational Health Services (OHSs) to the reform of the social security system by the government of the Netherlands; especially to inventory to what extent intended effects (more handicapped workers employed, more reintegration efforts) and unintended effects (exclusion handicapped workers, deteriorated quality OHSs) occurred. DESIGN: Inventory survey. METHOD: Data on number of OHSs and their sizes and staff compositions were collected in September 1997 through a questionnaire sent to all members of the National Association of OHSs (BOA). In addition, data on efforts of enterprises in the area of working circumstances in 1996 and in 1997 were derived from the published results of enquiries by telephone among a representative random sample of 4,000 enterprises. RESULTS: The number of employees in the care of the OHSs was twice as high in 1997 as in 1991. The number of OHS staff members had also doubled, but the proportion of physicians among the total staff had decreased. The number of employees per physician had increased by 34%. The nature of the contracts concluded with enterprises shows that the extension of the market has not led to more extensive OHS care, although it has brought about greater variation. Generally, large companies developed a policy to prevent disability and to employ more handicapped workers, while small and medium-size companies more often tried to exclude people that is at risk for disability or absenteeism. CONCLUSION: Intended effects occurred to a limited extent in larger companies and unintended effects mainly in small and medium-size companies.

[Market effect on social security and occupational health services]. / Marktwerking in de sociale zekerheid en Arbo-dienstverlening.

Between 1993 and 1998 a fundamental reform of the social security system and Occupational Health Services (OHSs) in the Netherlands was implemented in order to lower the relatively high sickness and disability rates. The principle of the government policy is to impose the financial consequences of incapacity for work as much as possible on those who cause it: employers and employees. The reform implies the creation of a market in both fields. Joining an OHS was made mandatory for all employers by ultimately the first of January 1998. Price and product competition between different suppliers of OHSs is promoted. This implies an explosive increase of the target population and the rise of commercial OHSs (which in 1997 provided for 570,000 employees). Other OHSs originated from industrial insurance boards (over 2 million) or from industrial health services (over 3 million). The change of system has increased the economic importance of sickness and health. The number of persons incapable for work has meanwhile grown, risk avoidance by enterprises being one of the causes. Owing to the enhanced interference of employers with absenteeism, the health care system is being asked for specific measures for employees and better contacts between industrial physicians and treating physicians.

[Professional integrity among commercial occupational health services]. / Professionele integriteit binnen commerciële Arbo-dienstverlening.

In the field of Occupational Health Services (OHSs) a fundamental change of the regime of supply of services was implemented in the Netherlands between 1993 and 1998 by introducing market competition. This regime change is characterised as a shift from a suppliers' market where occupational physicians were able to determine the supply to a large extent, to a buyers' market where companies can choose from a large variety of services at different prices. The regime change does affect the position of the occupational physician drastically and many consider their professional integrity and independence threatened. To meet the demand for an independent judgement and advice in problems concerning the interaction between work and health, the professional group should organize itself more as a party in the market.

Design and trial of a new questionnaire for occupational health surveys in companies.

In this article we present an example of our method for instrument development. This method is called the Development Cycle. It consists of four main stages: (1) defining the requirements for an instrument; (2) research, design and pilot testing; (3) implementation and (4) evaluation. An application of the Development Cycle was realized within a project for the development of a basic questionnaire about work and health, to be used at periodic health surveys. This questionnaire had to identify work and work-related health problems in employees with divergent occupations and working conditions. The design of the instrument and the results of its trial in 517 employees is presented. The evaluation of the test results and the modification of the questionnaire are discussed. From 1995, the questionnaire has been implemented in the Dutch OHS services quite successfully.

Quality improvement by means of "differential' occupational health care: an experiment in a regional occupational health centre.

From a general policy of quality improvement, the regional Occupational Health Centre Eastern Gelderland has developed a method of company health care based on the particular demands and needs of companies. A procedure of care "made to measure' based on company and work characteristics was designed. For one year, an experiment was carried out in seven companies, to investigate if this "differential care' is feasible, and if its quality is better than the traditional "standard' form. After the experiment, the companies' satisfaction proved to have increased. The influence of the Occupational Health Centre on working conditions was estimated more important than before. The increased satisfaction is considered to be an indication of better quality of care, compared with the traditional "standard' care. The differential approach appeared to be feasible. The method requires skills of professionals in the field of planning, cooperation, estimating costs and negotiating.

The Atlas of Health and Working Conditions by Occupation. 1. Occupational ranking lists and occupational profiles from periodical occupational health survey data.

In this article, we describe methods which have been applied in the compilation of the Atlas of Health and Working conditions by Occupation. First, we discuss the need for information systems to identify problems concerning working conditions and health. Such information systems have an exploratory purpose, being deployed to identify work risks in companies, groups of occupations and sectors of industry, and can also be a starting point for the generation of hypotheses on the causes of adverse health effects. In the Netherlands, occupational health services gather questionnaire data about work and health as part of periodical occupational health surveys. In the atlas, aggregated questionnaire data for 129 occupations with male employees and 19 occupations with female employees are presented. In this article, we explain the methodology used to compare occupations with regard to each item in the questionnaire. We then discuss applications of these occupational ranking lists. The cross-sectional nature of the data collection, various forms of selection and the limited size of some occupational populations have to be taken into account when interpreting the results. Occupational ranking lists can be applied in the allocation of resources and in the design of scientific research. The overviews for each occupation, presented in the second half of the atlas, provide an occupational profile of existing problems with respect to work and health. These profiles are used as basic information to develop a practical policy on working conditions and health.

The Atlas of Health and Working Conditions by Occupation. 2. A comparison with the "Atlas of Health and Working Conditions in the Construction Industry".

The results of the general Atlas of Health and Working Conditions by Occupation were compared with the results of the Atlas of Health and Working Conditions in the Construction Industry. Both are based on questionnaire data from periodical occupational health surveys [POHSs]. The scores on most of the items showed considerable differences between the two atlases, partly due to differences in the regional origin of the data. Therefore, direct comparisons between the atlases are biased by regional differences. To study the reliability and the generalizability of the results of both atlases, similarities between the data files with respect to occupations in the construction industry were studied. Most of the items on working conditions, especially those with a widespread distribution, showed a close resemblance between the data files in terms of the relative position of an occupation compared to other occupations in the construction industry. The items on health showed less resemblance, except for the items on musculoskeletal complaints, which showed results similar to those of the work items. These results indicate the reliability and generalizability of the judgements based on both atlases outside the regions of origin, as far as items with a widespread distribution are concerned. Therefore, we recommend the aggregation of POHS data on a national scale, taking regional differences into account. In that way, a greater number of occupations will be described and the reliability of the results will be enhanced.

Do smokers get more back pain?

Recently smoking has been increasingly implicated as a possible risk factor for low-back pain. One explanation for this finding is confounding by occupation. To investigate this possibility, the relationship between smoking and self-reported back pain was studied within 13 occupations. A relationship between smoking and back pain was observed only in occupations that require physical exertion. The relationship between smoking and other musculoskeletal pain also was explored. Pain in the extremities turned out to be related more clearly to smoking than to pain in the neck or the back. This suggests confounding or a general influence of smoking on pain. It is concluded that prevention of back pain could be a beneficial side-effect of anti-smoking campaigns. However, the prime target for prevention of low-back pain would have to be other factors.